Dec 9, 2012


People have funny ideas of where miscarriages come from.  A "misconception", if you will.  I suppose it is the natural way of humans to try to assign blame for a bad outcome.  It's difficult to accept that sometimes things just happen, and we can't control them.  Whenever I counsel someone for a miscarriage, I always say that "this is not from anything that you did or did not do.  You didn't cause this."  My personal philosophy is that it is quite amazing that any pregnancy succeeds, given the complexity of things, and it's not surprising that things sometimes don't go right.  And it always breaks my heart a little when I have a woman convinced that y or z made her miscarry.  Here are a few of the things I have reassured women about:

I drank too much chamomile tea, and it made me miscarry.

I spent too long in the hot tub.  Did it cook my baby?

It's a punishment from God.

It's because my pap was abnormal from herpes (All kinds of wrong here.  Paps are not abnormal from herpes).

I ate the wrong food. 

It came out when I went in a bounce house.

I had a massage, and it caused me to start to cramp and miscarry.

I had sex.

The cat licked my belly.

To my patients and women everywhere- I hope that your doctors, and myself, continue to assure you that this is not your fault.  It happens to about half of women.  Please try to not blame yourselves. 

My Term Baby

I haven't delivered a baby who would live for six months.  It's part of the second year of residency- to hand over the term, live babies to the intern and take the more complex, sadder cases.  The little babies are so tiny, their whole body fitting in my small hands.  They are scrawny and purplish, and cool to the touch.  I feel like I've almost forgotten how a healthy baby feels. 

Today the interns were so busy.  I offered to take one of the new patients to help, and I was just tickled with my term young woman without any health problems.  Six months ago, she would have been just another lady on my long list of postpartums to see, but now- she was my reminder as to why I loved obstetrics.  She began to push, and there was a brief moment- right as the head was crowning- that I wondered if I still remembered how to deliver a big baby.  The little ones just kind of come out on their own.  I did, and it was a nice delivery with no problems.  And I held that baby in my arms just a few more seconds than I needed to, as I cut the cord and suctioned his mouth and nose, just enjoying how his weight felt in my arms, how I could tuck him under my arm rather than in my hands.  And I handed him over and I was so happy.  

A lot of the rest of my career will be these patients.  What a good job.

An L&D Story

A recent funny story from labor and delivery...

A questionable pair comes in, with the woman in labor.  She has just been released from jail earlier that day.
Due to years of drug use,  her veins are difficult to start in IV in, and the anesthesiologist has to come in to start it.  The boyfriend leans over and points "that's a good one!  I could get that one for you, if you like."

No thanks.

She delivers quickly.  The boyfriend crows "She held it in!  I'm so proud of you baby, you held it in til you got out [of jail]!" 

The next morning on postpartum rounds, the woman pulls me aside and asks "Does this baby look just a little bit black to you?  I think this might be from someone different than who I thought"   She is white.  I glance over at "Dad."  Also white. 

I tell her that I can't tell any paternity just by looking, there would need to be blood tests to confirm who the father is.

But the kid looks black. 

Oct 22, 2012

The Gallbladder

I got paged last night down to the emergency room for a patient with abdominal pain.  The ER physician was fairly sure this was gynecologic in origin, and wanted to me to come evaluate.  This is a common occurence, and one of the jobs of the second year resident.  I pull myself out of bed and head down.

The history is unrevealing.  No pelvic issues in past.  Pain aggravated by eating, particularly fatty and spicy foods.  Hmmm.

The pelvic exam is unremarkable.  But I touch her gently in her right upper quadrant of her abdomen, and she just about jumps off the bed.  She can't take a deep breath in when I push there, because the pain is so bed.

I've only seen a positive Murphy's sign once or twice in medical school.  But, I've read about it, and after seeing this lady, I really know what it looks like.  Textbook case.

I presented the case back to the ER doctor with all my findings, saying I didn't think this pain was gynecologic in origin, but had he considered the gallbladder?  Maybe an abdominal ultrasound was in order?
He stares at me.  "Wow.  I never thought about that.  I was so sure it was gynecologic that I didn't consider anything else."

Come ON.  I know I'm a gynecologist, and my expertise ends well below the belly button, but this seemed so clear.  Did he really have to drag me down for this?  There are like five things in the belly that people commonly present for, and the gallbladder is fighting for the top of the list with the appendix. 

The imaging came back a few hours later, showing cholecystitis (an infection of the gallbladder) along with gallstones.  Annoying, yes.  But I was secretly quite pleased that I could diagnose a cholecystitis on my own, just based on clinical presentation.  I guess that's why they send you to medical school.  Most of what I learned I will never use, but you never know when that textbook case will find you, even out of your specialty. 


