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I’ve had a stretch of heavy-duty workdays. This is “heavy” in the sense of illness and acuity… It’s just odd how things come in bunches and bundles.

Monday, I got a page from radiology that a patient I had sent for a scan had a mass that was probably cancer. As soon as I saw the page was about her, I cringed… It was one of those cases where the symptoms could have been something benign, where her exam was totally normal, where I could have just as easily not ordered imaging, where we could have decided to “wait and see if that happened again”… It was another doctor who said, I would image that. So I did, and it wasn’t good. That was a tough phone call to make.

Yesterday and today I sent very sick people to the emergency room… a handful, actually. All with different things, all requiring alot of coordination/ communication… Two are admitted to our hospital now.

And each clinic session I usually see one or two new patients. The past week, I’ve seen more complicated new patients, lovely folks who truly require long initial visits and a real study of their records. Usually, the records are paper records faxed or mailed or carried to the clinic, and it takes forever to find meaningful data. I’m flipping through sheaths of fuzzy copies during and after the visit, searching for: that last hemoglobin A1c; the last colonoscopy with the path report on those polyps; that abnormal EKG; those darned immunizations… Then making referrals, getting the lady with the advanced chronic medical illness linked to the key specialist; connecting the depressed lady with therapy and psychiatry; beginning a workup for unexplained gastrointestinal symptoms of several months’ duration…

It’s all fine and good, it’s my job, and overall, I like it. But.

But Hubby’s been away and the traffic has been horrendous and Babygirl woke up before 5 am today and needed to be rocked back to sleep…

I need a bit of a mental break, a chance to get back into my exercise routine, to go shopping, to take the kids to the Children’s Museum or the beach. Or even, dream of dreams, to go out to dinner with my husband! We did that once, a couple of months ago, thanks to Nana.

Saving grace: The kids have been so, so good lately. I don’t know what it is, maybe the fact that they are in a consistent bedtime routine resulting in longer and better sleep?

Just a few weeks ago, when I would pick the kids up at Nana’s after work, and come home, I could count on Babyboy bolting into the yard and needing to drag him kicking and screaming up the back stairs, or beg my neighbor to help me. Lately, for a week at at least, he’s a little angel. I say “Go up up up the stairs hon, we have to feed our hungry kitties!” and he says “Okay mommy,” and climbs right up the stairs. The both of them help me feed the ravenous cats, then we all trundle up to the bath.

We often have some kind of protest around bathtime and/or getting into pajamas, but it’s short-lived and they seem very happy to get their warm milk and start settling in…

Bedtime has been easier and easier. They seem to LIKE going to bed: both will “request” to go into their cribs even when I would have sung one more lullabye… I suppose the moms out there know, but I can’t begin to explain to people who don’t know, how amazing it is when your kids start going to bed easily and sleeping well. Amazing.

And so, heavy week, but also, amazing week. Need a break for balance/ fun/ breathing though.

As of February, our nights were a mess. We had one-on-one prolonged bedtime “routines” with each child: singing and rocking Babygirl to sleep in our arms, which was starting to take one to two hours, and coaxing/ cajoling/ begging Babyboy to get into his crib, which was starting to become a nightly battle. Then, on top of all that, Babygirl was waking up 2, 3, 4 times a night, for a bottle.

Then, we realized that Hubby’s job, starting in March, would involve alot of prolonged travel. Like, he’s away now for an 8-day stretch. There was No Way I was going to be doing hours-long bedtime routines and then be up for every overnight feeding, solo. I knew I would not survive!

So the bedtime cleanup began, in serious earnest. I’ve written about our approach to eliminating Babygirl’s nighttime feedings: Cry-it-out all the way. Yes, she screamed. Yes, she cried. Yes, she puked. Several times. But each crying episode was shorter, and each night was fewer episodes, and after three or four nights, we were done with any overnight awakening from her. So it was worth every late-night pukey crib change.

