M loves all things related to diggers at the moment, so when this showed up in front of the daycare one morning, he was very excited to see it. In fact, he may have requested that J take this photo. I believe it is a skid steer loader (I would never have known that three years ago), but I am not positive. It's got to be a Y-chromosome thing.

Tags: M

Caput succedaneum is diffuse swelling due to accumulation of interstitial fluid in the soft tissues of the scalp in a neonate caused by pressure from the uterus or vaginal wall during vertex delivery. In other words, the baby's scalp gets swollen from being squished in the birth canal. It is caused by mechanical trauma and may occur on any part of the scalp. It can cross the midline (unlike a cephalhematoma) and is a common phenomenon that resolves in a few days without treatment.

If you haven't already found it, I just started a new regular section in the Family Life area of the site. It's a gallery of photos that M has taken that I have put on the website. I usually post the photos in this blog first (see here and here), but now I've placed thumbnails of them as well as slideshow viewing capability.

Tags: M, photography

Yes, that is a plastic steak he is chewing on. And yes, that is his favorite stuffed friend. Hmm. Just a little bit disturbing, yet still adorable.

Tags: A, food

I've been busy with my ob/gyn rotation, so it's been tough to post. I've had some long days where I haven't been able to pump, eat, or even pee (I know it should be easy to just go ahead and walk away, but sometimes we get caught up in the moment and it is very difficult to take a break even for a few minutes). I'm trying to be better about all that (would hate to have bladder or other health issues), so I am making an effort to stay hydrated, carry snacks, and empty my bladder regularly throughout the day (sad that I have to consciously plan this into my schedule).

I hate how medical professionals often don't prioritize taking care of our own bodies and I am just going to to have to stop adhering to everyone's crazy expectations about working hard. I don't usually talk about myself like this, but I work pretty damn hard. It's ridiculous that I have been told to "enjoy my long weekend" even though I was post-call on a Friday (last weekend, not this one), and to "take an easy lunch" when I had 20 minutes between operating and clinic (and hadn't pumped or peed all morning). Pumping is a total pain in the you-know-what (butt and boob), but I'm determined to get to a year so A can transition directly to cow's milk, rather than have to start him on formula first. I don't like how the medical student schedule is so different from the residents' schedule, which makes it even harder to find a free moment, since we're always running from place to place (not always with the team). I'll post more about my experiences after the rotation, but this is a tough month. I know that I should just speak up and say something, and no one would or really could object, but the few times I have requested to take 20 minutes to go pump (when I was on call, for example), the residents didn't really seem to welcome the idea (none have babies) but allowed me to leave anyway. It left me feeling uncomfortable about it to the point that I am only pumping very minimally at the hospital (once every 8-10 hours) and playing catch up when I get home (every 3 hours, including in the middle of the night).

Since I am in rant mode, I'll just mention another thing. Medical school is totally do-able. It baffles me when students get really stressed out about how much they have to do or study and how busy they are. Everyone in medical school is busy. Heck, everyone I know is busy. Medical school is not the center of the universe.

I can't remember if medical school ever consumed my entire life like that (I doubt it) but trust me, there is plenty of time to study for school when you are a student without too many other extraordinary responsibilities (especially a typical single twenty-something-year-old medical student). Really. I remember as a preclinical student how everyone would get all worked up about how much studying they'd have to do and how there were only 4 weekends left before the exam. Four weekends! Assuming that you put some effort into it and study 12 hours each day (3 blocks of 4 hours and 8 hours sleep will still leave 4 hours to eat and take breaks), there is a potential 48 hours or more of studying there, and that is a lot of learning. And let's say you splurge and go out to dinner and a movie one night (~5 hours), that's still over 40 hours of study time, which is substantial. And I haven't even added in the hours during the weekdays yet. So yes, there is enough time to study. I'd love to have just 5 hours of uninterrupted time to study, having had a good night's rest.

I mention this because the other med student on my team (I am grateful that we get along really well) mentioned that she was really worried about the shelf (about 4 weeks away) and really needed to read more and that she was going to have to read all Memorial Day weekend. We have learned about managing patients on our service, but we have barely learned any textbook stuff yet. Lots of scut so far. I, too, am concerned about the shelf and was immediately envious because she could read all weekend if she wanted to, and probably still have time left over for some fun because of the holiday. Since I only study after the kids go to bed (or before they wake up, which is why I am up at 5am this morning), it doesn't give me a lot of time. Either that, or I make J take them out for a while, but residents have to study too (he's got Boards to take in June).

