spinning into butter

Hello? Is this thing on?

Well! I have a blog! It's been increasingly difficult to find any good time to update, but in the meantime, I present to you a home food project that is so unbelievably easy and satisfying to accomplish it's going to make you feel like a magician. If you follow my Twitter or Facebook you've probably heard me yammering about the weekend after Thanksgiving, but for those of you blog purists out there, I'm talking about making your own butter.

Did you know you can make your own butter? You can! And you don't even need any special tools! Seriously, this is probably just Food Science 101, but butter is just one of those things I have only considered buying from the store in stick form--I'd heard of churning your own butter, of course, but why bother, it seemed (most likely) cumbersome and thankless.  And anyway, who the hell am I, Laura Ingalls Wilder?

Apparently, yes. I tried this two weekends ago, and it was such a fantastic trick, I did it again yesterday. And this time I took pictures!

What you will need:

- One quart of heavy cream (just the supermarket brand is fine)
- One large jar with a screw-top lid
- Some salt

So. Get the heavy cream out of the fridge and let it sit until it comes to room temperature. (This makes the process go faster, I think.) Pour it into your jar. Screw the lid on.

Shake that mother.

See, this is the part where I thought, "What a fun project for the kids! I should get them involved and they too will share in the wonders of food science and creation and it will be so wholesome we'll just be high-fiving and group hugging forever!"

(The reality of it is that Cal shook the jar for, like, five seconds, and when the cream didn't instantly transform into a blob of butter he handed it back to me, told me encouragingly to keep up the good work and let me know when it was ready, before scurrying down to get in his weekend allowance time of frying his eyeballs playing Super Mario Brothers on the Wii. CHILDLIKE WONDER, AM I RIGHT?)

Making butter doesn't take a long long time, but it takes at least 10 or 15 minutes of shaking that jar. And at first, you're going to feel like nothing is happening, because the cream is just going to get thick and a little frothy, at which point it's not going to feel like you're agitating much in the jar at all. (Truth be told--my arms got tired and I took a little break midway through. Probably it would have gone faster with a blender or food processor, but what's the fun in that? In the low-tech lies the fun. WE'RE SHAKING JARS ALL UP IN THIS PIECE.)

Just when you're about to give up and call the supermarket about the DEFECTIVE CREAM that they sold you, the contents of the jar start to...loosen up.  Suddenly your silent thick jar contents will start to sound like sploosh sploosh SPLOOSH and you will look inside your jar to see that lo, butter is separating from the buttermilk.  SCIENCE IS HAPPENING.  Keep shaking for another few minutes, until you get a nice big butter core all teased out.

Pour the jar contents through a strainer, and save the buttermilk if you want (you'll end up with about a cup) to make other things.  What other things?  I don't know.  Things.  Or save it to bathe your prize-winning pig with, like in Charlotte's Web.

Rinse the butter with cold water (cold so you don't melt it) and squoosh it around to get the excess buttermilk and water out.

Mix in some salt if you like.  Or other flavors!  I thought a salt-rosemary butter would be super fancy, but I wanted the kids to eat it and was worried they'd protest against butter with "things" in it.

You'll end up with a tennis ball sized glob of soft, fluffy butter.  Put a lid on it, stick it in the fridge, smear it on everything, unless you're one of those health food nuts that thinks a little butter is going to kill you--in that case, give the container to someone that you hate.

You made butter!

(Yes, that smug feeling afterwards is normal.)

because disasters are apolitical but choices aren't

One of the things Joe and I were discussing (because we are SO ERUDITE--in between making a series of fart noises, both faked and authentic, and then blaming them on the dog) is the impact that Hurricane Sandy and its aftermath is going to have on the election. It's difficult to calculate, I think.

First, the regions hit hardest by the storm (that is to say: the Northeast) are traditionally firmly Democratic, and logistically, it may be difficult for people to turn out and vote come Tuesday. But will this actually make any difference in the electoral college, or will it just impact the popular vote?

Secondly, people inside and out of the affected regions may respond differently based on their perception of storm readiness, reaction and aftermath. I think that overall the reaction has been largely positive (at least compared to the level of preparedness for Katrina, "heckuva job Brownie" and all), but it's clearly a difficult time for everyone impacted. Will that change anything come election day? Again, difficult to say.

Campaigning for both parties has obviously been put somewhat on the back burner, or at least a burner off to the side--for the president firstly because he's busy, you know, leading the country during a crisis; and somewhat for the Romney camp as well, to (rightly) avoid politicizing and tragedy and, perhaps more importantly, avoiding the opportunity to say anything completely offensive of tone-deaf to those suffering losses. What did these two campaigns have planned for the final two weeks of the campaign? Would that have made a difference either way?

And on and on and on. Like I said, the political effects are incalculable, and though I think the post-mortems at the end of next week will pick apart this and that trying to frame whatever the outcome ends up being in the light of inevitability, but that's all Monday morning quarterbacking to me. Regardless of whichever presidential candidate wins the election, the effect of an unprecedented natural disaster of this scale is as unexpected as it is difficult to predict.

But there's one thing I do know that everyone can take away from the stories of Hurricane Sandy, and which is: you are not immune. Terrible things happen, and they can happen to any one of us. The single mom in Staten Island and the hedge fund manager in Tribeca. The elderly couple in New Jersey and the CEO in the Hamptons. Terrible things can happen, and they can happen quickly, unexpectedly, without prejudice. And all of us, whether we think we will or not, will occasionally be grateful for some help.

I think back to my own reaction to the aftermath of Hurricane Katrina in the days and weeks that followed that particular storm. I was shocked and horrified and of course I pledged my support and dollars to help the survivors, but still, even though it happened in my own country, it all still felt a little removed for me. I admit that fully. The words and the situation: Lake Pontchartrain? Levees? Superdome? It seemed so foreign from the everyday life of a dyed-in-the-wool New Yorker that my empathy, and my ability to relate, while present, still felt a little bit distant.

But this? Oh, this.

I walked here, on my way back from a late night out in med school after finals, from restaurant to dive bar to seedy club, trying to find my way back to the subway station to take me home.

