death or something like it

Good discussion on that last post!  It's clearly a topic that many are hungry to talk about, and I think what's becoming increasingly evident to me is that the choices we make with our lives in medicine really aren't any different than the choices people make in any other high-powered field where a lot of people are counting on you.  In some ways, it makes the choices more difficult, but in other ways, the clarity of purpose and the natural inclination to triage makes getting through our days, if not necessarily easy, than at least one where our top priorities are unambiguous.

OK, ready for the next thing to talk about?  And--hey, look.  Usually I don't go hunting around for topics to stick in my craw.  I swear, usually I just wander around with a smile on my face and a song on my lips with little birds braiding my hair, a regular blithe spirit.  Or Blythe Danner.  But then, oh look, one of my partners at work e-mailed me this article from The Wall Street Journal Online.

What You Lose When You Sign That Donor Card
Giving away your organs sounds noble, but have doctors blurred the line between life and death?

An excerpt:

The last time I renewed my driver's license, the clerk at the DMV asked if she should check me off as an organ donor. I said no. She looked at me and asked again. I said, "No. Just check the box that says, 'I am a heartless, selfish bastard.'"

Becoming an organ donor seems like a win-win situation. Some 3.3 people on the transplant waiting list will have their lives extended by your gift (3.3 is the average yield of solid organs per donor). You're a hero, and at no real cost, apparently.

But what are you giving up when you check the donor box on your license? Your organs, of course—but much more. You're also giving up your right to informed consent. Doctors don't have to tell you or your relatives what they will do to your body during an organ harvest operation because you'll be dead, with no legal rights...

...The exam for brain death is simple. A doctor splashes ice water in your ears (to look for shivering in the eyes), pokes your eyes with a cotton swab and checks for any gag reflex, among other rudimentary tests. It takes less time than a standard eye exam. Finally, in what's called the apnea test, the ventilator is disconnected to see if you can breathe unassisted. If not, you are brain dead. (Some or all of the above tests are repeated hours later for confirmation.)

...But [beating heart cadavers--the term used in the article for brain dead patients]...don't receive anesthetics during an organ harvest operation [though they] react to the scalpel like inadequately anesthetized live patients, exhibiting high blood pressure and sometimes soaring heart rates. Doctors say these are simply reflexes.

...Organ transplantation—from procurement of organs to transplant to the first year of postoperative care—is a $20 billion per year business. Average recipients are charged $750,000 for a transplant, and at an average 3.3 organs, that is more than $2 million per body. Neither donors nor their families can be paid for organs.

It is possible that not being a donor on your license can give you more bargaining power. If you leave instructions with your next of kin, they can perhaps negotiate a better deal. Instead of just the usual icewater-in-the-ears, why not ask for a blood-flow study to make sure your cortex is truly out of commission?

And how about some anesthetic?

(Read full article here...such as it is.)

OK, let me leave off the table now the details of the neuro exam and EEG monitoring and the criteria for brain death.  I can talk about those too of course, but I am not as qualified to do so as some, and, unlike the author, I know better than to ignore my somewhat less than expert grasp of the nuances of the subject material and trumpet my knowledge, whatever its flaws, as the clarion bell of unimpeachable fact.  These issues may be better for a neurologist or neurophysiologist to discuss--one may well be reading this entry now and want to weigh in in the comments section--and, I venture, the author of the article may well have benefitted from talking to such an expert in researching the article himself.  (They're called "cold calorics" or "vestibular caloric stimulation" sir, ask any second-year medical student.  We're not looking for "shivering" in the eyes, even though, yes, ice is cold.  By the way--you see a similar response with warm water.)

What I want to talk about is this accusation that we don't use anesthesia during organ harvests.

WE ALWAYS USE ANESTHESIA DURING ORGAN HARVESTS.

