Dreams of a (soon-to-be) Father

Ok, I was going to include this in my last post but it got too long so it gets it's own separate post. Sara also mentioned the wacky dreams I've been having.

Several weeks ago, Sara and I purchased a nice dresser from Ikea for Champ's bedroom (like the one to the right but blue). As we were putting it together we listened to a podcast from This American Life. The theme of the show was "fear of sleep." Each bit featured stories about horrible things that happened at night to the story tellers. The first segment included Mike Birbiglia, a comedian who is frequently on the show, talking about his struggles with sleepwalking. It is hilarious and I highly recommend listening to it (it's about 15 minutes) before reading the rest of the rest of the story below.

A couple weeks after that show, I woke up to find these huge, dark black spiders with very bright colorful markings dangling from the ceiling right above me in bed. They looked like big black widows but their markings were of different colors. They were in a ball and there were two or three of them together. Then the string of web they were on broke and they feel on to my stomach in the covers. I bolted up and jumped out of bed and, standing next to the bed, began rifling through the covers and sheets to locate the spiders. I couldn't see them so I turned on the bedside light. But the light was too bright and I struggled between dimming and brightening the light. I didn't want to wake Sara up but I needed it to be bright enough to find the spiders. Finally, I left it pretty dim and went back to digging through the covers.

At this point, Sara, confused by my grabbing at the covers and the disco strobe light effect I had been making wakes up and asks what I'm doing. I tell her about the spiders and she informs me that there are no spiders in the bed and I should go back to sleep. This sounded like crazy talk but I needed a second to think about it so I went to the bathroom to relieve myself. Upon returning, I still think there may be spiders in the bed, but I'm tired and, if there are spiders, I'll find them when I get in the bed.

Sara's been working some odd shifts recently and, at times, has struggled with sleeping. A week after the incident above (yes, the spiders were in my dream) Sara couldn't sleep so went downstairs. Soon after, I got out of bed and charged to the landing above the stairs. When I woke-up, I found myself at the top of the landing and was very confused about why I was there or where I was planning to go. I didn't realize Sara was awake so I quietly walked back in the room and went back to sleep.

So, Sara thinks the sleep walking might be baby related. Honestly, I have no idea, but I hope it stops and doesn't escalate into me jumping out of windows or climbing on top of tall furniture in the middle of the night. I would hate to have to wrap myself in a straighjacket before I go to sleep. Or maybe we could just find a really tall crib for me.

P90X

In her previous post, Sara alluded to both my working out. So, as not to leave all of our blog followers hanging any longer, here's the follow-up.

I quit playing Ultimate seriously in August 2007. At that point I was in pretty good physical shape - I weighed around 167lb, and as we'd trained pretty seriously for the Peachtree Road Race that previous July, I had a pretty good base of endurance. I was practicing or playing Ultimate at least twice/week and doing at least weekly track workouts and felt good. I kept up training for a few weeks after that but then, without a specific goal to motivate me, I stopped. Every few months since then I would occasionally start "working out" (typically running 2-3 miles a few times a week) but that would last for a few weeks or a month at most and then peter out. It was particularly hard during the Spring when I was coaching and working. Between the two I was working from 7am-8pm or later and didn't have the time or energy for conditioning.

At some point I got it in my head that I would have abdominal definition (a six-pack) either when I turned 30 or when I had my first kid. Now, despite being semi-athletic, I had never had much core strength and had never had anything close to what one would call a six-pack. But this idea had made it's way into my head sometime in my mid twenties. Both turning 30 and having a kid represent to me the "end of my youth." And having a six-pack represents "athletic and in-shape" to me. I think I believe that if I can't be "athletic and in-shape" before the "end of my youth" than it would be highly unlikely that I could achieve that state at a later point in life. To the right is Wolverine, a super-hero for hairy people everywhere and my inspiration.

