Patients(ce)

Patients take patience. On any day, interaction with a high number of people can be trying, especially for an introverted personality like myself. But patients are uniquely frustrating in that many of their disease processes are self-induced. This becomes difficult to manage in an outpatient setting, where patients have the capability of making lifestyle choices. By the time they reach inpatient status, the problems are sometimes beyond repair. I've had many such cases this week in the ICU, and have been struck by how preventable they all could have been.

Besides the typical obesity/hypertension leading to heart disease, and smoking leading to pneumonia and pulmonary complications, there has been some interesting cases of causality casualties. Here are a few examples from my last couple days:

• A young man so obese that the weight of his chest wall compressed his own lungs to where he couldn't properly oxygenate his blood. He needed a tracheostomy and a gastric tube and placement in a long-term care facility to lose enough weight to be weaned off of the trach.

• Two teenagers with multiple gunshot wounds to the chest following a gang fight.

• A Jehovah's Witness dying from complications of low hemoglobin post-surgery. She would walk out of the ICU if given a few units of blood, but instead will die within a day or so from heart failure from her steadily dropping hemoglobin.

• A patient with severe aortic stenosis who declined a valve replacement for years. Now she has consented to the surgery, but her heart is four times a normal size from the pressure exerted on it from the stenosed valve, which makes her a poor surgical candidate. Even if she were to survive the operation, her heart is too badly damaged to expect any change in prognosis.

• A young mother, brain-dead from an overdose of cocaine, meth, marijuana, and other drugs. She was brought in after crashing her car with her baby daughter in the backseat.

• A woman who wrote an alternative-medicine book on radiation poisoning, who failed to follow up with her doctor after he told her the treatment for her lung mass was radiation therapy. Now she is in the ICU with a lung completely filled with tumor and metastases to the liver and brain, causing intracranial bleeding. She didn't even want the CT scan that yielded that information. She died a few hours later, only 58 years old.

It takes a lot of patience to manage these situations; to explain to a family member that choices their loved one has made has caused irreversible damage. Families sometimes displace anger over the uncontrollable nature of the situation onto the doctor, and that takes a lot of patience to work through. You force yourself to be patient and thoughtful with the treatment, because it is unmotivating to try to heal someone who made such damaging decisions. You try to be patient and kind with yourself, acknowledging the frustration and discouragement that comes with an easily preventable death.

One thing I am learning quickly upon entering doctorhood...patients require patience.

Intensive Care

For the past 2 1/2 weeks, I've been working in the intensive care unit. I love it- each case is interesting, there is a lot to think about in terms of medical management of multiple organ systems, the nurses are very knowledgeable, there is a wide array of procedures to perform, and the hours are good. One of the things I've particularly liked about it is the communication skills that it takes to do the job well. I hadn't thought of this as an important requirement for this specialty; after all, a lot of the patients are completely unresponsive. What I forgot about was the families.

Communicating with families is probably the most important thing the intensivist does each day. The doctor has to manage patient care, in some cases making them well enough to walk out of the unit, in others, providing a comfortable death. He does a variety of bedside procedures and stays on top of every electrolyte and troponin and ventilator setting. But that's not really the intensive care. Intensive care is for the family, not the patient. Intensive care is a clear and detailed explanation of their loved one's disease, treatments, changes in status, and prognosis. It's obtaining a compassionate and clear do not resuscitate order. It's putting a dying patient on morphine so the only discomfort in their death is felt by the family, not the patient. It's being willing to be the only doctor in the hospital to recognize when medical management has failed, and to make the judgement to decline further treatments that have little chance to improve prognosis.

This is a very unique role for a doctor. Our job is to fight death by treating the entities that lead to it. Acceptance of death equivocates failure. After all, many other professions are measured by outcome. Teachers are graded on how many of their students pass exams, retailers by how much they sell, lawyers on how many cases they win, preachers on how many souls they save. Doctors are assessed by how many of their patients live. This places far too much responsibility on the doctor for patient outcome, rather than a recognition of human mortality. It's true that some physicians are better than others, but none of us can alter or reverse all disease processes. This outcome-based measurement doesn't allow for a practice that by it's nature cares for those with poor prognoses.

Many beds in the ICU are occupied by dead people. The only thing separating them from the morgue in the basement is a ventilator, balloon pumps, medications to keep blood pressure up, dialysis machines, defibrillators, fluids, blood products, and a crash cart. The thing is, death is temporarily optional in most situations. If your heart stops, we can start it. Lungs don't work? No problem. I can keep a body warm and a heart beating until family comes to discuss end of life care, but I have I saved them? No. Dead but with a living body, patients are suspended in a sort of physiologic purgatory until families indicate their last wishes.