Organ harvests, who for those like the author of the article (OK, I'll stop) are unfamiliar with the terrain of organ transplantation in a hospital setting, are always booked in the operating room, and always booked with anesthesia staffing.  We as the anesthesia team help transport and support the patient, usually from the ICU, vented and on drips, down to the operating room.  We put them on our anesthesia machine, monitor them just as we do any other patient.  We anesthetize them, give them medication, oxygenate them, treat their hyper/hypotension and tachycardia, just like any other patient.  The definition of "pain" lands into some sticky semantic territory--so far as I understand it, "pain" implies a perception and processing that requires some higher brain function, which brain-dead patients by definition lack.  But I don't argue that even brain-dead patients have sympathetic (in the central and peripheral nervous system sense) reaction to nociceptive stimuli, such as surgical incision--and we treat those responses the same as we do in any other patient, often with pain medication.

The hard part is when the surgery is over and we have to walk away.

Because it's not what we do.  We take care of patients, and those who donate their still-working organs after brain death--that is to say, after they themselves have lost all reasonable expectation for meaningful use of those organs--are still our patients.  In some ways, it's harder as an anesthesia practitioner to separate out these patients from the others we take care of--almost all our patients look like they're sleeping, almost all patients under our care require ventilatory support and/or circulatory support, almost all our patients lie completely still and largely unresponsive.  We tend to them with attention, respect, and care, until the very end.  And in the case of an organ harvest, it's the anesthesia providers who are turning off the life support.

And that's hard to do.  It's hard because we respect the patients, respect life and its passage, respect the choices they have made to help others.  To imply otherwise is ignorant and insulting at best--and it is quite flatly an insult, to imply that doctors simply regard patients as a collection of interchangable profitable parts--and irresponsible at worst.

Because the implications and the ramifications of this article and articles like this are irresponsible.  It's irresponsible to write as a voice of expertise (the author has, I believe, written a book on this topic which, SHOCKINGLY, is coming out next week) in a major news outlet on a topic of which you clearly have an imperfect understanding.  It is even more irresponsible to use that platform in a way that has some very real, lasting public health implications for life-saving treatments and therapies for other patients for whom the breadth and depth of the organ donor pool is, quite literally, their last and only chance.

And look, I'm not an idiot--I understand that The Wall Street Journal has, in the past, published incendiary shock-value pieces that have been quite successful in book promotion (Amy Chua's "Tiger Mom" article comes to mind, and I don't deny that, when that particular firestorm hit a month before my own book came out, I wished I had either the subject material or iron-clad balls to generate that particular caliber of self-perpetuating publicity).  But this is about more than selling a bunch of books, or generating a lot of attention, or getting a lot of replay on Facebook.  Because of this article, someone might decide not to donate their organs, and because of that, someone else is going to die.  A real person.  I've met and taken care of many of them.  You may have too.

Again, it comes down to choice--obviously the choice of whether or not to donate ones organs after death is a personal one and should be at least considered seriously.  I know people don't live their lives explicitly to benefit strangers, nor do they usually intend to die toward that same end.  But fact is that this is the moment we're at in the evolution of medicine.  When organs in some patients fail, we sometimes have the ability to transplant in organs from other patients who can no longer use them.  Maybe someday we'll grow organs in jars--no doubt that kind of research is in its infancy or early childhood--but for now, to save and improve lives, this is what we're working with.

I don't wish this kind of decision on anyone, and may we all live happy and healthy to the ripe old age of 100, but the fact of it is, some of us don't.  Death, in the circumstances where organ donation may be an option, is often unavoidable, after the exhaustion of all  other options.  But the choices, the informed choices you make before death with what happens to your body afterwards--well, that's up to you right now.

But know that, whatever decision you make, we as your doctors will take care of you.  Always.  All the way to the end.

life or something like it

OK, so let's talk about this:

Some of you may remember an Op-Ed in The New York Times this past summer, written by Dr. Karen Sibert, entitled "Don't Quit This Day Job." If you haven't read this piece already I strongly recommend that you do, because I think it can spark a lot of good dialogue on the topic of work-life balance in medicine and what it means, personally and on a systems level, to find that balance. I wrote a response to that Op-Ed here, and we all discussed and discussed and discussed that some more. In particular (I've been doing a bit of traveling and speaking this past year and as a result have had the pleasure of spending a lot of time with doctors in various stages of training--pre-meds, med students, residents, fellows, what have you), I find that young doctors are especially hungry for dialogue on this topic, which seems to be foremost on everybody's minds and yet often discussed furtively, behind closed doors.