Then came bedtime. I cleaned up Babygirl’s routine first. I had someone sitting downstairs with Babyboy while I tried to get her into a predictable SHORT routine. We’ve gotten into the swing of it– bathtime, milk bottle, read a few stories, lights out/Dreamlight on, and a bit of rocking/ lullabyes, then into the crib. Yes, she screamed. Yes, she cried. Yes, she puked. Again. But after a few nights, again, she is now pretty easy, and we can do the whole thing in about a half an hour, if I’m on my game.

Babyboy’s routine came next. It’s pretty much the same as hers, but he brushes his teeth first. He was tougher. I forced him through each step, pulling him onto my lap for stories, then singing, then plop into the crib… He was so used to playing whatever he wanted until he basically passed out. He screamed for ages, and he can say things like “No mommy come back! COME BACK MOMMY COME BACK!” which really pulls at the heartstrings. But at least he didn’t puke. And he did get the hang of it. He’s now also pretty easy.

The next step was to be able to get them both down solo, to somehow handle both routines without any help. This is still a bit of a work in progress, though I’ve done it several times.

They do tubbies together, which sometimes is a bit of a battle, if one or the other doesn’t want to go in, or if someone had a blowout and the other is really psyched to go into the bath and doesn’t want to wait… so that can be not very peaceful… Then I get one and the other dressed, which also can be a battle…freshly scrubbed babies running around escaping diapers… we’ve had the rug peed on a few times. Then we all go downstairs, and they get milk: Babyboy’s chocolate milk in a sippy cup, and Babygirl has a bottle, with one nighttime cartoon (Usually I grab some dinner or do some kitchen cleanup here). Then I ask Babyboy if he’ll help me with putting Babygirl night-night. Most of the time, he says, “Yesss!” and we all go upstairs, and I do Babygirl’s usual routine with him playing as quietly as he can (not very)… I put her down in her crib and we tiptoe away. Babygirl doesn’t always go down so easy, with Babyboy around. Tonight, she cried for a long while, but kind of an intermittent, whiney crying. No puke. Babyboy whispered as we “tiptoed” out of her room: “It’s Okay little baby. Don’t cry.”

Then I go right into his abbreviated routine: brush teeth, read books, lights out/ Dreamlight on, rock and sing songs, then I ask him if he wants to lay down with his Kittycat (his favorite toy/ lovey) and usually, he says, “Yesss! Go Crib!”. I put him down into his crib, pull his blankie over him, and he falls asleep cuddling Kittycat. It’s adorable.

And then I don’t know what to do with myself. Tonight they were both asleep by 7:45 pm… So I emptied the dishwasher, did laundry, read the paper, and… am writing this blog.

It’s Being Imperfect topic week on the Mothers in Medicine website. Check out my post on this topic:

http://www.mothersinmedicine.com/2013/05/snippets-of-imperfection.html

To say that it’s been a whirlwind stretch is a supreme understatement. Of course the marathon bombings, shootouts, subsequent manhunt and citywide lockdown were the main events of the past two weeks…The sense of connection brought on by the crisis has only been reinforced by learning of actual connections to those wounded or killed in the attack: the mother of the child who died belongs to my gym; one of those killed was a neighbor of a friend; a nurse in our hospital lost a leg. I found myself wondering if I’d seen or even spoken to any of these people, if our paths had physically crossed… though it doesn’t matter really, as we are all connected somehow, whether we know it or not.

People are clearly rattled by the whole mess, as evidenced by a whole lot of patient requests for Benzos at the office. And I’m writing the prescriptions. Why not? As one PhD psychotherapist I know once told me, “Everyone should be able to use at least ten Xanax a month. The world would be a better place.”

With this all in the background, we’ve also personally had alot going on. Babyboy’s schedule is always booked, with behavior and speech therapy almost every day. Hubby is on the road, a very long road trip, almost 2 weeks this time. Our childcare resources are stretched… Nana is working overtime, and is coming down with something to boot; our babysitter has put in some really long days; our next door neighbor and savior/ cupcake baker has been over here several nights helping me with the bedtime routine…

And Hubby has had a major career boost this week. He’s landed a high-profile media position, his absolute dream job, a well-deserved big break. I am so, so happy for him, even as, as he put it, “It’s all falling on you right now.”