The boys go to bed around 8pm and are up around 6am, so if I wanted 8 hours of sleep (ha!), I'd have 1 or 2 hours of study time (dishes, laundry, shower, pumping included). So I usually stay up until 11pm or midnight and try to squeeze in about 3 hours of study time. I like to get up early to study nowadays since at night I find myself fighting to stay awake at night, which is pretty ineffective. And while I am tired when I get up, it is a little bit easier to read in the mornings than it is as night (at least for me).

I certainly don't want to complain (in response to my teammate, I smiled politely and acknowledged that studying all weekend was a good idea), since it's another pet peeve of mine when people get angry at other people's situations for circumstances that they can't necessarily control. "You think one baby is tough?! Try twins!" or "Don't complain about the work hours, we used to sleep at the hospital on non-call nights!" It would be totally awful of me to start ranting and tell her "What?! I only get to study two hours a day if I am lucky so don't complain!" She's got every right to vent about her stress as much as I do. But, I still feel quite envious.

I chose to have two babies in school, so I have to balance the consequences. But I have two adorable little boys in return (and can avoid worrying about infertility or being an older new mom), so there are lots of perks for me too. Besides, how much someone else studies really shouldn't affect me (although I guess the percentiles of shelf scores are based on averages across the country, so who knows). As long as I do the best I can, I can't really complain. But it's still very tough, and few people can really empathize so it is easy to feel isolated. And I know I could and should be studying more, but I am just so exhausted at the end of the day. I hope I am absorbing more but just don't know it yet.

Anyhow, that's plenty of ranting. I'm done pumping, I hear M singing something about heads and shoulders and A is saying "gla gla gla" so I better go see what's going on upstairs. Have a great holiday weekend everyone!

Tags: school

Here are some more photos that M took. He's definitely improving, and really enjoys using the camera. I think he understands the concept of capturing an image of something, since he's started taking photos of things he likes. He has difficulty holding the camera steady, but he definitely captures something.

There is a blue heron that regularly hangs out on campus. M loves to watch it when we have a chance, and we usually end up creeping closer and closer until it flies away. You can see it in the bottom left corner of this photo:


Here's a partial shot of A and me:


I'm on a tough month and I miss the boys. Sigh.

Tags: M, photography, A, me

One major thing that changes when you have young kids is that weekends are no longer rejuvenating. I'd love to have the weekend to sleep in, read, watch tv, work out, and do all kinds of fun stuff. Not only do those things not happen, but I am usually more tired at the end of the weekend than at the beginning. The kids are early-risers (6am) and the days are exhausting. We do fun stuff, but it isn't really relaxing or recharging. The boys don't usually nap on the same schedule so I can't nap during the day, and there is also a ton of busy work (laundry, etc.) that needs to get done on the weekends as well. That makes rotating through clerkships tough, since there isn't that much time to read. It's now 11:23pm and I am just now getting to read about my cases tomorrow. Fortunately, I don't have to get there until 6:30am but I still have to get up early enough to pump, get ready, and drive 20 minutes to the hospital. So I am setting my alarm for 5am. Better get cracking...

Tags: school

That was the exact text of the very first email that my mom has ever sent (the subject was "hello"), and I am honored to be the recipient. J and I recently helped to purchase a new computer for my parents. Technically, it's only new in the sense that it is not refurbished or used, rather than new as in replacing an older computer. In fact, my folks have never owned and used a computer before, so we're finally bringing them into the 21st century.

My mom was a quick learner, figuring out how to use the mouse to move the pointer, select icons to open, and scroll. She's pretty overwhelmed, but we've tried to make it as simple as possible by only placing necessary icons on the desktop, and locking most applications so that they can't be accidentally deleted or altered. So far, she's able to send a basic email, view photos, and initiate a video chat with us, which is pretty much what she wanted to do. And I can always help her by phone as well.

The next time I visit, I'll show her how to (gasp!) use the internet, which my folks always talk about as if it was a far away place. That's probably my fault, since whenever my folks ask me where I bought a certain item, I usually say "online." So it makes a lot of sense for them to think that "online" is a store somewhere that does a lot of mail order, which is kind of cute if you think about it. On the phone the other day, my mother asked M about the toy car he was playing with and asked him who gave it to him. "Mailman," he replied seriously. He's a riot.

Anyhow, I'm not sure if my mom will read this website (at least not yet), but I emailed her the link anyway and explained to her that she can click on it to access our site. I've loaded the best photos of the kids onto their new computer (over 1000), so she'll have plenty to browse before I send her more. And J (computer geek that he is) managed to arrange for us to have remote access to their computer so that we can update software, add photos and videos, and troubleshoot. That has already proven itself to be essential - my mom accidentally moved one of the iPhoto windows partially off the screen and couldn't figure out how to get it back. So we're pretty much cleaning up the desktop routinely so she can have a fresh start every time she logs in. It's a pretty big project for all of us at the moment.