Dr. Sibert has recently started blogging as well, and posted a piece today entitled, "Give yourself a break--don't have a baby during residency." An excerpt here:

Overheard in the OR—a surgery chief resident ruefully explaining to a senior surgeon why no intern or junior resident was available to scrub in on his case. “Everyone in our department is either pregnant or on maternity or paternity leave,” he said.

The senior surgeon just shook his head. 

From my vantage point as the anesthesiologist on the other side of the drapes, I thought to myself, “Really? What’s wrong with these people? What would give anyone the idea that residency is a good time to have a baby?” When I look back to what it was like to deal with pregnancy, give birth, and look after an infant, all I can say is that internship was easier. After all, as an intern—even in the bad old days—I had some nights off. 

Yet having a baby during residency is increasingly common among male and female residents alike. For women especially, it sounds perfectly awful. We’ve all heard the stories—pregnant residents struggling with nausea and fatigue during long nights on call, or vomiting into a trash bag in the operating room; new mothers trying to breast-pump in the hospital locker room during a half-hour lunch break. 

One possible response is to argue that senior physicians should be more sympathetic to pregnant and nursing residents, and give them longer lunch breaks. This would be in keeping with the kinder, gentler world of limited resident duty hours and mandated nap times. 

But it’s equally fair to consider that residency might be a bad time to have a baby.

Even with today’s work hour limits, residency training in any field involves stressful days at work, limited control over your schedule, and frequent nights on call. It’s hard to get nutritious meals on a regular schedule, even if a pregnant resident could stomach the food in her hospital cafeteria. Nor can she get enough rest. Anyone who’s been pregnant can recall moments of such profound fatigue that she would kill for an afternoon nap, and a resident can’t simply lie down when she feels like it. Can this be a healthy way to go through pregnancy?

(Read the full blog entry here.)

So, a little background to catch everyone up first, just to show that I have some perspective of which I speak on both sides of the "when to have kids" quandary.  I got pregnant with Cal the fall of my second year of Pediatrics residency.  I can't speak for every Pediatrics residency experience, but to be a resident at the Children's Hospital of New York was a very intense experience--lots of call, tons of ICU time, patients on the general wards that would have been on the unit in any other hospital, it was (and I think I can safely say this now) much more difficult than my anesthesia residency, even on the "best" months. Cal was born soon after I switched into Anesthesia residency, after which point I began in earnest the balancing act that is having a child during training.  (Because, you know, that's the real difficult part--not so much the pregnancy, but the part where you and your baby are actually in two separate places.)  I spent the entirety of my first trimester with Mack finishing up my Anesthesia residency, and he was born about five months into my first job out of training, when I was a junior junior junior (junior) attending.  Now I'm about three and a half years into my post-graduate career, working full-time and more or less settled in my current job situation, and as you know, our third child is due in July.

OK, so to sum: one pregnancy early in residency, one half-in-half-out-of residency pregnancy, and one pregnancy as an attending.

First things first: Dr. Sibert is right on a couple of points.  It is more difficult to have a baby during residency, for many of the reasons that she mentioned and more.  I can't argue that.  I lived it.  It's a daily challenge.

But here, now is a partial list of just a few other things that are also more difficult during residency: Being in a relationship.  Being a good partner to your spouse.  Spending time with your friends.  Calling your parents.  Keeping up with current events.  Making time for your hobbies and creative pursuits.  Studying for your boards.  Reading a book for fun.

I wouldn't tell you to not do those things either.

Right, so in part I jest, because obviously the choice to have a child during residency (and that is what we by and large have as privileged, educated ladies and gentlemen: a choice--that is, unless certain members of the Republican Party intelligentsia have their say) is obviously a huge one that should not be taken lightly.  Nor do I think it is one that people do take lightly, or look at as just another point on their "achievement checklist" (as per Dr. Sibert's blog entry):

In a way, the determination and single-mindedness of physicians may help to explain why they have children during residency. Having a baby becomes part of the achievement checklist. Finish college—check. Finish medical school—check. Score residency position of choice—check. Find life partner—check. A baby becomes the next item on the list, and residents often feel additional pressure from parents and in-laws who are anxious for grandchildren. For the young female resident who’s been a bridesmaid in her best friends’ weddings, it can be hard to watch them all start having babies without feeling the urge to have one of her own.