It’s not really, as I said, our childcare resources are all engaged. Of course, it is alot of work to go to work five clinical sessions a week, and share care of two kids under 3 years old, while your partner is away, no matter how much help you have. On the other hand, I am truly so proud and honestly thrilled to have Hubby achieving his lifelong dreams. I don’t think there’s any reason to feel resentful that he’s away. I feel like I can be supportive and still keep my job and not get mad about it… though I recognize that I have good reason to be tired.

I had an eye appointment last week, with an ophthalmologist who actually went to medical school with one of my (female) colleagues. Every time I see him, he asks about so-and-so, and we chat. Last week, I had an appointment with him, in the midst of all the craziness. He asked me how my husband was, and I told him a bit about how well things were going for Hubby; then he asked me how old my kids were now, and I told him.

He shook his head and laughed and said, “Wow, and you still choose to work outside the home?”

I think I was so shocked to hear that question that I didn’t say anything at all. I think that regardless of anything Hubby is doing, it would never occur to me to NOT work outside the home. The question was just so preposterous. It seemed to come from another culture.

We got through the appointment and I left… without addressing the question.

The events of the past week have made us so, so grateful for what we have. Yes, our lives are kind of hectic, our house is a mess, and I work, and Hubby is away… but with all the family help we have, and the tight neighborhood and church communities we enjoy, we feel that our kids are being raised right. No one needs to “stay home”.

We are home.

The text alerts started before midnight. I subscribe to our medical school’s urgent alert system, if only to have an early warning that we’re likely to have a slow snow day in the office.

But at 11:30 last night, I awoke bleary-eyed to my phone beeping, and read:

“ALERT: Shooting with inuuries near MIT campus… Suspects at large…Stay out of area…”

I shrugged it off and went back to sleep. But then more alerts came, at almost 1 a.m.: “ALERT: MIT Shooter situation remains active. Stay out of area.”

Then more, and more.

2 a.m.: “Shootings reported in Watertown. Stay out of area.”
4:45 a.m.: “…Police searching for armed and dangerous suspect… Stay out of area…”

And so on, with additional alerts all early morning telling us that the medical school is closed and to stay out of the area of the shootings and manhunt.

A little after 5 a.m. Hubby called. He’s on the road and so, so worried.

I put on the news. It’s like an action movie: the replay of the shootouts, the reports of dead and wounded, the ongoing manhunt for an armed and dangerous terrorist.

Nana came at 6 a.m. to take over the kids. I figured, hey, I’m a doctor. I had no indication that my office would close, and there were patients to see, so I decided to drive in to work. After all, my hospital and office aren’t that close to where the shootings were, and to where the manhunt was centered.

I also kind of assumed that they would catch this guy sooner than later, and the workaday rythyms would resume…

So I drove in with my brother, who, as coincidence would have it, is also a physician here, and who lives down the street. Traffic was as thick as usual, and though there were security personnel at my parking garage, the garage was about as full as usual.

However, the walk to the hospital was kind of eerie. Usually there are streams of people pouring out from the MBTA and the commuter rail
stations to go to work at the hospital and business complex. But today, all the trains are shut down, and there was little foot traffic.

Here in the office, on a usually busy Friday morning, we had two docs, on N.P., one nurse, one medical assistant and our assistant office manager. This is a skeleton crew for us. AND a few patients actually showed up. We saw a handful of patients… Until the city went on lockdown.

Now, people are being asked to stay put as much as possible, not to come into the city or leave.

Throughout this whole thing, the hospital has been good about delivering updates, and the latest:

“Ambulatory staff who are currently at the hospital are requested to remain on site.”

With all public transportation service suspended indefinitely, we have staff that were in the hospital overnight who have not been able to leave. They have continued on, mostly on the floors and in the E.R., working until replacements could trickle in somehow.

So here I am waiting to hear if I am needed anywhere. Seems that not many patients are coming in today, for many reasons… So I sit and await notice, catching up on paperwork, and watching the news.

Monday afternoon, I was busy in my clinic, at this great hospital, in our great town. My medical assistant grabbed me between patients and asked, “Did you hear about the bombings?”

