FreshMD

Stains

Pete and I were getting ready for work when he set down the iron, inspected his pants, and said, "Not these ones too! All of my pants have grease stains across the thighs."

"So do mine!" I told him. "Grease stains, mid-thigh."

We puzzled over the consistent appearance and placement of the marks for a few minutes, and then it dawned on us. The range of the stains exactly matched the heights at which our two- and four-year-old plant their little hands when they grab us.

I've been a mother for seven years, and I don't think I've ever gone into work wholly clean in that time. I've had breast milk spit up on my shoulder, crusted rice cereal on my shirt cuffs, teething biscuits cemented to my pant legs, apple juice splash marks on my shoes and now a tideline of grease across my thighs.

Maybe I should go back to wearing a white coat. Do they come in floor-length?

(Cross-posted at Mothers in Medicine.)

Gala and jonagold

When we went to a Christmas tree farm for the first time last year, I expected to wander through a still, winter forest with an axe over my shoulder, pulling a sled. Hunting for a parking spot in a packed lot, and then marching through fields of tidy aisles of six-foot trees with hundreds of other people was not the natural experience I had hoped for.

I had some of the same sentiments picking apples this year. I had envisioned a quiet old orchard with ladders leaning against the apple trees; I would do the climbing while the kids played in the shade of the trees, collecting the fallen fruit into baskets. Then we would milk a goat and dance to accordion music in the autumn afternoon.

The reality of the Apple Barn involved first navigating through throngs of preschoolers, arriving by the bus load for their annual pumpkin patch visit. We made our way past the jumping pillow, the thirty-foot slide and the petting zoo to the orchards, which were mercifully quiet. The trees were all dwarf varieties, not big enough to cast shade, planted in long, straight rows.

I was disappointed, but the kids were thrilled. When Saskia picked an apple and marveled at the leaves still attached, I was sorry that I hadn't introduced her to fruit-on-the-tree earlier. Ariana knew better than to eat fruit we hadn't paid for, but that didn't stop her from kissing her picks repeatedly.

Leif abandoned picking to watch the wasp on apple action. He was spell-bound.

We took home 40 pounds of apples. The van was filled with happy crunching on the ride home.

I think we're going to hunt for apples with leaves attached every fall. Maybe next year we''ll venture a little further afield to the Okanagan, or just find a local backyard apple tree on Craigslist.

(Thanks to Mary for the Apple Barn recommendation.)

Kissing kids on the lips

When Saskia was a year or two, Pete and I decided to gently implement a kids-kiss-only-on-the-cheek rule.

Our toddler trying to kiss our grown male friends on the lips, completely innocent though it was, caused some awkwardness among all parties involved, save Saskia herself.

The physician in me wanted to reduce the risk of contracting herpes simplex virus type I (the cold sore virus, which can be transmitted even in the absence of visible lesions). Then there's the risk of catching a run-of-the-mill rhinovirus or adenovirus. And if I hadn't already made the decision not to try to protect Saskia from the bacteria responsible for dental cavities, that could have been another consideration.

Pete didn't grow up kissing his parents on the lips, and my own upbringing was fairly undemonstrative.

So we encouraged Saskia to kiss only on the cheek, and did the same for Leif, and haven't given it a second thought for five or six years.

But Ariana insists on kissing me on the lips. When I offer her my cheek, she'll have none of it. She giggles delightedly, grabs my face with her little hands, and plants a big one right on my mouth. The other day in Superstore she gave me a smooch on the lips right in the middle of the frozen foods aisle, and it took me a minute to disentangle her arms from around my neck.

The thing is, I don't mind these wet, loving kisses on the lips from my two-year-old. Our usual peck on the cheek now seems rather reserved.

So I'm curious. Do you kiss your kids on the lips? Do you let them kiss family and friends?

Golden morning at the beach

Melasma

A diagnosis that I regularly make in and out of the clinic is melasma. While it's a satisfying one to offer to patients, I keep my mouth shut when I notice it on strangers or acquaintances, although I'm curious whether they've noticed the pigmentation changes to their face and whether they know the cause.

Melasma is an acquired increase in pigmentation to exposed body areas, usually the face. It's most often caused by the birth control pill or pregnancy, and is precipitated by sun exposure. It is not painful or itchy - it's a cosmetic issue only.

* Photo from the Color Atlas and Synopsis of Clinical Dermatology. (That volume is quite delightful as a coffee table book, by the way. Guests pore over the images; they can't help themselves.)

Melasma is also known as chloasma or "the mask of pregnancy," and can be striking, as in the patient pictured above. But in my experience, melasma more often presents as a subtler darkening of the cheeks, or as a brownish smudge along the upper lip. If they notice it at all, patients usually attribute it to aging, freckling or tanning.