It's two in the morning.  There is a delivery that is "unattended", meaning the attending physician isn't there.  The nurse has paged for the intern to deliver and me as (as an upper level resident) to be present.

Over the past year, I have come to find this word "unattended" fairly annoying.  I mean, I'M attending the birth in the wee hours, aren't I?  I'm the one delivering the freakin kid.  It's like my presence isn't even worth recording.  And look who's doing all the work.  Let's say the attending "attends" the birth.  Half the time he doesn't even put a pair of gloves on.  Just stands in the corner, humming to himself. 


So I have now moved up in life from being the delivering intern to the "supervising" upper level resident.  I get paged, and come to the room to find the intern in the room, quietly gowned and gloved, ready for the main event.  The nurse is furiously tapping at the computer.  "I PAGED THE INTERN?  WHERE IS SHE?  WHERE?  I PAGED HER TEN MINUTES AGO!"

The intern says "um...I'm right here."  The nurse relents.  Fine!  I didn't see you there!

I ask another nurse if the attending has been paged.  I stand there in the room, waiting for this unattended woman to start pushing.


The intern and I look at each other.

The nurse resumes her aggressive typing.

I clear my throat gently.  "I'm here"  I say.  "I've been here for awhile now.  I made sure that attending was paged."

She looks at the intern, and at me, and back at the intern, and frowns.


At this time, I hear someone come in and start humming behind me.  I turn around, irritated, and there he is.  Now, this delivery is attended. 

Can I go back to bed?

Oct 19, 2012

My Shells

My second year of residency has altered my job from delivering healthy, term babies, to preterm babies that will either not survive or babies that have died.  It's a new interpersonal skill, to give parents this life-changing news, and to support them through the process.  It's a new technical skill- the delivery of either a term fetus who has died and thus lacks the muscle tone to complete normal delivery, or the delivery of a baby so small that goal is delivery within an unruptured amniotic sac.  It's also a new intrapersonal skill for me to do this during the day (or night), and then proceed with my own life without carrying with me too much sadness or emotional fatigue. 

A resident a year ahead of me (and thus much wiser) keeps a small memorial for these children.  She told me that it helps her to cope with the job, and also is a memory of babies that parents do not acknowledge.  It seems right to her that someone would remember and honor these children.  I decided this was right for me too, and thought hard about the way I would like to do this.  I was really anxious about this task of second year, and this seemed to soothe some of the anxiety and give me more control over managing my job and emotions. 

My last night in Hawaii while on vacation early in my second year, my husband and I walked along the beach at sunset.  I had bought a little jar earlier that day from a craft fair, with a sea turtle design on it, but I wasn't sure what I was going to put in it.  Walking along the shoreline, I picked up a small shell, and then a piece of sea glass, a small piece of driftwood.  It started to come together for me, and I picked up more and more special shells, gifts from the sea.  My husband helped me find them, and held them in his pockets for me.  I wondered how many I should get.  Is twenty enough?  I wish there wasn't going to be even that many.  I pick up one and look at it, a micro-conch shell with tiny pink swirls.  What baby will you be for?  What will be my thoughts and experience that makes me drop you into my little jar? 

The jar sits on my nightstand, the sea turtle on the front of it.  About six shells so far have been dropped inside.  So far I can name each child the shell goes with, but I know this won't be forever.  Over time, the jar will fill, and I'll forget the details, but it'll serve it's purpose- a reminder and memorial of the work I do this year, and for many years to come.  And hopefully provide some closure, where I can place a shell and walk away. 

Oct 16, 2012

The Page

I hate getting paged at home.

I feel obligated to call it back, but don't really want to answer any hospital-related questions once I leave.  I'm away from the hospital computers and feel disorganized and unable to give good advice.  Just the sound of the pager in my bag at home gives me a quick palpitation and anxiety.  I would leave it in the car, but then I'm anxious about it going off in the car and me missing something important.

Like tonight.

6:03pm  Pager goes off

6:05pm  I begrudgingly call it back

6:07pm  "Oh Dr. Kennard.  I'm so glad you called back.  There was a code with your patient."

"What?  A code??  So what's going on?"

"Well we were coding I guess, but not anymore.  I really don't know.  I'm actually just helping the secretary out."

Soooo...does that mean the patient is dead?  Alive?

"Well, can I speak to somewhat that does know what's going on?"

A nurse picks up the line, and here is the story:

The patient that I operated on earlier that day was wheeled back to the recovery room after surgery.  Around this time, a nurse notices that the bathroom door has been locked shut, for an indeterminate amount of time.  They decide maintenance should open the door.  And there is the patient's boyfriend, dead on the toilet, after an overdose of heroin.