Meanwhile, my mom is diligently "practicing" every night so she won't "forget how to use it." My dad, on the other hand, spent 20 minutes watching my mom and decided he wasn't ready yet. I think he's waiting until he retires. It's okay though, he usually joins in on the video chats when he can and enjoys seeing and talking to M and A.

Tags: grandparents

Those of you who have toddlers will appreciate how difficult it is to get them to hustle them out the door in the mornings. Something that should really take 10 minutes ends up taking 45, which means that it takes at least an hour for M to get up, have breakfast, and get dressed for school. Putting on socks and shoes and getting buckled into the car also takes a while. Lately, what has been working for us to get him moving is to have A "chase" him. We started doing it to get M upstairs for evening bath, and occasionally do it (so as not to lose its magic) to get him to hurry in general. M thinks it is funny (so does A), and it helps shave those few extra minutes so we can get to work/school on time.

This particular day needed to be a quick drop-off at daycare:

Tags: M, daycare, J, A

I don't know about you, but I'm not sure I could ever be a pelvic exam instructor/standardized patient under any circumstances. It's hard enough for me to get an annual exam (by an experienced physician) for myself that I can't imagine teaching medical students and then have them practice (often for the first time) on me. Most women I know cringe at the mere mention of stirrups, speculum, and Pap (myself included). It's just so uncomfortable. And having now gone through two pregnancies and deliveries, being subjected to all kinds of poking, prodding, and displaying of private anatomy to total strangers (and I got two beautiful babies for it), I appreciate them even more. Whatever these women are getting paid to teach us is most certainly not enough, so I figure they have to be the some of the most genuine advocates of women's health and patient care around. Several times each week at multiple institutions, they patiently guide awkward med students through these sensitive exams so that we can perform them well on our actual patients. And for that (as both a student and patient), I am truly thankful.

Tags: school

I am starting a new regular feature on the site, and will proudly display photos that M took all by himself. He's taken over our old digital camera (our very first one), which is a Sony Cybershot from at least 4 or 5 years ago. At first, he just liked to see the flash go off, but J explained to him how to look at the LCD screen to capture the image he wants, and now he's started to take some decent photos.

Here he is with the camera:


Here are two of his very first photos:

Tags: M, photography

Tags: holiday, me, M, A

Often called IIH, or idiopathic intracranial hypertension, pseudotumor cerebri is a disorder of unknown etiology which predominantly affects obese women of childbearing age. It is basically increased cranial pressure without a secondary cause (malignancy, for example) and most often presents with symptoms of headache and visual changes (particularly, papilledema). As such, the visual exam (visual field, fundoscopy, motility) is critical for diagnosis, and untreated disease may lead to progressive optic atrophy and blindness. The rest of the neurologic exam, as well as MRI and CT, can often be normal. Increased pressure on cerebrospinal fluid analysis is confirmatory. Treatment varies, but include using a carbonic anhydrase inhibitor (acetazolamide) to lower the ICP, corticosteroids, and surgery (CSF shunt or optic nerve sheath fenestration).

The question I was asked had to do with associated etiologic factors, particularly oral progestational drugs. Other associated conditions are mastoiditis and lateral sinus thrombosis, head trauma, marantic sinus thrombosis, cryofibrinogenemia, Addison disease, hypoparathyroidism, tetracycline therapy, and hypervitaminosis A.

This sequence of photos makes me laugh out loud. Now that they are posted, I can look at them from any computer with internet access. That'll be great when I need a pick-me-up at work, or miss the kids when I'm on call, especially if I can't play the video of A giggling.

"Hmm. What's that?" (It's a photo sculpture of M that we got at the mall)


"I must have it."


"Arrrgggh! Look how strong I am!"


"Let's take a closer look before I dig in." (I love the dainty fingers)


"Yum!"


Cracks me up every single time. I love these guys.

Tags: A

What cardiac anomaly occurs with the highest frequency in fetuses exposed to lithium in utero (especially during the first trimester?)

I'll stick a random photo here, in case you didn't want the answer right away. It was taken a long time ago, during a pre-medical school vacation to my old college alma mater, but looking at it now, it could pretty much be anywhere.



And now, back to work.
The answer is Ebstein anomaly, which is a malformation of the tricuspid valve. Specifically, it is a congenital malformation that is characterized by downward (apical) displacement of the septal and posterior tricuspid valve leaflets, as well as malformation and abnormal attachment of the anterior leaflet to the right ventricular free wall. In other words, the tricuspid valve between the right atrium and right ventricle did not develop appropriately and does not work properly, so blood can leak backwards and cause atrial enlargement and potential heart failure.