30 came and went without much protest from me. I continued to occasionally make slight efforts at working out but never pushed past some very basic conditioning (but even running two miles when I hadn't done anything for a month or two was a huge challenge). But overtime I continued to put on weight pushing past 170 and 175 and nearing 180. I started to not like the way I looked in pictures. When having a photo taken, I would try to angle my face in a way to prevent the creeping double chin from making its way in.

Last summer, two of our good friends, Maggie Jackson and Jason Simpson, did P90X together. P90X is a 6-7 day a week training program that combines many aspects of fitness (strength, balance, flexibility). It typically consists of resistance training on Mon, Wed, and Fri, plyometrics on Tue, Yoga on Thu, and Cardio on Saturday with optional stretching on Sunday. Workouts are between an hour and an hour and a half. It is broken up in to 3 four-week segments. Each 4-week segment has a slightly modified resistance routine. Every fourth week is a recovery week and has no resistance and increased flexibility and core strength work.

Both Jason and Maggie had pretty dramatic results in terms of fitness and looked great as they neared the end of the 12 week program. The physical results were obvious. Jason tried to sell Sara and I on the program and I went out and bought a doorway pull-up bar, but I wasn't yet motivated enough to commit to it.

When we found out that Sara was pregnant this spring, my goal of being fit by the time we had a kid suddenly had an end date. But it was the spring and the hardest time for me to commit to myself because of my other commitments (see the "In like a Lion, out like a Lion post"). In March, I played an Ultimate tourney with a Brown Reunion team and I was clearly in the worst shape of my life - I had a very noticeable spare tire and after a possession or two was gassed.

But when Paideia's spring break rolled around, I got moving, literally. I started running every morning and going in to work later. My goal at that point was just to show myself that I could fit fitness in when the Ultimate season ended in May but once the week ended I kept running three days a week - slowly increasing both my pace and distance.

Encouraged by my ability to carve out time for exercise and Sara, I started talking to Jason again about P90X. He burned me the DVDs and we decided that on June 7th we would start P90X. Because it would be hard to meet up, we agreed to gchat or video chat with each other each morning when we started. On Memorial Day weekend I was in Madison for the College Ultimate Championships and, watching the athletes run around, was even more motivated to get back in shape. But, in my mind, I still wasn't sure I would actually wake up and push through the work out that following Monday and keep it up.

When June 6th rolled around, I printed out all of the documents to keep track of my workouts and popped the first DVD in to see what I was getting myself in to. It made me nervous - I've never been big on lifting weights (as Harper Alexander would say "you want to lift weights? Those things are heavy.") But on June 7th I woke up and did the first workout - Chest and Back, one hour of push-ups and pull-ups (literally, that is pretty much the whole workout with variations on those two themes). That was followed by 16 minutes of "ab-ripper X." My performance wasn't pretty. I was a drenched in sweat and dizzy, while doing less than 50% of the reps that the people on the video were doing and far less weight. I felt like I had been run-over by a train. But as Tony Horton (the dude running the workouts on the video would say) "Just do your best and forget the rest."

A quick word on Tony - At first I thought I was going to be really annoyed by Tony. He's cliche, makes corny jokes, and clearly is attracted to Drea (one of the women doing the workouts in the video), constantly flirting with her. And you hear the same jokes again and again every time you watch the DVD. But let me say, I warmed up to him really quickly. I find myself snickering at all of the little silly things he says. "Up on your tippy-toes. Why do they call them tippy?" "This is a mixture of static stretching and ballistic stretching. Stablatic. I just made that word up." At one point in the Ab Ripper X DVD (which you will watch 30 times over the course of the program) he says "That's the croton!" after an intense portion of working out. I have no idea what the word "croton" means but I plan to start using it when coaching to mean something like "intensity."

