Thursday, July 3, 2014

Work. Kids. Balance.

There was a hilarious post from The Honest Toddler blogger and author, Bunmi Laditan yesterday on Huffington Post: How to Breastfeed Appropriately.

So. E is 8 months old! She sits up! She crawls! She climbs over things! She feeds herself with a spoon! (so what if 80% of it ends up on the floor?) She turns light switches off! She's pretty much the cleverest baby in the whole world. Not to mention the cutest. :)

Work is . . . . . . . . I don't really know what to say about work. A lot of things about it right now are great:
  • Hours-wise, my schedule is PERFECT!!!! When I went back after maternity leave, I modified my schedule so I'm only working 2-3 days a week, and they're short days. I'm only gone for about 9 hours on an average work day, which is really nice! It's a lot better than the 15 hour average I had before. I only miss bedtime once a week. M only has to do the morning routine by himself once a week. We all love that!
  • H is in daycare only 3 days a week, and E is there only 1.5 days. Both of them spend more waking time at home with me than they do in daycare, which for me is a major marker of work-life balance. If I'm totally honest, I will admit that I have been increasingly interested in working a little bit more, but that only works out financially if I just work longer days on the days I already work. If I add days to my schedule then I have to add days to our daycare contract, and that seriously cuts into my take-home pay. And right now we don't quite have the caseload for longer days on my work days, so I'm kind of in scheduling limbo.
  • We're building our ER staff and transitioning to having 24/7 ER coverage that's separate from the GP side. So I only see emergencies once a week (crammed in among appointments) and I'm almost never responsible for the ICU, which is a HUGE decrease in my stress level at work.
  • For whatever reason, in the past 2-3 weeks I've had mostly cases that I felt like I could handle (being bluntly honest, this is not because my clinical acumen has suddenly skyrocketed; out of sheer happenstance I've just had a relatively simple caseload recently) so I've been feeling a little more confident at work, and enjoying it more. The feeling of "I don't know what the hell is wrong with this patient, and I don't know what to do next" is terrible. NOT having to feel that way is amazing!!!
  • I'm able to pump every 3-4 hours even when I'm at work, which is great for maintaining production and keeping up with E's demand. I am SO much less obsessed with milk production with her than I was with H, I think mostly because I'm with her most of the time so she nurses on demand 4-5 days a week. With H, I would sometimes go days at a time without seeing him at all, so I really needed* a big freezer stash.

Of course, few things in life are perfect, so while there are a lot of changes at work that make me happy, there are still things that could improve:
  • While my reduced hours are awesome from a personal standpoint, they obviously come with a proportionately reduced paycheck. Actually, it's disproportionately reduced, because I'm not eligible for any benefits as a part-time employee (medical insurance, 401(k), PTO, etc). And daycare, man - it is expensive!!! We live in a smallish suburban 2 bedroom apartment (it's in a decently managed complex but certainly nothing luxurious), and between rent and daycare we're spending almost $3000 a month. We'd like to buy a house someday, hopefully before the kids are in college, and that is just not in the cards without my full-time salary.
  • While I'm enjoying the decreased stress of not having to see emergencies and be responsible for all the hospitalized patients, I would LIKE to be a good emergency/ICU doctor. The only way to get good at that is to do it a lot, so moving toward being more exclusively a GP is actually not benefiting me professionally, even if it significantly reduces my stress in the short term. 
  • I also feel, with my caseload of relatively simple patients, that my medical skills even as a GP are deteriorating. Use it or lose it! Especially when you haven't been practicing for very long. I also have to look things up a lot more frequently than I should, and that slows me down a lot, and then I'm behind schedule, and then everyone - the clients, the nurses, the other doctors, and me - gets stressed out. And then not being there every day interferes a little with continuity of care - some patients that I'd like to follow up with myself end up having rechecks with other doctors instead because of scheduling issues, so I miss out a little bit on being able to follow my own cases.
  • Work isn't super cooperative about letting me pump. They pay a lot of lip service to the idea of being family-friendly, but I get a lot of emails requesting that I move my pump breaks to times of the day that aren't physiologically possible (I take one break, most days, and I'm gone for about 18 minutes. Surely the hospital can survive that long without me). My last long email exchange with HR ended in a stalemate and I haven't heard anything from them about it in a few weeks, and no one has changed my schedule since then (sometimes I'd come in and find my pumping break deleted, or moved to a time slot that required me to go 6 hours without pumping, or some similar shenanigans), so as long as they leave me alone I'm going to consider it not an issue.
Finally, for whatever reason, I haven't been producing enough milk at night for E's bedtime feeding. She'll cluster feed all evening, nurse well at bedtime, AND then drink another 3-5 ounces from a bottle. I've started taking fenugreek and blessed thistle, and doing "super pumps" (12 minutes on/12 minutes off/12 minutes on) to simulate an extra cluster feeding right after she goes to bed, but she still wants that whole bottle. I was getting all stressed out about this (OMG! It's depleting my freezer stash! -- I am such a freaking miser about that freezer stash, you'd think all our lives depended on its existence) but the past couple of nights, she's just been so CUTE with her bottle that I've started to kind of enjoy it! Prior to this recent development, I'd given her a bottle maybe 3 times before, and it was months ago. So getting to cuddle my sleepy little baby while she holds her own bottle and spins it back and forth between her hands while she drinks her milk, gazing into each other's eyes (which we don't really get to do while nursing because of the way she ends up being positioned - facing me at eye level between my elbow and shoulder) is really nice! I actually like it! I still do worry that she'll develop a preference for the bottle because of faster flow and not having to wait for letdown (she can be a very impatient nurser, sometimes) but as long as that doesn't happen, I think I'll be fine with this.