And this is where the intensive care really happens. You place a patient on "comfort care" measures- morphine so they don't feel shortness of breath or pain. You take out the uncomfortable endotracheal tube and allow them to breathe on their own. Dialysis stops, feedings stop, medications are withdrawn. They die within minutes, hours, or days, with no discomfort. The loved ones are the people experiencing pain, not the patient. They are the ones that need to be updated daily on patient status, repeatedly explained prognosis and options to, and reassured that their loved one is not in pain and no, they couldn't have prevented it. Comfort care is for the patient. Intensive care is for the family.

Thus was my situation this afternoon. A patient brought in this morning, down for hours at home following a cardiac arrest. Minimally responsive, with a poor prognosis, the attending had a conference with the family to explain these things and let them know that we would watch him for 72 hours to get a better idea of his neurological status and possibility of recovery. That afternoon, the attending left to place a difficult central line, and the patient's oxygen dropped from 96 to 30, pressure dropped, pupils were dilated and nonreactive, no response to sternal rub- all signs of neurologic death and rapidly approaching cardiopulmonary death as well. Since he didn't have an end of life directive (at age 44, who would?), it needed to be ascertained quickly from his wife and daughter what their wishes were. And there was no other physician there. So, I put my big-girl coat on and was the physician, kneeling next to his wife, explaining his new signs and that a decision was needed more prematurely than we had anticipated. It was my first time explaining an impending death in order to get a DNR status, and it was an intensive experience for me to explain his deterioration, to say that the prognosis wouldn't change much despite more aggressive life support, and to try to help the family believe that his death wouldn't be their fault, even if they elected to turn off the ventilator. It was an intensive experience to look into this patient's eyes- glassy, fixed, and dilated, and know that even though I was watching his heartbeat on EKG, he wasn't alive.

No matter what I go into, this rotation has great value not only in learning to think critically about many organ systems at once, but in developing finesse for talking with patients and their families about sensitive topics, including end of life care. It's good for me to see that a good outcome doesn't necessarily equal life. I am grateful to see that just because another treatment is out there doesn't mean it should be initiated. It's good for me to know that I am capable of having difficult conversations. I'm glad to be more exposed to and comfortable with death, accepting that it's a universal truth and that I as a physician can't change that truth. I know these realizations from the intensive care unit are reflective of the intensive process of becoming a doctor.

Dress Shopping

In high school, I loved to shop for dresses. Prom, homecoming, winter formal, Sadie's....my mom and I would head out to Macy's or Jessica McClintock to pick out something really special. Often this would happen before I even had a date to these dances. The date was negotiable; the dress was not. We'd spend the day checking out the racks of dresses and even though the styles and materials changed over the years, the dresses always fell into the same categories:

Category 1: The dress looked great on the rack, but not on me

Category 2: The dress was neither attractive on the rack or on me

Category 3: The dress looked good, my mom liked it, but I wasn't in love with it

Category 4: The dress didn't stand out on the rack, but looked fantastic on me

Sometimes I walked in thinking I knew what I wanted, and left with something completely different that I loved. Other times I left with what I thought I was looking for. Each time, it was a fun adventure.

It's the end of my third year of medical school. I'm starting to ask for letters of recommendation for residency, set up "audition" rotations, and look at programs. I'm setting up all these things like I know what I'm doing, but I don't. I have to figure it out soon, though. It's almost time to pick a specialty. Rotations are set up so students can "try out" all the different disciplines of medicine, and see what they want to do. And strangely enough, it reminds me of dress shopping.

I knew some disciplines were not for me. They were a category 2 dress, a specialty that I knew wouldn't fit and it didn't. I never had aspirations to be a general surgeon, and I would have rather done just about anything than stand next to the OR table for a seven hour abdominal surgery. Radiology is a wonderful diagnostic tool, but the darkroom put me to sleep. Neurology was painstakingly meticulous and gave me a headache.

Category 3: I did wonderfully in family medicine. The attending physicians and patients loved me, and I scored the highest score in my class on the family medicine board exam. The high score actually created some anxiety, because I wondered if I was so clearly dispositioned to this specialty, shouldn't I go into it? I did like it, but I didn't love it.