They call a code (and call me).  The ICU team comes down, and then intensivist says what everyone knows- this person has been dead for at least six hours, and there is no point in resuscitation.  He suggests to call a priest.

At this point I am imagining the transport team removing the patient from the bathroom to the morgue.  I mean, he probably has rigor mortis at this point.  Is he stuck in a seated position then, and should go down in a wheelchair because he can't lie flat on the gourney?

Meanwhile, the patient is still pretty groggy.  Another resident and I look at each other.  We weren't planning to do a full hysterectomy, but the laparoscopy was so bad that she needed it.  What should we tell her first?  "What do you think is the worse news, the boyfriend's death or the hyst?"  I ask the other resident.  (The attending is long gone by this point).

"The hyst" she says, without missing a beat.

Later that night, the patient decides to leave against medical advice, but she doesn't sign the necessary paperwork.  Security finds her padding down a major street in her hospital gown and booties.  They bring her back, not for readmission but to sign release paperwork.  And probably get the hospital gown back.

I don't really know what happened to her.  I do know that we thought this patient would be unreliable to follow up, and closed her with dissolvable stitches instead of staples for this reason.

And I will always leave my pager on at home.

Sep 24, 2012

The Bidet

I have never considered leaving a patients room before because I couldn't control the urge to laugh.  Uncontrollably. It happened today.

I stare at the dandruff on her hairline. I imagine myself in my morning commute, frustrated and stressed and tired. I cover my mouth with my hand and clench my jaw. I will not laugh, I will not laugh, I.  WILL. NOT. LAUGH. I am the doctor, the professional this woman has come to see.

And all I want to do is laugh.

She has come to see me to request a bidet toilet. She went to her primary care doctor, who told her no, she would not recommend this so the insurance would pay for it. Undeterred, the patient came to me.

"I need you to give me a bidet."  She doesn't say hello.

I fight the urge to tell her that they are in the back, along with all of our other plumbing devices, light fixtures, and home improvement hardware.  Instead, I quell my snide thoughts and already present dislike for this patient and ask "Why do you need a bidet?"

"I can't wipe my butt."

I indulge her.  "why can't you wipe your butt?"

"my arms are too short."

I clench my jaw and try to forcibly turn the corners of my mouth down.  "how long have your arms been too short to wipe your butt?"

"about four years, since I got fat."

So, I am to assume that she has been able to wipe her butt successfully for the prior 63 years?

"I can't reach my butt.  Look, I'll show you". She starts to get up.

"No, no. That's all right. You don't have to show me."

*please note, at time of this conversation she is seated with her hands below butt.

The patient narrows her eyes at me. "I'm not leaving until you give me a bidet."

I glance through her history. No recurrent infections that would suggest that she indeed cannot maintain hygiene. A note from her PCP that I completely agree with.   So what do I do? 

I pass the buck. 

I tell her that I can put in a prosthetics request form for them to evaluate her necessity, while writing all over my note that I do not think she medically needs one. I tell her that in the meantime, I can give her a pericare squeeze bottle to help clean herself. I dont have any in the clinic, but tell her I can bring one in from the hospital if she wants to come back.

No, she will wait, she says, and proceeds to sit in my waiting room for three hours until I have it. Her problem is, she doesn't have anywhere else to be.

I get back to my office, shut the door, and howl with laughter.

My Blog

This blog started for me to write down some of the things that I was learning in medical school, to share my thoughts and experiences with others, and with myself.  Anything funny, I found joy in writing down and sharing with others, laughing again to myself as I relived it by writing.  Anything sad, I found some peace and closure in finishing my essay, clicking "publish post."  And over the years I was thrilled by the feedback- family members laughing, medical students I didn't even know writing me and saying that my writing was exactly what they felt but couldn't express.  They showed it to their spouses to help them understand.  Patients- not mine, but some searching on their internet for answers- found my writing and valued the glimpse it allowed them into a young doctor's thinking.

I kept it public for all these reasons- so it could be shared freely between students, so people without email addresses to log in could still see it, and so it could find anyone that might enjoy it.  Knowing this, I was very careful to keep anonymity, to abide by patient privacy laws and confidentiality.  But, despite this, my program director would like me to take it down, despite enjoying my "creative flair."

Who told you I had this?  And how long have you been reading it?  Shit.

But, he is as free to read it as anyone else.  I had kept it that way for all the reasons I listed above, and because of this, he was able to read thoughts that I wouldn't have otherwise shared with him.