Also, having 2 kids is awesome. They are SO ADORABLE together - H loves to make E laugh, and E wants to play with whatever H is playing with, and he likes to hug her and she likes being hugged - I often think my heart will just burst from the sweetness. I love them so much individually, and I think I love them even more together.

I would say that right now, overall, I have pretty close to perfect work-life balance. I would like to work a little bit more (maybe another 6-8 hours a week), and the occasional weekend when M works both days and I'm home for 4 days in a row with both kids by myself (happens once a month) can sometimes feel like it lasts about a month, and we could definitely use a little more income. But I'm also astonished by how quickly both kids are growing up and wish I could slow them down a little bit, and I'm incredibly grateful to get to spend this time with them while they're this young. I LOVE the baby years - I'm not in the camp that can't wait for their kids to be older so they can do more things with them (M is like that), and I wistfully realized the other day that I'm almost done with the first of what will probably end up being the best five years of my life.


*Need is of course a relative term. I could easily have formula supplemented him and that would have been fine. I think because I was away from him so much, I felt like exclusively breastfeeding him was something I could do for him even when I wasn't there (by bottle-feeding pumped milk) and that made me feel a tiny bit better about having to spend so much time away from him.

Sunday, February 16, 2014

Back to work

I go back to work in just a week - augh!!!!!! I'm so grateful to have gotten this extended time home with E (she'll be 4 months old the day before she starts daycare next Monday) but it still feels like it FLEW past. I actually feel like I got less time at home with her than with H, and I had a 10 week maternity leave with him, compared to 17 weeks with her - almost twice as long! Part of it is because there were a lot more minor management issues with her, and H's maternity leave was all completely smooth sailing. E had a horrible diaper rash that needed days of being diaperless (all day long) to clear up, then she had RSV, then she forgot how to sleep on her own because we'd been holding her around the clock since she was coughing so much from the post-nasal drip, so we spent a couple of long, painful weeks having to coach her into sleep for every single nap and night waking. Then she got another cold (not nearly as bad, thankfully).

The other part is that because of the holidays, and all the freaking SNOW we've had this winter, daycare attendance has only been about 50% for H, so instead of him going to daycare 3 days a week, there have been many weeks where he either didn't go at all, or went once or twice in a 2-week span. And when he's home, all I really do with E is hold her or sit her in her bouncy seat or swing, while I play with H, so although we're together all day, I don't really get to actively engage with her as much as I want to.

Finally, being a SAHM to 2 kids is a LOT harder than I expected! Everyone says the change from 0 to 1 child is earth-shaking, the change from 1-2 is no big deal, and then the change from 2-3 gets difficult again. Obviously, going from having 0 children to having 1 child is a monumental change (I mean, you become a parent when you weren't one before!), but because H was such a ridiculously easy baby, it wasn't particularly difficult. I think going from 1 to 2 has been a lot more challenging. I'm sure there are parents who are able to effortlessly juggle the demands of two small children and feel like they're spending adequate time with, and giving adequate attention, to both children, but I feel like I can only really focus on one of them at a time, and by default that's H when he's awake since he's much more of a squeaky wheel. :) And having so many days when I expected to have the day alone with E, and it turning out that I kept H home too, I had to adjust to that a little bit. I feel like I've only, FINALLY, in the past 2 weeks or so, gotten into the swing of parenting both children. Managing them both well, giving them both enough attention, coordinating naps in such a way that I get uninterrupted time with each of them alone, I've finally gotten the hang of it. Just in time to go back to work!