Category 1: Internal medicine was like one of those dresses that looks fab on the rack and then adds fifteen pounds to your hips. You had high hopes for it, but then can't peel it off fast enough. I was sure this was going to be my specialty; a springboard for internal subspecialties like oncology and gastroenterology. Instead, addressing multiple chronic (and often preventable) diseases in medically complex patients became a draining task, bringing me a sense of weariness instead of the reward of knowing I helped someone. It is an important specialty, one of the backbones of medicine, but I was ready to unzip it and move on.

Category 4: Pediatrics and ob/gyn were time-consuming specialties that I thought I might enjoy, but would certainly not pick as a career. Crying kids held little appeal to me, and I was not particularly interested in women's health. But trying them on was like slipping into a great dress- curves in all the right places without being too tight, a gorgeous color and on sale. I felt like I easily molded into the role of obstetrician, into a kind pediatrician talking with a scared mom. It wasn't a tense stretch, it was just a gentle extension of my own personality, of my own strengths and skills.

So I'm left with two dresses that fit well, a scenario that often happened in the shopping trips with my mom. Sometimes we bought both, if I had occasion to wear them; perhaps perinatology, a mix of obstetrics and newborn care, would be a good choice. Other times we put them on hold and went out for lunch, returning to buy the one that stuck the most in my head. That's another option- just finish up my rotations now, and return to my thoughts in August, assessing which specialty has persisted out of all the disciplines.

I'm don't know yet. I'm still out to lunch. Hopefully it will be become clear soon, or maybe there is nothing to become clear. Either specialty fit well, and I could be a good doctor either way. I need to let go of the idea that there is only one "right" choice. I'm just not sure yet.

For now, I think I'll order dessert.

The Oranges of Wrath

I grew up in Orange County, CA. Back in the 1980s, it lived up to its name. Every spring, my life was punctuated by the sweet smell of orange blossoms that heralded summer fun. By the time I was eight or so, that smell was gone, replaced by the smell of multimillion-dollar new construction. That orange scent always stayed with me though, bringing forth happy memories of my childhood.

Fifteen years later, both the orange blossoms and I have been transplanted to the Central Valley, and that smell is just as good as I remember. However, the scent of oranges now brings a reminder of the long work of harvest. Before living here, I never had an appreciation for the human demands of orange picking. It's expected that delicate fruits such as peaches and strawberries have to be carefully handpicked, often justifying their high prices. But oranges are hardy and plentiful- couldn't they be shaken from the tree like their neighboring crops of walnuts? No. This Valley is covered in thousands of acres of orange groves, each tree bringing forth a harvest of hundreds of oranges...and they all have to be laboriously picked, one by one.

The ladders lean precariously against the leaves of the tree, wide at the base and narrow at the top, and the workers wear a sack that will eventually be filled with about one hundred pounds of oranges. They advance up the ladder, filling the sack, reaching for the oranges in the middle of the tree, and then come down the ladder to place the fruit in crates that hold 400 pounds apiece. Too many times I've seen a worker that's been left hanging by his arms as the ladder slipped, with 80 or so pounds on his back. Fascia tears, creating hernias, shoulders dislocate, rotator cuffs strain, vertebrae compress as the picker falls and his sack falls on top of him. But the fruit needs to remain clean and the day finished for the worker to receive their pay, so back up the ladder he goes. I see him several days later in the clinic or ER, when he has a day off, after his hernia has strangulated, his arm hangs limply at his side, and he can't walk.

John Steinbeck wrote about this same ordeal in his 1939 book, the Grapes of Wrath. He writes about pickers who are starving, who work for almost nothing because its still better than the alternative, which is nothing. The Dust Bowl has abated, but the premise has not. Despite the establishment of a minimum wage, workers (especially illegal ones) have pay that is contingent on productivity and doesn't reflect the overtime worked. The creation of food stamps relieved hunger, but I wonder if it galls the pickers to pay at the store for the all-too-familiar fruit. Maybe available healthcare is better, but mass amounts of toxic pesticides used create high rates of cancers, lung problems, and birth defects. I should see only a few cases of DiGeorge syndrome, a rare type of immunodeficiency, in my entire clinical career. Instead, I've seen six cases in four months.

I still love the pungent, spring smell of orange blossoms. But now the happy memories of early childhood comes with an awareness of the effort and sacrifices made for these fruits. In saying grace, I used to thank God for our food, and the hands that prepared it. Now, I thank Him for the hands that picked it.

