hedonic adaptation and more

Our friend Katie (mom and Pete, you met her) told us about a documentary we should watch, Happy. Just before the onset of internship, Richie and I snuggled up to be educated on the science of happiness. Happy The Movie explained a concept that we sense on some level is true, but is nonetheless fun to measure and name:

HEDONIC ADAPTATION.

 Here's what I know: Cookies make me want more cookies. As soon as I am having ice cream every night, I am jonesing for ice cream 'round 8 pm regardless of my level of caloric satiety. On the other hand, when I keep myself from some small comfort, say, ice cream, it heightens my senses for ice cream. Ice cream can seem too sweet (okay maybe a 3 musketeers can seem too sweet) if I have been eating Real Food exclusively for a bit.



When I deny myself in other ways - of sleep, of relaxation, of time to regroup - I clamor to achieve my comfort set-point by filling in the gaps in my comfort level, usually with food. My metabolism mostly keeps up with it, but I'm not going to tell you that I've never had a day where 3/4 of my calories came from Cheetos and Breyer's. In that order.

The reason I'm writing in the first person, "I, I, I, I," is because, in the words of Gunaratana "I am the punk, I am the crazy." Today I ran a red light - completely by accident. I lingered too long at my left turn, crept forward too far to see the light turn red, and pressed the gas of green car just as opposing traffic began advancing toward me. Yesterday I got confused during signout, spoke out of turn, and then flung my folded paper across the room in some sort of spasm of massive uncoordination. The day before I was eating a very ripe plum that was dripping on my hand, so decided to clean up by stuffing the entire remaining half-plum into my mouth. The pit landed right up against my hard palate, so when I tried to initiate the overstuffed mouth chewing process, I inflicted a mighty scrape upon the roof of my mouth. And worst of all, tonight I yelled at my kids. Now, I was being yelled at, but that's no excuse. My actions were unhelpful.



So, I don't know. I think my weird off-kilterness is from stress. Not some intentional well-circumscribed time of aescetism, but long time without enough sleep or enough time to catch up or process. Long time with busted routines.

Problem: It's just the beginning of residency.

So, I guess I'm okay - theoretically - with being thrust way outside my comfort zone. That's good, right? It gets me off my personal brand of hedonic treadmill. I think I'm resisting the stressors the way I resisted labor out of fear. I'm making up for them by raising my level of hedonic coping. I'm going faster on the treadmill, in other words. More ice cream. More coffee. Just a little more comfort. I owe it to myself. Right? Isn't that right? Wait a minute. Isn't that sort of like what Jack said to the bartender in The Shining? Uh-oh.


At this point, I feel like I might not cope without some treats now and then. I recall now a conversation with a friend who is at her absolute wits' end. She lives M-F so she can play music and drink beer on Sat and Sun. All the doctor sense in me says stop drinking beer, which is probably NOT helping, but all the Spidey sense in me says not til you have Something Else to cling to.

Science recapitulates truth. Religion initially wooed me with truth, and has pushed truth farther than is comfortable in my life (though not far enough). Where does that leave me? Depending exclusively on the strength of the Lord my God. I am weak. I am the punk, I am the crazy. I can't do this alone. I lose purpose, I lose joy, I yell at my kids on my own. Here I am again on my knees. I am partly relieved that it will never stop.

Conversations with Mimi (my maternal grandmother)

I chatted with Mimi last night.
She said:
- She feels all right, healthwise.
- She got the tip of her right ring finger caught in her daddy's car door when she was about 4 years old. It was fine. They didn't go to the doctor.
- She always went to church, and Pop-pop went along but never wanted to join. After years of noncommital attendance, something shifted. One Sunday at Wesley Monumental in Savannah he caught the preacher's hand after the sermon and said, "I want to become part of this church. Would you baptize me?" The next Sunday he got sprinkled and was ever after a member of a church.
- She is very, very sad that her little sister, the sister for whom we named M, is in hospice care. But she knows M the elder has suffered so much...it's just so hard to see someone she loves suffer so much.
- Aunt M has been a wonderful sister to Mimi.

Aunt M sent our KidM a tiny porcelain doll and a commemorative coin collection the year she was born. Aunt M's husband, Uncle Fred, had been a high school football coach and a school principal. He was a big, gruff man with a huge heart. Aunt M loves to laugh and have cookouts by the lake.

What it's like to deliver a baby: TMI

First, it's always different. Second, I'm a novice, so I am not necessarily the best source of information. Nonetheless, I have a few reflections on the privilege of being the one to catch.

Laboring women - unmedicated laboring women - can be...let's call it sharp. Nobody cares, least of all me, that a laboring mom has just said, "I'm going to puke, I'm going to puke," then, "Get that out of my face," regarding the emesis basin she just asked for. It's expected. She's very busy. Her brow is furrowed, she's getting in and out of her pushing position, and she's profoundly uncomfortable.