I had several more patients to see, but of course I checked the news. It was a bit too much to absorb. Horrible. Bizarre to think that all was quiet in our outpatient offices, while it was right there in the news that our own ER was receiving multiple severe trauma cases.

From then on, it was a topic of discussion in the clinic rooms.  I opened up the topic with each patient, letting them decide how much to discuss. Everyone wanted to talk more about what was going on: how they learned about it, if they knew anyone who might be directly affected, trying to understand how someone could do something like this. It’s only human to need to talk about these things, to want to frame things, to better understand, to sort it out.

The hospital disaster coordinators sent out emails with updates: all clinical staff were asked to stay until they knew for sure what manpower was needed. All of us in the office stayed until the email came that if we hadn’t been contacted directly we were free to go.

The medical walk-in unit had been cleared to offload the emergency room of all the medical/ nontrauma or minor trauma cases (barotrauma, minor lacerations), while the emergency room handled the many major trauma cases. Offices like ours were asked to handle overflow nonurgent medical care, and NOT to send patients to the ER or walk-in clinics, if we could.  So, I stayed put and saw my panel.

Even so, I felt a little useless. It was a bit of a slow afternoon for me. I imagined the blast and injuries and the care required, from the finish line, to the ambulances, to the emergency rooms. Injuries like these required calm, cool and collected care from level-headed and experienced providers: immediate stabilization with hard pressure and tourniquets, volume rescuscitation, blood products; then surgeries for extraction of shrapnel, fixation of fractures, or amputations; then attention to detail with delicate blood vessel and nerve reconstructions, burn treatment…

There wasn’t much for an outpatient doctor like me to actually do. I found myself compulsively checking and rechecking all the news feed, meeting with colleagues in the hallways, murmuring about what we heard, wondering what to do.

When I left, I walked through our lobby, past our emergency room. Security personnel were everywhere, uniformed officers and dark-suited FBI-types with earpieces. People were being directed, “Keep walking, don’t stop, keep walking!” Outside, there were rows of police cars, official sedans with tinted windows, officers and secret-service guys all over. Things were tense. I found myself striding, practically jogging through the hospital, across the grounds, to the parking garage.

They were searching bags; they searched mine, and I got to my car and got on the highway. It was a holiday, and a day many people who work downtown take off anyways, because of the marathon. There was no traffic. I got home in record time. I was so glad to see my kids, Babyboy playing in Nana’s kitchen sink, and Babygirl toddling right into my arms.

Family and friends from far away called, to check in. Many people assumed I must have been pulled in to treat traumas… I felt almost guilty that I had not.

Since then, it seems there are still no clear answers, and only more details of horror from the blast sites.  The targets were innocent civilians, ordinary people and families enjoying a classic day celebrating health and physical accomplishments. Here at our office, we’ve heard from many patients who are suffering from anxiety, re-awakening of past traumas, PTSD symptoms… I’m offering reassurance, and prescribing alot of Ativan. I guess that is my small contribution…. That, and mentally preparing for the next time, when maybe I will be pulled in, to provide calm, cool, and collected care.  

We officially have two talking kids. Babyboy’s speech was pretty delayed; we didn’t hear any consistent language from him until late fall, when he was almost two and half years old.  It was the speech delay more than anything that prompted his evaluation and then diagnosis with mild Autism.

With intensive speech and social pragmatic therapy, he has made great strides. While we are so, so happy to hear everything he does have to say, he does have an odd way of talking. At his Developmental evaluation in February, they described  as frequent echolalia, with “an unusual prosody”. He repeats almost anything we say to him, deliberately, carefully, divided into slow syllables; he almost sounds as if he has a thick Southern accent.

But we marvel at his day-to-day progress, and how much clearer his speech is becoming. The other day, we were preparing to brush his teeth. He wanted to put the toothpaste on the toothbrush, and grabbed it away from me, to try. He struggled with it a little while, then handed it to me, saying “Here you go mummy PEESE put toof-paste on.”

