tie my hands

After years of being a student, an intern, a resident and a fellow, I am poised to become a real, grownup doctor. This coming July, I will be unleashed on the population with my skills, knowledge and sanitized hands. The question is, "which population"?

I have, at this moment, 3 options.

1. Buy out the Return of Service obligation - this will cost around 360 thousand dollars, up front, in cash, 30 days from graduation.

Pros: Goodbye Ontario, flexibility to work in the GTA if I so choose, flexibility to take on short term contracts instead of committing to 5 years in a single under-serviced location.

Cons: Holy jebus the debt. My daughter will have to wear bread bags on her feet instead of shoes. I will have to do a side business doing illicit organ farming.

2. Sign a contract with a nearby hospital (peripheral to GTA) and start working.

Pros: I have offers from several locals, including one where several of my friends are on staff. They assure me that I am "tough enough" to handle the patients and the flow. They are also financially solvent after only 2 years of grownup work.

Cons: FIVE FRICKING YEARS?!? I know, I know, medicine is all about delayed gratification, but I have delayed and delayed and...I would like my kid to know what my home province looks like. I would like to take a few months to travel with my family before we're all stuck in school holiday scheduling. I would like to have a choice to try something else if my first job isn't what I want.

3. Run run away... I only have to deal with the ROS if I choose to practice medicine. What if I finish the program and then run away and become a goat farmer on Pender Island? Free free free!!! Never to be held accountable for deaths and disability! Never to be spat or bled or shat upon (well, by a human)! Never to have to smile while someone insults me!

Believe me, I'm leaning towards three.

tiny rant

According to the internet, books, friends and my mother in law, I'm doing everything wrong when it comes to my baby.

This doesn't particularly bother me (today) as Bub is growing well, feeding well, sleeping occasionally and appears happy. However, I've been finding the trends of what I'm doing wrong interesting to map.

1. I'm coddling/spoiling the baby.
- this is mostly from older folks; my parents, friends of ours with older kids etc. They feel that a 3 month old infant should not be in charge of her own schedule, that I should ruthlessly dictate her waking, sleeping and eating. Which I would love to do! Honestly! But, as she is 3 months old, she is essentially a brainstem, capable only of reacting to stimulus. Hence, she cries when hungry, sleeps when sleepy and wakes when...you get the picture.

2. I'm abandoning/abusing the baby.
- Hippie friends, midwife friends, ladies on the street (who flip flop between one and two) all agree; if the baby is not on me every minute, being sung to and nursed and rocked, then I am failing as a mother. Most of these people do not have kids. They don't have to negotiate alone-time in the bathroom.

3. I'm taking too much time off work.
- This comes from my medical friends, and also from my own guilty, pulsating brain. I will have been off work for almost a year by the time I go back. During that time my peers have worked, passed exams, started jobs and saved lives. And earned money. And used their brains. My brain is currently fixated on learning baby sign language and plowing through the West Wing again.

4. I'm not taking enough time off work.
- My partners male friends are unanimous on this one; as I am only taking 6 months of mat leave (the other 6 months were "my pregnancy is killing me" leave) I am a bad mother. One of Mr G's lovely friends, who is otherwise a very feminist seeming person, actually recoiled and said, "But what about the baby? It needs a mother!" on hearing my plans.

Other things have come up randomly - my sister in law suggested I was giving the baby hip dysplasia cos I was using a Baby Bjorn (false). She also suggested that giving my baby tylenol was immoral (yeah, she's an idiot). I heard that I needed to get back to the gym ASAP to "get that weight off and feel like yourself". I've heard I should be studying more, or studying less and working sneaky shifts once a week to keep my hand in. I've heard I should move to Manitoba to take advantage of the reasonably priced child care.

The creme de la creme came yesterday. I have yet to unsubscribe from "Fit Pregnancy", a magazine that was full of tips on how to exercise and eat well and look good in preggo pants. They sent me an email simply titled, "Talking to your Baby; you're doing it wrong".

And with that, I quit.

I will listen to no one.

I am going to stay in my undies, eating peanut butter toast and feeding the baby when she cries. I will watch the rest of the West Wing and occasional lectures on left ventricular aneurysms. I will go back to work in March and I will love every minute of it. I will be totally happy to come home and see my family.

Done and done.

boom!

Things I have learned: (in no particular order)

When you attend a parent-baby group, people do not want to know your name, your profession or your marital status. Instead they want to know; how old your baby is, what other baby groups you attend and your position on any of the following - cloth diapers, home births, breast feeding or attachment parenting.

