Surprise Delivery!

I know I haven't written in months. I've delivered tons of babies, taken out bunches of ovaries and uteruses, and tied many tubes. Overall, things are good, and I miss blogging. If I had more time again, I would tell all my stories to you. It will probably have to wait, and I'll just publish my own medical memoirs in a few years instead, and add my name to the long list of physician-authors out there. But here's just a quick note to say that I had one of the most exciting deliveries I've had in a long time, and it was relevant to the blogosphere -- last night I delivered Bea from Finding Equanimity! I hope she doesn't mind that I share that she had a beautiful baby boy, and did it in one of the most calm, controlled deliveries I've had in a while. She is an inspiration to delivering mothers everywhere! I hope she and J enjoy the new addition to their family. It was a funny series of little hints that led me to ask her, after one set of pushes, after J revealed he was a surgery resident, if she wrote a blog. And suddenly, we figured it out! I love these small-world moments!

Congrats to Bea and J!

Spring!

January and February, as they always do, had me in a funk this year. The only good thing about it was the snow, and even that wasn't all happy, because once I had the taste of a real, honest-to-goodness snow day (last one ever, I'm sure!), I just became more and more bitter at ever having to go to work at all, snow or not. Give me an inch, I'll demand a mile, and all that.

March, on the other hand, has been a whirlwind of work. I'm working very long and very hard hours this month, including a 20-day-in-a-row stretch, the only "days off" being two, one at the end of each of the last two weeks, because I was post-call. And "day off" is a misnomer, because while it counts toward compliance with the 80-hour work week, no one could honestly call it a full day off because it only lasts 20 hours, and I have to catch up on sleep since the night before, while on call, I got anywhere from 0-60 minutes of sleep, total. So, 20 days in a row, with 20 hours off on day 6 and 14. Today, however, was day 16, so the end is in sight!

And what an end it's going to be. After this crazy stretch, I get one. entire. week. off! To do nothing with! And hopefully the weather will warm up again.

Even though my day-to-day life sucks right now -- I come home, eat either on the couch or out somewhere, watch TV, and fall asleep on the couch until Eric drags me to bed -- my work life isn't that bad, despite the grueling hours. I'm getting to be a better surgeon, and my C-section time is decreasing, while my skills with a scalpel and needle are getting to be pretty impressive. It's been [relatively] quiet on Labor and Delivery this week, so I'm getting to do some reading at work. And I've had some good vaginal deliveries, including a patient who took my picture -- holding the new baby -- after I delivered her.

Still, I can't help but wish I had the time to sit at home all day and cook, start my seedlings, and read magazines. It's probably time to start playing the lottery.

But in other good news, we bought plane tickets to Brussels! We'll be in Europe at the end of May, and I'm quite excited.

"You're a doctor?! But you're so..."

"...young!"

"How old ARE you!?"

"Are you old enough to be a doctor?!"

I'd say I get one of those comments at least once a week.

Worse, though, is what used to happen when I tried, in the beginning of intern year, to introduce myself as "Holly, the resident who will be taking care of you." I was trying to come across as a young, personable doctor. Don't stand on ceremony, don't worry about the title. Inevitably, I'd hear, "So when will I see the doctor?"

Or, "So you're my nurse?"

I put up with it on my medicine rotation; I let the little old men get away with calling me a nurse or being confused about what a resident is (granted, it IS confusing if you have no idea how the medical system works). But then I got to OB full-time, and when it's a 17-year-old, dropped-out-of-high-school-and-got-knocked-up, who is screaming at me that the cervical exam at 5 cm is excruciating and clamps her thighs down on my hand in the middle of the exam who refers to me as a nurse, I have very little patience for it. So I started introducing myself as "Dr."

Can I also mention that usually, the way the 17-year-old refers to me as a nurse is when she answers her cell phone, in the middle of while I am trying to talk to her or examine her, and says to the caller, "Hey, I can't talk right now, the nurse is in here talking to me, let me call you back." Drives me absolutely crazy.

So I switched from "Hi, my name is Holly and I'm one of the OB/Gyn residents" to "Hi, I'm Dr. Cummings, one of the OB/Gyn residents."

