straddling

I had to take our minivan to the dealership for a physical (I don't know--what do you call it when you have to take your car in for a visit to the car doctor? A well-car check? I plead ignorance and this parenthetical is now threatening now to take over the whole intro) and at the dealership they have honest to god carrels in a room off the waiting area, like a damn library. On one hand--how great! A quiet area with a desk and a chair and a power outlet to get some actual work done! And on the other hand--how long do you expect that I'm going to be sitting here, exactly?

Well, nothing like a stretch of captivity to force you to update your foundering blog. Ahoy hoy.

Last week was my last week of working full-time. My first "official" week of working at a 60% schedule is actually the week of Labor Day, but I had this week fortuitously scheduled as a week off from almost a year ago, like I planned it this way the whole time, for transition. It's not so much a vacation as purely a maintenance period for our family (MAINTENANCE! That's the kind of car visit I'm at now! Le mot juste!) meaning yesterday I took Mack to the dentist and tomorrow I'm taking Nina for her one year well-child check and now I'm here looking at a wonderful hubcap display and wondering if I should get purple under-light effects to make our suburban splendor-mobile that much more splendid. I mean, it seems excessive and yet this pamphlet makes such a compelling case for them...

I am so excited to enter this next phase of being more engaged or at the very least present for my out-of-hospital responsibilities, but I acknowledge that various internalized cultural attitudes have been a little difficult for me to shake. Namely, I find that I really have to check myself from being too defensive when people talk to me about my part-time status. 

JOE

(As we are engaged in high-level strategy talks about managing yet another week of juggling 

call schedules, OR and clinic times, childcare, meal timing, and after school activities)

Man, this is hard. I can't wait until you start slacking off at work a little bit.

MICHELLE

SLACKING OFF?

JOE

I mean...not slacking...I mean...you know what I mean! Working less! Working less at the hospital!

MICHELLE

THERE IS NO SLACKING INVOLVED HERE. NO SLACK. 

ALWAYS WORKING! HARD WORKER ME!

Or possibly this:

CO-WORKER

So, you're going part-time, huh? Sounds nice.

MICHELLE

(Cautiously)

Yes...

CO-WORKER

Gotta go be mom. I get it. I wish I could do that.

MICHELLE

DO YOU THINK THIS WAS AN EASY DECISION OR SOMETHING?

BECAUSE IT WASN'T! NOTHING EASY! EVERYTHING HARD!

CO-WORKER

Uh...

(Starts backing away, feeling for the doorknob)

And also:

RANDOM PERSON

Hello--

MICHELLE

(Pointing)

AND YOU! I'LL HAVE YOU KNOW THAT I HAVE AN EXCELLENT WORK ETHIC.

RANDOM PERSON

Aha. Huh. Well, as I was saying, "Hello, and welcome to Target."

Anyway, sorry world. Obviously I am having feelings. It's like I'm all messed up on my Erikson's stages. Instead of "Generativity vs. Stagnation" I've regressed back to "Identity vs. Confusion." (Also, can we all acknowledge that the fact that I even remember any of this from second year med school psych is pretty fucking impressive? OK, not so impressive, but notable at least.)

I don't know why I default to the defensive--maybe I need to prove to myself and everyone that I'm not "slacking off" or "opting out" or taking some slow boat to Shangri-La. Not that anyone has implied that, I think it's pretty clear that going part-time at work amounts more to scaling back on one type of (rewarding, highly-paid) work and scaling up on another type of work which is both unpaid and elicits a less direct, calculable form of appreciation. Not that I need my head patted constantly, but I think many of us have experienced the Moebius strip that is the endless cycle of keeping a three-kid household running smoothly, and how the loss of old workday landmarks can make things both easier and harder.

I know I'm probably stomping all over the landmines with this but just hear me out, I'm sitting in the backroom of a Toyota dealership waiting for them to finish checking my brake fluid or god knows what else so this is a bit of a rush job. I realize that my defensiveness is just part of my natural adjustment to our new situation (see also: guilt at bringing home less bacon than I was before, particularly after many years of being the primary or equal bacon...herder) but this all makes me happy that I have the option to partially scale back as opposed to having to make a binary choice to be all in or all out. The identity loss I'd have without some career focus would definitely be traumatic, and I think that this option, the part-time option, might allow me the best of both worlds. That's the theory anyway, and hopefully once I see that, I'll stop alternately taking everyone's head off and showily doing one-armed push-ups to prove that I'm JUST AS POWERFUL AS I EVER WAS.

(Psychological problems! I has them!)