You can survive on much less sleep than you think. Survival is all relative, however. You will cry at inopportune moments, have rage blackouts about who's turn it is to wash nappies, dream up conspiracy theories about people who glance at you on the street and think about running away.

You won't necessarily love your baby right away. In fact, you may think of them as a fleshy source of pain and frustration for about 6 weeks. Apparently, you will eventually love them and they will become the greatest source of joy in your life, but I'm still waiting on this. She's pretty cute though. And she's starting to smile when I smile at her, not just when she's farting.

You should definitely try and have kids in the city where you have family. Your friends will be a great source of kindness and comfort, but they are no substitute for people you can scream at while topless and leaking milk, then collapse onto them crying, then ask them to do laundry. And they will love your baby from day one, setting a good example for you.

You can shoot a jet of milk up to 2 feet if you've built up enough pressure. How To: 1) Delay feeding for 4 hours. 2) Hold crying child near you with shirt off. 3) Grab your breast and aim at target approximately two feet away. 4) Write your name if you're feeling creative!

So. I am a parent. I am eternally grateful for my medical friends who already have babies, cos there is no bullshit there. Everyone says it sucks, everyone is kind when I text them at 4am offering to sell them a baby (slightly used).

I am also grateful for Mr G, who is willing to trade places with me - I so want to go back to work where I am the boss, where I can talk to people, where I have some structure and idea of what I'm doing. He just wants to look after our little poop-tube and watch her grow and learn and become a person.

So. At 7 weeks, this is where we are. I am supposed to start studying for my exam this coming Monday. I am also supposed to start Mommy & Me classes to teach Bub to read.  It's all happening.

breast milk and other lies

With 2 days to go before my due date/parasite extraction, breastfeeding has been on my mind.

In an ideal world, I would be able to use a combination of pumping and straight breastfeeding to provide fats, carbs and protein to my child. This would continue until she is 6 months old, then we would begin introducing solid foods. At 12 months we could consider adding cows milk to her diet and gradually weaning her off breastfeeds at around 18-24 months. This is the position of the Canadian Pediatric Society, the Aussie one and the American group too.

The arguments from the pro-breastfeeding teams include statements like, "Breast milk is the natural way to feed your child" and "Breastfeeding is the cheapest, easiest option for you and your baby".

Don't get me wrong. I am not anti-breastfeeding.

I am against the idea that if you cannot breast feed, choose not to breastfeed or choose to supplement your breast milk with formula, that you will be harming your child.

I am backed up in my position by my (new) pediatrician who met with me JUST to talk about breastfeeding. She didn't use the term "Nazis" but her tone was clear when she explained that, despite what a lactation consultant will tell you, there have been NO randomized double-blinded controlled studies that actually demonstrate the superiority of breast milk over formula.

This is partially due to the nature of the intervention (can you trick a mother into not knowing whether she's breast or bottle feeding? No). It also relates to the fact that if you can't physically breastfeed, you can't fake it.

The recent Fraser Health "breastfeeding contract" demonstrates how much power the pro-breastfeeding lobby has. They are actually asking women to sign a document saying that they will choose to breastfeed (with a list of benefits) or not (with a list of weakly researched drawbacks). They are asking women to declare something that they may have no control over in the days after the birth of a child.

The other major red flag of the contract is the idea that breastfeeding is the cheapest option. This veers into a whole other world that assumes that a woman's time is worth nothing and that she contributes nothing to the economy (breastfeeding 8 times in 24 hours does slow ones productivity slightly).

For myself, I already know that the "ideal" situation will not be happening. I will attempt to breastfeed during my 6 months of maternity leave. If it goes well, great! If not, formula feeding is on the horizon!

However, when I return to work, it is highly unlikely that I will be able to continue to pump/maintain my milk supply. In theory, hospitals are lactation-friendly environments, but in reality, if you have a crashing patient you will not be able to step away from the bedside for a 20 minute "expression" session. I rarely eat or pee during my ER shifts so I cannot imagine being able to take time to sit back, relax (as this affects milk flow), pump, package my milk, chill it and then get back to work.

Yes, I have the option to take a longer mat leave. However, I have already been out of the workforce for about 6 months and cannot imagine being away for much longer. For financial reasons, for professional reasons and most importantly, for my mental health.

I was a doctor long before I got knocked up. I will be long after this kid is weaned and eating smushed peas.