Meantime, Babygirl is 15 months old, and every day seems to have a new word. She’s started to put them together: her current favorite is “No Way.”

As in, “Would you like some more yogurt?”

“Nooo waaay,” she pipes up, waving me away with her chubby little hands

We have no idea where she picked that up.

Likewise, Babyboy comes out with phrases, and we can’t figure out where they come from. Yesterday Hubby called to him from the other room, where he was tending to Babygirl. “What are you up to, little guy?” he called.

“NUTHING.” came the reply.

What? Where does a home-care little kid come up with that? Yes, he does go to a Behavioral playgroup through EI, but bless their little hearts, it’s a whole group of boys like Babyboy: 7 barely verbal (likely on the spectrum) toddler/ preschool boys. So who knows.

Our kids, they are so, so cute. Their little voices are so, so cute. I want to record so much of their day and keep it forever.

Bedtime with Babyboy: “No want night-night YET. Want watch more Caill-ou.”

Morning with Babygirl: “Milk. Milk. Milk. Momma!”

Playtime with Babyboy: “Go OUT-side? Go PAY-gownd?”

Playtime with Babygirl: “Mucka mucka mucka mucka mucka.”  (We don’t know either.)

We both have phones we can record video with. We’re working on figuring out where we will upload and store home videos of these little moments, the funny phrases and conversations, their adorable squeaky pipey little voices.

Because we know they’ll grow and change… and so will their voices.

Last Friday, hubby was away for work, and I had clinic at 7:30 am. I have to drive into the Big City, so I usually leave the house really darned early. I was tiptoe-ing about, in the dark, trying not to trip over one or the other cat. The cats are often underfoot, but that morning they were being ridiculous. I also remember thinking it felt really cold in the house. I shrugged it off, as I was just waking up, and still half-alseep… Darned cats….

Generally, I can count on being able to shower and dress while the kids are still asleep. Then, Nana shows up, and we pass off child care, me on my way out the door with my travel mug of coffee.

Unless one of the children wakes up extra early… as they did last Friday.

Babygirl cried out. I froze. Sometimes she’ll roll over and go back to sleep…

But no. She stood up and started rattling the bars, so to speak. I went in to her, lest she wake up Babyboy.

I picked her up and noted that her hands and cheeks felt cold. Was it really cold in the house or was it just my imagination?

I wrapped her in a blankie and we ventured downstairs, me very acutely aware of the ticking clock. I’m supposed to be in shower by now…

The thermostat read 59 degrees. What? We never keep it lower than 65, with two little ones to keep toasty warm…

I tried doing an override on our fancy new thermostat, to no avail. I cursed out the fancy new thermostat.

My mom came over at 6 am, ostensibly to let me get out the door, but this morning I was still all bedraggled, in PJs, with a fussy baby in a blankie. The three of us made our way to the basement to look at the heater. It was very clearly not on. Then Nana, in all her brilliance, noted what the problem was: the emergency on/off switch was set to “off”.

What? Who would have done that? I certainly didn’t. But we switched it back on, and the heater purred back to life.

OK, OK. I ran to get showered and dressed.

Once dressed, I ran around the kitchen trying to get my coffee and lunch together. Our fat cat jumped up onto the counter at precisely the same instant as I set my travel mug down to doctor it up.. and then there was a mess. Ugh. I plopped kitty onto the floor perhaps a tad too rough for comfort… I didn’t thrown him across the kitchen, but I think I would have liked too… Nana noted (with some disapproval) that maybe the cats were cold, too, and that’s why they were being pains in the butts.

Ugh. I cleaned up the mess and got out the door.

On the highway, traffic was much thicker than normal, very slow. I cursed some more…

Then I saw what the problem was. There was a police cruiser parked in the fast lane, just in front of, and protecting, a badly injured coyote.

This was a section of expressway overpass, with concrete borders almost right up to the traffic lanes. The coyote was lying right up against the fast lane concrete border, almost on the line; it was resting with its head on one paw, and you could see how awkwardly the hind half was lying, suggesting at least a broken leg, if not spine. In a flash I had an image of the coyote being hit, maybe by more than one vehicle, overnight… injured and unable to walk, it must have scrunched itself as far back as possible against the concrete, inches from fast-moving traffic.