*          *          *

I was going to write some more stuff here, but in the interest of just getting this up and saying BLOG UPDATE: MISSION ACCOMPLISHED I'm going to save that for next time. My goal in general, by the way, is for there to be a next time more consistently, and to do a little more writing in addition to the other thousand things that I've been neglecting in the past year. And now I have no idea how to end this  entry so I guess I'll just put in this video of Nina lurching around because didn't you hear, she's a toddler now.  Unreal.

recalibrating

I know there's a touch of irony in adding this disclaimer given that I haven't updated this blog in, like, half a year, but: LONG ENTRY AHEAD.

There's a snippet of a cartoon I remember from my childhood--I can't remember if it was "Tom and Jerry" but if it wasn't it was in a similar vein--where a mouse is reclining in a hot tub. He's sitting back with his arms along the rim of the tub, maxing and relaxing as cartoon mice do, wearing that look of smug satisfaction he was prone to. (As an aside: I never liked Jerry. I always thought he was a real jerk to Tom, a cat who was just fulfilling his evolutionary imperative after all. Ditto Road Runner. Ditto those capering harpy kids that keep taking the Trix away from the rabbit. JUST GIVE HIM A BOWL, YOU ASSHOLES.)

So anyway, the mouse. He's enjoying the hot tub. He's relishing the water, the heat. But the water starts to get a little bit hotter. And a little bit hotter still. Suddenly it's not so comfortable anymore. Not hot enough that he wants to get out of the tub or anything, but just...hotter. He starts sweating. His fur starts getting a little frizzy (from the humidity, you understand). Then, finally, he turns around and notices the cat behind him, slicing onions and carrots to add into the now boiling water. (My memory of this part is not quite as clear, but the cat may have been wearing a chef's toque.)

I've thought of that cartoon clip a lot in the last year.

But let me back up for a second.

If you've ever followed this blog with regularity in the past (though I'm sure with my sporadic updates I've winnowed that number down to only the die-hardest of die-hards) you've probably noticed that I haven't had the time to write much of substance since I went back to work after my maternity leave last September, and that I haven't updated basically at all since December. The reasons are all those that you could probably expect: busy job, three kids, and the responsibilities and duties associated therein. The explanations are always boring because everyone's reasons for being busy are pretty much the same, but to put it in medical terms: it's just a matter of triage.

It's hard to know where the tipping point was--though I have to presume that it was at least in part associated with the addition of our much-beloved third child into the mix--but at some point in the last year, things started getting hard. Not impossible, not un-doable, but subtly, Joe and I started to notice just how tight things were getting. Time was tight, at home, with the kids, with each other. Emotional resources were tight. Patience was less of a resource we could reliably depend on. The days and weeks started becoming these things that we were enduring, rather than living, let alone enjoying. Again, the imagery from an old movie comes to mind--inmates in a prison, grimly notching off yet another day on the wall of their cell.

I don't mean to imply that our life is a joyless dirge--far from it. We love our family, we love our jobs. Even working the hours that we do, we try carve out quality time when we can--long weekends, holidays, family vacations where they fit in. We bolus our family time because our basal infusion rate is so parsimonious, but we do make an effort to compensate. And we liked to tell ourselves that this bolus dosing was sufficient, and it worked...not well, but well enough.

But it didn't change the fact that over the past few years, and over the last year in particular, the feeling of our everyday lives becoming something that we were tolerating started to feel more an more pervasive. When you only see your kids for an hour or two at the very tail-end of each day, only to perform the most basic of maintenance for them (bath! brush teeth! yell at them for not taking their baths and brushing their teeth quickly enough because I'm tired and they're tired and everyone's tired so LET'S ALL GO TO BED AS SOON AS POSSIBLE) you start to feel like you're consisting on a diet of discarded crusts in an otherwise empty pizza box. Maybe you can piece together a life in these scraps of the day, but split between three kids, it's simply not enough time.

Joe and I have been discussing for years our long-term outlook for modifying (read: decreasing) the work hours for at least one of us to have more time with the kids, and for the longest time, our party line has been: soon. We're going to do it soon. "Maybe in a few years or so," was the stock phrase. But there was always the next thing. We'll think about it when I finish my fellowship. We'll figure it out it when I get more settled in my job. We'll do it if I make partner in my group. Later. We'll do it. But later. Meanwhile, time marches on.

Then: I was talking with one of my partners at work a few months ago. He has four kids, the oldest of whom had just turned eight. "I just realized," he said as we were chatting in the front hall of the OR, sidestepping a stretcher careening down the hallway from the PACU, "that he's eight. In another eight years, he's going to be in high school, driving, getting ready to go to college. Half my time with him is already done. I mean, they come home after they go to college and all, but you know what that's like. It's not the same. Half my time of having my son in my house is over already."

There feeling that I had after having that conversation was not unlike being wrapped in a piece of wet burlap and gently asphyxiated. Because Cal was turning eight too. Half our time raising our oldest son in our home was done, and not only had this particular calculus not ever occurred to me, but looking back, I can't say I really know where those eight years went.