The macules or patches can range from light brown to black in colour, have well-defined margins, and are  distributed symmetrically. The most common locations are the cheeks (especially below the eyes), the forehead and bridge of nose, and the upper lip.

Darker-skinned individuals and those living in sunny climates are more prone to this skin condition. The incidence among Vancouverites with fair skin is much lower than among Cubans, say. In northern climes melasma may be seasonal, fading over the darker winter months and become more pronounced again in summer.

Discontinuation of the pill or delivery of the baby usually causes the pigmentation to fade over months. (With subsequent pregnancies, the pigmentation tends to return, and to progressively darken.)

Avoiding sun exposure can prevent the onset or worsening of melasma. Sunscreens with an SPF of at least 30 and containing a physical sunblock such as titanium oxide or zinc oxide should be applied liberally and consistently.

Prescription skin bleaching creams can be effective. Hydroquinone 3-4% cream, sometimes in conjunction with tretinoin, may be prescribed for weeks or months.

Patients are impressed when, at the first visit, I know their contraceptive choice the second I lay eyes on them. I've made deductions about some friends and family as well, but haven't yet tested their reactions.

From the breakfast table on a sunny fall morning

 

That's Indian Arm under there. Sometimes we wake up to boats blasting their foghorns.

Virus doilies

Reader Rosa recently alerted me to these virus doilies by Laura Splan, a New York-based mixed media artist and phlebotomist.

 
 

Clockwise from top left: HIV, Herpes, Influenza, SARS.

The doilies are computerized machine embroidered lace mounted on black velvet, based on digital images of the viruses.

When I turned thirty my Oma, the giver of unusual gifts, gave me thirteen crocheted doilies. I'm going to have to take a closer look at those; maybe the gift was more complex than I realized.

Splan says in her statement:

My work explores perceptions of beauty and horror, comfort and discomfort. I use anatomical and medical imagery as a point of departure to explore these dualities and our ambivalence towards the human body . . . I often combine scientific images and materials with more domestic or familiar ones. The . . . design of a doily lends a sort of relief in its familiarity and pleasing pattern. This juxtaposition creates a response that fluctuates between seduction and repulsion, comfort and alienation.

Her website features a number of other interesting medical projects. Check out the latch-hooked Prozac, Thorazine, Zoloft pillows. Splan explains, "These soft, oversized anti-psychotics and anti-depressants provide a different kind of comfort than their prescription counterparts."

Or the Blood Scarf, which "depicts a scarf knit out of clear vinyl tubing. An intravenous device emerging out of the user's hand fills the scarf with blood. The implied narrative is a paradoxical one in which the device keeps the user warm with their blood while at the same time draining their blood drip by drip."

 

Makes my own fall plans to knit a vest for Leif seem rather dull.

Chestnuts on 17th Street

I thought we were done picking things for the year after the wild blueberry session on Mt. Seymour a few weeks ago. But last Sunday afternoon we found ourselves heading out to West Vancouver to collect chestnuts.

The Boy Scouts planted horse chestnut trees along 17th Street in 1934 to commemorate the visit of Lord Baden-Powell. The trees are beautiful and, happily for the kids, productive. There were thousands of chestnuts littering the ground. Some were still in their spiny green shells, sometimes two to a pod. 

Leif filled the pockets of his hoodie, Saskia hunted for the tiniest baby chestnut ever, and Ariana packed her bag to the point where she struggled to cart it back to the car.

We took sacks of chestnuts home, where another benefit quickly became clear: they're the cleanest, tidiest bits of the outdoors my kids have ever brought into the house. No stains, no smell, no detritus. Just smooth brown nuggets scattered everywhere.

(Flickr photo set here.)

There are no refugee camps in Canada

We are expecting a group of Bhutanese refugees to arrive in Vancouver next spring.

I recently received a copy of the bulletin that is being handed out by Canadian visa officers to each family interviewed at the camp. It explains the next steps in the resettlement process and introduces the refugees to Canada, in English and Nepali. Some highlights:

• Once you have passed all exams and your documents are ready, you will be taken to the IOM centre in Kathmandu. You will stay there for a few days to learn more about life in Canada. You will also learn about airports and airplanes to help prepare you for the trip to Canada.

• Rumours that you will be “sold” for slave labour or forced to fight in Iraq are false.  It is also false that you will be forced to live in a refugee camp. There are no refugee camps in Canada.

• Water in Canada is safe to drink. Every home has its own hot and cold running water. You can get water any time of the day or night. All you have to do is turn the tap on and then off when you are finished.
  