So, I almost died on Day 1. But I came back for plyos on Day 2. Plyos was more my style but still an incredibly difficult workout (I still find it hard here in week 11 - particularly the rock-star hops). In the first week, I felt pretty good about the plyos and legs and back (which are much closer to the training I've done in the past for Ultimate) and struggled with the arms, chest, and shoulders portions of the workout. And I had always disliked Yoga - and while I still can't really do half-moon or twisting half moon, Yoga has become my favorite workout. My favorite Tony quote is "just put the DVD in." That really couldn't be more true for me. The biggest challenge is getting out of bed and starting the DVD. Once I get past that, I'm not going to quit half way in to a DVD.

I was out of town (in LA) for most of the second week of the program an so I just went on 30 minute runs every day and pushed the workout back. But I was fired up that I was still working out every day. Jason and I managed to connect most mornings for the first month, but we petered out after that. Still, knowing he was there in the beginning really helped push me to get out of bed and do the work in the beginning.

I know this is already long, but I should add that early in Sara's pregnancy, she challenged me to see if I could weigh less than her at some point before Champ was born. Sara started the pregnancy at 145 and I was at 178. The average weight gain is 25-35 lb. So, this was a completely reasonable challenge. While, I'm not measuring my success by my weight, I expected to get below 170lb and perhaps to 165. By the end of the first month, I'd managed to drop to 172 lb. but then leveled off. Sara meanwhile I had gotten up to 168 but leveled off. At that point, with about 3 months left in the pregnancy, I was pretty sure that if I kept up working out that Sara would pass me - but I was hoping that we would cross the 170lb. threshold at around the same time.

Somehow though, we went about four weeks without either one of us gaining or losing weight. I was seeing physical changes but was putting on muscle at about the same rate that I was dropping other weight. Then, at the beginning of the 10th week of P90X I threw my back out while doing plyometric (clap) push-ups on the chest, shoulders and triceps day. I could barely move for two days. After that, I tried to do some stretching and Yoga for a couple days but my back was still hurting too much to do anything more intense. So I took a week off (almost two total weeks off). During this time I found that I was less happy and less productive at work. But not working out meant that I was losing some of the muscle weight I had put on. At the end of those two weeks I actually weighed in at 168 lb! And Sara passed 170 and made it up to 171! (It's funny, when I tell people at work who don't know Sara about her weighing more than me they always say "you don't tell her that, do you?!" as if she would freak out about putting on weight during pregnancy. First, if you haven't seen her, Sara is incredibly beautiful while pregnant and second Sara is far less concerned about her weight than I am about mine (as you might be able to tell from this blog post)).

Last Tuesday I was able to resume the 10th week of the program and quickly put the muscle weight back on to get back over 170. Getting re-motivated to start again was challenging but it has definitely made me happier and more productive at work. And I was sore again like I hadn't been since early in the workouts.

I've got two weeks left in the program. After I finish week 12, I plan to do a week of recovery with mostly stretching and running. I'll then start again through Champ's birth and after that, who knows.

I don't have a six-pack yet, but I've learned a lot about myself in this progress. Most importantly that physical fitness is critical to my happiness - which I'd never really known before. Sara, who's being doing Yoga has been too busy this week to do her work-outs and that has clearly taken a toll on her as well. I think we have a very similar emotional need for exercise which is a really good motivator and bond for us.

I've also learned that I can commit to a serious work-out regimen and get through it. I'm pretty proud of that. I'd always thought that I was only motivated by being on teams where others were dependent on my fitness. But knowing that I'm can personally motivate myself has really changed my view of myself.

One thing I did not commit to was the P90X diet. Maggie had said that the diet made a huge difference and I'm pretty sure that the physical differences would have been even greater had I been more conscious of what I was putting in to my body.

Perhaps I can get that six-pack by the time Champ is born - but even if I don't I'm sure I'll get it before I turn 35 (or he turns 5).

Kyle

Lessons from the Emergency Department

Spending a few weeks in the pediatric emergency department while pregnant has eased my parenting concerns considerably. I have spent much of my time doing something we refer to in the medical field as "reassurance." This consists of telling first time parents that their baby is just fine, is healthy as can be, and is lucky to have such concerned, observant parents. And then redirecting them home and reminding them to return only in the case of a true emergency.