No, I don't think that it is a decision that people make on a whim, or a life milestone that people fall into secondary to intertia or because of societal expectations or because their parents are screaming for grandbabies.  Remember, these are people who to this point have been through between four to eight years (give or take--if we're talking about medical residents) of post-college education and training, who knew what they were getting into (med school isn't exactly something you end up doing by accident), knew that it was going to involve a lot of hard work, and make choices to live their lives outside the hospital a certain way. The life of a medical resident is not a "Cathy" cartoon, after all. (I'd say my life is closer to a Calvin and Hobbes strip, actually.)

Would I tell all med students to try to have baby during residency? No, of course not, that would be ridiculous. But equally ridiculous, in my mind, is the blanket statement that no one should have a baby during residency. These are individual choices that people have to make for themselves given their specific circumstances, where they are in their lives, where they're looking to be in the future--all with more nuance and interpersonal variability than can be covered with any overarching recommendation. What I would say on this issue is the same thing I tell people when they ask me if they should go into medicine in the first place.

"You can do it. But you have to want it."

You have to want it. It comes down to that. Very few things in medicine are easy--and if I may venture, very few parts of parenthood are easy.  (In most ways, like I said before, the pregnancy is the easiest part.  Never again will you be able to have this much control of your offspring, nor will they ever again be so portable!  But I digress.)  You have to know exactly what you're getting into, you have to know your own limitations and what you're going to have to do in order to make a more difficult than average situation work...and you have to want it.  But you can do it.  It can be great.  And you and your family can thrive.

Joe and I (and I say this just as a personal anecdote--everyone's situation is different) went through a kind of specific calculus when we decided to have kids during residency.  And our calculus, basically, was this: "What exactly do we do with our time when we're not at work?"  Well, we were medical residents living in Manhattan.  Obviously we worked long hours, and we not infrequently worked for 24 to 36 hours at a stretch.  We weren't big partyers, and since most of our friends were also medical residents (and therefore pretty busy as well), most of our free time we spent with each other.  We'd eat out, get coffee at the bookstore to read free books preview books that we intended to pay money for, go to the movies, occasionally splurge and go to a nice restaurant or go see a play. And this was fun, having that kind of relative free time, and a little teeny bit of disposable income.

But then came the next question, "Are we willing to give some of that up--have less free time to do adult things and spend more time doing baby things, as a family?"  Yes, we decided, we were.  Also we considered, "Are we making enough money to have a baby?" Yes, we decided. It would be tight, predominantly because of childcare costs, but we could make it on what amounted to a single salary after paying for a nanny.  "Do we have enough time between us to take care of a baby?"  Again, like with the financial resources, we would be tight, but we thought we could do it.  (It helped, I think, that we had a dog for a few years by this point--the juggling act of allocating time and responsibility for the care of another living thing was good training for us in terms of the childcare calculus.)   In other words, we went through the exact same decision method that most other couples go through when deciding to start a family.

And finally, the last question, "Do we really want to do this now, or do we want to wait until later?"  Later was, I think, kind of an indistinct entity.  When, exactly, is the best time to have a baby in your medical career?  Everyone has different opinions, but I will tell you this as someone who has basically tried it a lot of different ways: it's never a good time.  It's always going to be inconvenient.  There's always going to be something making it difficult, and there's always going to be conflicting demands on your time, attention, and resources.  With Mack, for example, I had just started my first job as an attending anesthesiologist, and Joe was a newly minted fellow who was taking call every single night, including weekends and holidays, for a year and a half straight.  Thing 3 is set to be born this July, and I don't think I can even anticipate what that's going to be like--three young kids at home, two parents working full-time, lots of expenses, both of us taking night call. Also, to be honest, I'm going to be seven years older this time around than when I had Cal, and I worried (and continue to worry) about the byproducts of my sad old aging eggs.  The "perfect time" to have a baby is a myth.  So you have to do your calculus.  You decide if and with whom and how you you're going to get there, and you decide how much you want it, and when.

Joe and I wanted it.  We wanted Cal, we wanted Mack, exactly when and where and how they came about.  They made things harder.  But they also made things better.