Saturday, January 25, 2014

Re-entry

Wow - happy almost-one-year anniversary of my last post on this nearly defunct blog!

It's hard to write about patients when I'm afraid that (even with many details changed) an owner could recognize their dog or cat from my post, and it's hard to write about work when I spend so much time there and would rather think about my family when I'm at home!

To briefly recap, since my last post I:
  • Saw hundreds more patients (duh)
  • Celebrated H's 2nd birthday (!!!)
  • Had another baby (a girl! Little E was born in October)
  • Am enjoying the heck out of an extended maternity leave (I've been off since 2 weeks before I delivered, and go back at the end of February)
  • Have realized that there is no way in hell I could ever be a SAHM (I ADORE both children, but I need to get out of the house and do work that is intellectually challenging, and I sadly lack the patience for remaining cheerful in the face of the one thousandth, "Mommy, I need [x]!" of the day)
I did strongly consider not going back to my current job. It has a lot of advantages:
  • Extremely well-equipped hospital
  • Specialists on staff
  • Decent client demographic
  • Decent salary
  • I really like my supervisor 

But also a lot of disadvantages:
  • Specialists on staff :)
  • Longish commute
  • Crazy long hours - I'm gone for an average of 15 hours on my full days, which while short by the standards of vet school or internship/residency, is a lot longer than I want to be working as a general practice associate
  • Way more interpersonal drama than I ever could have imagined
  • Some of the management staff are borderline crazy

(BTW, specialists appears on both lists because it is REALLY nice to have a specialist immediately on hand to ask questions of every now and then, and it's great to be able to transfer very complex cases to them. On the other hand, they have a tendency to be condescending and critical of GPs' case management [whereas external specialists are generally nice to you since they want you to keep referring to them; internal specialists don't have to worry about that since you pretty much HAVE to keep referring to them, so instead of, "Hi, Dr. LIVS! Thanks for the referral! Here's what I think of the case...", I get, "Hey, Dr (and I use that term loosely) Dipwad, your workup of this case SUCKED (did you even GO to veterinary school?) and you really should not even have touched the patient before referring them to me. Try to pretend that you have at least 3 functioning brain cells next time."] which is kind of demoralizing, especially when I stayed 3 hours after the end of my shift working on that patient the day before.)

Anyway, I considered either not going back at all (maybe doing a couple of weekend vaccine clinics a month to supplement our income), or looking for a job at a more local hospital that is more of a traditional GP clinic (rather than a 24 hour hospital). But the weekend vaccine clinic thing would kind of be the worst of both worlds - I'd be a SAHM who ALSO worked weekends, and MM and I would only get 1 weekend a month together, since he also works one weekend a month - and wasn't quite enough income (and isn't intellectually challenging at all). And when I met with my supervisor to discuss returning to work, it turned out she was willing to give me a SWEET schedule, and management agreed to convert my previous salary to an hourly wage (based on SCHEDULED hours, not hours actually worked, so I effectively got a 15% hourly raise since I always got stuck at work way beyond the end of my shift), so I'm going back.

I'll be working 2 days a week (technically 6 hour shifts, but I know they'll turn into 8 hour shifts most of the time - which I'm a lot more okay with since I'll be paid for the whole 8 hours!) and 2 Saturdays a month. I could pretty much not have asked for a better schedule than that! And we'll be a lot better off with 2 incomes, even if mine is just part-time -- student loans, rent, health insurance, and part-time daycare cost us about $4000 a month (just for those 4 expenses!!!). We would have had to cut out pretty much everything not absolutely essential, and completely freeze saving for retirement, if I didn't go back to work. Finally, again, while I adore the kids and love spending time with them, when that's the only thing I do, it becomes work - it's my job. When I'm working outside the home, the time I spend with the kids becomes my fun recreation, which is much better for my relationship with them.

Sunday, February 10, 2013

More cancer

I missed a giant tumor last month. A dog (old, large-breed) came in for coughing, and the owners thought he had kennel cough, because he'd been groomed a week before. I was more worried about other things, given his age, and took chest rads. There might have been some hilar lymphadenopathy, but it wasn't dramatic. The cranial abdomen was also in the films, and I took a quick glance at it and noticed a little piece of bone in the stomach, but he has a history of dietary indiscretion so I didn't think too much of it, and went back to ruminating over whether the hilar lymph nodes were actually big or not. Well, he came back last week, for GI upset, and had a large splenic mass removed. So I went back and looked at the rads I took a month ago, and there is obviously a splenic mass on those films. It was squishing the stomach. I totally missed it.