Over the course of high school I got off at this subway station hundreds and hundreds of times.  We'd take the 6 train one stop down and switch here to catch the express, or maybe venture above ground to get something to eat, or browse through the new CDs at HMV (remember when we used to do that?), or just walk around and people watch.  Do you know how vast, and how deep those tunnels are?  Do you know how much water it must take to fill them up?  I don't.  I can't even imagine.

The cutoff for power outages on Manhattan was at 25th street and south.  I used to live on 25th Street and Second Avenue, on the 19th floor of our building.  Most likely we would not have had power.  Now, with three kids, in the chill of November, it's difficult to imagine how we would have handled it, though I can say for sure we would not have done it with the grace of those in New York the even more seriously affected outlying communities.  Probably I would have just cried.  Well, cried and eaten all the ice cream, like we did after that big power outage in 2003.  (IT WAS GOING TO MELT ANYWAY YOU GUYS.)

We lived just a few blocks away from NYU Medical Center (it is, in fact, the hospital at which I was born), which of course was evacuated after the storm when the power went out and the backup generators failed.  I can't even imagine what it must have been like for those staff working that night.  I read accounts of patients, fresh CABG post-ops and others, being walked down 10 flights of stairs or more to evacuate after the elevators failed, NICU babies being carried out one by one, nurses and housestaff and techs and everyone forming lines up the stairs passing buckets of fuel up the fire escape to the emergency generators after the fuel tanks in the basement of the hospital became overwhelmed with water.  I think: what if I had been in the OR at that time with a patient when all the power went out?  What would I have done?  I see myself reaching for the ambu-bag, sending someone to run for more IV induction meds, and holding up the flashlight we keep in the bottom drawer of our anesthesia cart so that the surgeon could see enough to sew faster.  I can kind of imagine it.  But also, of course, I totally can't.  Not really.

In the final days before the election it's hard to conceive of people who are still undecided about who to vote for, but I know they must be out there because the news and the polls say its true.  And I ask these people to think not just about jobs or the economy or foreign policy (though these are, of course, also crucially important issues) but to also think about the role of government in the face of crisis.  In the face of bad things happening, indiscriminately and free of political bias.  And think not just of how the candidates are reacting now, but of what they've said in the past.  About the role of government.  About "dependency" and "entitlements."  About the size of government and how some might propose both a smaller government with a diminished role and ability in providing help to its citizens in deep trouble, but also concurrently one that paradoxically insists of legislating and restricting our personal lives.  Think about these things.  And then go vote.

It's easy to accuse and tell people what they should have done or what you would have done when bad things don't tend to happen to you, but Hurricane Sandy reminds us in the most explosive and shocking way possible: bad things can happen to us all.  And everyone needs help sometimes, and sometimes the help we need is bigger than that which individuals or private institutions are able to provide.  And it's a credit to our civilization when we as people, and yes indeed as a government, are able to help those least among us.  Because next time, it could be you, too.  And where do you want to be living, and under what kind of leadership, do you want the next time something does?

My family are all OK, thankfully.  Much love to my friends in New York and the surrounding areas devastated by the storm--I'm with you in spirit if not in person.  If you need help, just ask.  And if you're looking for ways to help, two good starts are here and here.

costume drama

He's my firstborn and so I say this with all possible love and bemusement, but Cal is a weird child when it comes to dressing up for Halloween. It's not so much like he has sensory issues--he doesn't have problems with the costumes being itchy or bulky or too hot, he just thinks they're dumb or something. I think in reality he just gets self-conscious. Like the act of wearing a costume garners too much attention, and he doesn't like the fuss. At all.

Above is, unfortunately, the only surviving photo of his first Halloween costume that I can find (there must be more out there, but I didn't use iPhoto during Cal's first year so many of those digital image files are archived somewhere unreachable). It also showcases Joe's unfortunate predilection for grafting cheesy beyond belief titles and borders onto photography--just be grateful we're spared a wreath of pumpkins around Cal's face or something similarly Printshop circa 1988. Anyway, I just show you this picture because this, taken at the time that Cal was about Nina's current age (they were both born in July), is the last time that we were able to cram Cal into a Halloween costume without him complaining.

Here the following year. You can't see most of the costume since he's you know, running away from Joe (I think I was actually on call that particular Halloween so I wasn't even there) but he's supposed to be a monkey. See how happy he looks? SEE THE LOOK OF CHILDLIKE WONDER WHILE TRAIPSING THROUGH THE MAGICAL WORLD OF MAKE-BELIEVE?

Above, the following year, when he was two years old. We, thinking ourselves terribly clever, dressed him as a medical resident. Cal quickly stripped himself of the accessorizing accoutrement (the scrub cap, the pager, the stethoscope which had been doused in alcohol and Clorox to eliminate all traces of Enterococcus fecalis--it's the small touches that really make the costume, after all) and just barely tolerated the rest of it, mostly once he realized there was candy involved. This was back when we still lived in New York by the way, so his exposure in costume was minimal--mostly we just walked down the hallway, trick-or-treated one apartment, and then walked back. (Some of the candy he got may have been from our own bowl.)

I had some high hopes the following year, as in September Cal specifically requested a pink butterfly costume. Yes, a pink butterfly. So I got the costume (OK, so maybe I got a red and orange butterfly costume--I am as open-minded as the next parent but maybe it's my own bias that led me to apply some well-meaning edits to his original intent), but by the time it came Cal decided that he didn't want to wear any costume, butterfly or otherwise. "I just want to wear regular clothes," he said, a refrain that would dog us again and again subsequent Halloweens. We went to his nursery school Halloween party that year wearing khakis and a grey cardigan (I begged him to let me put some baby powder in his hair so that we could at least pass his costume off as "old man," but he was not having it) and had no further costume planned as of October 30th.

Finally, we just ended up putting him in his beloved "regular clothes" (black long-sleeved t-shirt, long pants), gussied it all up with his rain boots and a two-tone bolt of electricity that I cut out from construction paper and taped on his chest. Enter "Captain Lightning Bolt."  He was OK with this for some time, but then had a little potty accident after hitting three or four houses (three year olds never feel like they have to go to the bathroom until all of a sudden OMG THEY TOTALLY DO) so trick-or-treating was cut short and the costume issue was put to rest for another year.