Now let's also talk about the fact (because in many ways having a child as a medical trainee is very different from having a child in any other professional context) that you have to want to be a good doctor too.  That's an important part of it, just as important as the other half.  As a trainee, especially, you have an awesome responsibility to your patients and the future of your medical practice, and you have to figure that into your plans as well.  You have to make time for your education, and having a lot of responsibility outside of your work does not excuse you from your responsibilities while you're there.  There's no half-assing this one--people in the hospital need you too.  You have to put in the time and you have to give that sweat and blood the same as everyone else--in some ways, you have to put in more than everyone else.  But that's part of knowing what you're getting into as well.  Like I said: you can do it.  But you have to want it.

I have seen the argument again and again that having a child during residency makes you a sub-par doctor and a sub-par parent.  I would beg to differ, of course, but how I'm doing on those two fronts is not really for me to judge.  My patients and my colleagues decide how good of a doctor I am.  My kids will decide how good of a set of parents Joe and I are--maybe not right now, because they are both young and therefore still think we are awesomesauce--but down the road, ten or twenty years from now, they'll be able to tell us.  Still, we try.  We knew what we were getting into and we work hard and we try to do our best.  And if I may say, I think we're actually doing pretty OK on both fronts.

On such weighty, personal topics, I would never tell people what to do purely based on my own experience.  (In fact, the only real advice that I can give unreservedly to all medical trainees is: learn at least a little Spanish, and buy some comfortable shoes.)  But I will gently remind you that no matter what stage of training you're in, medicine is just one part of your life, not your life in its entirety.  You'd be surprised how easy it is to forget that.

No doubt residency is hard.  Being a doctor is hard.  But know what you're getting into, get as much information as you can, and thus armed, decide: do I want to do this?  Am I equipped to do this?  Do I have the support to do this?  And then make your choices.  Reading opposing viewpoints is good.  Reading different people's experiences is good--it's largely why I wrote my book, and why I continue to keep this blog, year after year.  Talk it over with your partner, your friends, your colleagues, your mentors.  All these things will inform your choices.  Live your life in whatever configuration, in whatever order you choose to live it in.

And then let the rest of us know how you're doing it too.

(Edited to add: I would love to hear discussion on this issue from all sides, and I'll thank my excellent readers in advance for keeping things collegial--in particular towards Dr. Sibert, who I don't know in person but is obviously a professional colleague in the world of anesthesia. We don't all always agree, but how boring life would be if we did.)

home improvement, outdoor edition

We moved into this house about a year ago, which of course means we haven't really done anything major with the house until maybe the past two or three months.  Oh sure, we did a few things (painted exactly two walls, hung some pictures) but overall we just sort of putzed around as we do, because not being overly fussy we were happy just as long as thing were functional, if not optimized.

I did make one offhand remark last weekend though, which was: "I really wish we had a swingset for the kids to play on outside."

I do.  We have a nice, medium-sized backyard--it was, indeed, one of the things that drew us to the house in the first place (it didn't otherwise show particularly well, it was only because we looked past some of the more glaring, uh, design flourishes that we fell in love with the house in the first place) but it's not really a yard for kids.  It's a gardener's yard.  A gentleman's yard.  A puttering around looking at plants yard.  Not a run around and play ball yard.

It's very pretty, don't get me wrong. Whoever originally engineered this backyard was also very smart in how they planted things (again, it's more of a gardener's yard) in that they staged things very nicely--there's always something blooming or looking pretty somewhere. But most of the yard is unusable for traffic. It's kind of tiered yet sloped at the same time. There's the deck (medium-sized, mainly kind of an entryway to the house--we also have a table out there for eating when it's nice out). Then there's a few stone steps to a kind of small middle staging area, only a small portion of which can be walked on (most of the rest of the hill--I mean, like, 90% of it--is taken up by shrubbery and ivy and pine straw), and then a path up a few more stone steps up to a tiny little third area, which in total is about the size of a medium-to-large-sized Chinese banquet hall table. (Round, I mean.) It's a gorgeous yard, don't get me wrong, and we do love it--it's just not quite for kids. Believe me, I've tried.


KIDS
(Killing each other)

MICHELLE
You kids! Stop killing each other! Go outside!