I also (tentatively) diagnosed a dog with ALL this week. That was pretty bizarre! I can add this one to my list of patients who came in with diarrhea, and went home with terminal cancer. The peripheral blood was so screwy that our machine couldn't even read the CBC, so I made a smear, and there were abnormal lymphocytes EVERYWHERE. They almost outnumbered the RBCs in circulation! No peripheral lymphadenopathy. Giant spleen. Referred him to an oncologist, but it probably won't matter much. The owners were very upset, cried a lot, and asked very thoughtful questions - I was impressed. I'm very curious to see if the oncologist agrees that it's ALL.

Another dog came in with hematuria, and ended up having a giant bladder mass. That client can't afford surgery or chemotherapy, so she'll probably be euthanized soon. She was mildly coagulopathic and moderately thrombocytopenic, so I'm actually more worried about bleeding out than about the mass, in the short term. I didn't recommend a transfusion, because at my hospital it costs almost $1000 and the guy could barely afford the $500 in initial diagnostics, but in retrospect I wish I'd at least mentioned it.

On the pettier side, I got yelled at by a client this week on the phone. Her husband had brought in their geriatric cat on emergency, with urinary signs. I recommended a urinalysis, abdominal radiographs to look for uroliths (and tiny or giant kidneys), and bloodwork, both to look at her renal values and because she was also not eating very well. I didn't push him to do all those things, I just explained why I was recommending each thing, and he opted to follow that plan. She did end up having an uncomplicated UTI, and the wife was furious that I hadn't JUST done a urinalysis. She even talked to her regular vet, who AGREED with her that my plan was excessive and unnecessary. I explained that even if I'd just done a UA, the cat STILL could have had bladder stones, neoplasia, GI or liver disease, etc, and finding a UTI doesn't rule out any of those other possibilities. AND that I hadn't pushed her husband into following my recommendations, I just made and explained my plan, and he elected to follow it. She was still disgruntled when we got off the phone. The part that really galls me is her other vet telling her the rads and bloodwork were unnecessary and excessive. I would never say that about another doctor. Especially since I still think it was a perfectly reasonable plan.

Being a doctor is really stressful. REALLY stressful. I'm constantly worried about missing something, not ordering the right diagnostic tests, not interpreting the tests I DO order correctly, not asking the owner the right questions to elicit the complete history, making a mistake with a drug dose or combination . . . . . . . I frequently wake up at 4 AM and can't go back to sleep because I'm so worried about patients I should have pushed harder for, or should have done another diagnostic on, or should have explained something a different way to their owner, or should have emphasized something harder. It's stressful.

Wednesday, January 30, 2013

Fluff

I have to mention my new favorite material possession, because I use it every single day. It's the Take Me With You bag from Lululemon. I saw it in the store (it's the only thing I've ever bought from them!) and loved it, and I've been looking for a BIG tote bag with LOTS of pockets forever. I mean, I have spent many hours combing the internet for the perfect bag, and haven't found it. Until now. So the price tag initially prevented me from buying it (it's $148!!!!) but after considering how much I would use it, how durable and well-made it is, and how much more free time I would have if I could stop looking for a stupid bag, I went back and bought it. This was about a month ago, a few days after Christmas. And I LOVE it. It makes me happy every time I see it. :) I bought the black and white one, and the lining is electric blue, and I really love this bag.

I also bought a little tin of Trader Joe's dark chocolate-covered chewy caramel squares last week, and at THE WHOLE TIN in the past week. MM ate a couple, but I ate 90% of them. At least. So of course when H and I went grocery shopping this morning, I bought another tin. WTF?!? I do not run enough these days to put away a whole box of chocolate covered caramels every week.

H is being weaned from his papi (what he calls his pacifier) because at his 18 month checkup, the pediatrician gave me the side eye when she saw him sucking on it, and I don't feel like wading through years of PubMed looking for peer-reviewed articles on the effect of prolonged pacifier use on orthodontic development, so I'm playing it safe. She recommended reserving it for sleep, which I thought would be nigh impossible - he LOVES this thing, and when he couldn't find one, he used to walk around the apartment, crying softly and plaintively calling, "Papi! Paaaapiiii!" like one of them was going to hear him and come running. But it turned out to be great!!! The morning after that visit, when he woke up we asked him to leave papi in his crib, because papis are for sleeping and he's awake now, so he doesn't need it! But papi will still be there waiting for him at nap time. He looked at us for a minute or two, considering, and then dropped it in the crib and never looked back. Now it's an awesome incentive to take a nap, because we can hold out the promise of papi, which he is always thrilled to see. AND, his speech has totally taken off now that his mouth isn't full all the time. He talks SO MUCH!!! He's starting to say 2-word sentences, and his vocabulary of spoken words includes at least 50-100 words. His vocabulary of understood words (things he can point to if we ask, but doesn't pronounce yet) is at least another 100 words. I love listening to him talk!