To give you the full effect, I've made a video that incorporates some of the most common ER complaints I've received:

31 Weeks

Champ's Development:

- Size of a squash (they keep saying that now, week after week and it's pretty unhelpful because there are too many squash varieties out there)
- More specifically: 15"- 17" and 2.4-4lbs
- Rapid brain development
- All five senses fully developed: iris color appearing and baby can see faint light filtered through belly
- Baby is "practicing" breathing which helps stimulate surfactant production, the solution that allows the lungs to inflate
- Baby at peak of movement in uterus and will likely turn head-down around this time



My development:

- Shortness of breath worsening as Champ is still breech and his head is up around my diaphragm. It sometimes gets stuck between me and the table as I'm eating. I've been practicing yoga-like inversions to encourage him to turn over.
- Feeling lots of movement, sometimes I think he's digging a hole to China. He had a case of hiccups this morning.
- Have gained 25lbs and increased 2 cup sizes!
- Getting LOTS of comments at work. First stranger to ask to touch my belly was in the bathroom of a bar. Luckily she asked first, but she touched my belly like it was a crystal ball as she tried to guess what his name will be... weird.
- No heart burn, no leg swelling, and no stretch marks yet!
- Had failed my initial glucose screening, but then passed the 3 hour glucose tolerance test, so feeling relieved about that
- Switched providers last month to a pair of nurse midwives who practice in a hospital with OB back-up. We wanted to have the full array of options: water-birth to c-section available and providers who would let me eat, move around, and not have an IV during labor. They are great! http://www.intownmidwifery.com/
- Done with month 1 of internship in the ICU, and on to month 2 in the emergency room. Have 10 hours shifts at any time of day: did some 9p-7a, and now on 9a-7p.



Kyle development:

- He's been keeping up with reading: "The Expectant Father"
- Still brainstorming names daily
- In week 9 of P90X, a rigorous 6 day/wk, hour long work-out series. He's been trimming up and losing weight. We're now neck-and-neck in the "who will weigh more at the end of 40 weeks?" race. Expect a proclamation from him sometime soon...
- Having bizarro dreams (that I'll let him describe) which have been causing him to jump out of bed. I think he's prepping for a crying baby...

Life Cycles

My most recent call night was exhausting. It wasn't the lack of sleep because we actually got to rest for four hours. It wasn't an onslaught of new admissions because we only got 2 early in the evening. Both were straight forward gastrointestinal bleeds. It was exhausting because 3 of our 12 patients died within eight hours of each other.

The first was a man in his 40s who came in severely septic with an unknown infection that triggered his diabetes and put him into a diabetic coma. By the time he reached us, he already had major brain injury and had even lost some of his reflexes, the brain's most primitive function. The prognosis was clear. The family was consulted and after a few days agreed to remove the breathing tube and the medicines holding his blood pressure up. As the interventions were withdrawn, nearly 20 relatives crowded into his room crying, moaning, and wailing. I could hear them even down the next hallway and the sound of their voices was harrowing. We sat outside his room and watched the telemetry on the screen, observing his heart beat slow, change rhythms, and ultimately flatline.

The second patient was my own, a 75 year old lady who had been battling metastatic pancreatic cancer for nearly 3 years. She was admitted for a blood stream infection which we had successfully treated, but the infection tipped her cancer over the edge. I watched each day as first her liver failed, then her lungs, then her kidneys. I met with her family early on and with the help of the palliative care team, explained to them that there was nothing left to treat, that her body was letting go. They told us they had family coming from out of town to say goodbye and wanted everything done until then to keep her living. So we kept her on the ventilator and we kept the norepinephrine dripping to keep her blood pressure up. I crossed my fingers over the next 3 days that her heart wouldn't give out because there was no amount of CPR that would resuscitate a woman that ill and to attempt to do so would be a traumatic way to die.