KIDS
There's nothing to do outside!

MICHELLE
Yes there is! Go play! You're kids! Go do kid things!

KIDS
But it's boring.

MICHELLE
Where's your childish sense of wonder? Go find a worm or whatever.

KIDS
Can we go to the playground?

MICHELLE
Not right now, it's too late/cold/far/I'm busy/gassy etc.

KIDS
(Continue killing each other indoors, where I can unfortunately still hear them.)


I guess Joe had been thinking the same things as well, because upon my single half-baked musing (and granted I was not totally serious, because I figured we just didn't have the right kind of yard for a swing set) he marched right outside and started prospecting the site.

There's this one kind of sloping area--not flat, but as close to flat as you can get in our yard--that seemed amenable. Joe used to do some landscaping in high school, so he started talking about leveling this, putting a retaining wall in that, blah blah blah, and it became evident that, yes, perhaps we could put in a small swingset into the one little plot of dirt that used to be a path and a spice box, and is now a pile of muddy mulch and a weed box. He wasn't sure exactly the scale of the job or how much it would cost, so we had a contractor come by this weekend to weigh in and give us some ideas.

Well, the contracter came, and he and Joe were talking and talking and talking outside, like, a lot.  There was a lot of gesturing in the yard--gesturing in areas where no swingset could ever live.  Eventually I got curious and popped my head out there to realize that the plans had morphed from "level this one little area of the yard" into "level out a full half of the yard, incorporating a swingset area, a flat grassy play area, and building in a stone wall around a fire pit."  Also he suggested that we move the damn shed.





I have to admit the contracter had a good point when he noted that this shed (and it's not bad looking as sheds go, but still--it is just the place where we keep the bikes and poisonous/stabby things) is inexplicably the focal point of our backyard.  I mean, literally, it sits right in the middle of the yard.  He said: I can move the shed to the back near the fence, get it out of the way.  We'll save all the plants, transplant them, move them around.  Let's level out all this shit.  Give your kids space to actually run around.  And then we can put in your stupid swing set.

(He didn't really say stupid.)

I was hesitant at first, because it sounds like kind of a big project (translation: expensive), and we're having a baby this summer, shouldn't we save all our money to buy, I don't know, diaper wipes and nasal aspirators or what have you?  But then the other argument is: we're having a baby this summer, and we have two other kids.  We have a yard that we never use.  We even have a mosquito system in the yard to make it more usable (oh, the mosquitos in Atlanta are the size of small birds, I tell you) but again, why did we put in a bug system into our yard if we're never outside to enjoy it?  I mean, I enjoy our yard--it looks pretty through a window and it's nice to eat out there and have a beer and watch our kids fall down the hill (kids! gravity! two great tastes that go great together), but as uses of space goes, it's not the best for our purposes.

So I think we're probably going to go ahead and do it.  What the hell, right?  We've been here a year, let's make this house look how we want it to look.  Part of me feels a little guilty, because like I said, it is a very pretty garden, and it makes me feel like I'm killing nature or something.  But then I remembered that this yard has already been pretty aggressively landscaped (just not quite to our functionality requirements) and that almost everything growing there is artificially transplanted in anyway.  Besides, the landscapers say that they're not going to get rid of any of the plants, they'll just replant them in other parts of the yard so we can still enjoy them/continue killing them with benign neglect.  So--hooray!  Nature and Man both win!

(Now to start worrying about ways that my kids will crack their melons open by falling off the top of a swingset.)


* * *


Thank you all SO MUCH for all the name suggestions on the last entry, by the way!  (It was, by the way, I think the most comments that I've ever gotten on a single entry.)  I think I also mentioned in the comments (though I realize not everyone reads them so I'll repeat here) that our original name choices for the baby we thought was going to be a boy were either "Ben" or "Beau," leaning towards "Beau"--but we can't use those now, can we?  I know Rebecca Woolf calls one of her twin girls "Bo," but that's short for "Boheme," and though that's such a gorgeous and fitting name for her little girl I really don't think Joe and I are bohemian (ho ho) enough to pull that off.  But you've given us a lot of great choices, many of which we love--and I'm not saying that in a placating Cal way.  Again, thank you!  Best readers on the internet.

the name game

I find it particularly adorable (among the many many things that I occasionally find adorable about my kids) that one of the first things Cal did after I told him that his new baby brother was, in fact, going to be a baby sister; was run to his room and get his dictionary.  "So we can look up some girl names for the baby."