Because see, we've always lived like this. Cal was born when we were residents. His entire life--and thus of course, Mack and Nina's entire life too--we've worked. Both Joe and I have worked our tails off. We're not residents anymore of course, and some of the specifics of our jobs have changed from year to year, but the fact of it is that we each work on average 50-60 hours a week, more if we're taking weekend call, and although we've been saying for years that we were going to try to get more control of our work schedules to put some more time into our family life, it hadn't happened yet. The decision point was always pushed off down the road. Later. Soon. Not yet. Someday. And now Cal was turning eight and I have no idea how time passed so fast.

If I'm going to be completely honest with myself I'm sure some of this particular grim inertia was also linked to a perverse macho pride. I've always spoken a lot about work-life balance in medicine and how these antiquated notions, about doctors functioning as around-the-clock automatons sacrificing their personal lives for the greater good, would have to evolve along with the rest of the world. But I think that in some ways I felt safe championing the choice for others to go part-time because I myself chose to work full-time. You do what works for your family, everyone's definition of work-life balance is different. But saying it from the vantage point of someone with three kids and still worked full-time herself felt like a secure platform from which to proselytize, like I was somehow above reproach from people who might accuse all part-time doctors of being lazy or uncommitted. DO WHAT YOU NEED TO DO; BUT AS FOR MYSELF, I AM DOING ALL THE THINGS.

And to be honest, we were getting by. It wasn't wonderful, but it was OK. We were surviving. Maybe we weren't "living our best life" to invoke an Oprah-ism (and I don't even know how I know that since I never even watched Oprah) but...day to day, we were getting by.

And then, the week before Memorial Day, our nanny of five years quit. With no warning, and giving zero notice. She just left one day and mentioned on her way out the door that she wasn't coming back.

Boom. Game-changer.

I'm not going to talk too much about the nanny thing because frankly, after probably the most stressful two months of our lives, I'm just over it. It wasn't even so much the issue of finding a new nanny--though that, obviously, was a huge part of solving our problems, at least in the short term.  But the larger and more important part was having to honestly evaluate our life, our choices, and just how much time we did indeed spend at work, away from our children. It was like turning the stark, faintly buzzing fluorescent exam light onto the fish-white underbelly of what kept things functioning at a level that passed as "OK" for the past five years. And what we realized was that: it really isn't OK. Having to outsource this much of our children's care--of our children's lives--to someone else, particularly someone who after five years could walk out on them without so much as a backwards glance...is not OK.

(This is putting aside the obvious logistical difficulty of finding a non-live-in person to work 50-60 hours a week. It's a tough sell to say the least. One suggestion, perhaps less helpful than most, was that we should just hire two nannies. To which my reaction was, if you have to hire two people to take care of your kids while you're at work, it's possible you're not spending enough time with your kids.)

So. Joe and I discussed and agonized and number crunched and evaluated. We talked to a lot of people. We agonized some more. And what's going to happen now is this: as of September 1st, I will be going part-time at my job. Joe and I would have been fine with either one of us working less, but because of the ways our jobs are structured, it makes more sense right now for the part-time working parent to be me. My new schedule will have me working three days a week, mixed in with my share of nights, weekend and holiday call. And my main goal for the other two days of the week? To do some of the things that I've never been able to do with my kids because I've haven't had the time. Simply to be around more.

I know this all seems unnecessarily melodramatic of an announcement to some, because plenty of people in a multitude of fields choose to work part-time. But for me, it is a big deal, because to be honest, when you're accustomed to following a prescribed path, swimming against the current for a change can be scary. And there are a lot of issues--job guilt, fear of resentment from co-workers or being perceived as less than fully committed to medicine, concerns about crippling my career potential--that I'm working through having finally made this decision. There's a fear of not wanting to let people down.

But that's it on the other side too, isn't it? I don't want to let people down. I want to do my job well. All my jobs. And I think that right now, I need to spend more time with my kids. Nothing's broken, I still love being an anesthesiologist, and the fact that I've worked full-time for the first eight years of parenthood wasn't the wrong call nor has it damaged our family. It's just that our choices then are not the same as our choices now, and when we have better options we owe it to ourselves to take them. We could be making more of this life. We could be doing better.

I'm not going to be there hovering in the periphery for every single second of my kids' lives, nor frankly should I be. But I'm looking forward to just being around more.

So that's what's going on with us. In most ways, it's really no big thing. But in other ways, it's the biggest thing.

Wright State University Boonshoft School of Medicine, commencement address, May 24, 2013

Good evening and congratulations to the Class of 2013!

I graduated medical school almost exactly ten years ago today (which sounds like a much longer span of time than it actually feels) so naturally when I started to write this address I thought back to my own med school commencement ceremony, or what little I remember of it.  Particularly I tried to recall the invited speaker we had that year and what pearls of wisdom he imparted, so that I could frankly plagiarize them and pass his pithy truths off as my own.

