FreshMD

Fired

I had a preceptor once who told me that every year, as a Christmas gift to herself, she fired a patient.

The idea of an annual tradition of firing something that's not working for you appeals to me.

The friendships may not last the year

I've often thought a practical and entertaining New Year's activity would be to get together with friends and make resolutions for each other.

Isn't it obvious to you what others should be working on, which weaknesses and annoying habits they should be tackling? And less clear where your own faults lie?

Win-win!

Favourite gift

Wrapped in a scrap of green felt and bundled with an elastic band, it doesn't matter what was inside.

Ontario

We've made an eleventh hour decision to go to Ontario for Christmas. Considering not going this year, for the first time since 1998, reminded me of all that I love about our annual visit.

I love staying at the big old house Pete grew up in, with the four bedrooms upstairs, tucked under the eaves; eating croquettes in front of the fire with the whole family on gift-opening night, while batting the babies away from the wine glasses on the coffee table; and Sunday dinners of roast beef and tomato soup.

We visit each of Pete's siblings in their homes and I update my mental picture of their daily physical context. Visiting other people's homes is one of my favourite activities, and catching up over tea and watching our kids playing with their cousins is very satisfying. On the fairly long drives to and from each of their places, coffees in hand, we analyze our lives from a fresh vantage point. We toy with the idea of big changes, and usually settle on smaller ones.

I always remark on the brick houses, and a particular road in Hamilton with grand old heritage homes. I like the cold and snow, because it's for a brief and defined period of time, and I do like the sun, which appears more consistently than I'm used to. I'm fascinated by Ontario maps: the roads spidering out from every city and village in all directions, and the infinite number of ways to get anywhere, unlimited by geographical barriers, is novel to me.

So we're off today to celebrate Christ's birth and the start of a fresh year with our Ontario family.

Posting will be light for the next two weeks.

Merry Christmas!

Paint

We've hired the Palestinian painter who did work for us on our last two houses to finish painting our place. I can hear him in the other room, grunting as he deftly manoeuvres the roller. The house smells like paint and sweat.

We hire him partly for the meticulous job he does and partly for the opportunity to interact with an unusually kind and decent person. He waves aside offers of being paid up front: "What if I die before the job's done?" he roars. He goes outside for cigarette breaks between rooms and strikes up conversations with the neighbours.  When he takes time off, he heads up north to hunt. He's demonstrated a moose call for me, and given us packages of moose steak and hamburger. His favourite exclamation is, "Holy God!" said appreciatively, with a quick upwards glance.

The previous owners of our house were a writer and a window designer, artistic types who translated their creativity into the paint choices on the walls: bright orange, forest green and lime green, even on some ceilings. The house was designed by the first owner, an architect, and we're after a clean modern look that will do it justice. The whole thing's going to be the creamy side of white.

"We just moved, and I just had a baby," was my all-purpose excuse that I've just recently acknowledged to be outdated. The baby is eighteen months, and we've seen every season from our new house, some twice. In that time, I painted three rooms. Do-it-yourself home improvement projects with three kids are next to impossible.

I was a student for a very long time. I'm home with the kids three days a week. And I'm Dutch. Which have all contributed to a deep-seated notion that I have more time than money. I'm finally beginning to admit that the reverse is true; more because of competition for my time than an increase in earnings. And so I'm spending the morning decorating a gingerbread house with the kids while the painter works in the next room.

I go through periods of restlessness. During one such time, a few years ago, Pete and I considered a move to Paris or San Jose. In the end we bought a new couch, and it turned out that was all the adventure we needed. I've been feeling unsettled again, and here's hoping a creamy coat of satin paint over the entire house, applied by a particularly kind human being, will do the trick.

Methods of weeping

Crying and sobbing are not synonyms. They are both modified respiratory movements, but opposites.

Crying is an inspiration followed by many short convulsive expirations.

Sobbing is a series of brief, spasmodic inspirations followed by a prolonged expiration.

I'll admit I can't think of any practical application of this knowledge to either medicine or parenting. Although the next time someone bursts into tears in your presence, and you're desperately casting about for something, anything to do - you could try to determine which of the above definitions applies. But maybe keep your conclusions to yourself.

Animal toys

(This is Part Two of a series on recommended children's toys.)

Our bucket of animal figures provides hours of entertainment for all three of my kids.

Unlike a puzzle piece or Lego brick, an individual animal toy is not rendered useless when separated from the pack. This becomes important when your home and car are littered with random toys.

My favourite animal toys are the vintage Fisher-Price, with their hinged legs, charming faces, and the barn with the mooing door. They're available from thrift stores, eBay and grandparents' basements.

In terms of contemporary animal toys, I've only found one company that I like: Schleich. It's a German company, and their toys are durable and detailed. Most toy stores carry them.

Photos from Schleich website.

A child life specialist at BC Children's Hospital mentioned to me a that these figures have been a very popular toy there for years, and are none the worse for wear.

(In addition to all those gorgeous renditions of creatures of the natural world, Schleich was also the first company to mass-produce Smurf figurines.)