Its eyes were open, but it wasn’t following any of the movements of cars pulling past. It was alive, but barely, with an expression of, truly, beyond misery. This was the apathy of an animal that is just waiting to die, and for whom death would be a blessing.

I made a quick prayer: Please God, let someone come and euthanize that poor coyote soon.

Once at the office, I tried to put that image of the coyote out of my mind. I was able to touch base with hubby via emails. We decided to make a list of all our servicepeople to hang in the kitchen, as I learned that morning, if we had actually needed a heater guy, I would have had to go upstairs, find the file with service receipts, and dig through until I found one with our heater guy’s number on it. THAT is not realistic.

We also realized that it was my fault the heater was off. I had let Babyboy come down to the basement with me the day prior, as I did laundry. Usually he plays with the toys in the bin that we’re rotating down from the playroom… But he must have flipped the heater switch. Ugh, scary. No more trips to the basement for Babyboy.

I also reflected on how badly I felt about tossing the coffee-spilling cat onto the floor… He was fine, but seeing that suffering coyote made me want to go back in time, and cuddle with our big fat spoiled rotten pain-in-the-butt cat.

It wasn’t such a bad morning for me after all.

And I still remember that coyote, and feel so badly for it.

Thanks to everyone’s advice and support on Babyboy’s Autism diagnosis and plans to enter the big, bad, scary world of PUBLIC PRESCHOOL at the end of June. (see last post)

Despite having completed a pediatrics residency, and being a physician, I have no experience and no clue how to handle the real-world logistics of an Autism diagnosis, and it’s overwhelming at times. I was wondering if we needed to hire an advocate and/or a lawyer ( learned that they ARE different) to help us through.

Our town’s recent Parent Advisory Council (PAC, i.e. group of other parents with special needs kids) was key for me… both reassuring and alarming at the same time. It was held in the library at the local Middle School at 7 p.m., and of course, I was the first one there. I parked, and just walked in the unlocked front door.

The foyer was large, really beautiful, and there were three hallways to choose from. I heard some noises, and wandered down one hallway, until I ran into a startled janitor, who directed me to the second floor library. It occurred to me that school security could be a little tighter.

Lucky, when I found the library, there was another parent there and we chatted. About twenty parents attended, who had children with Autism, anxiety, Down syndrome, ADHD, or other genetic syndromes… and also without clear diagnoses, but who are struggling. We covered a bunch of issues…

The gist of it is, that for this first foray into the public school system, Babyboy’s Early Intervention (EI) team will be his advocates. If we want, we can hire a professional advocate; these are specially trained people, looks like usually with Education degrees, who can help us to navigate the system, at $150/ hour fee. The lawyers come in if we’re really fighting with the system, and they’re more expensive than that. That’s my understanding, anyways…

So, we will have advocates for Babyboy, in the form of his existing, wonderful, EI team.

Still, I hear from the other parents that the school is severely limiting what services they will be offering to kids over the summer. They say that the school told them that there will be no group/ social pragmatic/ classroom setting services at all…. This is anxiety- provoking, because this is what the kids with Autism need.

They also warned that kids with summer birthdays get screwed (actual language) as evaluations and IEPs (Individualized Education Plan) take time to set up, and by the time your child has been evaluated and you agree on services, summer is over and your kid missed out. This is anxiety-provoking.

 We were encouraged to contact the school Special Ed superintendant and get the process of Babyboy’s enrollment started STAT. This means he has to be evaluated by the school, and then we set up an IEP with them and his EI team, to figure out what services he can get through the school, after he turns three years old, at the end of June. We were encouraged to put our request in writing and save the document. This is anxiety-provoking.

Other parents had good and bad things to say about our school system. Other parents were happy or mad. Other parents had hired advocates or lawyers… It seemed that most parents who had had run-ins, fights or all-out lawsuits against the school, had been in the system for awhile, and had older kids.

So, mysterious as the process seems to be, with all the conflicting reports, we will initiate the process, and wait to see what happens…