The problem is, I can’t remember anything he told us.

Our med school commencement speaker for 2003 was Jimmy Breslin, a reporter for the New York Post and certainly a more illustrious figure than I.  And he had a very well-written speech—I mean, probably he did, because again, I can’t remember—but all I really do recall is that he spoke a lot and he spoke for a long time.  And I remember thinking to myself, as I sat there in my academic regalia, sweating under the layers of polyester like one of those cook-in-the-bag microwave meals, that this man and his endless speech were the only things standing between me and my medical degree.

(He did eventually stop talking, by the way.)

I can’t convey to you what an honor it is to be invited to share this day with you all, which with the possible exception of this address, is likely one of the most important and memorable days of your life.  So when I sat down to write this speech, I had only two goals in mind.  First goal: to give you real advice that you can actually carry with you for the long road ahead.  And my second goal: keep it short.

Now, as a fourth year medical student, you probably already experienced the fact that the world is teeming with people all too eager to give you advice.  Much of the advice from senior doctors in particular will be strangely centered around when, how and if you should eat, sleep, and eliminate during residency.  (Clearly people have strong feelings about such things.)

But as a fairly junior attending physician myself, the idea of giving you all advice outside the realm of the purely practical does feel a little presumptuous.  The field of medicine is constantly changing—maybe now more than ever before—and I can’t pretend that I know what the future will look like any more than you can. Therefore, I only have one piece of advice, so as to make it easier for you to remember, and that is this:

Remember who you are in this moment.

And who, exactly, is that?  At this moment, you are a fourth year medical student, just minutes away from being granted your medical degree. You are proud, and you should be.  You are excited, and you should be. You are a little apprehensive about what comes next—intern year, residency, the hours, the new responsibility. That, you should be too, but I’ll not belabor the point—other than pregnancy, there’s no condition about which people like to recount horror stories more than medical residency.  Finally, and perhaps most importantly, you are still idealistic. I hope, at least, that even at the end of medical school you have retained the idealism that brought you into medicine in the first place.

And why did you go into medicine? I’m sure there are a host of different reasons, phrased in a number of different ways—but I think, and I hope, that it all boils down to this: you want to help make the world a better place, one patient at a time.  And right now, this seems like the most obvious thing in the world, the thing that has powered you through years and years of books and finals and 4:00am scut rounds done on no sleep and an empty stomach.  You’re doing all this not just for yourself, not solely for any kind of personal glory or reward, but to help other people.

Remember who you are in this moment.

Older doctors, particularly the more cynical ones, will speak of idealism as though it’s a bad thing, some sort of marker for naivite.  But I’m going to tell you this right now: idealism is never a bad thing.  And idealism seasoned with experience is maybe one of the very best characteristics a doctor can have.

Remember who you are in this moment.  A young doctor on the cusp of doing great things.  Some of these great things will be large acts, the majority of them will be small, but all of them will stem from who you are in this moment, who is someone with the energy, idealism and work ethic to make the world a better place.  With all the pomp and circumstance of this particular day and all those that preceded, it seems like the concept of service would be difficult to forget.  But believe me when I tell you that forgetting is the easiest thing in the world.  I have forgotten it many times myself.

Because there will come a night on call during internship when you’re going to feel beaten down and tired and regretful of having ever gone to medical school in the first place. And right when you manage to sit down, the first time that you’ll have had a chance to sit down all night, the charge nurse on that floor will yell at you for sitting in her special chair. And right then, you will forget who you are in this moment.

Or during residency, you’ll have a patient who will push all of your buttons.  And that patient will be loud and belligerent and unappreciative and will say things that make you feel inadequate even after the hours and hours of work you’ve put in trying to take care of him. That patient will make you angry, unsympathetic, and when that happens, you will forget who you are in this moment.

Or there there will come a time when you’re an attending, after you’ve been working late for the fourth evening in a row. This will be the one day that you have any hope of getting home to see your spouse and kids before bedtime, and right as you’re finishing up your dictations and ready to hit the door, an emergency case rolls in that no one can staff but you.  And that particular evening, you will forget who you are in this moment.

Cynicism is a protective adaptation.  It is a shell that doctors build around themselves after they feel that they’ve worked too hard, seen too much, been burned too many times.  It’s a way for doctors to broadcast to their colleagues and to the world at large that they’re so expert in the human condition that nothing surprises them anymore.

But don’t be that person.  Don’t be the cynic.  Be for the rest of your career as you are today, someone who doesn’t tuck your idealism away like an obsolete relic of your years in training, but proudly wears it on the lapel of your white coat. 

Be ready for everything you think you know now to change. Be open to new experiences. But always remember who you are in this moment.