I'm disappointed to move this to a private site.  My writing has become such an important part of my life.  I write the entries in my head, in quiet moments, when I exercise or drive, or just walk and think about what I can say to make my life make sense to others, and to myself.  They never take me long to write- maybe ten minutes, limited only by the speed of typing.  And there are always others, ones that I never write down.

I loved sharing this publicly.  It has helped me tremendously not only to verbalize my own experiences, but to hear from others that my stories mirrored theirs, or that they helped someone understand their own life a little better or that people just enjoyed them, and were laughing somewhere in front of their computers.  I will continue to write, and post under a private site, but only for those not connected with my work or medicine.

It is my hope someday to put these into a book, and to finally have it "out there" for others to enjoy and relate to.  I dream of it reaching medical students that don't know me, but feel like they do after reading my book, because my stories are the same as theirs.  I hope patients can read it and know that doctors care about them, and went through a lot to be in a position to help them.  And as always, my grandmother will read these, as she does now, and enthusiastically share them with her friends and nag me to put up another post soon.


This last weekend was our resident retreat. Last year, when I heard we were going on retreat, I imagined a quiet weekend with my co-residents, in a nice location and fun activities, with time for introspection and deep conversation.

I was wrong.

The resident retreat was a wild party, an overnight trip filled with more alcohol than id ever seen in one place other than Costco. The drinking started early, during our team building activities. Which were very stupid, i.e. working as a group to pick up a bowling ball with ropes, working as a group to create a pipeline and fill a bucket, working as a group to put together a giant wooden puzzle while blindfolded.   We decompensated a little at at the end, with someone yelling "who has the corner?  Who the fuck has the motherfucking corner?", and us throwing the puzzle pieces at each other.  But i think we did well overall.

There is a party the night of the retreat, where each class comes in costume, and presents a skit. One classes' costumes this year were all the names for a vagina. We had a pussy cat, an orchid flower, a muff diver (wetsuit with English muffins taped on), a box (girl had cut a hole in a box and wore around her waist sans pants and with a t-shirt up top saying "party all night."), and so on. You get the idea.  Box girl has not worn pants for three years running.   The attending oncologist-who treats every major GYN cancer in a hundreds of miles radius-  is walking around with a blow up doll strapped to his waist.  It's that kind of party.

The skits start.  Ours is wildly racially insensitive, involving a response-type song where the girls sang "empuje!  No puedo!" and the boys employed a baseline of "all in the bottom now, push all in the bottom now."

After the skits, the karaoke machine is turned on. And I can't tell you what glee comes with watching your attending perinatologist- who has literally written the book on critical care in pregnancy- sing "when I think about you, I touch myself" into the microphone.  Off key.

Outside, the pregnant girl and the Mormon residents are hanging out.  Drinking Sprite.  The Mormons are okay with this, but the pregnant girl  takes a sip of my wine.  Her drunk friend (also her obstetrician) comes and sits on her lap.  She taps the pregnant belly and slurs,  "I'm gonna reach up in your cervix and say hey, little baby, come on out.  Come out now baby."

The night ends with the game "two truths and a lie", where you say two things about you that are true and one that isn't, and everyone else has to guess which is which. And it's amazing what's true.  Arrests. Menage a tois.  My "I've played the violin since I was five" is not an impressive Truth. 

The next morning, we are ready. There are bottles of ibuprofen and Zofran for each class. IVs are standing by.  We go outside for breakfast and our final activity, the breaking of the wooden boards. Our director thinks it symbolizes breaking through negative self assumptions and doubt. Each chief takes an intern and shows them how to do it, and we line up, with applause after each board broken. I watch as thirty two surgeon's hands- and one surgeon's head- breaks through the board, this a good idea?

And then it's over. We drive back home, with five lucky people returning to the hospital to stay overnight on call (I was one of the Chosen). Life goes on. We don't put a lot of pictures up, for liability reasons, but tease each other about our Truths, start planning our costumes for next year, and refill the Zofran. 

May 24, 2012

The Hunger Games

An funny email exchange between the (very tired) intern class of 2011-2012 (names have been anonymized):

"Dearest colleagues,

A very serious matter has come to my attention. On Sunday night I left
an unopened milky way bar on my nightstand in the girls' call room.
Today, I arrived to find it half eaten and still in the wrapper! Why I
ask you? Who stole it? Who enjoyed the delicious taste of the caramel
and milk chocolate?!