It snowed the other night, and it was a BEAUTIFUL fluffy snow with perfect individual snowflakes. It's really weird - my entire childhood, I looked for snowflakes every time it snowed, and never saw any. I feel like it was always, invariably, the kind of snow that's just tiny little particles. NOW, I see them in at least two snowfalls a year. I don't know if the snow has changed, or if I just never saw them for some reason when I was a kid, but I LOVE snowflakes! H loves snow, and points it out every time we go outside. We took him sledding the last time it snowed (on a cookie sheet, cause we're ghetto like that . . . . . . . apparently that's how I afford $150 bags, by depriving my only child of a proper sled) and he seemed to like the IDEA of sledding, and loved it when MM or I would go down the hill, but when we put him on the sled (er, cookie sheet) he would get this very tense look on his face and then just lay there stunned at the bottom of the hill until we retrieved him (it was a tiny hill - it's actually just the slope up to one of the other apartment buildings in our complex, and it's a slow 3-second ride to the bottom), so I'm not sure how much he actually likes sledding. Maybe if he had a real sled . . . . . . .

I am feeling completely betrayed by the book I'm reading. I usually listen to NPR in the car, and they were interviewing Ayana Mathis the other day, whose debut novel is called The Twelve Tribes of Hattie. It's about a woman who moves from Georgia to Philadelphia during the Great Migration in the 1920s, and Mathis read the first 4 paragraphs during the interview -- it was so beautiful, so happy, this young woman in her first house in the beautiful early summer, with her sweet newborn twin babies, and the whole neighborhood suffused with the scent of strawberry cakes that everyone left out to cool on their windowsills. She's a wonderful storyteller, and I could picture the whole scene, and it was so lovely, and happy, I ordered the book as soon as I got home that night. WELL, **SPOILER ALERT** those sweet little twin babies, who in that excerpt were napping on the porch with their mother, listening to the chirping birds in the trees overhead, DIE OF PNEUMONIA before the end of the first chapter. I stayed up way past my bedtime last night, trying to reach a point in the book where I felt like it wasn't going to all be tragedy, and I got too tired to keep reading before I ever got there. Mathis is a brilliant writer - I was completely invested in the characters before I'd finished the first PAGE!!! But the book is tragic, and I hate that. I feel like the excerpt they featured on NPR was completely misleading, and I'm upset about that!

We've discovered a new TV show (new to us, I mean). It's a BBC production called Sherlock, and it's a modern retelling of the Sherlock Holmes story. It's freaking brilliant, and the guy who plays Holmes is absolutely perfect. Each season only has 3 90-minute episodes, which is unfortunate. But the first 2 seasons are on Netflix, and we're really enjoying them.

Sunday, January 27, 2013

The big C

I've been on a cancer spree lately. It got to the point where I was irrationally almost afraid to see patients with diarrhea, because that's how they kept presenting. I had two patients in a row, both older dogs, who presented with diarrhea and ADR of several days' duration. Fine otherwise. One of them, a boxer named Baxter, ended up having a bleeding splenic mass, and I referred him to the nearest university hospital because I'm not a radiologist and couldn't be 100% sure of the source of the bleeding, and I knew he'd need surgery (and probably chemo) if they wanted to treat him and I've never done a splenectomy. Those people were nearly hysterical, and I spent almost 2 hours with them, on a day when we were slammed with other emergencies. Luckily we've started a new pilot program of scheduling 2 doctors for part of the weekend when we tend to get a high ER caseload, so the other guy was free to see the cases that came in while I was counseling this family. It was very sad. :( He ended up going to the university hospital the next day, had a giant bleeding splenic mass, and they euthanized him.