Congratulations to the Wright State University Boonshoft School of Medicine Class of 2013.  Congratulations, doctors. May each of you have a long, fulfilling career filled with interesting patients, challenging days, and a lifetime of surprises. The rest of us have been waiting for you, and are so happy to have you join the team.

Now roll up your sleeves and get in here. We’ve got a lot of work to do.  

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!)

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.

glow worm

Hey, thanks for those in the comments who helped me convert the RAW files to JPGs.  Insert Eddie Murphy's "Raw" joke here!  (I don't even know what that joke would be, I just like to say "Eddie Murphy's 'Raw'".)  A few more pics from Nina's birthday.

Yikes.

Big ups to Dr. Moore.

And now, Deep Thoughts.

I had lying-down-for-too-many-hours hair.

So today we brought in Nina for her first Peds check after being discharged from the hospital.  We didn't have any real concerns--she's been doing all the things that she's supposed to do, she's less than an ounce shy of her birth weight (my milk came in yesterday afternoon--we'd been doing some supplementing with formula up until then to avoid dehydration and jaundice) and she's just been generally delightful.  So we were a little surprised when a quasi-routine heel stick for bilirubin turned up levels in the high-risk range.  (She was about 82 hours old when the blood was checked, and her level was 16 point something.)  Honestly, she doesn't look that yellow to me, I almost wonder if hemolysis from heel-stick sampling plays a role in the number being high (does it do that?) but whatever, better safe than sorry.

WHO'S THE GREEN LANTERN NOW, MACK?

Apparently we have this really shit health insurance that doesn't cover bili blankets via home health nursing--the nurse says in the past when they've had patients with our insurance needing phototherapy the only thing that has been covered has been those baby tanning beds in the isolettes, which would be TERRIBLE, since you're supposed to just leave the baby in there all the time, by themselves, for 24 hours or more, only taking them out for feeds and diaper changes.  Boo-urns to that.  

However, the Peds group that we're with has a bili blanket system that they loan out for just this kind of situation--thankfully no one else was using it.  (Actually, from the equipment log, it looks like no one has needed to borrow it since February, which either means no babies need phototherapy or everyone has better health insurance than us.)  NO MATTER.  We were so very grateful to have this option, and to be with a Peds group that has a loaner unit because they know that babies need to be held and touched even if they are busy isomerizing the double bonds in their excess bilirubin.  Two thumbs up for the Children's Medical Group of Atlanta.

We're going to go back in tomorrow afternoon for another bili check, aiming for at least a two point drop in her level after about 24 hours on the lights.  Let's hope we're already moving in the right direction.

independence day

I did want to put the birth announcement up here first, as this is something of my Primary Address when it comes to the internet, but something was weird with the wireless network at the hospital and my computer couldn't connect, blah blah blah (now I'm just boring myself) and besides, everyone is on Facebook and Twitter anyway, right?  But just because I'm a completist when it comes to documentation:

Introducing:

Nina Qiao-Ying Walrath
Born July 2nd, 2012 at 12:05am
6lbs, 13oz
19 inches long

(Her Chinese middle name, picked out by my dad, means "witty" and "intelligent." We figured she'd have a lifetime of people telling her that she was "pretty"--I mean, not that we knew she would be pretty, though she is, but you know what I mean, people always tell little girls that--and we wanted to pick a middle name that would emphasize that there are more important things.  When it comes to first names, we don't make a big thing about choosing first names that have a lot of symbolism, we just go by the "like the way it sounds" school of baby naming, but so far as I can tell, Nina means "girl." So, you know, story checks out.)

Nina came into the world in her own way, which I am coming to understand is determinedly unique and certainly on her own timetable.  You remember I was admitted to the hospital for about 12 hours in what was first deemed to be active and then downgraded to a sort of meandering prodromal labor last week--and I spent the time since then doing exactly what I didn't want to do with the final stages of my pregnancy, which was puttering around, hyperaware of my body, and sort of obsessively cataloguing every squeeze and twinge and thump.  This is so annoying, I thought to myself.  If I was at work, I'd be busy, I'd have more to do than naval-gazing, and I wouldn't be so focused on every little thing going on all up in my junk.  This is a waste of time.

(She said with great PORTENT.)

Sunday morning--the day I turned 38 weeks--I woke up, and Nina, intrauterine, was still asleep.  I had gotten pretty accustomed to her sleep/wake patterns by this time, and usually she would perk up and start kicking around pretty soon after I got up myself, but this morning, she was a little slow to get going.  So I did the usual things they tell you to do.  I had some breakfast.  I had some coffee.  I started counting her kicks.  It wasn't that she wasn't moving around AT ALL--obviously that would have been very worrisome--she was meeting her minimum kick count, which I believe is 10 movements in 2 hours, but it was just different from usual.  She was just kind of pokey in there.