I must admit though I am secretly pleased because I would have eaten
it. And I need to lose like 20 lbs before I wear a bikini on vacation in the

Intern #1

"It wasn't me.  But I did think about it."
-Intern #2 (me)

It wasn't me, but by the time I got to my naps shift it was already open and half eaten and I was tempted to finish it off.
-Intern #3

"To add to the intrigue,

Two chocolate bars went missing from my personal clear plastic drawer several months ago. Far be it from me to suspect a fellow intern so I ran through other likely suspects. Dr. Attending?  She works like a machine and never seems to tire. It has to take tremendous energy input to keep her going.  What if an idle unguarded candy bar was simply too much temptation?  But no, she would have already bought dinner for us.  Dr. Doctor? I pictured him peeking carefully around the doorway, left and right, before emerging and running hastily down the hall, chocolate in hand, white coat tails trailing in the breeze, to devour my treasures out of sight.  But no, he doesn't move fast enough. He would have been spotted.  What about one of the pregnant upper level residents?  The curse of the cravings of pregnancy respect no boundaries.  Even the level-headed Resident1 or even-handed Resident2 may have succumbed.  But no. Even at the height of their pangs of hunger, I could not imagine them betraying one of their own fellow residents.

In the end, after observing the subtle body language of various employees of the hospital I have come to the firm conclusion that it could have been none other than Dr. ProgramDirector himself.  He has the perfect alibi. Who would ever suspect him?  Who else would be cunning enough, and daring enough, not only to take my candy bars  leaving no trace, but to eat HALF a candy bar, leaving the remaining evidence of his misdeed in broad daylight, sure that no one would suspect him.  I submit it could be no one else.

For the time being we must keep this to ourselves."
-Intern #4

"There was candy?  Where?"
-Intern #5

"Not anymore.  Dr ProgramDirector ate it."
-Intern #6

"F**** *&^*(*& a*$$*(*"
-interns 2, 3, 5, 6, 7, 8

A Brief History of St. Jude Children's Research Hospital

I recently visited with my mentor, Dr. Pinkel, and had the privilege of hearing his stories about the inception of St. Jude Children's Hospital, a place that has changed the lives of millions.  He tells me about getting cards from his patients who now have their own grandchildren!  The pride in his voice and love for his patients, even those he had fifty years ago, is so obvious. He is 87 years old this year, suffers from post-polio syndrome (he nearly died from the disease as a resident), and won't be around forever, I know.   I am so pleased to hear these stories, and share them here.

Danny Thomas recruited Dr. Pinkel to be the medical director of St. Jude, as he had started a pediatric cancer center where he had done his residency, in Buffalo, NY.  He refused.  He didn't want to move to Memphis, and Memphis didn't want the hospital there anyway.  Danny continued to call him, and he finally accepted the job after receiving some advice from his own mentor: "You're young.  If it flops, you can always do something else."  Don Pinkel accepted the job under two conditions.  The first was that the hospital would accept all patients, regardless of ability to pay.  The second was that it would be fully racially integrated, from the patients all the way up to senior staff.  A pretty controversial demand, for a Southern state in 1959.

As I sit talking to him, his wife, also a pediatric hematologist/oncologist, tells me she is preparing to go to Memphis for the 50th anniversary gala to represent him as he is unable to travel now.  The gala, which many celebrities attend, is to celebrate the hospital's first opening it's doors in 1962, and is specifically honoring the first five medical directors, of which Dr. Pinkel is the first.  He tells me in detail about the other four, who is still living, who is coming to represent each.  He tells me about the influential researchers he recruited to come to Memphis, how he wouldn't get off the phone with one young man- for seven hours- until he agreed to come.  How another man, a virology researcher, was eager to come to Memphis and study cancer after losing his wife at age 34 to a particularly virulent breast cancer. (At the time, they thought ALL came from a viral source mutating DNA.  Keep in mind how new of an idea DNA was in the late 1950s).

I am amazed by this history.  I'm laughing at his mentor's comment, that if it flops, he can always do something else- knowing the global presence of St. Jude's in 2012.  The thought that a virus caused leukemia.  The realization of how significant racial integration was at this time.  Everything he said, fit into the framework of today, realizing how different our framework might be had he done something else with his life.  

And I secretly wish I could go to the gala to represent him too, because I am so proud of him.  And also to meet Gwyneth Paltrow and Jennifer Aniston.  I just know we'd be friends.


I didn't want to see Dr Pinkel the last time I went home. It was October, and I was four months into my residency, struggling with this troublesome truth:

I wished I hadnt become a doctor.

Honest to God, if I could've taken back my four years, thousands of notecards, and literal house of debt, I would have.  It was so hard, and so unrewarding, and I was so unhappy. I remember hiking around the time of my graduation, looking at the green hills and flowers, excited about the new growth in my own life, the direction it had taken. I hiked the same trail again in October, and all the grass was brown and dead, the flowers were gone, and I was staring at the hills, resentful of how the flora reflected my life once again.  I wondered why I had done this, why I had thought it was such a good idea and the only direction my life should go.  Because it didn't seem now like it was such a good idea anymore.