Because of the increased pressure of backflow blood into the right atrium, many people with Ebstein anomaly also have an atrial septal defect, which allows blood to go directly from the right atrium to left atrium, bypassing the right ventricle and lungs, thus sending deoxygenated blood into the circulation.

Depending on severity, Ebstein anomaly can be asymptomatic, or present with cyanosis, heart failure, dyspnea, tricuspid regurgitation, fatigue, arrhythmias, or many other signs and symptoms. Definitive diagnosis is by echocardiogram study, and the treatment varies from none to surgery (repair/replacement).

Sometime last year, Pampers started the Gifts to Grow program where you create a login on their website and enter in codes found on all their diapers packages to accumulate points that can be used for a variety of toys, book and other products. I don't usually join point programs since most of them are for products that I don't buy regularly or in quantities enough to accumulate a useful number of points. Diapers, on the other hand, are an exception. Without fail, we go through at least a few boxes each month, and we have been loyal Pampers customers for quite some time now. So when this program was launched, I decided to give it a try. I created a login and started tracking our diapers purchases by entering codes (I'd save them up for a while and then enter them all in while I was pumping, since the codes are long and take a few minutes to enter). Originally, there was a program end date of early 2007 (not too long after the program was started), which made it difficult to decide when to cash out the points for a product. But I guess the program was such a success that Pampers decided to extend the program for another full year (now set to end March 1, 2008). It's a bit crazy - some people even sell their points on eBay (and people buy them!). I wouldn't recommend doing that, since most of the products are not that expensive to begin with, and you have to pay shipping on the items. In any case, since each of the economy plus boxes is equivalent to 9 points, it didn't take that long to reach 300 points, which was the number needed to get a Kettler Scooter Skiddy.



There is a Kettler Brummi tricycle available for 400 points, which we would have waited for, except that M already has a Kettler tricycle that we bought for his second birthday. So last month (just in time for the nice weather), I finally traded in enough points for the scooter. We paid about $13 in shipping, which wasn't too bad, considering we were getting the scooter for free (retails for about $100, Amazon sells it for $89). I'll add it to the list of things I need to review, but in general, it's a very well-made and sturdy scooter (Kettler sure does make nice stuff). I'm not sure I would have bought it as a separate purchase, since $90 seems a bit much for a scooter, but I'm glad we were able to get it through this program. The site states that shipping can take 6-8 weeks, but we received the scooter in about one week.

Of course, M is more than thrilled to have a scooter, and he is quickly learning how to ride it. He's been very cautious, and it'll take him a little while to get used to balancing on it, but he really enjoys riding it. I'll try to review it soon.

Tags: diapers, toys

The Consumer Product Safety Commission just recalled the soft blocks on this activity center, which we have (and love). The bulletin can be found here. You can go to the Graco website to request a free replacement, and in the meantime, remove the original blocks off the toy.

Tags: toys

A rare type of hypergonadotropic hypogonadism characterized by failure of the ovaries to respond to FSH and LH because of receptor defects. Apparently, this is rarely seen and a somewhat obsolete term. It is also known as ovarian resistance syndrome.

I started a random list of pregnancy facts a while ago, and I just thought of another one:
It is much harder to lose the weight after the second baby than it was after the first (at least for me). Almost eight months past, and I am still not back down to pre-pregnancy size. Sigh. The worst part is that there are tons of super-fit new moms around here who run or work out on a regular schedule. I'd just like to be able to wear more of my old clothes at some point.

Tags: pregnancy

A is quickly becoming more active every day. I mentioned that he was rolling around a lot in the last few weeks, but now he's pretty much ready to crawl. He's started getting up on his knees, and sometimes gets up on his toes, but he sort of gets stuck at that point and then usually tips over. At this point, his improvement is noticeable on a daily basis, which is just mind-boggling. I'm glad I'm not missing these moments, but my ob/gyn rotation is right around the corner. I just got the orientation materials yesterday.

Tags: A, M, me

Am I the only one who finds the medical terms "incompetent cervix" and "irritable uterus" awkward, to say the least? I mean, how do our patients feel when we tell them "Oh by the way, you have an incompetent cervix." "Incompetent" and "irritable" are generally not words most people want to hear about themselves (or their anatomy), and they most definitely are not words you want to hear when you are pregnant. Am I being hypersensitive?

I look terrible in stripes, but all of the boys (including J) look great in them. A will demonstrate below. He's the only one in our family who can pull off wearing blue, green, and orange stripes (and a giraffe on his pant leg) and look totally cute doing it. Happy May!

Tags: A, clothing