11 September 2016

It All Goes Pear-Shaped (Part 2)

The day after our midnight medical adventure was fueled entirely by caffeine (me) and opiates (Benjamin).  I had the sensation that I was dragging myself through the day by my fingernails.  I somehow got the children out of bed and dressed.  Bear requested a chocolate bar for breakfast, reasoning that he had pancakes in the middle of the night, so this was actually "breakfast dessert."  I could not argue with that logic.

While Bear ate his chocolate bar, I checked on Benjamin.  Having partaken of the aformentioned opiates, his level of consciousness did not engender a great deal of confidence in his ability to care for a seven month old.  Wednesday was not a planned day for Pax to go to "school,"  but I stuck her in the car anyway, hoping they would have space and staffing to take her.  My backup plan involved quickly babyproofing the staff room at the office and/or assigning the medical student to a surprise "developmental pediatrics" rotation.  Luckily, they were able to take her at daycare.

Chewing on a hammerhead shark and talking to her friend

After depositing my offspring with surrogate caregivers, I made my way to the bakery next store to the office and acquired the first of many caffeinated beverages for the day.  When the barista handed me the hot paper cup, I thanked her a bit too emphatically.  Her eyes looked concerned for me.  "You're welcome?" she said.  I was already scalding my tongue and scuttling out the door.

We muddled through the week.  I fell asleep while putting the kids to bed. Benjamin's pain level was up and down.  There was no sign he was passing the stone but it did seem to get better from time to time.

By Saturday we were feeling well enough to attempt another walk on the trail.  My phone rang in a particularly windy area, but I answered it because it was my co-GP.  (I haven't actually gotten permission to use her name on here so we'll call her Laura).  Laura was inviting me to a peer group later that day.  I could only kind of hear her and wasn't that sure what a peer group was but sure, I was game.  Great, she could pick me up.  Did I want to bring the kids? Not knowing what peer group entailed and seeing as it was during nap time, I declined on behalf of the kids.

Guys, it turns out peer group is the best thing ever.  It's a bunch of women doctors getting together to let their kids play and talk about medicine.  And there were muffins.  I think it's lucky I was still moderately exhausted because otherwise my enthusiasm may have overwhelmed them.  I basically want to be at peer group always.


On Sunday morning, I was just getting things packed up for our weekly trek into Whakatane when my phone rang - it was Laura again, but this time she sounded like ... like Benjamin sounded the week before, frankly.  She sounded quite sick.  Could I possibly do the weekend surgery hours for her? Of course.

On weekends, our surgery opens for one hour - all patients who get through the door during that hour get seen, no matter how long that takes.  Sometimes there are three patients and sometimes there are thirteen.  The staffing is just one doctor and one receptionist, so it's kind of like climbing without ropes in terms of nursing support.

On this Sunday, there were fifteen patients.  Of them, I sent four to the hospital in Whakatane.  One of the others needed sutures.  It was busy but it was fun.  I hit a rhythm, found my groove, etc.  Part of it is that I've grown accustomed enough to the Kiwi accent that I don't need to strain so much to understand people.  It was one of those days that makes me remember that I really like my job.  I like talking to people and hearing their stories.  I like the puzzle of making a diagnosis.  I like the craftsman satisfaction of bringing two edges of a wound together.

I came home tired but happy.  The week would be slightly disorganised given that we hadn't gotten to do our big meal-planning and grocery shopping trip or the massive laundry turnover that I had planned - but we would manage.

When I got to work on Monday, Laura was not there.  She was not just home recovering from food poisoning; she was in the hospital with appendicitis.  And so our two doctor practice (which was actually already short a doctor - we should have three) was down to one.  And the one doctor was me.  Gulp.

The next week was Rough.  On regular days, squeezing patient encounters into their allotted 15 minutes is difficult.  Now I had my patients to see, as well as some of Laura's patients who had urgent concerns that could not be rescheduled.  On top of that, I was signing off on the notes and scripts for four nurses and supervising a medical student.

Our EMR has a little counter so you can see how long your patients have been waiting.  As I finished with a patient and sent him on his way clutching a script for an increased dose of Metformin and a handout on carb-counting, I thought, "my next patient has only been waiting 45 minutes! That's not so bad in the grand scheme of things!" And then I opened my door and found two nurses, a medical student, and a receptionist all waiting to talk with me.  Rinse. Repeat.