• During even the coldest months, buildings and houses are well heated and comfortable. To stay warm in winter when they are outside, people wear outdoor clothes like an overcoat, boots, gloves and a hat. They also wear several layers under their outdoor clothes such as an undershirt, a shirt and a sweater.

• People from many different cultures live in Canada. You can find most of the foods you usually eat, such as rice, green vegetables, spices, lentils and chicken, in a grocery store near you. Canada also has many other stores that carry specialty products, such as goat/lamb meat, which are not usually sold in most grocery stores.  

• In Canada, the law lets you practise your religion freely. You will not be asked or forced to change your religion. Freedom of religion is one of Canada’s basic freedoms. There are many Buddhist and Hindu temples, and Christian churches across Canada. In many cities, you can invite Hindu Pandits home for religious ceremonies.

• Canada is a large country and is almost 68 times bigger than Nepal. You might be resettled to any one of a number of cities. Most of these cities are in the southern parts of Canada. Attached is a map of Canada to show you where some of our cities are located.

Having my own country presented to me this way was profoundly moving. It's Canadian Thanksgiving, and I am so thankful for my country.

The glorification of gout

My residency research project was on the glorification of gout in 16th- to 18th-century literature.

While the other residents were investigating parental attitudes to the (then new) varicella vaccine, and interviewing injection drug users about why they routinely cut their hospital stays short, I had my nose buried in old issues of the Bulletin of the History of Medicine. My preceptor encouraged me to pick a topic that I enjoyed, and I did just that.

We concluded our final year with a research day. We were assigned to one of three rooms to give our presentations, which ran back-to-back throughout the day. When we weren't giving our own talks we attended the ones that most interested us.

There was a prize. It was something paltry, a $30.00 gift certificate to the Health Sciences Bookstore or something, but few things motivate doctor types more than the chance to win a prize. My colleague always says that our clinic administrators could get us to do anything if they just hung a star chart in the office.

So I was determined to win. The room was packed when I did my presentation, which went without a hitch.

At the end of the day, we gathered in a study hall for the day's concluding remarks and the announcement of the prize-winning research project.

It wasn't mine.

And when I saw what we had been graded on, I knew why. One of the categories was 'relevance.'

Anyway, I feel somewhat vindicated, because (a condensed version of) my paper was published in the CMAJ this week.

Although I got chest pains when I saw that they had edited a comma splice into the final sentence of the article.

Someone sat on her

A young African man was interpreting for his grandmother, who came in with right upper quadrant pain of three days' duration.

"When the pain started, did it start gradually or suddenly?" I asked.

"It started when someone sat on her, " he replied.

I waited expectantly.

"We went to a feast," he said simply.

Wanting to respect any tribal customs, I picked my questions carefully. "How big was the person who sat on her?"

"A sixteen-year-old girl. A big girl."

I pictured the banquet table. Maybe her granddaughter had come over to greet her and affectionately sat on her lap. "How long did she sit on her?"

"One hour."

I jettisoned all efforts at cultural sensitivity. "Why?"

"There wasn't enough room in the car."

"You drove one hour to the feast and your grandmother had another adult sitting on her lap?"

"Yes."

Thinking maybe I had misunderstood the time line and this had occurred in Zimbabwe, prior to immigrating, I clarified, "What city was this?"

"Vancouver."

I examined the patient's abdomen, and filled out the requisitions for some investigations. I decided I couldn't ignore the issue of their transportation methods. "In Canada, you aren't allowed to travel in a vehicle with another adult on your lap."

"You're not?" He was genuinely amazed.

"No. It's an issue of safety. If the police catch you, you'll be fined." He looked alarmed, and I reassured him, "I'm not going to call them. But you need to know that each adult must travel in their own seat, with a seat belt."

He looked like a reprimanded schoolboy. "But we had to do that," he said earnestly. "Or someone would have been left behind."

All of my DIY projects involve a staple gun

I finally got around to fixing up this desk for Saskia:

I've wanted a craft table for her for a long time. I don't mind scratches and glue on our kitchen table, but clearing it five times a day for snacks and meals becomes tedious. When we moved here two years ago and I found this desk sitting outside with a stack of paint cans on it, I earmarked it for Saskia:

I used a leftover can of white oil paint to cover all of the desk but the top, which was gouged and buckled beyond repair. I staple gunned a piece of vinyl (purchased online for $8) to the top. Those polka dots are covering a multitude of sins. And it's an easy-wipe surface that is simple to replace should Saskia destroy it or Leif eventually want the desk for his room.

There's a bin on her desk for those treasures that I come across every day that I'm loathe to throw out because I see the potential for seven-year-old crafting: bits of ribbon, extra buttons, sales tags, packing peanuts, tiny boxes.