And I didn't want to see Dr. Pinkel, disappoint him with this news that he had been wrong. He had seen a good doctor in me at twenty-one years old, had written a glowing letter of recommendation for me, and happily gave me a graduation gift of more money than I'd ever received at one time.  I respected him more than just about anyone I had ever met- this elderly man that had a career including finding a virtual cure for acute lymphoblastic leukemia and being the founding medical director for St. Jude Children's Hospital.  And now I was in town, and avoiding him.  I'm really sorry, I thought, and went back to work a few days later.

I just got back from visiting again, now in May, now  eleven months into my training.  I called him up the minute I got into town, and visited him the next day.  We had a nice lunch that turned into a three-hour chat.  I told him about my patients, my surgeries, all the things I can do now that I couldn't do the last time I saw him.  He told me about how in his time, GYN surgery was a fellowship from general surgery, and obstetrics was a very separate specialty.  Interesting.  He also told me about some pearls from his own training, like this story:

In the 1950s and prior, it was hospital policy that parents were only allowed to visit their children for a few hours each month.  It was thought that the families had made children sick, so they were limited in seeing them while inpatient.  In his medical school training, he watched families wave to their children through a window, standing outside.  As a resident, he let in parents and grandparents as much as they wanted, and paid hell for it, but eventually changed the hospital's policy.   He tells me about his graduating class, how there was not one woman at commencement.  They started out with six, he tells me, and five had a child and dropped out in their first year.  One made it to the senior year, and the professors/attendings/other students teased her for it.  But, she got pregnant too and left school before graduating.  How very different from today, where my class was split 45/55, and we intentionally have to look for men to join our OB/GYN program.

He also tells me about the inception of St. Jude Children's Hospital (this was so special, I thought it deserved it's own post.  More on this to come).

I am amazed by his history, realizing how he has indeed changed history.

And he tells me my life is important too.  That he is glad I became a physician, because we need more doctors like me.  What a compliment.

I go hiking again after I leave his house.  The spring growth is back on the hillside.  I am glad I became a doctor too.

Apr 17, 2012

For My Husband

For my husband, who has done approximately 221 loads of dishes since I started my residency
And unloads the dishwasher too.

For my husband, who installed blackout curtains during my first week of working nights
And pulls them shut each morning when I am coming home from work.

For my husband, who helped me pick out the perfect "first day of residency" outfit
And curled the back of my hair for the fancy residency banquet.

For my husband, who feeds my cats
And picks up the dog poop.

For my husband, who knows more gynecologists than I'm sure he ever thought he would
And listens and laughs to their stories and jokes at parties.

For my husband, who rubs my feet after a long shift
And puts lotion on the parts of my back that I can't reach, since it's dry from the hospital air.

For my husband, who shops at Costco instead of me
Even without a list.

For my husband, who knows more about menstruation and menopause than most women
Because he has quizzed me on every flashcard I've made.

For my husband, who turns down my bed when I'm coming home from a long night shift
And puts clean pajamas on my pillow.

For my husband, who listens to me complain
And is indignant on my behalf, even when it is undeserved.

For my husband, who iChatted me in to my family Christmas morning
Because I was at work.

For my husband, who takes care of me, and our pets, and our home
And if we can make it through residency, I think we can make it through anything.

For my husband, Ryan.

Feb 22, 2012


Her vitals are okay to start with. Blood pressure, pulse...they aren't alarming yet. The patient, a young woman transferred from another hospital for higher-level care, looks at me but doesn't see me. Her eyes are glassy, pupils nonreactive. She is sick after an intentional overdose of Tylenol and a "handful" of other drugs. The specialists descend into the room, like flies on a picnic- toxicology, hepatology, transplant surgery, neurology, nephrology, pulmonology, intensive care.

I'm pretty sure there is some graph that directly correlates mortality with the number of specialists involved in your care.

She gets the Tyelenol overdose treatment started. She gets an ICP monitor screwed into her head, poking out like a funny antennae. We learn that she's not a liver transplant candidate, on the account that this was intentional.

She is young, and pretty. The nurse tells me she thinks she looks like Beyonce. I think to myself, maybe, if Beyonce was yellow as a canary. But I can see it too. It scares me a little that she's only a little older than me, and this sick. I don't understand how she could do this to herself. Is this outcome really what she wanted?

Her blood pressure is falling a little today. She looks the same, quiet and nonresponsive. She's not doing well, despite all the treatments and specialists. I didn't expect her to.