I hope that women aren't bullied into feeling bad about the choices and realities of raising their kids the way they want to. Alas, to quote my erudite & lovely husband, "There are 100 ways to raise a child, and all of them are wrong in the eyes of someone."

Unicorn Birth

Andre Picard is the health reporter for the Globe and Mail. This weekend, he wrote an opinion piece about how childbirth has been "over-medicalized" with 97% of births taking place in hospitals. He feels that, since birth is a natural process, and can be done at home with minimal medication or intervention, that women should be strongly considering this as their first option, with hospital birth second.

I have a few thoughts on this.

My first, visceral, reaction is this; kidney stones can be managed at home. Why don't you try that and get back to me?

Mr Picard states that "pain relief can be offered in the home" and this is true. However, your options for pain relief in a non-monitored, non-medical situation are extremely limited. There can be no IV or epidural. Your medication must be delivered orally, or if you're lucky, with a shot to the muscle (if you deign to allow a nurse/midwife into your home). This analgesia is less reliable; if it's in your muscle, it gets a prolonged release time, meaning you can be doped up and woozy for much longer than the duration of the labour. Epidurals are great because you control when the quick-on, quick-off pain relief kicks in and WHEN IT STOPS.

I would like Mr Picard to endure passing a kidney stone, at home, with only the limited options of analgesia available to him. It meets all the conditions of his argument; it's natural, has been done at home since the dawn of man, and would vastly decrease hospital/health-care costs.

My second reaction is that this man is comfortable assuming risk for people who are not him. I have only attended about 40 births. The majority of them went smoothly. However, the few that did not go well had almost no warning.

The child who came out with the cord wrapped three times around it's neck? Normal birth/labour until the head appeared. Required immediate suctioning (not available at home) and pediatrician-led resuscitation, then time in the NICU. The change from happy-delivery to terrifying ordeal happened in 10 seconds. That's not enough time to call an ambulance, get mum and baby to hospital, get the team assembled and so on. Mr Picard would be comfortable with this child's potential cerebral palsy/oxygen deprivation/death, as it would cost the medical system less in the short-term.

The other terrifying situation I was involved in included a post-partum haemorrhage. Again, normal labour, normal delivery, but this woman's uterus couldn't clamp down fast enough after the placenta was delivered, so she started dumping blood. She lost about a litre in the first 30 seconds. It took us another minute to get large IV's into her and a third minute to get fluids running. If she had been at home for this situation, she would be dead. There is no home "rapidly replace blood loss" protocol. Again, an ambulance would have been required.

During this bleed, I remember trying to wrap the baby in a swaddle (I was a medical student at the time) and handing it to her new father. He pushed the baby away, unable to take his eyes of his potentially dying wife. If we hadn't been in a hospital, with trained OB staff, I might not have been able to congratulate them the next day (as Mother received a third transfusion) and visit the baby.

Mr Picard states that we are over-medicalising a natural process to attempt to get rid of risk. Statistically, he says, that's impossible and home births should be just as safe.

The problem with statistics is that if you're the one in one hundred who has a bad outcome, you get 100% of the bad outcome. 100% of the dead baby. 100% of the brain-damaged child. 100% of the dead mother. Yes, you're the exception, but your life is all you have. As such, you should not be pushed to try a "natural, beautiful" option that puts you at higher risk.

My third and final reaction is that this is a man with limited medical experience trying to tell women what's best for them. There are some women who absolutely prefer to give birth at home. They are aware of the risks and feel that the benefits outweigh them. There are women like me, who are paralyzed by the potential risk of popping a sprog, and want to be in the most controlled setting possible to minimize the chance of death for myself and my bub. Mr Picard would like us to put the home birth option first. I don't want to take the "natural" 50% fetal-maternal risk of dying in childbirth. I would like to keep my freedom of reproductive choice.

The reaction on Twitter and around the internet has been varied, but ultimately, it has to come down to choice. If you are the one giving birth, you can't let an old white guy tell you that the birth should be "natural", "magical", "messy" or "beautiful". Ultimately, it's one more man telling you what to do with your body, regardless of your own desires and experience. And that's unacceptable.

I've made a huge mistake...

Standing in line at the grocery store today, I was sweating.

The couple in front of me were chatting to each other and the checkout woman. "Wow, how about this weather? How's your day going? You must be tired, on your feet all day..."

The lineup behind me was long and the cashier was moving slowly. People behind me were shifting their weight and sighing, jostling their food to get closer to the scanner.

Then, the gentleman ahead noticed a mistake on the screen.