The family came on Friday. By this time her liver was so dysfunctional that her belly and lungs had filled with fluid. She had stopped urinating. She was completely unresponsive to voice or even pain. She was still breathing, but at a much faster rate than the machine was set for. She was going to tire out very soon.

The palliative care team was unavailable, so I met with the family myself. I told them the story of her cancer, why she came to the hospital and how we had treated her. I explained that there was no surgery and no medication that could cure her and that her body was already letting go.

They asked, "So what are you telling us, doc? What should we do?"

I tried my best to be direct. "Her body is letting go. It's dying and our machines are just keeping her longer. At this point, I would suggest removing the medicines and the breathing tube so that her body can let go peacefully."

It was an obvious solution and the best option for a feisty woman who had already beaten the odds of her cancer. Her family was tearful, but in agreement. As this was my first time leading a withdrawal-of-care conversation, it was a relief to have a unanimous decision. I signed the orders to remove all the supports and 3 hours later, she passed. As the physician, I had to walk into her room and listen to her heart and lungs. Silence. I flashed a light in front of her eyes. No response from the pupils.

"Time of death, 1832."

And then there was paperwork.

Then a CPR code came over the loud-speaker and we ran to find our third patient dying. He was a man in his 50s with lymphoma, admitted for an as-of-yet undiagnosed abdominal infection. After a round of CPR, he regained his pulse, but he was getting IV infusions of norepinephrine, vasopressin, and dopamine just to keep his heart and blood pressure working. The family crowded into the room, still wanting everything done for him. So we kept the medications dripping and again watched as his heart beat slowed on the screen. Because of the IVs, for 30 minutes, it wound flatline and then pop back up again. Then when we were sure, my co-intern walked into his room and pronounced him. Again, the family's crying was painful to hear.

I felt like I needed a drink. So, I did the next best thing a pregnant woman at work could do: bought myself some peanut M&Ms. I ate the whole bag at once.

Then before I could sit down, I had to go upstairs and see a Mrs. H., 55 year old woman with bacterial meningitis who had lost peripheral IV access. I placed a central venous catheter in her internal jugular vein. Then I got called back downstairs because Mr. T, a 47 year old man with AIDS and PCP pneumonia, wasn't breathing well on his ventilator.

And so the night went...


All these deaths in the same day had me thinking a lot about the cycle of life. How could I ignore it when I'm walking around, carrying a new, growing human life? When I was giving the patient chest compressions and feeling my baby kick at the same time, I felt just overwhelmed by life force. It is a beautiful and completely mysterious thing.

I can imagine that when Champ is growing up I'll tell him, "When you were just a tiny baby in my belly, I was running around the hospital taking care of very sick people and getting very little sleep in tiny sterile call-rooms. And when patients got very, very ill and died, you kept me sane because you reminded me everyday that there is rebirth and hope, that there is a cycle to life that is both natural and peaceful."

What Sarah Said by Death Cab for Cutie

And it came to me then that every plan
Is a tiny prayer to father time
As I stared at my shoes in the ICU
That reeked of piss and 409
And I rationed my breaths as I said to myself
That I’ve already taken too much today
As each descending peak on the LCD
Took you a little farther away from me
Away from me

Amongst the vending machines and year-old magazines
In a place where we only say goodbye
It stung like a violent wind that our memories depend
On a faulty camera in our minds
And I knew that you were a truth I would rather lose
Than to have never lain beside at all
And I looked around at all the eyes on the ground
As the TV entertained itself

‘Cause there’s no comfort in the waiting room
Just nervous pacers bracing for bad news
And then the nurse comes ‘round and everyone lift their heads
But I’m thinking of what Sarah said
That love is watching someone die

So who’s gonna watch you die? So whos gonna watch you die

Residency Begins

A few days ago, Kyle surprised me with this vintage locket with an anatomical heart design to congratulate me on beginning residency (He's the best). I love the anatomical heart. It begins at first as a simple tube that spontaneously starts beating 21 days after conception. It then folds on itself and eventually develops into four chambers of muscle, pumping blood to a beat determined by a little bundle of nerve cells. I plan to put pictures in it- maybe of mom and champ- or maybe a mantra-- something to remind me to work from my own heart, to be patient, to be kind.