At age four, Cal finally acceded, after weeks of cajoling to think of a Halloween idea, any idea; to go as "a builder man." Again, a costume involving his everyday clothing and some accessories from the toy bin.  The hat, tool belt and goggles were, of course, instantly shed the second after the pictures were taken, and he ran around his school Halloween party somewhat incongruously dressed in jeans and a blue oxford shirt.

And then, the year he was five, Cal refused to wear anything even approximating a costume. In fact, we didn't even go trick-or-treating that year because he just flat-out refused to do anything and Mack was too young to know any better. At the 11th hour (that is to say: 6:00pm on Halloween night) we thought maybe we had convinced him to go as Steve from "Blues Clues" just by wearing stuff out of his closet (green striped rugby shirt, khakis, blue dog stuffed animal--boom, instant Steve) but then at 6:05 he decided with finality that costumes were BOGUS and trick-or-treating was DUMB and a horribly humiliating ordeal for LOSERS. Also maybe he whined and cried and acted like we were asking him to eat not but burning hot coals and drink not but burning hot cola.

"But if you go out and wear a costume, people will give you candy!" I told him, playing what I thought was my trump card.

"We have candy at home," he said, quite reasonably.

So after that debacle, we decided last year, when he was six, that he was going to find a costume that he would tolerate and we were going to go trick-or-treating whether he liked it or not. I don't think we're of the type necessarily to force our kids to do stuff that they hate, only it seemed like he was getting himself all worked up over nothing, and that if only he would stop being so rigid and just relax about "looking dumb" and allow himself have fun, that maybe he could actually have fun and we could be like a normal family going trick-or-treating. And then maybe I finally get some candy runoff at long last. IS IT SO MUCH TO ASK?

We decided, after brief discussion, that he would be Harry Potter, which was cool because he already had a Harry Potter wand, and anyway, Harry Potter wears regular clothes, he could even skip the glasses, all he'd have to do is let me draw on the forehead scar and wear this Gryffindor scarf that he got just so it looked like he was trying a little.

After a lot of discussion (and more whining, and more crying), he finally let us tie the scarf on him. But he was not real happy about it. "You know, Cal," I told him, "most kids actually really like Halloween. They think it's fun to dress up, and go around, and they like going door to door to get candy. It's kind of a really big holiday for kids, you know?  Some kids look forward to this all year!"

He just grunted.

(Though eventually he did get into it.)

This year, we didn't even have a discussion. We were going to do this thing. After polling Cal to see if he had any costume ideas (to which he responded, "I don't know. I have to consider it.") I just decided, boy, you're going to dress up as a Star Wars character, and I don't want to hear any more about it. Originally I bought a whole pile of cream and brown fleece and was going to sew all the kids matching Jedi costumes (pause for laughter), but reality testing eventually intervened and I ended up buying the chintziest of chintzy drugstore Jedi outfits for both boys, coupled with these foam colored light up rods that I highly recommend to anyone who has kids that are into Star Wars.

And when we went to the third grade Halloween party this Friday, he put it on without any discussion.

Cal!

Put on an actual non-regular clothing costume!

WITHOUT DISCUSSION!

(High fiving a million angels)

I know it's not a big deal (and believe me, I'm trying not to make it into one, especially in front of him), but it's been seven years and eight Halloweens to get to this point so...yeah, it is kind of a majorly big deal.

Both of the boys, by the way, decided to be Obi-Wan Kenobi for Halloween.  Originally Cal wanted to be Obi-Wan and Mack was going to be Anakin Skywalker (which I found actually quite fitting), but then Mack decided that he wanted to be Obi-Wan too, and Cal got mad because what are you nuts, there can't be two Obi-Wans, haven't you even seen the movie?  Like, a couple hundred times? And there was much squabbling, and I came in and decided, perhaps at a slightly higher volume than strictly necessary, YOU KIDS SHUT UP EVERYONE'S GOING TO BE OBI-WAN.

Ah, Mack.  Mack, on the other hand...

The only problem we have with Mack is getting him out of costume.


* * *


I'm kind of hustling to write this while the kids are asleep so I don't really have time to reflect on this fact or get overly introspective/profound/lachrymose about this fact, but: this weekend marks the twelfth anniversary of this blog.

Twelve years. That's a lot of years, boy. Twelve years ago I was starting my second year of medical school and decided, on a whim, to start an online journal in lieu of memorizing the complement pathway to have even a faint hope of passing my immunology midterm. And now I am an attending anesthesiologist, married to my med school classmate (who, not to knock my own clinical skills, but I often think is a better doctor than me, or at least good at different things), a mother of three, living in the South.

Aside from the part where I now have a medical degree, at the moment I started this blog I had no idea where I would end up ten-plus years down the line.  I can't say that everything that has happened to me since has been expected. But as much as we Type A personalities like to control things, the unexpected can be exciting, and what's more, the unexpected can be quite good. And really, I don't think that this blog anniversary requires much more reflection than that, only to say that life now is busy and full and, most importantly, fun. I think I've reached a point in balancing my life and obligations where I feel that if something extracurricular ceases to be fun, it's probably not worth doing anymore. But keeping this blog, even after twelve years, continues to be fun, and that's why I keep writing. So thank you for sticking around with me.

And yes, if the finer details of the CXCR4 signaling pathway are indeed important to my clinical practice, I am pretty much screwed, because I don't think I ever really learned it in the first place.

indian summer vacation

The way Joe and I schedule our lives we end up planning most of our family vacations more than a year in advance, and around the Spring of 2011 we made plans to rent a cottage in Jamaica for summer vacation the following year. Well, turns out that despite my neurosis about planning things well ahead of time, you actually can make plans too far in advance, because it turns out we were a little busy this past July. Luckily, the rental place was very nice about allowing us to reschedule once we told them the reason, and so we took our family summer vacation and moved it to a week in the fall. To this week, as a matter of fact.

It actually doesn't take that long to fly from Atlanta to Jamaica, but we did have to take a car to a shuttle to a monorail to a plane to a van, so it ended up being a fairly grueling trip for the three kids. Luckily we now have no other plans for this week other than to hang around and let the kids beach and pool themselves stupid.  So you know.  Vacation.