Different women have different laboring affects, different concerns, and different styles. The divisions seem to be somewhat ethnic and somewhat cultural, but very individual. One laboring mom came in the other day smiling - really grinning - through contractions. Her expression bore both a furrowed brow and a look of giddy acceptance of whatever her plight may be. So sweet. We checked her cervix and she was at 6 centimeters - well on her way to the golden 10. Well on her way to adding another baby to the world. Smiling so big. (I took out most of this paragraph)

Speaking of cervical dilation checks, these take some amount of skill. My patient OB/GYN co-interns and upper-level residents have helped me begin to develop my skill in feeling cervical dilation. At first it just feels really mushy and amorphous with maybe some puzzling contours. I had a great 3rd year tell me, "Feel all the way back and you'll feel something that feels like a rubber band. That's it." At first I was utterly lost. No rubber bands presented themselves to my fingertips and I started to feel really awkward with the time I was spending searching for the rubber band. Then, sure enough, the tip of my finger found that rubber band thing (the dilating cervix) and my eyes shot wide open.
     "I found it! 4 cm?"
     "Close - about four and a half," she replied.
Oh, man, that was awesome. Some women have very obvious cervixes and these checks are not at all uncomfortable. Other women's cervixes are angled way backward toward their sit bones. Some amount of forcefulness is necessary to access the "posterior" cervix. Experienced OB docs will sometimes brace themselves against the floor, lean onto the bed, and put all their weight forward into their two fingers as they search for a hiding cervix. This tends to be less comfortable for the check-ee, but necessary to assess how far they are in their labor.

Okay, so labor. Labor rolls in waves. Women will roll along for a while in relative peace, dealing with contractions as they come in whatever way works for them.

When labor progresses further, near the end, the woman changes. You can see the contraction coming as the woman's eyes start to rove side to side and she starts grabbing for things - your hand, a bed rail, the edge of the bed. If she's a sounder, she starts to sound. I worry about high-pitched, squeaky sounds, but I know things are getting good when she starts to make low moans, and then - thank the lord - to GRUNT. Grunting means pushing is absolutely unavoidable. It just does. I've felt it myself. When I hear a low-grunting woman, I practically feel the urge to push again. The first time I heard another woman making these characteristic labor noises - she was behind a closed door in a labor room at Hospital and I never even met her - I cried. I cried because it brought me back viscerally to my own labors with my girls. It's a little like the phantom brake pedal when you want to slam on brakes on the driver's behalf. When a woman is pushing, and I'm wanting her to push so so well, to make the contraction count, I have to stop myself from actually pushing, too. 

Anyway, in labor, sometimes we hold the woman's legs for her. Sometimes the woman needs that counterpressure and wants it; sometimes she doesn't like that. One woman recently wanted to sit on a bed pan the entire time because it felt better. Another wanted to flip over and labor on hands and knees. All this and more is fine. But there's a catch. No thinking happens during a contraction, and between contractions women are so tuckered out that very little can happen between one contraction and the next. So you have to plan and generate courage to make a change during hard labor.

Once pushing gets toward the end, the baby's head starts to emerge into view. A dark little sliver comes into view during the biggest pushes, and quickly vanishes again between contractions. Soon, lo and behold, the head doesn't vanish. Then more of it creeps down, and then slowly even more. This is when the person doing the delivery can begin to help. First you take three fingers and apply downward pressure onto the head as it comes into view. This is to limit tearing and to relieve pressure between pelvic bone and head. Finally, the head pops past the perineum and you check for a cord around the neck - which you loop over if you find - then deliver the top shoulder of the baby by pressing baby down. Then you deliver the bottom shoulder, which is easier, by pulling back up again. Then baby slides out all of a piece, cord trailing behind, along with a gush of liquid.

We put the baby on mom right away, in all its slimy blue glory. We clamp the cord and, Voila, baby is taking its first breaths and going through that miraculous transition from placental breather to air breather. The heart starts switching its circulation, rerouting right away...and this normally happens without any problem and extremely little intervention. It's nothing short of astounding, miraculous. Part of me wants to tell the mom: LOOK THERE! your baby's body just accomplished one of the most amazing physiologic feats known to mammals.

But I restrain myself. Instead I focus on the matter at hand: finishing this thing up without too much bloodshed and NO retained placenta.

The cord is cut by dad, and I start to gently tug the cord, which, deep inside the uterus, holds fast to the placenta. The placenta detaches from the uterine wall sometime in the half-hour following baby's birth, and comes plopping out. We massage the uterus because it helps with the amazing watermelon to grapefruit shrinkage (and hemostasis) of the uterus that happens in the next few minutes and hours. Again, it's truly miraculous. When you think about it, the placenta has just been intimately associated with the mother's circulation. It's had to glean all baby's needs from that association for nine months. Then, in 15-30 minutes, not only does it detach, it also seals up the blood flow so that mom doesn't hemorrhage as she undoubtedly would if the same amount of blood flow as nourished baby continued schlepping on out of her uterus. Anything wrong in the system can be deadly. But usually it all goes fine :).