I know that decreased movement at term can be normal--there's just less room in there, after all, and who knows, maybe they sense when birth is imminent and quiet down to save energy for getting borned and all that.  But it was still a change, and though I considered long and hard just going about my day (see above: with the lack of my usual daily runaround, maybe I was just being too obsessive about what was going on inside) but in the end decided to just call my OB and get his opinion.

Sidebar: I cannot recommend my OB highly enough, by the way.  I can talk about it more with anyone who wants a recommendation, but his name is Dr. Brad Moore, here is the website for his office, and he is truly an excellent clinician and bedside doctor--and this is from someone who is well aware of the Pressures of Modern Medicine and therefore very forgiving when it comes to how other clinicians practice.  He is quite simply and unequivocally excellent, so get thee to his practice, pregnant ladies of Atlanta.  End sidebar.

Anyway, I called my OB, kind of apologizing for calling on the weekend about something that could be nothing, I'm not a hysteric, I swear, but he listened and he did take it seriously.  "Come on in," he told me, "we'll check you and check the baby.  You're 38 weeks, contracting, with advanced dilation, GBS positive and a history of fast labors.  If things are in line, maybe we'll just get in your antibiotics, augment you with a whiff of Pitocin, and have this baby tonight."

I think his intent had been for me to check into L&D right from the beginning (since he was on call that weekend he was already in the hospital, puttering around) but because my chief complaint was "decreased fetal movement at term" they sent me to triage first, where the nurse was very clearly of the opinion that I was a hysteric and should be sent home.  "The best outcome here would be to send you home," she told me brightly with one of those tight, forced smiles as she was doing the admissions paperwork, and after she got the phone orders from my OB that I should indeed be admitted to L&D, she made it clear that she disagreed in the way that people do without coming out and saying so outright.  "Well, you're getting admitted.  It's what your doctor wants, I guess..."  I don't begrudge her the sentiment--I don't like being on call for the weekend either, I guess--but I was also glad that I'd called my OB first and that the decision was not up to her.

The actual lead up to delivery was completely uneventful, much with with Cal and Mack.  I got my antibiotics, started some low-dose Pitocin, got my epidural (great stuff, by the way, though it's not an entirely pleasant process getting it placed, and fact that I'm pleased to be reminded of every 3.5 years just for the purposes of patient empathy) and then had my membranes ruptured with my second dose of penicillin hanging.  We were on our way.  At 11:56, the baby's head was at +2, all the players were in the room, and we were ready to push.

"We've still got four minutes to make a July 1st birthday!" Joe kidded, and my OB made a little jokey show of putting on his glove and gowns real fast.  Then we started pushing.

I should mention that up until this point, for the hours we'd been there, the fetal heartbeat monitor was looking really good.  Lots of good variability, perky, with a rate right in the normal range.  When the head was all the way down and we started getting ready to push however, the tracing looked a little more flat, meaning that the rate was still normal, but it wasn't quite as variable as it had been.  I assumed she just didn't like getting squashed.  But then after the first two rounds of pushing, it all kind of fell off a cliff.

Even in an adult, a heart rate of 50 in an adult is slow.  That's what Joe's heart rate is, and he's on beta blockers, for chrissake.  A heartrate of 50 in a neonate is...well.  Let's just say that if I was in the NICU and there was a baby with a heart rate of 50, I would be doing chest compressions on that baby.  After the first two pushes, that's what our baby's heart rate did on the monitor.  The nurse adjusted the Doppler, thinking maybe that the baby was so low down that it wasn't picking up, but no, it was picking up, and it was 50.  So my OB--in a way that was very calm but also very quick and decisive, and I'm convinced that it was this quick response that really saved us from those things we don't like to think about--busted out the obstetric vacuum, applied it to the baby's head, told me to push one more time quick, and pulled that puppy out of there.

Nina was born vigorous, with good tone, and she cried right away.  Her Apgars were 8 and 9.  As they were warming her up and drying her off, I heard my OB, from the region I like to call Down There, say, "Oh my gosh, look at this."  Which is not a thing that I like to hear from Down There.  Because when he delivered the rest of the placenta and cord, it looked like this:

(Let me just insert here that this is not a picture of our umbilical cord, it's a picture I got off Ye Internet, though ours looked remarkably similar, only tighter.  That is not to say that we didn't take pictures of this phenomenon, because WE TOTALLY DID, once the placenta and associated works were safely and discreetly deposited in the specimen basin, but they're on our "real" camera and I can't figure out how to get them off, because someone switched the settings so that all our photos from that day are in RAW format.  If someone knows a good strategy to batch convert them in Photoshop so we don't have to do them one by one, let me know in the comments section, thanks--I'll update with those photos once I'm able to extract them.)