We invited my parents to come along with us for the trip too, because it's nice for the kids to be able to spend time with them, and also (selfishly) it's nice to have another two sets of eyes around to make sure no one's playing with anything dangerous/inadvisable/flammable.  Here are each of them holding the only remaining grandchild who will agree to sit on their laps.  In the picture on the right, Nina, like Kuato, wants you to open your mind, Quaid.

(I should also note that my dad came into town one day early so that Joe could do a blepharoplasty on him, which is why his eyelids still look a little bruised.  He would also want you know to know, however, that he got this done only because his lids were drooping and obstructing his vision, and not for purely cosmetic reasons.  Now, I don't know nothin' about no oculoplastics, but I do know that doing a good blepharoplasty is sometimes a tricky and subtle business--particularly on Asian people--but even just three days post-op, I have to say that Joe did a really amazing job.  First off, my dad can see better, so already: success.  But as someone who has been looking at my dad for my entire life, I also have to say that even this soon postop, he also looks really good and natural and himself, which is important.  So good for him, and less good for, you know, Kenny Rogers.)

Anyway, so we're here.  Cal's having fun swimming, Mack's having fun bobbing, and Nina's having fun lying in a variety of shady spots and looking at the ceiling fan in the bedroom.

I suppose there might come a time where our travels might not so reliably involve going to the beach.  Just probably not anytime soon.

Vacation!

spotlight on specialties: anesthesiology

Sorry, I'm a little bit in remiss in that I didn't post this link up earlier, but here's a link to the AAMC article on the field of anesthesiology, for which I was interviewed along with a number of much more distinguished and accomplished colleagues. If you're interested in the field of anesthesiology, either as a potential career or if you just want to know what exactly it is we do all day, check it out.

An excerpt:

“Anesthesia is hands-on, fast-paced, and has tremendous capability to make a positive impact on our patients’ lives as anything else we do in the hospital,” says Dr. Au. “In my opinion, it's one of the most interesting, most exciting fields in medicine, and I firmly believe I have the best job in the world.”

I've said it before and I'll say it again here because it's appropriate: it's a difficult juggle to balance work and family, but it's all the more difficult because I do indeed love my job.  If I didn't love what I did at the hospital as much as I love what I do at home, my choices would perhaps be easier, though maybe not as satisfying.  So really, in the end we should be grateful for the difficult choices, and the chances we have to make them.

(And on an unrelated note: the above photo panel is from pictures I took with my phone during residency--isn't it amazing to see how far cell phone photography has come?  Wow! The future! hovercrafts that fold up into briefcases! And etcetera!)

thar's a snake in mah boots!

Undoubtedly the scariest call I've gotten from work happened this Thursday, when the director of the chess club that Cal attends after school called that afternoon to say that Cal never showed up, and did I know where he was?  (I was at work and of course freaked out because OMG MY BOY IS LOST.  Long story short, Cal just forgot it was chess club day and so missed the bus that was to take him there--we tracked him down ten minutes later patiently waiting in the principal's office for someone to pick him up.)  So yes, that was scary.  But the second scariest call from home I received the day after that, when our nanny told us that she came home from school pickup to see two large copperhead snakes sunning in our driveway.

Joe and I pulled in from work at the same time, and there were no snakes visible, sunning or otherwise. Joe went peering by the back door to see if the snakes were hiding under this storage unit we keep there for balls and frisbees and assorted outdoor detritus, and said, "I don't see anyth--" before jumping back in the air about three feet.  Because there was this:

I don't think I realized that I was scared of snakes until that day.  I knew I was scared of cockroaches--growing up in an apartment in New York made me more than familiar with that particular evolutionary success story--but I honestly can't say I've really seen a snake that big outside of a zoo, behind a guardrail and an information placard and a thick, reassuring layer of plexiglass.  But now, peering out from the inside of my house at the venomous snake chilling outside, I can confirm that yeah, for sure, I'm afraid of snakes.

I mean, LOOK AT IT.

LOOK AT THAT FUCKING SNAKE!

(Borderline related: did anyone who got the iPhone 5 on release day have any input as to its improvements when it comes to low-light photography?  As someone who lives in a low ceilinged ranch house with not enough windows, I am interested.  Please weigh in if you're in the mood!)

Anyway, I looked at it and screamed girlishly. Then we called the kids to look at it and they did not seem particularly perturbed (or indeed even that interested), though I gave them both a stern talk nonetheless about if you see a snake don't go near it, it doesn't want to hurt you but it could bite you if it gets scared (I left out the part about tissue necrosis and the potential need for serial debriedments and fasciotomies because WHATEVER, TMI).  They shrugged, glanced and the snake through the window again before going back to their Legos.  But I could not be so blase about it because the snake, OMG the SNAKE.

About half an hour later the snake slithered away under some shrubbery along the side of the house, at which point we could see that the tip of its tail was a little squashed from our nanny accidentally running over it with her car when she first pulled into the driveway.  We noted where the snake was headed as we had already called A Snake Guy (I believe his official title was "Wildlife Removal Specialist") to come by and check our property the next morning, and wanted to give him a little help in finding what might be the nest, or as I called it, Snake HQ.

I was on call this weekend, so when I walked to the car Saturday morning (down a poorly lit driveway that my mind inconveniently imagined to be PAVED WITH SNAKES) I did again see one snake lying there in the middle of the driveway, not moving.  I didn't know if it was the same snake as yesterday and frankly I didn't care--I hurriedly got into my car (which was probably teeming with SNAKES) reached into my bag (also stuffed full of SNAKES) and started the engine (ditto SNAKES).

The Wildlife Removal Specialist showed up later that morning while I was at the hospital, and though I wasn't there, Joe said that he got rid of that one driveway snake (it was the same snake from the day before, already dead, probably from the inadvertent tail squishing--and it was inadvertent, because even though none of us like snakes and even though the snake could bite our kids/dog/selves, I don't think any of us has the stomach or cojones to kill a snake), sprinkled some "granules" in the high-suspicion region by Snake HQ (purportedly a repellent of some sort) and put down two glue traps that looked for all the world like the ones I could buy at Home Depot.  Total bill: $230 for half an hour of work.  He did not find a nest or any other snakes in the area, though it's not clear to me how hard he looked--half an hour in an area as dense with ground cover as our yard doesn't seem like a whole lot of time to spend combing the premises.  And the glue traps were covered with leaves by that evening, so it's really uncertain how effective those are going to be.