Neighborhood / work August 2013

Siegler time: believe it or not, 3/5 of the Sieglers were missing from this photo: Jenn and the two babies she's gestating were resting at home, leaving Baby Tuvia and Daddy Aaron to roam the neighborhood.

Most awesome thing ever: Miss Katie the child life specialist distracting Vivi from everything painful. AMAZING!

KidM and our neighbor. Our neighbor speaks only French, but she's beginning to learn English.

You can see what's on my mind as free time goes bye-bye again.

Me on Women's Urgent Care Center (WUCC) duty at Hospital. The person behind me is Jules - wonderful, capable, bright PGY-2 who oriented me and helped me get going on WUCC duty.

JayJay

Meet JJ. He is in our family now.

Old summer post

Okay, so it's late summer. The days are long but shortening. Sultry steam rises from the street and rooftops after a rain. The trees are a deepening green, dark enough to cover the latent yellows and reds that will be revealed as the weeks pass.

I am at home in a hot summer. The feeling of a soaked tee shirt and sweat running off my forehead and into my eyes is like eating Texas Pete on my beans - I really know I'm doing it.

Also, I have started internship. The chief emotional skill of internship has been quoted many times as follows: "To get comfortable being uncomfortable." Like eating Texas Pete and having sweat in my eyes, I really know I am an intern. I enjoy it, by and large, but it's not what you'd call "comfortable."

KidM posed Cindy this way

I made this for sleeping. Don't hate me because I am beautiful.

We got a lot of fun mileage out of our plaque-staining tablets.

KidM posing

I opened my closet and this is what I saw. KidV was working on a pet hospital.

Some days.

KidV and Miss Alice playing at the stream. Miss Alice is a friend of a friend who needed a couple of hours of playtime with a kid to fulfill requirements a psychology class. KidV is a kid, so they played. This is mostly to show the stream in midsummer. A major asset of our neighborhood.

A subset of my intern class. We are 21 in total. From left to right, top to bottom: Rahul, Zach, Jason, Kevin, Harjot, Tatiana (who is usually quite beautiful), Dr. Heron (a dean), Nadia, Claire, and Brandon (he always looks like that). Everyone's kind, talented, down to earth.

My work landing pad so that I don't forget things: chapstick, twisties, safety glasses, penlight, hand lotion, pens, foldy paper, keys, ACLS cards, trauma shears, tongue depressors, badge, pager.

The girls have started producing a family periodical. KidM gave KidV "The Topics," and KidV composed the copy.

A cookout for all of Our Hospital: barbecue sandwiches, corn on the cob, greens, cornbread, beans, and King of Pops. People talking to their people and a DJ in the corner completed the party atmosphere.  One thing is for sure: Atlanta knows how to eat. Hence the rampant Biscuit Poisoning.

Good job

I have a good job. I work with nice people - people I admire, people I enjoy being around. I get to stretch my capacity to work hard to its absolute limit every day. Every day I get tired by the end of my ten hours. Almost every day...sometimes several times a day...someone tells me, "Thank you, thank you. God bless you, baby." That's just for doing my job and helping someone's pain go away for a bit or getting them the answer they need. Once in a while someone dresses me down for doing my job...but when so many folks are nice to me, I know it's just that person's way of relating to the world. It doesn't bother me nearly as much as if it was all abuse all the time.

And I get to see so many different people, and listen to every single one of their hearts. Isn't that amazing? I get to say to everyone: Okay, now I'm going to listen to your heart. Then I place my stethoscope snugly but gently against their skin, moving it to my four listening areas, and I hear their discreet, dutiful heart. No matter how gnarly a living person is on the outside, they have a clean, fascinating heartbeat.

Sometimes a person in pain is crying, with tears just squeezing out of their eyes uncontrollably. Sometimes a person who's pretty much okay will demand and demand an inappropriate intervention: "Give me something to drink right f*&%#ing now or I am taking all this wires and  S^$* off me and walking out of here." (We can't let you eat right now because there's a substantial chance you'll need surgery tonight. How about some ice chips and more IV fluids?) Or: "If my CT scan doesn't show anything bad, will you still give me some percocets?" (We can't send home anyone with narcotic pain medicines if we aren't absolutely sure they need them. It's not in our patients' best interest.) But there are a lot more, "Thank you all so much for what you do," and "Thank you, ma'am," and "I appreciate it, doc," than anything else. It surprises me every time!

Meanwhile, everything is so big. The population we see at our hospital...huge. The ambulances making crooked spokes out from the hub of Our Hospital...huge distances traveled, so many trips. So much goes in the trash, so much gets used, so many pixels sporting so much new information. My brain hurts at the end of the day. That's 3/4 of the tired feeling. One thing is sure - the more I enjoy a thing the better I can learn it. So I am thankful to enjoy this.