In case you can't see for yourself, it was a knot.  What they call a true knot in the umbilical cord, which is pretty rare, and even rarer for it to actually get pulled tight enough to manifest with fetal distress.  The knot had probably already been there for months--Nina had probably tied it earlier in gestation when she was much smaller and there was more room to maneuver, and if you don't read about all the terrible things that can happen with a true knot in the umbilical cord, it's actually a little amusing to thing about her doing the loop-de-loop, then threading the needle while swinging her cord around like a lariat.  A little amusing, until she started to pull down on the cord on her way out and tightened that knot up but good.  Obviously we had no idea until after, it's not exactly something you screen for routinely without lack of other indicators for risk, and there's nothing you can really do to cause or prevent it.  We were incredibly lucky, and we know it.

I also do have to say this here, because these days, what my friend Veronica (also an OB-Gyn) has called "the fetishization of the natural" goes hand in hand with the demonization of the medical.  By no means am I saying that everyone should have the maximal interventions possible (Pitocin and epidurals and C-sections for everyone!) or that people's hearts aren't in the right places when they choose to have births outside of the hospital.  But if I were of the type to elect for a home birth (and let's be clear: I'M TOTALLY NOT) I would have, on paper, been the perfect candidate.  Multiparous with two prior uncomplicated vaginal deliveries, full-term with normal-sized fetus and an uncomplicated gestation.  But if this pregnancy experience has taught me anything, it's that you can't plan for everything, and there's always going to be things you can't expect.  And maybe because it's the anesthesiologist's credo (aside from vigilance), but I live by the idea of hoping for the best and planning for the worst.

This could have been bad.  It could have been catastrophic.  But it was not, and for that, and for our sweet baby Nina, we could not be more grateful.

Cal, upon meeting Nina for the first time in the hospital the next day, gave this assessment.  (Cal's demeanor is often overly serious--we keep telling him to lighten up, kid, for god's sake--and while we mentioned to him about the interesting little finding on Nina's umbilical cord we didn't really go into detail about what it could have meant; Cal's grave little pronouncements just happen on their own.)

"She's perfect." he told me.  "She's the perfect baby and we get to take her home with us."

Yes she is, and yes we do.  And we love her so much already.

Welcome to the family, Nina.  Now get ready to have some fun.

true labor, false labor, and that liminal space between

Hey there! Are you alive? Me too!

I'd been having a pretty rough week at work--on call over the weekend, later days, tough cases--and starting Wednesday morning,  I noticed a change in how my body was feeling.  First of all, Thing 3 felt much lower, like a bowling ball sitting on my coccyx.  I was also noticing an uptick of contractions accompanied by back pain, which is not the usual for me (Braxton Hicks contractions usually concentrate on the front, and I'm lucky that I haven't had much musculoskeletal back discomfort with this pregnancy at all) that would come and go--I'd like to say that I was scrupulous about timing these contractions, but I was at work and running around and I really didn't have time to attend to their frequency until much later in the afternoon, when I finally had a chance to sit down.  I will also say that there were a spectrum some other symptoms that I'm too polite (read: shy) to talk about but that you can read about after searching "signs of labor" in Google.  Something was different.  Something was happening.

I'm more of the type to sort of wait things out until something declarative occured, but the one thing is that for these past two pregnancies (three? I can't remember with Cal) I've been GBS positive, which means that I need to receive at least one round of penicillin prior to delivery.  The window for getting the antibiotics (I've been told--it's been a long time since I've done Peds and I don't purport to know anything about OB except what applies to the anesthetic management therein) is four hours, and my OB pointed out on my last visit, when I was 2-3 cm dilated on exam and 50% effaced, that this is my third child, and as a faster delivery could be expected, that with signs of impending labor I should high-tail it to the hospital sooner rather than later.  "Usually I say when the contractions are every 5 minutes apart," he said, "but for you, maybe every 8 minutes."  At the point in the afternoon when I could actually sit down and look at a clock, I was having contractions about every 5-7 minutes apart.

I sat and debated what I should do for a while.  On one hand, I'd been working all day, which tends to make the old uterus a little more irritable--it could all settle down once I got home.  But other the other hand...the other thing.  I thought some more.  The kids were at home, with our nanny.  The hospital where I work is directly across the street from the hospital where I plan to deliver.  Did I want to go home, relieve our childcare, and then find myself in a situation where I had to rush back in, with two kids in tow?  Also, Joe was working at an office location more than an hour away that day.  Did he need to rush back into town?  Did he need to reschedule any of his patients for the next day, or the rest of the week?  I had no real answers, and I figured the only way to get more data was just to go in to L&D and get checked, even if I did run the risk of being perhaps overly cautious.

On L&D, they noted that I was 4 cm dilated, 70% effaced, and contracting about every 5-7ish minutes. So they had me on a monitor, put me in a bed, and said they'd be back to check me again in an hour, to see if I'd progressed.  An hour later, the same nurse came by to check--I was now having contractions every 2-3 minutes, and by her exam, I was dilated to 5 cm.  She called back the OB on call, who decided to admit me to the floor.