And as a result, since I'm emphasizing the "Doctor," I am met with:

"But you look so YOUNG!" (From the older patients. The younger patients don't react, which is what I want.)

And I always have the same response: "[Smile] Yes, I'm told I'll appreciate that one day."

(In reality, I don't get too terribly upset about it. After all, if I were to get carded at a bar, I'd think it was a good thing. I just have to reinforce that I am, in fact, a doctor, and perfectly qualified to treat the patient.)

But this weekend, I got a new comment.

"But you're so TINY!"

And I could do nothing but laugh. As though that were a criterion for entering medical school.

***

Last week, I encountered another version of the assumption game. It was assumption combined with stupidity. I was working at an outpatient office, and at lunch, a pharmaceutical rep brought lunch. I went to the break room, and was dismayed to find I was the only one there -- the nurses and office staff had already eaten and gone back to the front, and my attending (who the rep wanted to talk to) was still finishing up with his last patient of the morning. So I politely said hi and served myself some pasta. And the rep did her thing, introducing herself, and asking my name. (I just gave my first name.) And she said, "Are you one of the nurses? Or medical assistants?"

And I about flipped my lid. I was wearing professional office attire, and still had my stethoscope around my neck. She assumed I was a nurse based solely on the fact that I was a woman. Because if she had even the slightest powers of observation, she would have observed that all of the nurses and M.A.s who had just finished their lunch in front of her (and who had introduced THEMselves as nurses and M.A.s) were wearing scrubs. You know, nurse's scrubs. Fun colors, pretty prints. And I was not. (And can I mention there's also a female attending in that office, too? What if she had said that to the partner in the practice!?!?)

So I corrected her. "I'm one of the residents rotating here." This particular office has a fairly regular stream of drug reps, and they know the deal with residents (they usually ask what year I am, and when I -- one of the rare times I volunteer this -- say I'm an intern, they stop showing any interest in me, which is just what I want). So I told her I was a resident.

"Oh. [Smile. Pause. Nodding.] So when will you finish school?"

Misinformed patients, I can deal with. Rude patients, I can deal with. Patients who think it's acceptable to undermine my authority by telling me I look young/small/cute, I can deal with. Someone whose job it is to interact with medical professionals who doesn't know how to identify a doctor compared with a nurse and who doesn't know the medical hierarchy? I have zero tolerance for.

***

And the third part of this post, this disjointed, written-while-slouched-on-the-couch-half-watching-Olympics post, is a link to a Scutmonkey comic that makes me laugh.

How to Annoy a Resident

OTC Meds

I promised you this post a long, long time ago. And then I felt nervous about posting medical advice online seeing as how I wasn't a doctor. And then I became a doctor. And then I felt nervous about posting medical advice online, seeing as how I don't know if or how my malpractice insurance would cover an incident in which you take too much Robitussin based on what I write here. Plus, you know, couldn't I [in theory] charge you some money for bringing you into the office to tell you all this in person?

[I don't think my malpractice insurance will cover me if you overdose on Robitussin. But all of the doses I'm giving you here are the same as what is written on the box. And all of the financial stuff is moot, because I am a salaried PGY-1. I see as many patients in the office as needed, and make no extra money from it.]

And even if I could make money off of office visits, let's be honest: While I love explaining some things to patients, I HATE talking about the common cold and OTC meds. So here you go.

Do you have a cold? Before you even attempt to call your doctor in a feeble attempt to garner antibiotics for your VIRAL infection, take these medicines. And remember, if you have any liver, heart, or other problems, or are pregnant, do call your doctor first. These are adult doses; if you are treating children, make sure you adhere to the child dosing guidelines.

Headache:

Take acetaminophen (brand name Tylenol), anywhere between 325-650 mg every 4-6 hours. Do not take with alcohol. You can also take ibuprofen (brand name Motrin, Advil), 400 mg every 4 hours, or 600 mg every 6 hours. Take with a little bit of food. It is OK to mix these two pain medicines, as they do not interact.

Fever:

The definition of a fever is a temperature of 100.4 or greater. A "low-grade fever" means a fever between 100.4 and 101.0. A temperature of 99.8 is NOT a fever, and is NOT a low-grade fever.