Role Models

The job of the physician is to promote health. Whether it be in treatment of disease, palliative care, mental well-being, or health promotion advice, patients look to doctors for answers. They really want to know how they can become or remain healthy. Part of the unspoken advice to the patient is in the physician's own appearance, the choices they enact in their own lives. After all, they are the ones with the wealth of knowledge; they beyond all others are enabled to maintain a healthy lifestyle.

I was in the hospital cafeteria the other day, chatting with a group of local physicians. Here's what I observed:

The cardiologist was holding a plate of fried beef chimichangas, french fries, and ranch dip

The pulmonologist was smoking

The gastroenterologist was eating meats loaded with nitrites

The internist was morbidly obese

Looking at this group of well-educated people, I sarcastically wondered where the dermatologist was? In the tanning bed? I mean, come on. Not only were these poor choices for anybody, but the infraction was directly related to the physician's line of work! Of all specialists, the pulmonologist knows the detrimental effects of smoking, the internist sees the ramifications of obesity, and so on.

I think physicians have a higher obligation to care for ourselves, not only for our own health but as an example to the patients we care for. The "do as I say, not as I do" philosophy is a contradictory and ineffective message to patients. After all, if doctors are making these choices with the knowledge and resources they have been afforded, why should a patient be motivated to make a change? The first line in the Hippocratic Oath is "first, do no harm." But being a poor example of health not only harms physicians, it has the potential to harm patients as well. Making lifestyle changes is hard. It's even more difficult with the professional demands of physicianship. However, I see this as an opportunity to serve patients; a demonstration that healthy choices can be made despite long hours, mentally-draining work, and personal obligations. The physician can be a role model in not only their treatments and advice, but in their own life.

Amputations

I never thought much about amputations. They are common surgeries, most often related to uncontrolled diabetes, and seemed routine and unremarkable to me.

I've had the experience of witnessing several amputations while in my surgical service, all diabetes-related. Each time it surprises me with the sense of loss that comes with the amputation of a toe, a foot, a leg. I had never really considered the emotional impact of losing a limb. To be honest, I sort of thought that amputation resulted from a lack of self-control; the inability of the patient to monitor their glucose levels and make changes. Not to say that anyone deserves this sort of pain, but it seemed like a correlation between sugar and limb loss equaled a well-documented and preventable consequence. And then I had a black foot staring at me from a sterile blue-shrouded operating table.

I looked at it, and it looked at me, and I thought about all the things it had done for that person over the course of their life, how it was part of the patient. Bodies last longer than people, and it's natural to think that the body remains intact throughout ones' life. The operation to remove it reflects the difficulty, the tense dichotomy of this separation. It is a very physical removal- powered bone saws, strong manual bone cutters, and large scissors coarsely separate the limb from the proximal tissues. Nothing is pretty, edges are not delicately sewn. The necrotic tissue is essentially ripped from the living person.

And then you are left with a toe sitting on the OR table; a foot without an owner. You look at it and think "that was just attached a moment ago. Now it's just sitting there." You think about the extension of the person that it was- a baby's tiny toe, taking a first step, running, stubbed, swimming, carefully painted- and the gaping hole that is left from the amputation reflects the loss of something that helped shape a life. It always seems wrong to me to bandage up the stump without the limb, like the surgeon forgot something.

Even as these surgeries seem in contradiction with life, they are performed so people may live. A missing foot is a small price to pay for the excision of gangrene. There is a picture of me (on my second birthday) and my grandfather, who looks absolutely enamored with his granddaughter. He died a few months after this picture was taken. After hearing about my emotional reaction to the excision of a limb, my dad sent this picture to me. He gently reminded me that this precious moment with his granddaughter would not have been possible if he hadn't had the operations to remove a diabetic gangrenous foot and leg.

This is the glory and curse of the surgeon: you either cure or kill. The operating room is the fastest place in the hospital to make a difference in the long term prognosis of a patient. It's not for me- I like ongoing relationships with (awake) patients- but I can appreciate the meaningful work of the surgeon.

Grandpa Irv and a (very) Little Doc, May 15, 1986

Slice n' Dice

I am lame.

On the first surgery of my first day in the OR, I got faint and had to sit down. I am so embarrassed even to write that here. And it was on a simple tumor excision- no big deal! This wooziness from a girl that was a phlebotomist in college, thinks emergencies are interesting, had a relationship with a cadaver (named Phyllis!), and enjoys nothing more than the gory display of childbirth. Granted, I had just recovered from a pneumonia, and have a propensity towards hypoglycemia if I don't eat every two hours, but I don't think that was it. I think it triggers something in me when I see a sign of life in the patient on the table. When they become a person, and not a body, it freaks me out.