Saskia was delighted with the desk and is putting it through its paces. A little too eagerly, actually. When I get up at six, I can see the light on under her door. When I check on her, she's sitting at the desk in her pajamas with a row of completed crafts in front of her, gluing feathers onto yet another popsicle stick. I'm not sure what time she's been getting up.

Yesterday she said, "Do you know what I would love to have on my desk?"

"A jar for your beads?" I guessed.

"No. A computer!"

And I must confess that this morning, I brought my laptop up to her new desk. Working with the sun streaming in her room and glowing pink vinyl as a backdrop is very pleasant. But it's going back in my study before she gets home at 3:30.

(See Yvestown's tutorial for details on table stapling.)

Breakfast Fruit Souffle

I originally envisioned this blog as a mix of the medical and the domestic, but it turns out I don't enjoy blogging about household chores any more than I enjoy doing them. That 'domesticity' category to the left is woefully tiny.

But I must share this fruit souffle recipe that I've made every Saturday morning for months. It's ridiculously simple to make, only dirties two dishes, uses whatever seasonal fruit you have on hand, and brings a blissful silence to the breakfast table as kids and adults alike savour their meal.

My only reservation is that the amount of sugar it calls for might require a dose of Humulin R prior to ingestion. I've been cutting back each time I make this, trying to find the point just short of where the souffle collapses or the taste suffers. Just remember that this recipe recommendation comes from me as a mother, not as a physician.

The recipe is from Simply in Season (p. 35). Here's my slightly modified version:

Breakfast Fruit Souffle*

Preheat oven to 375. Place 2T butter in a 9" pie pan and place in oven to melt.

In blender, mix 3 eggs and 1 1/2 cups milk.

Add 3/4 cup flour, 1/3 cup sugar**, 1/4 t salt and 1/4 t vanilla. Beat until smooth.

Pour into pie pan and bake until edges are golden brown and centre is set, 30 minutes. 

Mix 3 cups fruit with 2T sugar. (I use a different combination every time: pears and wild blueberries, nectarines and blackberries - whatever's in the kitchen on Saturday morning.)

Spoon fruit mixture onto souffle. Cut into wedges. Serve topped with sour cream or plain yogurt, and brown sugar. (Do not skip the toppings! They are crucial to the end result.)

* Technically, this recipe doesn't meet the textbook definition of a souffle. It's puffy, but it doesn't involve beaten egg whites. I don't mean to quibble, but I do strive for accuracy.

** I've reduced the sugar to 1/4 c with no trouble. Going for 3T next time. Tomorrow morning.

The bad A-word

"I know the bad A-word now," Saskia said solemnly as I drove her to school.

"You do?" I asked, surprised. That's one she wouldn't have learned from me. "Who did you learn it from?"

"Daniel said it to another boy at school. He got in trouble for it."

Daniel is the last boy in her class I would expect to have a potty mouth, so I probed further. "Is the second letter of the A-word an S?"

"Nope! It's an N."

I thought for a minute and couldn't come up with a single bad A-word with N as the second letter. "Spell it for me," I suggested, not wanting Leif and Ariana to be privy to the profanity.

"A - N - O - Y - I - N - G," Saskia carefully spelled out.

"Annoying?" I repeated, confused.

Saskia did a horrified gasp. "You said the word! My teacher told us there are some names you should never call other people, and that's one of them."

Looking out for them

A patient gave me a gift last week. Considering my patients are refugees who are typically of modest means, for whom bus fare can be an issue, gift giving is an unusual event at the clinic. I think I've been moved to blog about it every time it's happened (here and here).

I'd seen the woman, a Karen living in Langley with her husband and children, on three occasions. I hadn't done anything out of the ordinary: treated her for a parasite, done a Pap smear, diagnosed her with H. pylori.

At the end of our last visit, she handed me something wrapped in a plastic shopping bag. It was a long woven skirt in the most vivid pink imaginable, with yellow and green stripes. I promptly tried it on over my pants. It fit perfectly. As I thanked her, overwhelmed with how kind the gesture was, but also how unnecessary and costly, she repeatedly asked through the interpreter if I liked it.

When she had left the clinic, I pulled the interpreter aside and asked if it was appropriate for me to accept the gift.

She shook her head before I had finished explaining my hesitation. "You must accept it!" she said emphatically. Gripping my arm, she said quietly and firmly, "The Karens give gifts to people who they feel in their hearts are looking out for them."

I had tears in my eyes, because she said so simply what we strive to do in medicine, particularly for the very vulnerable patients at our clinic. And also, because it took so little for her to trust my care.