I looked at the cover of the Merriam-Webster.  "Well, this is kind of a dictionary for...words, not really names, Cal."

"I know, but we can use it to get ideas."

So far names he has come up with:

GANA ("It's the country where my friend Qadir was born.  Only I think where he was born has a letter 'H' in it too.") 

MISO (No explanation for that one, but if you didn't instantly think "Miso Horny," well, then you and I are very different people.) 

LUSHAN ("Because it sounds a little Chinese") 

MUZIE (He also included an alternate spelling "MUZEE" in his notes--how thoughtful) 

JULIA (The inexplicably normal name in his list--I think we had a little girl neighbor with that name a few moves ago who came over to play Wii bowling with him one time, and Cal was very impressed.)

Anyway, I didn't want to tell him "No way in hell" (at least to the first four) because, you know, I don't want to crush his dreams or anything, but I just said brightly that it was a very nice list to consider, and let's keep adding to it, shall we?

Cal and Mack are named Cal and Mack.  I don't recall thinking that long and hard about their names, they were just names that I'd heard and I liked, and pretty much after we found out we were having boys, I asked, "How about Cal?" and Joe said "Great!" so there we were.

We don't have an elaborate child naming philosophy per se, but if there was any unifying factor, I'd say that Joe and I are drawn to names that are shorter and straightforward--less common but not of the completely made up variety--and seem to convey a sense of laid-back friendliness.  They're both kind of nicknamey names (I have to tell people Cal isn't short for Calvin and Mack isn't short for Mackintosh or whatever, those are just the given names on their birth certificates) and in particular the fact that the names are somewhat less common have invited some less polite people (mostly via the Internet, not in real life thank goodness, at least not to my face) to be all, "Cal and Mack?  The hell?  What's your next kid going to be named?  Zip?  Pop?  Jet?  Nerp?"  I don't think Cal and Mack are the most eccentric names I've ever heard, but I guess, to some people, they are.

I'd say the closest set of names that I've happened upon to match our aesthetic (and I haven't found this website until a few weeks ago, so we certainly didn't go by this list to name our kids) is this list on Nameberry of "relaxed names for boys." I think I had posted this link on my Twitter feed a few weeks ago--I just thought it funny because it proved that, indeed, we had some sort of underlying unifying theme for naming our kids, even if we hadn't thought that hard about it originally.  I also find it somewhat amusing that the names "Joe" and "Moe" are also on that list--Joe is Joe, obvs, and "Mo" happens to be my Chinese nickname from childhood.  We are related!

Anyway, we'd been looking at boy names, and I think in many ways, boys names are easier, because there's just less frill to many of them.  Girls names, however, are more of a challenge.  What's a short, friendly, not overused girl's name that fits with our first two kids?  Joe and I came up with a few after Wednesday, but no easy favorites, and no slam dunks yet.  Obviously, we have time, but we are planners.  Us and Cal with his dictionary.

So internets, I turn to you.  Give us some ideas.  Some facts that may inform your brainstorming:

• I find old-fashioned names charming--I think the name "Mack," in particular, had its heyday at the turn of the century, and "Cal" is similar in its trajectory.  

• My parents are going to help us choose a Chinese middle name for the kid (Cal's middle name is "Leung-Han" and Mack's middle name is "Wei-Ping," both family names) so we don't know what that's going to be yet, but right now we just need a first name.  

• The kids take Joe's last name (which you can find here), and we don't hyphenate or do anything funny because my last name ("Au"--pay attention, people!) is just generally awkward for that kind of thing.  

• Joe's family is mostly Italian (there's some German/British extraction in there on one side too, which is why he looks...not so much Italian), and while we haven't really gone to that well for the boy's names yet, maybe, for a girl, it could be cute.  (By the way, I asked Joe of there were any nice family names for girls on his side that he wanted to entertain, and he said...well, I'll just say he said no, that's polite, right?)

Names!  Girls!  GO!