(This is probably a good point to tell you guys that I'm quitting my job and becoming a Wildlife Removal Specialist.  They have a higher hourly rate than I do and they don't have to pay malpractice insurance.  All those years of medical training wasted, but whatever, sunk cost.)

So that's that.  But what bothers me now--what really bothers me--is this: our nanny said that she returned from school pickup to find two copperheads sunning on our driveway.  Two.  One of them got accidentally squished by her car, and that's the one that we found, and that the wildlife guy removed.  (YOU GUYS HE DIDN'T EVEN KILL THAT SNAKE HIMSELF.  $230?  Really?)  But the other one we never saw again.  So in all likelihood, we may still have a large and extremely poisonous snake still hanging around our property.  He could still be in our yard.  He could be hiding under my car.  He could be calling me on the phone and oh my god, get out, the call is coming from INSIDE THE HOUSE.

So basically we have to move now, right?

great and lesser expectations

I had Cal three weeks after starting my training in anesthesia--a highly conspicuous move that I think indelibly branded me for the rest of my academic career as "that pregnant resident"--so I think it's fair to say that I have some insight into the assumptions that people tend to make about people mixing family with a career in medicine.

In most ways I imagine it's not unlike mixing family with any intense or high-powered careers--look at all talk that Marissa Mayer's pregnancy incited after she was named the new CEO of Yahoo. (Aside: I'm not saying that my career is anywhere near as high-powered as that of Marissa Mayer, just that the case is emblematic). Particularly in the field of anesthesia, where I'm in the room but often lurking in the background or behind a drape, I've heard a lot of conversations about medicine, other physicians, and things that fall in the rubric of "lifestyle choices"--conversations that maybe weren't meant for me to hear.  But as a result, and as a result of living my own life, I can say for sure that women in medicine (physicians in particular) who choose to have children during the most active parts of their careers suffer under what I'd describe as a handicap of perception.

Perception. Not an actual handicap, but one of perception. There's a Chinese saying that my dad always uses that roughly translates to, "When you're walking through someone else's pumpkin patch, don't bend over to tie your shoes." (OK, that's a very rough translation--I don't think the parable from which the saying was taken originated during a time when shoelaces were a particularly popular feature of Chinese footwear.) What it means is: if you're in a setting that breeds suspicion, try hard not to do suspicious-looking things, no matter how innocent they actually may be. Because you may be just tying your shoes in the middle of that pumpkin field, but a casual observer might be inclined to think you're actually stealing those pumpkins.

I think that in medicine (and perhaps in the working world in general but what the hell do I know, I've never had a real job doing anything else) people are quick to assume things about working mothers, not too many of them flattering. I'd like to say "working parents" because believe me, I'd love for us to get to a point where there is actual gender parity on the issue (to be fair, I do think that Joe and I do have gender parity when it comes to parenting, but...we do have to leave our household occasionally and interface with the world) in the year 2012, this is still more of an issue of perception for working mothers. The following is a list of some of the things that some people are quick to assume about women with children who work outside of the home.


1.) We don't work as hard.

2.) We complain when we do have to work as hard as everyone else.

3.) We want special favors and allowances in the workplace because having kids somehow entitles us to them.

4.) We are unreliable because something's going to come up with our kids and we're either going to leave our co-workers with the extra work, or sometimes leave our jobs entirely.

5.) We just don't care as much about our jobs as our counterparts.

5.) All this is somehow inevitable.


The problem with other people's perception, especially those colored by preconceived notions, is that there's very little that you can do about it.  It has very little to do with you, and sometimes even very little to do with reality itself.  And that perception can be insidious, like a Chinese finger trap--the harder you struggle against it, the tighter it binds you.  (Yes, again with the Chinese.  WE HAVE A RICH CULTURAL HISTORY, OK?  Actually I have no idea whether Chinese finger traps are actually Chinese, or just "Chinese," like fortune cookies or General Tso's chicken, but whatever, it's not germane to the metaphor.) You want for all the world to defy the lowered professional expectations that people have of you, to prove them wrong, but sometimes it feels that the harder you try, the more you're reinforcing them nonetheless.

So what I think a lot of female physicians with kids do--and what I know I certainly do--is overcompensate. You do it all and then some. You work even harder. You try to never complain about your schedule or your hours while you're at work. Not only do you not ask for special favors, you embrace situations that allow you to prove that fact. In other words, you try to work as much and as hard as everyone else, and then you go a little bit farther, just to make sure. You try to be above reproach.

Sometimes this works. Sometimes it doesn't.

I think often now about Michelle Obama, particularly during the president's first presidential campaign, and how hard she and her team had to work to control her image.  The reasons people might have a negative impression of her are perhaps multifactorial and not entirely flattering of a portion of the electorate, but there seemed a point where every little thing she did or said, no matter how innocent, was misconstrued as playing right into her detractors' expectations.  (The endearing but now notorious fist-bump comes to mind.)  Sometimes it feels that way to me too.  Representing not only myself, but working mothers in medicine as a group, I am very aware of trying to present myself, present all of us, in the best possible light.  Again, overcompensating.  I think this explains a lot of my personality at work, which I have often classified as "aggressively pleasant."  As in: I will be easy-going and pleasant to work with if it kills me.

Sometimes this gets pretty tiring.

I also will note that there's a segment of people who will respond to this blog entry with the opinion that I and others like me are far too sensitive about these issues, reading meaning into things that have no meaning, turning mountains into molehills.  I am perfectly fine with people responding however they want (as someone who has been writing online for more than a decade, I think that if it's your right to publish something online it's the right of your readers to respond, even if they disagree with you) but I also think that actually being a working parent in medicine, a working mother in particular, lends you a perspective that you don't have access to otherwise.  So saying that we're overly sensitive to the issue of low expectation or perception bias is, to me, a little like a straight person saying to a gay person that they're being too sensitive about homophobia, or a white person saying to a Latino that they're too sensitive about racism.  Or, maybe, like Mitt Romney condescendingly telling poor people that they just don't work hard enough.  If you don't know what you're talking about, sometimes it's best not to talk.