"Oh, that coffee is supposed to be on sale for $6." He turned to me and winked, showing off his teardrop tattoo and missing teeth.
The checkout lady sighed, grabbed the phone next to her.
"Price check for grocery."
The gentleman's companion blushed and looked at the long line behind me.
"I'm so sorry"

The price check came in. That brand of coffee was not on sale, another brand was.

"I'll just go grab the right one," the guy said.
He took off, leaving his dishevelled backpack with his now mortified partner. Half their groceries were scanned and bagged, half were not. The woman stared at her feet, then glanced back at us again.
"I'm so so sorry..." she said.

Now, pause here. In any big city I've lived in, people would be muttering angrily at this point. Some people may even try to push by or glare at the woman waiting for her coffee.

In Kingston, the lady behind me smiled. "Hon, don't worry about it. You're gonna save 6 bucks! That's worth a wait!"

As we stood, waiting, the cashier told us there had been a fight earlier between a teenager and a geriatric man. The old man had come up behind the youth and pulled his hood off his head, telling him he looked like a thug. He then proceeded to punch him until the youth was forced to protect himself by hitting back.

"The police just left..." said the cashier, smacking her gum.

At this point, Mr Tears returned, brandishing the correct coffee. They scanned, they paid and walked out into the sunshine. I went ahead and loaded my groceries onto the conveyer belt, feeling light and easy.

I am going to miss living in this little town. I think we may have made a mistake in leaving.

Lean In?

Yesterday I went to work.

I had an opportunity to complete my mandated practice ultrasounds, there was a slot open in the US rounds and my friend A wanted to try scanning my belly to see the kicking contents. It seemed perfect.

I walked to hospital, feeling self-conscious in my semi-formal maternity attire (work pants no fit any more) but excited to be using my brain. I met our instructor and A and we started wheeling the machine around the ER.

"Hi, I'm Dr G and I'm a resident..." The words sounded totally foreign coming out of my mouth. Am I a doctor at the moment? I am not licensed (on hold during med/mat leave), I'm not really a resident (not working, not attending lectures) and technically I should be at home, barefoot and cooking for my husband. Right?

Anyways, the patients didn't notice my indecision. I scanned 6 ladies of various stages of life. From the 78 year old woman with the tiny atrophied uterus to the 16 weeks pregnant teen, we saw the spectrum. A girl who was there cos she couldn't stop puking (diagnosis: cyclic vomiting, a condition associated with chronic marijuana users. Also pregnant.). A girl who was there cos she was peeing blood (dx: kidney stone, not pregnant). In short, the usual ER pantheon.

I was also petted and prodded by the nurses - I haven't been to work since becoming visibly pregnant. As the desk clerk said, "Oh! I haven't seen you since that last trauma! Remember? The one where you couldn't stop vomiting, then you passed out?" I do remember, oddly.

As we were packing up to leave (I can now teach Ultrasounds to others! Woot!) my instructor grabbed another resident. "Hey! Look at you!" She turns to me. "This girl had a baby about 4 months ago! Doesn't she look great!" This girl did indeed look great. In blue scrubs, clean, fresh, slim and perky. She smiled and asked how far along I was. On hearing 24 weeks, she laughed.

"God! I remember that phase! I was seeing a patient, throwing up in the bin, seeing a patient, throwing up in the bin!"
My instructor laughed too. "I was working ICU at 39 weeks pregnant and my ankles had 3+ pitting edema!"
I laughed, nervously. "Yeah, I was throwing up too much and fainting, so they put me on medical leave until the baby comes..."
Awkward silence.
Then the surg resident said, "Well, I wish I'd known that was an option at the time. Oh well!" and went off to do her job.

Instructor laughed it off and then told me the tale of her own return from mat leave. She took 2 months, worked 2 months, got super depressed and miserable, then took another 6 months off. She's still a resident now, in her 6th year of residency and will be done sometime next year.

I came home, exhausted. I threw myself on Mr G's desk (he tries to work from home, despite my best efforts) and started lamenting how weak I am, how lazy, how uncommitted to medicine, how unfit I am to be both doctor and mother. He (gently) swept me to the side and said, "Stop. It's done. The time is taken off, you're done."

And he's right. I may be the worst at being a pregnant doctor, but I sure feel a hell of a lot better now that I'm not working. I'm newly certified in bedside Ultrasound. I have a growing, kicking, hiccuping life inside me. I am tweaking the statistics on my research project. It's not perfect, but it's working for me.