Mixed in with this lot, we have dollar store dinosaurs, various animals received as gifts, and toys discovered buried in the garden. A few years ago I asked Saskia which was her favourite animal toy. She rummaged through the bin, tossing the vintage and European toys aside, until she found a fat, plastic, grinning cow.

"This one," she said. "Because it's smiling."

The headline factor

My medical decisions are sometimes influenced by what I call the headline factor, where I briefly consider what the newspaper headlines could read should a worst-case scenario play out.

A patient presents with a fever and productive cough, and the history and physical put a community-acquired pneumonia as the most likely diagnosis, but tuberculosis is also on the differential. The patient needs to go to the ER for a workup. He came by bus, and that's how he prefers to go to the hospital. Calling an ambulance for transport seems like overkill. But I can see the headline: "Tuberculosis patient sent by family doctor to hospital by public transit; dozens exposed."

Or the homicidal patient I had a few weeks ago. He came to see me because he felt he could kill someone at the slightest provocation, and this alarmed him. He was eager to walk the few blocks to VGH with an accompanying letter from me for the ER physician and psychiatrist. I considered the headline: "Mother and child stabbed by homicidal patient sent by family doctor on foot to local emergency room."

It's only the cautious side of me that runs through these scenarios. I never daydream about accolades for obscure diseases diagnosed or illnesses cured. But that's not front-page news anyway.

The five-ninety-five rule

A few years ago, before I had children, I visited a friend who had recently had her first child. "He's cute!" I exclaimed. He was, with big eyes and a little upturned nose. I don't lie about these things. If a baby isn't attractive, I'll make some other observation, like, "He's got quite the head of hair!"

His mother responded earnestly, "Really, Martina? Do you really think he's cute? Because I don't."

I was taken aback. Didn't all mothers consider their children perfectly beautiful, blind to any physical flaws?

I've since discovered that yes, some mothers of clearly curious-looking children proclaim them stunning. But other mothers seem fairly objective about their child's appearance.

The distribution of babies' degree of attractiveness appears to be such: 90% are cute, 5% are head-turners, and 5% are odd-looking. In other words, a cute baby isn't really anything special; he's the norm, right in there with 90% of his peers. When parents-to-be worry that their child might embarrass them, I reassure them that it's unlikely, the risk being only about 1 in 20.

This rule does not apply beyond childhood. I do have the numbers for teenagers, adults and seniors, but that's beyond the scope of this post.

I am one of those mothers who can see her children's imperfections, but finds those flaws attractive. One of my kids was in the bottom 5% as an infant; I horrified a few people by freely acknowledging that. But now I'd put all three in the middle 90%.

Although, to be honest, I do think this one is right on the cusp:

Supernumerary nipples

As a medical student, I was doing an abdominal exam on a fifteen-year-old girl in the emergency department when I noticed four small, tan papules running down her lower chest and abdomen. Two were in line with her right nipple, two with her left.

"How long have you had these?" I asked her.

"Oh, my birthmarks?" she responded. "My whole life."

I suddenly realized, with that exhilaration peculiar to a medical student connecting book knowledge with an actual living patient, what they were.

Supernumerary nipples (polythelia) are extra nipples present in 1-5% of the population. They typically follow the embryonic milk lines, which run from the underarm, through the regular nipples, down the chest and abdomen, into the groin and end on the upper inner thigh. (Think of the row of nipples on a cat or pig.) However, ectopic supernumerary nipples have even been reported on the foot and face.

Photos from the Dermatology Online Journal

Polythelia can present with just one extra nipple, or as many as eight. The nipples can range from a subtle nodule a fraction of the size of a regular nipple, to a miniature breast complete with glandular tissue, nipple and areola (polymastia). The extra breast tissue can change in size and tenderness and even lactate in response to hormones.

I wasn't sure if I should tell my patient this. I doubted a teenage girl would greet my diagnosis with the same enthusiasm I felt. I kept quiet and passed my observations on to my resident instead.

You might want to reexamine those "moles" on your belly.

Mixed Twins

I wonder if parents of twins get tired of the attention they get at supermarkets, of strangers enquiring, "Are they twins? Are they identical? Were they natural?"

Imagine the questions the parents of these twins have to field:

Photo by Gary Roberts

Kian (left) and Remee (right) Hodgson were born in April 2005, in Nottingham, England, to mixed-race parents Kylie and Remi Hodgson.

The odds of biracial parents having one white and one black twin are roughly one in a million.

Story here, more pictures here.

Choices, pregnancy and birth

Choices around pregnancy and birth have become less influenced by medical and more by social, political and emotional factors.

Home births, midwifery, doulas and birthing plans have become increasingly popular. The reasons I hear for these choices are varied: a quest for empowerment or control, a desire for an "honest" or "natural" birth experience, dislike of paternalistic medicine, a need for close emotional attention, a distrust of conventional health care.

I'm not arguing with the validity of these reasons or disputing that births unattended by physicians can be wonderful experiences yielding healthy babies.