I would love to hear your own stories about whether or not you feel that working parents in medicine are stymied by lowered expectations or perception bias, and what you all do in your lives to roll with the punches.  Because though the natural (or perhaps easiest) reaction is, "Screw 'em! Who cares what people think?" (this is Joe's response, for example) the fact of it is--I do care.  I care what people think of me in my career.  I care not only about being a good doctor, I care about being perceived as a good doctor.  I care not only about having a good work ethic, but about having that work ethic be a key part of how people see me. I care.  Maybe not as much as when I was in training (when I wouldn't even have dared to write a blog entry like this at all, for fear that I'd be seen as "whining") but I still care a lot.  So until I stop caring, or society changes as I continue to hope it will, I guess I'll keep walking through this field, head up, eyes straight ahead, and try not to look like I'm stealing pumpkins.

physician heal thyself *

Six hours into my second day back at work, while on call over Labor Day weekend, this happened.

I thought twice about posting this picture right up at the top, above the fold, but in the end, figured--you know this is a medical-ish blog, right?  It's just a little blood, right?  YOU CAN HANDLE IT.  (You can tell me if I should have thought three times about it instead.)

Anyway, I won't get into too many of the details of how the injury happened--mostly because in the past two weeks I've told this story at work about fifty skrizillion times and am bored of repeating myself--but let's just say that it was obtained while doing a procedure on the general medicine floor, and happened due to a combination of 1.) suboptimal conditions, 2.) poor equipment design, and 3.) poor judgement (my own) in persisting to use said equipment despite #2 in the setting of #1.  Be careful with your sharps, everyone.  They are...sharp.

Anyway, after finishing the procedure (I luckily had a second set of sterile gloves in my pocket that I was able to put on to finish off the task--a task on a patient that was not at a point where I could walk away) and though the glove was all flabby like a water balloon of blood by the end of the procedure, had a nice tight cuff that contained all my lifeblood quite nicely.  Then I irrigated my wound, finished the procedure note, and made haste down to the emergency room, where they took very good care of me.

I was instructed to get my stitches out in ten days, but the problem with wound care on your hand when you work in a hospital is twofold.  One, you have to keep your wound pretty covered up at all times--I basically had it laminated with a combination of Steri-strips, Tegaderms, and various configurations of bandages for the entire ten-day course the stitches were in.  Secondly, as I think I have mentioned before, I was my hands a lot during the course of an average work day, and no matter how occlusive I tried to make the dressing or how "waterproof" the various products used purported to be, my wound spent the better part of the ten days marinating in a brine of Band-aid water.  I tried to take the dressings off when I got home to let the laceration breathe, but the tails and knots of the stitches kept getting snagged on various things (clothing, towels, the kids' faces) so I ended up keeping the bandages on most of the time I was home too--another place where, between food prep and giving baths and changing dipaers--I had to wash my hands almost as often as I did at work.

So when my stitches came out this past Wednesday, the wound looked...rough.  First of all, it didn't really look like it had healed at all.  It was still gapping significantly, I could still see adipose through the edges of the wound, and the surrounding flesh and skin looked all ragged and macerated.  Joe offered to close it for me again, in layers this time with subcuticular stitches, but after mooshing it around and considering, I decided that I would just take off all my bandages whenever I wasn't in the hospital and let the whole thing dry out and close by secondary intention.  I was going to take a picture of the wound at this point, but be thankful I didn't, it looked even more gory on Wednesday than it did when I got the injury in the first place.  But anyway, it looks like Project Dessicate and Granulate is working, because now, three days after my stitches were removed, my hand looks much, much better than it did a few days ago.

(You'll just have to trust me on that last point.)

*          *          *

So, I'm back at work!  And it is...OK.  Actually, it's kind of hard to say how it's been and how it's going to be, since we haven't really officially pressure-tested the system yet.  Joe's mom, upon hearing how stressed we were about juggling everything, swooped into town the Tuesday after Labor Day and has been helping out with us at home for the past two weeks--getting dinner on the table, helping Cal with his homework when I'm working late, holding the baby so that Joe or I can go to the bathroom, entertaining-slash-distracting Mack, and any of about a billion different things that tip the balance of our mornings and evenings from smooth to totally unmanageable.  The kids have been delighted to have grandma in town, and it's made the transition overall much smoother.

Unfortunately, she has to go home tomorrow.  So after that, it's sink or swim.  Well, sink, swim or bob, I guess.

Overall, the difficulty with finding our new balance point now that I'm back at work is not so much getting everything done, but deciding if how we're choosing to allocate our time really is the best. Essentially a quality versus quantity argument. Well, let me revise that--it's not quality versus quantity so much as the concern that, with our current setup (three kids, Joe and I both working fairly extensive hours) that we may have neither. Part of the quantity element might be improved in a few months after my call schedule settles out--like I mentioned before, I have a pretty bad schedule for the rest of the year, I assume in part due to the leveling algorithm imposed by the computer system that my practice uses to assign our work assignments. And presumably, the quality of our time might improve when things settle down too--once the newness of the transition wears off, once the kids are more settled into their routines, once the baby gets a little older, etcetera etcetera. Maybe.

In the end, it's all doable, but we'll have to evaluate in another couple of months if the quality of the doing is really the best for everyone. Because I can't help but think--and this is judgement on no one but ourselves--that it feels awfully irresponsible to choose to have three kids and not choose to find some way to spend a little more time with them all.

* * *

You'll have to indulge me this last bit, but Cal's been just exploding with creativity since school started, and just recently, the stuff he's been writing is getting (in my utterly biased opinion) kind of good. He's been saying for a year or so now that he wants to be an author when he grows up, and while until now I've sort of considered it one of those classic Kid Aspirations (teacher, astronaut or similar--interesting to note, however, that Cal has absolutely no interest in becoming a doctor) this is the first time that I've thought there may actually be something to his plan. This (page one of his latest story) has a evocative "Hunger Games" or "Lord of the Rings"-esque feel to it, doesn't it?