When all the patients were finally gone for the day, the mountain of forms, notes, and lab results remained.  I trudged home with the surgery's laptop.  After putting the kids to bed, I stayed up writing notes and sifting through lab results.  Even after closing down the computer and crawling into bed, I kept jolting awake with thoughts like, "must remember to call that patient about his sub-therapeutic valproate level," and "did I send in the paediatric referral or did I just think about doing it?"  I was on call every night, fielding questions from the nurse about kids falling off horses and grandmas with pneumonia.

Every morning, there is a staff meeting.  The practice manager would report on her attempts to find another doctor.  She did find some locums to help with a day here, an afternoon there, but no one remotely long term.  There kept being whispers about doctors that people knew that might be free, but inevitably it would fall through.


There have been many meetings recently about the future of health care delivery in this rural community. As a newcomer and a temporary resident, I have not participated in these discussions.  But now I am right here, living the microcosm of these organisational decisions.  And all that is clear to me is that model of the solo GP must die.  We must have a system robust enough that it does not collapse when one person gets appendicitis.  We must make this work appealing enough that doctors want to work here.  It shouldn't be this hard, given the setting includes the glittering sea and rolling hills of verdant farmland.

Laura told me on the way to peer group that she used to be the only woman.  Now there is only one man, the rest are women, all with kids under six.  The older (male) generation of doctors always seems to be complaining that we younger (female) doctors don't want to work hard, that we selfishly want to spend time with our children and away from medical practice.  And you know what? I'm guilty as charged.  When I signed up for this job, it involved working four days a week and every third weekend.  Because I want to spend time with my family.  And I want to spend time exploring this amazing country.  But until now I have always subconsciously agreed with the assumption that this was to the detriment of patients, that I must be taking something away from the patients to spend more time doing anything else.

And because I learn best by doing, I now know that is not the case.  Right now, I am exhausted.  I cannot give my patients my best self because I am distracted and half asleep.  This is not a problem that can be solved by just doubling down and working harder, the system must change.

Unlike the US health care 'system,' I have faith that things here will change (and for the better).  Sitting around the table of another GP, another mom, at peer group, I saw that we young doctors actually have a community, it's right here.  It's just the organisation of things that make us feel alone - these women work right down the street from me.  And they all want the same things I do - to take good care of their patients and also their families, to have enough time away from medicine that they can bring their best selves to medicine.

07 September 2016

It All Goes Pear-Shaped (Part 1)

Benjamin and I are trying to establish a new ritual of taking a walk every day as a family.  We live near a walking and cycling trail that leads through the dunes to the beach.   The idea is we go every day right after I get done with work.  There is currently juuuust enough sunlight left for this to happen if we walk about 3km.  I recently purchased a second child-carrying device, so I wear Bear on my back and Pax on my front, trying to guarantee that I will never get osteoporosis.

Still more comfortable than being pregnant.

This is a fledgling habit, in that we've only done it a couple of times.  I feel protective of this tiny baby habit, I want to foster it, help it take root.  I feel like this will be a very positive thing for our family - getting some exercise, getting outside, having a routine.  Though right after shooing the last patient out the door I really very rarely want to dart home, change my clothes, and go for a brisk walk.  Going home and collapsing on the couch with an adult beverage sounds more appealing, but I am committed to this plan.  As the plan's main cheerleader I have to counter a lot of whining from ranks - "It's too cold," "I'm hungry," "It's raining," and other ridiculous objections.

So on Tuesday when Benjamin started with the, "my stomach isn't feeling so hot," I was having none of it.  "Put on your shoes," I growled at him.  And he did.

Attempting to just 'walk it off.'

We got out to the trail and he helped me strap the kids on.  We had walked less than 500m when he started grimacing and twisting around, hand on his belly.  "I think I need to go use the restroom," he said, "You keep walking, I'll pick you up."

So the kids and I continued on and he headed back to the car, but walking without Benjamin to talk to or keep pace with seriously eroded my enjoyment of the situation.  In the new child-carrying device I have for Bear, Bear's mouth is positioned approximately four centimeters from my ear.