Normally I am okay with surgery. I stand there, assist, do what I need to do, and have lunch afterwards. In fact, I'm usually hungry in the operating room. As far as I can tell, the only times I have gotten woozy is when I connect the parts to a whole. I was fine with c-sections, except one time when the patient began complaining of pain. The thought that she could feel the pain of my knife instantly made me anxious and dizzy. A hysterectomy is a removal of a part, akin to replacing the air filter in a car. That's the level of attachment that I have towards the body. But one time, I was assisting on an open hysterectomy and saw the iliac artery, pulsing just beneath my tools, and right away I was nauseated. Of course I know that the person on the table is alive, and this is normal anatomy. However, I think that a sign of life- pain, a pulsating artery, the woman today who was talking to me about western movies- these force the connection for me between patient and body, person and pain.

Surgery is a different mindset than medicine. As my attending said today: "In medicine, you help people live with their disease. In surgery, you either cure or kill." The more I thought about it, the more I thought he was right. There is something to be said for being a mechanic, for leaving everything you got on the table, and walking away. It's not for me though. Those signs of life that make me dizzy- I think that happens because I love patients, because I connect and empathize with them. I don't think I'd ever feel fulfilled having a practice where the patients were primarily unconscious. Plus, its hard on you physically- to stand that long, under those bright lights, with your bladder exploding and stomach grumbling. I'm kind of dreading the next month. And I'm hoping that I can breathe my way through those moments where I catch a glimpse of human pain, and maybe even learn something about being a good surgeon.

California Dreamin'

I had a young patient in the hospital last week that I went to round on, and met her mother. She was a young Hispanic woman, anxious and obviously trying to do the best she could for her daughter. She said that she had recently moved here, and I asked where from? She said Arizona. Making conversation while I examined her baby, I said my school was out by Phoenix, and what brought her to Visalia? She said "I can get much more assistance programs for my kids here- it doesn't make sense for me to live anywhere else. My whole family moved here because in California, we can get so much free stuff."

Her honesty took me aback. I've said before that I can't judge anything as right or wrong, black or white. To an honest and educated person, things are always shades of gray. I cannot- and will not- comment on what my thoughts were at that moment, because what I truly think is that things are much more complex than they may seem. And my opinion is not really relevant anyway. This was just a conversation that surprised me, and demanded some thought. And I wanted to record it here because I thought it might provoke some thought in others.

Soldiers: The Silent Underserved

I loved my elective rotation in a family practice in Orange County. The office was decorated nicely, the exam rooms had winged armchairs instead of standard-issue medical office chairs, the office staff was a close-knit group, and the temp was a cool 67 degrees. It was exactly the kind of practice I'd like to have in the future. I saw many patients there, ranging from newborn to elderly, and enjoyed the various presentations of illness unique to a diverse family practice. One patient in particular was memorable, a young man serving in the Army.

The first thing I noticed about this guy was that he called me "Ma'am." It almost made me giggle- he was about my same age, maybe a few years younger, and I wasn't even the real doctor. He was clean-cut, polite, and respectful, wearing a t-shirt that I recognized as military fabric, similar to the ones my husband wears that are leftover from his years in the Air Force. I asked him what brought him in, and he held up his pointer finger, which was an ominous black color with red marks streaking up his forearm. He said a black widow had bitten it five days prior, and he had tried to lance the bite to relieve some of the pus, but it was getting worse. I asked him what he used to try to drain the area, and he replied "a steak knife, ma'am." Ouch.

I called in the doctor I was working for (clearly this was over my head), and she told me she had never seen a black widow bite before. Unfortunately (or fortunately?) I had already seen many, because in the community I serve, grape-pickers come in after a full-day's work with several bites on their fingers and back from the spiders falling down their shirts from the tall grape arbors. I had seen this because I work with underserved pickers. I never expected this active-duty military member to be more medically underserved than the illegal farmworkers.

The best idea was to refer him urgently over to the orthopedic clinic, given the likely systemic manifestations of the bite and the underperfused finger, but he couldn't go over there due to insurance limits. (When telling this story to my husband, he stopped me here and said, "TriCare" and rolled his eyes). Apparently the military insurance, TriCare, denies unapproved specialist/emergency visits, unless there is an "impending loss of limb, sight, or life." This was getting close enough to loss of limb that the doctor was uncomfortable, but couldn't get the visit approved. He had only come to the office today under direct order from his sergeant.