(Cal hasn't watched "Lord of the Rings," by the way.  When I suggested that he might enjoy it, Joe shot me down saying that it was far too scary for a seven year-old.  I don't remember it being particularly terrifying, but what the hell do I know, I slept through the first two movies and didn't even watch the third.  What do you think?  Is it "Star Wars" level scary, or "Willow" level scary?  What is a scary kids movie, anyway?  Everyone talks about how magical "E.T." was, but that fucking thing terrified me as a child and still to this day.  That neck!  Those fingers!  THOSE WATERY TREMULOUS EYES.)

Anyhoo.  Everyone here's surviving.  Even doing well at times.  Hope you all are too.

-----
* I am fairly certain that I have used this title for another post before, but I've been keeping this blog for almost twelve years now so I'm fine with some creative reuse if you are.

the day before tomorrow

Today is my last day of maternity leave, and if you're thinking to yourself, "well, that went quick," I totally agree.  Not as quick as my five week leave with Cal, or my six week leave with Mack, but it still didn't seem much longer than those other times, somehow.  One's perception always expands to fill the timeframe allotted I guess, which is probably why, no matter how long I had or when I started, my papers in college were always finished at midnight the night before.  (See also: why I did not major in the humanities.)

I am something of a planner (this is what Joe calls me, though I think this is charitable--I have what might more accurately be described as a crippling attention to detail with a vivid imagination for catastrophe and outlay for at least three contingencies) so I've been gearing up for going back to work for, oh, at least the last month.  I knew I had to go back to work August 31st, so naturally I started stressing about it August 1st.  SHUT UP, I'M NORMAL.  So here's what we have going on.

Naturally, the milk.  I started pumping when Nina was probably about three weeks old (with the boys I started pumping sooner, both because I had less time was not as worried about weight gain with them than with Nina--she was on the smaller side when she was born and I didn't want to, you know, screw with the system until breastfeeding was firmly established) and I think we have amassed a goodly stockpile for my re-entry.

As I think I've mentioned before, the pump I'm using is the Medela Symphony.  I used the Symphony with Cal, lugging it into work with me for six months on the subway (it's not, like, 50 pounds or anything, but it's a hefty hospital grade pump so I crammed it into a giant L.L. Bean backpack and looked every bit like the former Hunter student that I once was: monstrous square backback on the subway at dark o'clock every morning--at least I wasn't reading "The Grapes of Wrath" or "The Chosen").  When the rental company I was using with the Symphony folded, I bought a Pump in Style, which I used for another six months with Cal, and then for almost a year with Mack, and it worked fine.  But now, returning to the Symphony, I have to say--it's a much better pump.  It's just solid, and it works more efficiently too, which is great when you need to pump but have only a short amount of time to get the job done.  Obviously it costs more too, but you can rent it, or buy it an resell it like I plan to.  (Since it's a hospital-grade pump, it operates on a closed system and is therefore approved for multiple users--the new owner would just need to get a new collection system and fresh tubing.)  I would also like to point out, for anyone else in the same boat, that the purchase of a breast pump can be deductible on your medical flex account if you have one for work.  (I printed out that article and stapled it to the receipt when I submitted it to my business office, and had no problems.)

I know a lot of people use those plastic baggies to store their milk, but I never have--experimentation in the medium led to a lot of spillage and of course the solid waste over the course of a year is not inconsiderable.  So for the third time in a row now I'm using this Mother's Milkmate system, which is basically a series of wire racks and little bottles (the bottles store up to five ounces I think but I never fill with more than four, because it can get messy, and of course if you end up freezing the bottle there's no room for expansion).  I obviously think this system is the way to go since I've gone back to it twice, because it easily shows you how much milk you have and dispenses the stash from oldest to newest in a way that satisfies my neuroticism attention to detail.  (If my use of masking tape labels color coded by day doesn't tell you everything you need to know about my personality, I'm not really sure what will.)

Some pro tips: get a few packs of extra storage bottles to have around, because between having some in the freezer and having dirty ones in the dishwasher, a good percentage of the bottles are going to be out of circulation each day and you want to have enough clean ones lying around to pump and store.  The rack itself comes with ten bottles those bottles screw directly into the boob horns of the pump setup, which means less pouring and transferring of your hard-won bounty. As an added plus, you can also screw on any standard-sized nipple (the Medela ones or the freebies they give you at the hospital fit fine) and feed directly from the storage bottle itself, which is very convenient as long as your baby isn't particular about bottle feeding.  (We didn't get one of these non-particular babies, however.  She's a woman of discriminating tastes, about which more later.)

I work at the same place now as I did when Mack was born, so luckily I have my pumping logistics and geography pretty much down.  Since the year I pumped with Mack, the hospital has actually added a lactation room pretty close to the OR, but from what I've heard they've missed the mark a bit because while it is a room with a door and a chair, it apparently doesn't have a sink.  People, you need a sink, both to wash your hands before and to rinse your pump parts after.  Sure, you could carry your stuff down the hall and rinse them in the lounge, but believe me, people get awfully squeamish when they have to see your lady gear.  So I'll do what I did last time, which is pump in the bathroom of the female doctor's locker room.  It sounds kind of grim, but it's actually leagues better than where I pumped as a resident--it's reasonably clean first of all, and there's an overhead light, which seems redundant to mention in this modern age, but believe me, it's not a given.  Also, 100% fewer dirty mops are stored in this particular bathroom.  So basically it's like Shangri-La.

So you need a place to pump at work.  Here's what you really need: a pump, a platform to put it on (desk, table, bench, what have you--I put my pump on a hamper), a sink, a door (for the sake of workplace discretion), an electrical outlet, a fridge, and an insulated bag with some ice packs to get it all home.  The electrical outlet is technically optional I guess, but using a battery pack to power a pump over the long term is going to cost you bank because those things eat batteries like Cookie Monster eats cookies, so just do yourself a favor and just park near an outlet.