My next diarrhea patient was another older dog, a Great Pyrenees named Snowy, who seemed fine other than diarrhea and decreased appetite. Liver values were very (VERY) elevated, and abdominal rads were very suspicious for a cranial abdominal mass. His ALT was over 7000 U/L, which I have never seen before, among other abnormalities. I couldn't definitively diagnose him based on the rads and bloodwork, so we hospitalized for supportive care, and I took a brief look with the ultrasound probe to see what the liver looked like before I called my senior clinician for advice. There was a HUGE hepatic mass. I talked to that family at length too, and they didn't want to put him through surgery or chemo since he was a big dog who was already 12 years old, and just wanted to keep him comfortable for as long as they could. He went home after 24 hours in the hospital, and came back a day later for euthanasia. That was a really sad case -- his family was SO nice, and loved him SO much.

After that, for a couple of days, every time I saw "diarrhea" as the presenting complaint on my appointment schedule, I was like, "NO! They don't want to see me! I'll give them cancer!!! They need to see a different doctor!" Which of course was ridiculous and irrational, and I have not diagnosed another dog with cancer in over a week. Whew.

You know what I still have yet to see? A mast cell tumor! How can that be?!? They're the most common cutaneous mass in dogs! And I've never even seen one! MM texts me iPhone pictures of his MCT cytology on literally a weekly basis. Part of it is that we practice in very different socioeconomic areas, and my clients only agree to cytology of suspicious masses about 30% of the time. I think part of it is that I don't push them as hard as he does, which I should do. I always feel obligated to present the pros AND cons of any procedure when I recommend it, and I warn people up front that sometimes masses don't exfoliate well, and we may not be able to get a diagnosis from FNA, at which point I would recommend biopsy. Then of course they say no to the FNA. He just says, "I'm concerned about this mass, and we should aspirate it and do cytology to get a better idea of what it might be". I ALSO always volunteer them the option of just keeping an eye on it for now, which is a stupid thing to do. What I SHOULD do is recommend cytology, and if they ASK if they really have to do it, then I could say no, you could keep an eye on it for now and bring her back if it changes at all. So, it's possible that what I really mean is that I have not DIAGNOSED any mast cell tumors. I may have SEEN several and just not gotten to do cytology.




Saturday, December 29, 2012

At least she had a seizure


You know your patient's neglected if . . . . . . .



. . . . . . . upon discussing all the (long-ignored) problems she has, your nurse comments, "Well, at least she had a seizure, so she could be seen".



Poor dog!

Saturday, December 8, 2012

Fun client phone calls

I got a phone call from a guy yesterday, asking about his dog, Effbee. The dog has had diarrhea for several days, so he's been treating her with Immodium. The man is not a client at our hospital, and I've never seen his dog. When I got on the phone, the receptionist had already recommended that he bring Effbee in to be examined, but the appointment schedule was full so they'd have to come as an emergency walk-in. He declined that option, and wanted to know if it was safe to keep giving her Immodium.


[LIVS]: Hi, this is Dr. LIVS, you're calling about giving Immodium to your dog? Tell me more about what's been going on with her, and how much Immodium you're giving.

[Guy]: Well, she's had diarrhea for days. So we've been giving her Immodium . . . . . . . . . and it's gotten worse and worse. Then yesterday she started vomiting, and she hasn't been able to eat anything. I Googled a bunch of things, and I just wanted to know if it was safe to keep giving it to her. I've given her four tablets in . . . . . about two days.

[LIVS] First of all, I'm concerned about the fact that the diarrhea has gotten worse, and that she's vomiting and not eating. This could be caused by many things, some of them very serious, and I strongly recommend that you bring her in today so that a doctor can examine her. Secondly, I need to know the tablet strength - do you know how many milligrams are in the tablets you have?

[Guy]: They're 125 mg tablets {I don't even think that 125 mg tablets EXIST, since that would be enough to treat several ELEPHANTS, but whatever}. And that girl I talked to just said you didn't have any appointments. But I could bring her in as an emergency? But that's more expensive? How does THAT work? What, do you have, like, two different doctors there, one seeing emergencies, or something?

[LIVS]: Yep, that's exactly right. We have two doctors, one seeing appointments and one seeing emergencies. The appointment schedule is full, but emergencies are seen on a walk-in basis, so you can bring her in anytime to see the emergency doctor. I'd recommend bringing her in as soon as possible, since this has been going on for days and is getting worse. And since I've never seen Effbee, I can't give you medication instructions, but if you're sure that they're really 125 mg tablets then I would not give her any more since that is an ENORMOUS overdose.

[Guy]: . . . . . . . . . . well, can I just keep giving her Immodium, but give her less? OH!!! And I also started giving her some doxycillin* a couple of days ago. She had a bunch left over from when she had some kind of infection last year. Should I keep giving it to her?