I find out that she's got eight kids, the youngest of which is still an infant. I clench my jaw, angry with her, forcing myself to lay my stethescope gently on her chest, and listen. I kind of want to hit her with it. She's got a stuffed bear laying in bed with her, holding a heart saying "Love You Mom." I don't understand how she's made this choice, how selfish it seems to me. I look at her own mom, lost with the idea of raising eight grandchildren. My anger grows.

She is failing, despite maximum blood pressure support. I know she might die soon, and dread the thought of performing CPR on her, dread breaking her ribs with chest compression and giving intervention to a woman that I know is already gone. She is still a full code status, and I am waiting to hear if she will be changed to a DNR when more of her family gets here. I read specialist after specialist's progress note saying "prognosis extremely grim." I know. I worry about the family. Do they know? Finally, later that day, they seem to understand. They change her to a DNR, and the tension in my stomach unknots a little as I watch her monitor.

There is a cart outside the patient's room with a large tray of muffins and cookies, and pitchers of coffee, tea, and juice. I ask the other residents what it is, since I haven't seem that before, but it looks like the hospital food service. I am informed that it is the "death cart."

What? I am stunned.

"It's the death cart" a senior resident tells me. "Once I see the muffins show up I get my death dictation ready, cuz it's gonna happen soon."

Apparently when someone is about to die, the hospital sends up a tray of food and drinks, since often a lot of family is there and they want to stay in the room with the patient instead of leaving for the cafeteria. I am touched that my hospital thought of this. But to the residents, the muffins are a herald, a sentinel sign for the events forthcoming.

I stop in the room to say hello to the patient and her family. Her mom asks me how long they can hold a body in the morgue, and if they have to pay more past a certain point? They are trying to make arrangements. I honestly don't know, so I call up the morgue myself and ask. The morgue guy tells "a few months, if we forget bout em, but most of the time, a week or so. We don't charge no rent for the fridge space."

I don't relay any information besides the fact that she can stay as long as needed. She is starting to feel cold under my touch already.

The nurse pages me, saying she has died and she needs me to come to a time of death and death declaration exam. I'm not sure what this is, and google it quickly, and find a checklist of things to do. I've never seen one before. For that matter, I haven't seen many people die before.

I hope the family is gone. I don't want them to see me do things to their daughter, their girlfriend, and mother, that just reaffirms concretely what we all know. Thankfully, they are out of the room. Some of the muffins are gone too.

I place my stethescope on her silent chest, easily gently this time. My anger for her has evaporated. My fingers don't feel a pulse on her cold wrists. I am scared by the empty look in her eyes, by her stiff tongue and blank expression. I can't unbend her fingers, and her calves are stiff and contracted under my touch. I open her eyes, look at her pupils, and touch a cotton swab to them. She doesn't blink. I shut them quickly, my fingers pulling down her lids, shutting my own eyes too. I tuck her Love You Mom bear a little closer to her in bed, and pull up the blanket. I wonder, is this really what you wanted? Somewhere, are you happy, succeeding in what you meant to do?

And somewhere, a tiny irrational part of me worries that I did it wrong. That I did something wrong, and am sending a live person down to the morgue, that there's some reason I don't know why I cant feel a pulse. That she'll sit up in the fridge and wonder how she got there. Funny, maybe. Irrational, yes. But true.

And, a tiny irrational part of me worries that there is something more I could have done when she came in. But, I know the truth. She was gone when she came to me. I guess that's what she wanted.

Time of Death: 1136.

Feb 17, 2012

Thank You

Here is a story of probably the nicest thing any patient has ever said to me. I wanted to write it down before I forgot, so I can look back at it on the days that I feel like my work doesn't matter, an attending berates me, the nurses undermine my work, or there is a sad outcome. I went into medicine because I wanted to help people. And I thought becoming a doctor was the best way for me to do this- to gain the technical and clinical skills to be helpful. Sometimes it is. Sometimes it feels like it isn't. But, I love what I do, and what I get the opportunity to provide. Sometimes it's easy to forget this, which is why I hold on to this memory, precious and vivid.

I admitted a young woman, pregnant with her first baby, at 34 weeks. She was feeling sick, and her baby's heart tracing was concerning. Both of them looked sicker within the hour, but the attending and I were slow to want to do a c-section on a premature baby. We gave her fluids, and I watched them both closely. Then, the baby's heart rate when down. I called a crash section, and with the help of the OR team, had delivered that baby before the attending even got to the hospital.

There are a few quiet minutes, in between initiating the crash and the quick ride to the operating room and swift delivery. They are precious, my one opportunity to sit calmly with a mother and her loved ones before the chaos begins. I take her hand, and tell her "Everything is okay. Your baby's heart rate went down, so we need to do a delivery now. But, we do this all the time, and can get your baby delivered quickly." Usually the panicked mother starts to cry about now. I let her know gently, "in just a few moments, it's going to get very busy in here, with a lot of people, but that's normal. We just need lots of hands to help. We are going to take a quick ride down the hall to the operating room, and I'll be waiting for you there."