What bothers me is that what should trump all other considerations is so rarely offered: "It's best for my baby."

The prevailing mindset appears to be, "It's my pregnancy, and I'm going to choose the experience that most appeals to me." Any elevated risk to the baby is a secondary consideration, and deemed acceptable, so long as it is small.

I don't think anyone would argue that parenting is about commitment to putting your child's welfare first. But it seems to be understood that this self-sacrifice begins after delivery.

Heavy pillows

You know how when you go to the cabin in the summer, and the evening's winding down, the card game's finished, the fire's down to a few popping embers, and the camping cups clang together as you rinse the last bit of hot chocolate out of them? It's cool out, the wind's starting to blow in the trees, and you call it a night.

You pile layers of blankets on the bed, and the musty familiar smell of the linens brings back happy memories of countless childhood summers spent under those covers. (If you had an Oma like mine, the blankets were crocheted in synthetic yarn, and you couldn't stand the feeling of your big toe poking through.)

You pull a couple of pillows out of the cupboard and toss them onto the bed. They're pleasantly cool, and very heavy, the way all cabin pillows are. The heft of the cushions makes you nostalgic for past vacations, and grateful for the current one. The heavy pillows make you feel good.

Except, that extra weight is due to a massive accumulation of dead dust mites and their feces.

Advice on obtaining medical marijuana

At the HIV clinic I am often asked by patients to complete an application form for medical marijuana.

The most recent request was accompanied by a handout from a local advocacy group which began: "If your health provider does not agree [to complete the application] please ask them to write down his/her reasons so we can help. There is a special release form for practitioners who are in question on this magical medicinal herb."

TIP: Referring to a substance as a "magical herb" is unlikely to convince a physician trained in evidence-based medicine to recommend it.

Crisp Monday morning in Deep Cove

Omentum

Today's front cover of the New York Post features Oprah Winfrey's support of Barack Obama.

I'm guessing that the editors weren't aware that the omentum is a membrane extending from the stomach to the colon and other viscera.

Bacon bandages

I wonder if these (available here) come in steri-strip size for surgeons. Imagine looking down at your chest after cardiac bypass surgery to see a neat row of tiny rashers marching down your sternum.

Cavities: something else your kids can blame on you

Most parents unwittingly infect their children with cavity-causing bacteria.

Dental caries (cavities) are now recognized as an infectious disease. They are caused by bacteria, mainly Streptococcus mutans and Lactobacillus. Babies are not born infected with these organisms. They acquire them from a colonized source, usually a parent. Free of these bacteria, your child could be regularly soothed to sleep with a lollipop with no dental consequences.

Transmission is through saliva. Kissing a baby on the lips, cleaning a dropped soother by putting it in your mouth, or sampling milk from a baby bottle can all transfer the bacteria to the child.

So should you make every effort to keep your child's mouth sterile? It's a good idea, but the infection control measures should extend to grandparents, daycare, friends and all other contacts. A plastic bubble might be easier.

Or you could resign yourself and invest in a little Dora toothbrush.

Fathers and parental leave

"Working at the downtown east side clinic was a walk in the park compared to being at home with the kids," I commented to someone recently, referring to my experience when Pete took parental leave a few years ago.

"Your job must not be that hard, then," he responded.

That is exactly why I think it is so valuable for fathers to experience being the primary caregiver to their children, if only for a few weeks.

When our second child was born, Pete took ten weeks of parental leave. "I'm going to take Saskia to the beach every day," he told me happily as he planned his time off.

"What about the baby?" I reminded him.

"Oh, yeah." Pete paused to consider this. "He can come along too."

I couldn't fault his ambition. I was the one who had planned to learn to play piano, take up sewing, and audit an architecture class during my first maternity leave.

After two weeks of caring for an infant and toddler, laundry, cleaning and meal preparation; of cycling through endless menial tasks, Pete began the countdown to his return to work.

"Five weeks down, five to go," he announced one night.

I did a mental calculation. "No, four down and six to go," I corrected him.

He was crestfallen.

Meanwhile, I was having a fantastic time at work. I clocked in at 8:30 and left at 4:30. It was civilized. I dealt systematically with one issue at a time. It was stimulating, an academic and clinical challenge. Every day I spent an hour eating lunch with a book in hand at a local eatery. I enjoyed the collegial atmosphere of the clinic. Nobody questioned the value of my work. And I was getting paid.

Being the one coming home to the kids, in time for dinner, gave me a new view of domestic chores. I came to greatly appreciate two things in particular: a path cleared from the front door to the kitchen, and a meal of any kind on the table. These days, I strive for that minimum, and some days I achieve it.

In many ways, Pete's stay at home wasn't comparable to my own. His was for a defined period of time, a matter of weeks. Mine is indefinite, making it more difficult to keep perspective. And postponing a career for a decade or two obviously has greater implications than a brief leave from work.

Still, those ten weeks in 2004 gave him an empathy for stay-at-home parents that only time in the trenches can.

Right in there with the angels and the shepherds

I feel a little better about Black Peter now that I've discovered he's a bona fide nativity scene character.