[LIVS]: {headdesk}

I doubt the guy was really overdosing the dog; he said it was children's Immodium and it's a big dog, and the only tablets I've ever seen are 2 mg. But how do you just randomly decide, all by yourself, to give your dog a drug without even knowing how much of it you're giving? And how do you think, "Well, I've been trying this treatment for days, and she's actually getting worse instead of better, but what I really want to do is just keep doing it, only LESS." ?!?!?

Needless to say, they never showed up. I really hope this poor dog just ate some trash and has some transient gastroenteritis, and doesn't have, oh, I don't know, a TENNIS BALL IN HER DUODENUM or something equally horrible.

*Yes. Doxycillin.

Wednesday, September 26, 2012

Fall as an adult

This is the first fall (except the one I spent as a postdoc, but I already knew I was heading back to school the following September so it wasn't the same) that didn't mean back to school. The year turns over in fall, for me -- both because of the academic calendar that I've been bound by for 29 years, and because I think of New Year's eve as being in October. :)

I kind of miss the thrill of a new school year, a clean academic slate, the opportunity to have consistent, regularly scheduled positive feedback on my academic progress (yes, I just said I miss exams). But it's also nice to know that when I get home from work at the end of the night, my time is my own. There are no demands on me after work (well, there's a lot I should be - and less that I am - studying, but it's semi-elective). If I want to spend a whole Sunday playing with H in a pumpkin patch, I'm free to do that without knowing in the back of my mind that I'm going to have to "pay back" that time later with late nights catching up on the work I missed. It feels free. I also feel crushingly weighted down with responsibility for patients for whom I am often the final word, and with the magnitude of the things I still don't know (or have forgotten - that feels so shameful, to have learned something and not be able to use it). And I do spend a lot of my days off studying when H is napping, or looking things up on VIN, or ruminating over things I think I did inadequately or just plain incorrectly at work.

BUT ENOUGH ALREADY, this is a post about having autumn fun with my cute baby! Why the heck am I brooding over work? I'll stop.

This weekend was AWESOME. We took H to a pick-your-own orchard about 30 minutes away. The one I always went to as a child has a big fall festival-type thing, and we took H to that one last year, and I was horrified by the number of cranky, impatient, ill-spirited parents snapping at their children. Plus the pumpkins are pre-picked in bins, and what's the fun of that? So we decided not to go back this year. I didn't know if we'd be able to find another one, and it turned out that there are dozens within easy driving distance of our suburb! So we picked one, mostly just based on hours and proximity, and headed out.

It turned out to have nice apple orchards. We picked a bunch of apples, H ate almost an entire gigantic apple by himself standing in the middle of the orchard, and looked absolutely adorable dressed in his little caterpillar jacket munching on a matching green apple. It also had a pumpkin patch! The pumpkins were mostly cut from the vine already (which turned out to be a good thing -- I never realized pumpkin vines were so prickly! I got a bunch of splinters in my finger when I touched one accidentally) and we just walked around and looked at them. H sat in front of one and slapped it gleefully a bunch of times, and then was over the pumpkin scene). We took a smallish one home, and it's sitting on our balcony. He goes out there a few times a day and pats it with his little hands. :)

They also had the most incredible apple cider donuts I've ever had. They sold out so we had to wait while they made more, and that was so lucky because hot out of the oven they were AMAZING!!! I think we ate 5 that day (they were small . . . . . . ish) and 2 more the next day. They were so much better hot and fresh; I'm thinking of going back just to get more donuts!

H loved the goats; they weren't in an enclosure that you could enter, so we just watched them from across the fence. I helped H feed them little kernels of corn that had fallen out of their feed bins onto the ground. I love the tickly way that goat lips gently brush food into their mouths!

He also loved the calf starters that were painted like jack-o-lanterns, and spent a long time going in and out of one. He liked eating barbecue chicken drumsticks at a picnic table, and climbing up and down the little step for the wooden photo things that you stick your head into (and it appears on top of a painted farmer, or scarecrow, or whatever).

It was a beautiful day. I had so much fun.

And then today is my day off, and I took him to an indoor baby gym that's 5 minutes away. He climbed around the giant foam obstacle course and played in the ball pit (I shudder to think of what lives in those things, but I don't want to be one of those parents who puts a fabric cover on their shopping cart and squirts Purell over everything every 2 minutes and won't let their children do fun child things because they're afraid of germs). And we signed up for a waiting list for a toddler gymnastics class!!! I don't know if we'll get a spot; since it's an Olympic year they're inundated with children wanting to be gymnasts, but it will be a lot of fun if we do.