This time was no different. Lots of nurses, a quick ride down the hall, me smiling at her with everything but my eyes covered by a mask. A few minutes later she was delivered, and I was stitching her up, just as the attending arrived.

The gem came later, two days after her delivery, during my morning postpartum rounds. I went to see how she was doing, and she grabbed my hand and squeezed it. She said "I just want you to know...that time you sat talking to me, when you told me how it was going to get busy, but not to worry, because that was normal? That was so calming, and I just wanted to tell you...when I think about my baby's birth, I think of you. My clearest memory of my delivery is you, sitting on my bed, in your flowered hat (scrub cap), holding my hand and telling me what to expect, and that it would all be okay. Thank you."

Thank you, dear patient.

The Light

This is one of my very favorite patient stories.

I am in the ICU right now, working with very sick patients. This 94 year old gentleman came in to us hypotensive and tachycardic, and needed a lot of fluids. We decided to put in an IV in the jugular vein, to allow high volume fluids to go in. I explained what we would be doing, and that he needed to have a drape over his face in order to maintain sterility during the procedure. He agreed, and masked and gowned, I covered him up with the drape and began the procedure.

It was a little dark in the room, with only the flourescent overhead lights on, so the attending reached over and turned on the bright surgical spotlight so I could see better. All of a sudden, under the drape, the old man begins screaming"I SEE THE LIGHT!! I SEE THE LIGHT! OH LORD JESUS DON'T TAKE ME I AIN'T READY TO GO YET!"

"Sir. SIR!!" I reach out and touch his shoulder. "We ALL see the light, sir. It's okay. We turned it on to see better for the procedure." He is wary. I tell him, now we are going to turn off the light, okay? He nods. I then tell him, "sir, we are going to turn the light back on. I just want you to know it's me turning on the light, and everything is okay."

He is calmer, and I place the line. He gets his fluids, and gets better. Apparently this 94 year old man's got a lot more living to do.

Jan 14, 2012

The Imposter

I'm still a little surprised that my name badge says Doctor. I've seen prescriptions filled that I've written, pausing momentarily to look with surprise and marvel that my name- Dr. A. Kennard- is on the label. And not as the patient. It's in the top corner; the doctor's spot on the label. I'm always surprised in the operating room when I say "knife, please" and they hand it over.

My mother laughs, and tells me I have Imposter Syndrome. She says its common in young professionals, and probably most so with a very important job, as I have. So, I looked it up. I thought she was making it up, but apparently it is actually a described and studied entity. Imposter Syndrome is described as " is a psychological phenomenon in which people are unable to internalize their accomplishments. Despite external evidence of their competence [ie, my name badge], those with the syndrome remain convinced that they are frauds and do not deserve the success they have achieved. Proof of success is dismissed as luck, timing, or as a result of deceiving others into thinking they are more intelligent and competent than they believe themselves to be. It is commonly associated with academics and is widely found among graduate students and especially in high-achieving women" (Clance, et al, 1978 and Lucas, 2008).

Huh. I wasn't aware I had given consent for researchers to observe me and exactly describe my thoughts and behavior.

I think part of my reluctance to realize my success is that I am in a group in which I am very, very average. I am definitely not the smartest. I am not the prettiest. I am not the most athletic, the thinnest, the tallest, the shortest, the hardest-studying. I am probably not the most insecure. And I'm quite sure I am not the only imposter.

I watch in awe (and jealousy) as these residents give presentations at world-class perinatal conferences. They run marathons. They have beautiful, highlighted hair, smart clothes, designer shoes and bags, toned arms, tight abs. They are mothers. They seem to effortlessly go through working twenty-four hours with a plan to go for a run afterwards, as I am blindly grabbing for my coffee, planning a workout I won't do, and stumbling towards bed. They spend hours pumping breastmilk so their babies can have the best nutrition possible while they are away at work. My dog is lucky to get his scoop of dry kibble.

What normal person wouldn't be an imposter, wouldn't be intimidated, by this group and this job? But my mother points out, I am not a normal person either. I belong here too. It would have been impossible to fool enough people for me to be here just on luck, so I must be here on my own merit, despite my veil of inadequacy. And the fact that it took a prestigious residency- one of the top in the country- to make me average is pretty un-average.

I'm back in the operating room, after reading this research. "Knife, please." They hand it over. I look at them suspiciously and with surprise. Are you really sure you want to do that?

I'll keep working on it.