When I explained the locket to my upper-level, she said "Wow it's only been a week and you already feel that way?" No, I don't, at least not yet. It's only been 10 days and I'm still enjoying work, still feeling very excited to be a doctor every day. My last post-call morning was a bit tough, though. After a 30 hour shift with only 1-2 hours of sleep, I noticed that I had less patience and was pretty eager to leave the hospital, a really difficult feeling when trying to transfer important patient information. Hence, I think the locket reminder may come in handy in the future.

I've started on the ICU and though our patients are very sick, there's actually not too many of them, so it's been a nice smooth start. There's a lot to learn and I've been reminding myself not to be too self-critical. I've been making plenty of rookie mistakes: writing the orders wrong or forgetting to follow-up on some lab results. Luckily, I get called by the pharmacy or my resident catches my errors. There's always back-up. It's just frustrating to be inefficient when there's so much to do. So again, I keep reminding myself to be patient, that the learning will come with time.



My biggest worry about residency is trying to balance the work load while still being human. I've seen plenty of doctors who are smart as hell but have no bedside manner. I've seen them explain a diagnosis in front of a clearly dumbfounded family and then leave without answering questions. Worse yet, I've seen them talk about the patient to the team- right in front of the alert and awake patient- without addressing the patient himself. I've seen doctors be rude to nurses and to each other. I don't ever want to be like that, but I can also see how lack of sleep and a busy schedule make one just a little more irritable, a little more rude and then it's a slippery slope...

Mindful of this potential issue, I'm trying to start out on the right foot. I've been introducing myself to all the nurses and getting to know their names. Luckily, they are all super friendly with me right now since I'm pregnant (they all want to know how far along I am and what I'm having, etc). I've been touching base with the patient's families almost daily, either in the hospital or over the phone. And I've been trying to treat each patient with respect and caring (even the homeless guy in alcohol withdrawal who peed all over himself and smelled like butt and the guy with AIDS/pneumonia/ with respiratory distress who yelled at me and threatened to leave the hospital if I didn't give him "a shot to put him to sleep." I'm sorry sir, there just is no such thing. I know you want to sleep and I want you to stop yelling at me, but if I give you something for sleep, you might stop breathing on me... so how about some morphine?) (And he did lose the ability to breathe on his own some hours later so we intubated him. I felt sorry for him and relieved that he wouldn't be yelling at me for awhile :)

What I am trying to describe has been summed up by "the mama's rule," That is, treat each patient "like they yo mama" (this must be said with my program director's black southern accent or else it doesn't sound as good). I carry Mom in my heart everywhere I go. Even when I had a routine blood draw recently and felt a ping of anxiety, I remembered how many IVs and blood draws she had and I felt more brave. I think about Mom a lot. And I think about how families feel about their loved one being in the hospital and how effective communication and good decision making can effect their perception of their loved one's life forever. I feel very grateful that my last memories of mom were at home, that she was afforded a graceful death from an otherwise terrible disease. It is this memory that inspires me. In death, we should be able to simply grieve the passing of a person and not harbor resentment over their medical care.

26 Weeks- Let the third trimester begin!

Champ's development:

- the size of an eggplant: 13.5-15 inches long
- about 2 lbs
- learning equilibrium: up from down
- hearing fully developed and eyes start blinking

Mom's development:

- feeling more short of breath
- belly starting to feel itchy
- belly button has never been cleaner because it's flush with belly
- uterus is the size of a soccer ball (whoa)
- has gained about 20 lbs!
- getting congratulated by strangers (but luckily no one's touching me yet...)