We gave him antibiotics, and she let me drain the pus using a scalpel (not a steak knife). He was a tough guy, but I knew it was hurting him. He left with strict instructions to come back in the morning to have it looked at again (Yes, Ma'am).

I was appalled. Here was this young man, putting his life on the line, and he was in danger of sepsis and loss of a finger because of insurance regulations? He should have absolutely the best insurance available, able to show his military ID card at any medical facility and receive care, no questions asked. Antivenom should have been given on day one, not palliative care on day six. This doesn't seem to be a topic civilians know much about, but I believe that if a feature article was run about it in a prominent newspaper, taxpayers would demand better medical care of our military personnel. I think this system compromises the medical well-being of the thousands of people that are responsible for protecting our country's safety. My own husband cites it as the main reason that he chose to leave the Air Force and reenter society as a civilian.

I don't know what happened to this guy. I wasn't in the office the following day (another doctor was on call), but I still wonder about him, and hope that everything healed well with no loss of function. Especially since the affected finger was his trigger finger- important for an Army man. I hope everything is okay, but I'm doubtful. If it did heal, it's because of his staff sergeant's orders and his own immune system, not because of care provided by the military. And that's a shame.

Babyfinder.com

I adopted all my animals. Either they were from the pound, browsed for on petfinder.com, or someone didn't want them anymore. In any event, they joined the family. While I know babies are a lot different than dogs or cats, this was my only personal exposure to adoption.

A few weeks ago, while attending to the NICU babies, I noticed one that didn't seems sick and wasn't getting visitors. She was labeled a "boarder baby" on my rounds report. I asked the attending what that meant. He said "it means that she was born and her mom gave her up for adoption. She's just staying here until we can find a home for her." He turned away, and then turned back suddenly. "Hey, do you want her? She's really cute. She has a little heart murmur, but that will probably close within the first year."

I was surprised. I thought that finding a baby to adopt was a huge, prolonged process, and maybe it is. But they were looking for a home for this little one right away. What struck me as funny was the way the baby was presented. All of the animals I adopted had a similar advertisement. The only thing missing for the baby was the "free to a good home" sign, a cardboard box replacing the isolette, and maybe a listing on a website like babyfinder.com.

I told the doctor I wasn't really looking for a baby right now, but I hoped she finds a good home. The doctor looked disappointed and said he understood. And then he turned to one of the nurses and said, "Hey. Do you know if Susie's still looking to adopt? We've got a cute one here." She must have been adopted, heart murmur and all, because when I came back a few days later, she was gone.

Then I started working in pediatric gastroenterology, and saw the most medically fragile kids I've ever seen. I loved it- the challenge of keeping these kids thriving, comfortable, and developing as normally as possible. I loved the challenge of talking with the parents about every aspect of their complicated kid's medical health, and enjoyed the rapport that was built between the patient, parent, and physician of this pediatric subspecialty. I marveled at these young parents' ability to care for their kid and be so knowledgeable about the multiple medical problems they had. They knew much more about their child's care than I did as the medical student. Premature crack babies with a short gut due to resection of necrotizing enterocolitis, feeding tubes, Down syndrome, epidermolysis bullosae (where the kid was wrapped in head-to-toe sterile gauze because of the deep blistering), kids in strollers with oxygen and parenteral nutrition on board, little girls with Crohn's disease, rare metabolic defects, and everything else- these kids needed care. I would sit there and observe, wondering, how do these moms do it? They are happy, invested and knowledgeable about their complicated child's care. Every minute of their lives is consumed with this kid, and they accept it as a part of a full life.

What ultimately came to amaze me was that the most complex kids invariably came with an adoptive parent. The crack kid? The nice lady in front of me wasn't the one who had smoked crack while pregnant. She was the one that accepted the kid after the prenatal damage was done. The kid with cystic fibrosis? She sat breathing noisily on her adopted mom's lap as her adopted grandma fussed over her. It was absolutely amazing- the unquestioned commitment that these parents had to their kids, kids that sometimes had preventable problems due to another adult's irresponsibility.

I think when most people look for a pet, they want to adopt a young, healthy animal. But these moms had committed to kids with disabilities, with lifelong special needs. How much of a commitment is a dog, really? Fifteen years? Compared to a lifetime commitment for a child. It was one of the best lessons that I got out of the rotation. And I hope that the little boarder baby, wherever she is, was adopted by a mom such as this.