"Mom, can I have a snack when we get home?"
"Mom, can I watch Paw Patrol when I get home?"
"Mom, do you remember when we got a cupcake at that store? Can I have a cupcake now? Can I have a cupcake for dinner?"
"Mom, Waitangi at school has a Thomas backpack."
"Mom, is Maryland close to New Zealand?"
"Mom, Skye from PawPatrol has a helicopter."
"Mom, I want to go back now.  Can we go back now? Is our walk done yet?"

We did not make it 3km.  We went down to the beach and I let Bear run around a bit, hoping to run off some of the energy flowing out of his mouth in the form of a continuous verbal onslaught.  It was unsuccessful.

"This is my dune-running game!"

"Mom, it's too windy."
"Mom, are we there yet?"
"Mom, can I have a cupcake for dinner?"
"Mom, Pax is touching me."

When we got back to the trail head, Benjamin was waiting in the car, still looking a bit uncomfortable.  We got everyone loaded and then unloaded.  I busied myself getting some dinner together for the kids (spoiler alert: it was not cupcakes).  Benjamin disappeared into the bathroom, where I assumed he would take care of whatever unfortunate gastrointestinal situation he had going on.  Later I realised I had not seen him in a while.  I checked my phone and found that I had a text from him, "Why aren't you helping me?"

I was confused because my husband is the only family member that I usually don't have to assist with pooping.

So anyway, I went to the bathroom.  When my obstetrics patients look the way Benjamin did, I generally ask the nurse to assemble the delivery table, so that we have the gauze and suction bulb and umbilical cord clamp at the ready because we will be needing those things soon.

While I was standing there wondering why my home first aid kit lacks both injectable drugs and portable CT scanners, Benjamin motioned that he was going to vomit.  So I provided him a readily accessible vessel, the baby's bathtub.

I was proud of myself for keeping my sympathetic vomiting reflex under control, but apparently more was expected of me.  I am, after all, a doctor.  So shouldn't I be fixing this situation?

I hate being my family's doctor.  Like, if my in laws need their blood pressure medication refilled, fine.  But when it comes to diagnosing my family I am often awash in self-doubt. So I sort of stared at my husband as he writhed around on the bed.  Appendicitis? Gall stones? Small bowel obstruction? Gastric ulcer? Gastric adenocarcinoma? Pheochromocytoma? (It has to be a pheochromocytoma some time, right?)  Eventually I snapped out of it and loaded Benjamin into the car.

I took him to the town's tiny hospital and dumped him unceremoniously at the feet of the ward nurse, Debi.  When she asked what to do I said, "Whatever you do for people who aren't my patient."  Then I went to bring in the kids from the car.

The beneficiary of his wife's compassionate medical expertise.
Debi, having considerably more medical experience than me and also her wits about her, quickly determined that Benjamin should go to a larger hospital.  Like one with a CT scanner.  She also requested a urine sample, which when produced looked like cherry Kool-aid.  This jogged Benjamin's memory enough to mention that time about nine years ago when he had a kidney stone.  Right.

Debi called an ambulance. And I took the kids home and put them to bed.  I tried to get some rest myself, but I couldn't fall asleep.  So I got up and cleaned the vomit out of the baby tub.  And then I got a bit carried away and cleaned the rest of the bathroom and folded two loads of laundry and did a bunch of dishes.

Benjamin made contact around 2am to say that he was feeling much better and he was being discharged without having taken a trip through the hospital's famous CT scanner but with a fistful of pain medication.  I woke the children and put them in the car.  I drove through the dark to the hospital, I retrieved my husband from the hospital entrance, and I took him to that fine 24-hour drive-through dining establishment, McDonalds.  Bear got pancakes because, "they serve breakfast all day, now,  Mom."


One of the reasons Benjamin wanted to come to New Zealand was to establish some independence for our little family.  At home in Maryland, we enjoyed the support of a wide network of family and friends.  Finding middle of the night emergency childcare so that I could go pick up my kidney-stone riddled husband from the emergency room would have been no problem.  In fact we often partook of free childcare for totally frivolous things like "date night."  To Benjamin this somehow represented unacceptable dependency.  I have always maintained that I have absolutely no problem taking the grandparents up on their desire to spend quality time with their grandchildren.  But I must admit, driving through the dark with the kids in the car, I did have a small sense of pride, like, this is tough but we can do it.