We spent the rest of the day at home, playing on the floor -- I cut a door into one of the giant U-Haul boxes that we used for moving, and he goes in and out of it like it's a little playhouse. And we made some pretend soup together the other night in the big pot that we keep in "his" kitchen cabinet, and now he likes to make soup by himself. :) And he typed on the computer, which he also loves, until he picked it up and dropped it onto the floor from 6 inches in the air, which ended typing time. But he had fun. And I had fun. And fall is definitely my favorite season, and despite my work angst, this is probably my favorite fall. :)


Monday, September 24, 2012

Up the Wall

I'm now 2-3 weeks into my regular schedule at work, which consists of two 12-hour days and one 7-hour day where I am both the ICU and emergency doctor, AND see appointments (sometimes I only have 3 or 4 appointments, which is awesome because then the hospitalized patients actually get some attention, but sometimes I have 14 appointments, several emergencies, and hospitalized patients that need diagnostics and treatment plan changes during the day, and that is not an environment conducive to good patient care), and Saturday, where I work 6 hours and ONLY see appointments.

I think emergency and ICU work is orders of magnitude more interesting than annual checkup appointments and vaccines, but I have to say that it is REALLY nice to hear the receptionist page a triage nurse to emergency on Saturdays and know that I'm not going to have to deal with it.

Anyway, Saturdays have a generally calmer atmosphere overall, due to the fact that 1) most appointments are annuals or puppy vaccines, 2) there's a different doctor on emergency duty, and 3) I'm the only doctor seeing appointments so no one else is siphoning technicians away from me. But they're still busy, partly because my practice schedules 15 minute appointments for EVERYTHING. 3rd round of puppy shots? 15 minutes. Dog scratching its ear for the first time and needs cytology and a topical med? 15 minutes. First new puppy visit for clients who've never even had a PET before let alone a puppy, and know nothing about raising one and have 2 pages of questions? 15 minutes. Extremely sick dog with 4 separate medical problems, all of which need diagnostics and extensive client education? 15 freaking minutes. So it's very easy to get behind.

The more aggravating problem on Saturdays is that the receptionists apparently have no training whatsoever on how to field calls. This post was inspired by my colleague over at 2nd Career, who seems to have a similar problem. I started to leave a comment and realized it wasn't going to fit in the comment box, so I came back over here to vent more thoroughly. :)

I'm sure this happens every day, but since I'm the only doctor there on Saturday I notice it a lot more. The receptionists come back literally between EVERY APPOINTMENT to ask me a question about someone on the phone. And it's always something where I need to stop what I'm doing, close the chart I'm in, look up the patient, look through their chart, and make a decision about something. I have never been in a practice before where the doctor is expected to be at the beck and call of everyone who can dial a phone!!! The EFFICIENT way to handle these phone calls is to take a message and tell the client I'll call them back. This is made even more simple by our computerized message system, which allows reception to leave me a message with a time and date stamp under my account in our EMR system, where all I have to do is check my calls and I'll see the whole list pop up and can then work through the calls when I have time. They wouldn't even have to get out of their chair. But instead they write a note on a scrap of paper, hang out in the pharmacy waiting for me to finish an appointment, and then when I'm in the middle of writing up a record or trying to calculate a medication dose, they start talking to me about the message.

The serious risks of this habit are that I'll make a medication error (which already happened once; luckily it was both very minor and caught by my technician) or that the client won't get a call back because I lost the scrap of paper that the message was written on. But even if neither of those things happens, it's distracting, it pulls me away from what I'm working on, it takes time to deal with, and then I'm even LATER for my next appointment, which is inconsiderate of the client who has actually made an appointment to see me. So it's driving me UP THE WALL.

I don't actually have the authority to make management decisions, but next Saturday I'm going to sit down with the receptionists at the start of the shift and tell them I'd like to try a new strategy. There are 3 (and only 3) things that can happen when someone calls:

1) It's something the receptionist can handle, and then they deal with it as usual and that's the end of that.
2) The client is told, "The doctor is in the middle of seeing appointments and will call you back when she's done seeing patients for the day. It will be before 5 PM". And then no matter HOW MUCH the client insists it'll "just take a second" or they "really need an answer right now", the receptionist takes a message and puts it into my messages list in the computer and does not interrupt what I'm working on to tell me about it.
3) If it's really something that can't wait for a call back, they can come in on an emergency basis. 

That's it. Three options. We'll see how it goes.