"I guess I should call my people at work," I said hesitantly to the nurse.  "I mean, should I?  Should I tell them I night not be at work tomorrow?"

"Oh no, you're not going in tomorrow," the nurse said.  "You're having a baby tonight."

So...OK.  I got an IV.  I got my antibiotics.  I settled in for the night with a toco monitor and a fetal heart rate monitor strapped to my gut parts.  Our nanny stayed overnight with the boys.  Joe came in with the bags and slept on the most uncomfortable couch sleeper ever.  Since I was only 37 and a half weeks at the time (I'll be 38 weeks on Sunday) they actually couldn't give me anything to hurry the process along (I've gotten Pitocin aumentation for my prior two deliveries) and I guess that was fine, because overnight, the contractions started getting more irregular, spaced out, and then kind of petered out to every 10-15 minutes.  In the morning, a new nurse came in, the kind of nurse that I would have been terrified of as a med student but now as an attending I love--a gruffly, senior nurse, direct and to the point--and told me, "You know, I don't think you're in true labor."

I said I kind of wish I had been told that before our little slumber party, but I knew in actuality it had been a tough call.  3rd pregnancy, GBS positive, seemingly regular contractions with progression on exam on admission--I don't fault the original team for tilting towards caution and admitting me "in labor."  I think my OB was torn too.  "We have two choices here," he told me.  "The risk of fetal lung immaturity at this stage is really very low, but because it's a possibility, the literature tells us not flat-out induce prior to 39 weeks.  However, it's hard sending someone home who's 4-5 cm and contracting.  I guess if we gave you Pit it wouldn't really be an induction so much as an augmentation.  But then again..." he thought some more, "you're not contracting as much now.  You said you came straight from work yesterday?"  I confirmed that I did.  He kind of cocked his head, considering the options.  "It's a bit of a tough call.  I think we have two choices.  One is we can keep you here and watch you.  The other thing is we can send you home and wait until you declare yourself there."

Having already spent a night in the hospital, I was not crazy about spending another day there unless, you know, I knew I was getting a baby out of the deal.  Also, as a former Peds person, I knew he was right--that at 37 and 4/7 the likelihood of lung immaturity, especially for a baby girl, is very, very low.  Yet...we spend our lives minimizing risk for our kids, and if she wasn't quite ready to come out yet, then I didn't want to be the one making the decision to force her out.

Don't get me wrong, I'm as ready for this pregnancy to be over as the next lady, but also, you know, I want to be a rational person about things, not like those ladies who show up to L&D at 37 weeks on the dot demanding TAKE THIS BABY OUT OF ME NOW.  I could handle a little more discomfort and waiting.  The uncertainty I'm not crazy about, nor the idea of having a precipitous delivery in the car, but...we live pretty close to the hospital, and we have a pretty fast car.  I told him I that if it was OK in his judgement, I would like to go home.

So, that's why I'm home.  After some deliberation (and I know this will seem crazy to many of you, but my OB even said that medicine is the only field where he's encountered people that are determined to work up until the very second the baby is crowning) I have decided to start my maternity leave five days earlier than scheduled.  On one hand, it kills me to not be at work when, you know, I'm not doing anything else (I've always said that a single day spent on maternity leave without a baby is a DAY WASTED--yes, I get paid for work, but it's more than that, it's the idea of being at a place where people need you and you're useful and where you're sharing responsibility with others) but I think that at this point it's the best idea.  I have to remind myself that I'm not doing my patients or my partners any favors by weeble-wobbling in at 5 cm dilated with the omnipresent risk of having to leave their case unexpectedly and emergently right before, you know, the cross-clamp comes off the aorta.  I know it sounds like an obvious decision to most people, but believe me and try not to judge too hard the medical culture when I tell you: it feels a little like a cop-out to me.

So!  Here I am!  At home!  Contracting some, a little uncomfortable but feeling basically the same (they confirmed that Thing 3's head is at -1 station which probably explains why I feel like I have a baby coming out of my butt) and I'm hoping that we'll declare ourselves one way or the other and head back into L&D sometime soon.  Today my plan is to walk around, like, a lot, though yes, I will be safe and not over-exert and hydrate adequately, given that the 5 day weather forecast for Atlanta looks a little something like this:

Did I mention that I'll be 38 weeks on Sunday?  And the next time we feel the need to go into L&D for a little visit, we're not leaving without a damn baby?  Lord.

For the craft-minded, I made that skirt (love seersucker), made a pair of boxer shorts for Cal out of the same leftover fabric, and last night made a flannel fitted crib-sheet for the baby after I realized while in the hospital that if we'd actually brought her home today, she'd be sleeping on a bare Ikea mattress.  Might as well be useful somehow, right?