Let me say here that although I've nursed all three of my kids, I have a problem with people being a little too adamant about breastfeeding as the be all end all. Feeding your kid formula is just fine as I and millions of other formula-fed humans will attest, and what you feed them is probably somewhat lower on the list of things that are essential to their health and well-being than, you know, loving them and being attuned to their needs and safety, all that jazz.  So I have a problem with people making moms feel like they're failures if they can't/choose not to breastfeed.  Look, breastfeeding is great if it works for you, but it's not as important as many, many other things you can do for your baby, like, for example, getting them vaccinated against dangerous childhood diseases.  BUT I DIGRESS.

Anyway, what got me to that last point is that I was going to say that the more militant of the breastfeeding literature says that if you're going to dare to go back to work and tear yourself away from your tiny human, that you should ideally be pumping every two or three hours during the day.  (Pause for laughter.)  I don't know anyone who has a job that allows them to pump every two or three hours, do you?  I mean, maybe if you work from home, but even then, I bet it would be rough, because of the actual "work" part.  So just get that out of your head.  It is impossible.  I pump maybe two or three times a day total.  Once in the morning before I leave for work.  Once midday, around lunchtime.  And once later in the evening, if I'm working late.  I also usually take some sort of galactagogue--with the boys I took domperidone, and with Nina I've been taking this Lactation Support stuff (basically fenugreek with other herbal jazz) and supply has been pretty good.  Once I get home, I just nurse on demand, which basically means I have a baby attached to me all evening and all night.  Good stuff.

Ironically, it was much easier to find time to pump as a resident than it is now that I'm an attending.  This seems counterintuitive, but the reason is that as an anesthesia resident we were mandated to get a thirty minute lunch/bathroom break midday, during which time I knew someone was covering my patient and I had no explicit clinical responsibilities.  As a grown-up (that is to say, now that I'm an attending), I don't get lunch breaks anymore.  I mean, I eat lunch (usually), but I just grab it between other things to do, because I can be (and am) called to do something constantly throughout the day.  A thirty minute break is the stuff of pure fantasy.  So when I pump at work, it's kind of like playing Frogger.  I eye the rooms I'm supervising, calculate how long it will be until they need me or until my next patient shows up in pre-op or how long it's going to be before the surgeon removes The Big Clamp or starts dissecting around The Pulsating Thing--and then I just run for it.  Really, I just need ten or fifteen minutes, because I have everything in place and for the most part assembled.  So I run in to pump, give the parts a cursory rinse and dry (I do the real wash at home, in the dishwasher--the heat effectively sterilizes everything) and run my stash to the refrigerator, all hopefully before I get called to do the next thing.

Of course, pumping the milk is just the first part of going back to work if you breastfeed; you also have a way to, you know, get the milk inside your baby.  With Cal and Mack, I introduced the bottle in earnest at about two weeks, and they had very little trouble transitioning between the two (something that made me seriously doubt the phenomenon of "nipple confusion" that people talk about) but Nina has been a little more of a tough nut.  She really, really, really strongly prefers to nurse over bottle feeding.  I started having my high-level surrogates (sorry, I just rewatched the entire run of "The West Wing" in its entirety over my leave and my mind is still half in the Santos-McGarry campaign) giving her a bottle or two a day starting around three or four weeks, but she just kind of hated it for a while.  We tried a bunch of different nipples and bottles, but so far what works best for her is the same thing we used for her brothers, which is this Playtex nurser system set.

It's marketed as better for breastfeeding babies, and I don't know if that's just a bunch of hooey but it does have the widest nipple base of any that we tried (how many times have I said the word "nipple" in this entry?  NIPPLEZZZ!) and I think that she's the most comfortable with it because it's the most boob-like non-boob that we have in our arsenal.  I also like it because it uses these drop-in liners, which not only means that we don't have to actually wash a bottle (the plastic "bottle" is really just a tube-shaped frame to hold the plastic liner and for you to grab onto) but it allows you to really squeeze out all the air from the milk reservoir before feeding, not unlike priming a syringe.  (Yeah, I just said that.  WHAT?)  For a happy refluxer like Nina, this ability to minimize the air swallowed is a nice benefit.

Nina's smart though, in that she will rarely agree to take the bottle from me, probably because she knows that when I'm there she has better options.  Sometimes she won't take the bottle (or will at least fuss more) if she knows I'm even nearby--this leads to the hardest part of transitioning out of maternity leave, which is: leaving before you really have to leave.

I knew I was going to be on call my first day back at the hospital, and would be away from her for maybe fourteen hours or more.  Obviously that's a long time, and I didn't want my first day back (stressful for many other reasons) to be all the more shocking to the baby because OMG WHERE DID THE BOOB LADY GO?  I wanted Nina to know well before it was time for me to go back to work for real that even if I wasn't there, there were other people there to hold her and feed her and love her.  Maybe it was more for myself than anything else, but I needed to see for myself that she was going to be OK before I actually left.  So starting a few weeks ago, I started "leaving" during the day, for increasingly long periods, a few hours at a time.

We are very lucky to have a nanny that has been with us since before Mack was born, and she knows and loves our kids, which has made it a lot easier.  But still, I will tell you that the hardest part of these "trial separations" is being in the house, hearing her cry, and letting someone else get her.  I've literally had to sit on my hands a couple of times.  Which is probably why I end up leaving the house during most of these "training" periods, and why Target has all of my money.  But Nina now takes the bottle during the day, she and our nanny now know each other pretty well, and we have our little schedule and routine pretty set, including coordinating school pickups and drop offs for the boys with the baby in tow.  I'll be sad leaving tomorrow morning but I won't really be too worried, because hey, we practiced.  We got this.

It's both wonderful and terrible to be needed so much by someone, but then also see that they're OK with someone else too.  I remember when I went back to work after Cal was born, thinking, "How can this little person possibly survive without me?"  But he did.  They all do.  But I guess this period is the act of parenting a child in a nutshell.  They'll do fine, but you try your hardest to prepare them for success and happiness the best that you can.  And look, I know, DRAMA QUEEN, you're just going back to work, not joining the Foreign Legion.  But these little transitions can be hard on everyone, though hopefully with all the prep it will be harder for me than for her.

Hey guys.  See you at work tomorrow.