Take acetaminophen 325-650 mg every 4-6 hours, and/or ibuprofen 400 mg every 4 hours or 600 mg ever 6 hours. If the fever keeps coming back, keep taking the medicine. If you truly have a fever, be sure to call your doctor, to make sure nothing else more serious is going on.

Sore Throat:

1. Take acetaminophen 325-650 mg every 4-6 hours (the range of doses is because your standard OTC pills come in different doses. "Regular" strength is usually either 250 or 325 mg, while "Extra Strength" is usually 500 or 650 mg.

2. Also take ibuprofen, 400 mg every 4 hours, or 600 mg every 6 hours, with a little food. The ibuprofen is very important for sore throats because it is an anti-inflammatory and decreases the throat swelling that is giving you pain in the first place.

3. Warm salt water gargles really do work.

Nasal Congestion: For stuffy noses, especially during a cold.

1. Saline nose spray, just like babies use. Really. It rinses out your nostrils and keeps your mucous membranes moist. You should strongly consider using the Neti pot method (you don't need the actual Neti pot). Mix 16 oz of warm water with 1 tsp salt, or use store-bought saline solution in a regular squeeze-and-drip bottle (not the kind that sends a misting spray up when you depress an activator). Tilt your head to one side (do it over a sink or in the shower), and pour/spray the saline into your top nostril. It will run into your other nostril and probably into your mouth -- just spit it out. Tilt your head to the other side and repeat with the other nostril. Blow your nose to get rid of any extra liquid. Congratulations! You've rinsed out your sinuses. Do this regularly.

2. Pseudoephedrine. This is a really good nasal decongestant. It constricts your nasal blood vessels, thus decreasing all the liquid/stuffiness that builds up in your nose. Do not take if you have high blood pressure without talking to your doctor first. The key to taking pseudoephedrine is that in most states it is sold behind the pharmacy counter, because otherwise people buy it in bulk and use it to make crystal meth. You don't need a prescription (although some states are considering changing that), but they'll take down your information to make sure you're not buying too much of it. The most common brand name is Sudafed. The dosing is 30-60 mg every 4-6 hours. A common side effect of pseudoephedrine is a woozy sensation, because of the vessel constriction throughout your body. For me, I've found that 30 mg every 4 hours is the best balance between symptomatic relief and not feeling woozy. See what works for you. It's important to stay well hydrated while taking this medicine, so push the fluids. Don't bother buying the still-on-the-shelf version of Sudafed, which is the active ingredient "phenylephrine." It doesn't work as well as pseudoephedrine. And also remember that you need to take the medicine every 4-6 hours on the dot. I can't tell you how many times a patient has said to me, "Yeah, I took some Sudafed, and it worked, but then it wore off after a few hours." I'm sorry, but that is how medicines work. You need to keep taking it for it to keep working. If it's working, keep using it.

3. Oxymetazoline. Commonly known as Afrin. This medicine is very effective, but should be used with caution. The official dosing is 2 sprays in each nostril every 12 hours. DO NOT USE FOR MORE THAN 3 DAYS IN A ROW. The reason for this is "Afrin addiction," which isn't really an addiction, but rather what happens is you develop rebound nasal congestion. So even though you are using the medicine, your nasal membranes become more swollen, instead of less. Not good news. I recommend using it only at night, to ensure that you get a good night's sleep. During the day, stick to the pseudoephedrine.

4. Cetirizine (Zyrtec) or loratadine (Claritin, Alavert). These are anti-histamines, which are good if you think any portion of your nasal congestion or runny nose are related to allergies. You may not have allergies regularly (or may not know it), but when you have a cold, it may contribute to some of your symptoms. In any case, there are almost no side effects to giving these medicines a shot.

Cough: There are two types of cough. One is the kind where you are hacking up all sorts of thick mucus. The other is a dry, spasmodic cough that you just can't control.

1. For the mucousy cough, take guaifenisen. This is sold under the brand names Robitussin or Mucinex. Make sure that you get the right kind, as Robitussin in particular has many different formulations. Guaifenisen 200-400 mg every 4 hours. Take LOTS of fluids with this medicine, as it dries you out. Guaifenisen is a cough expectorant, meaning it helps thin out your mucus and makes it easier for you to bring up and spit out. Comes in liquid and pill/capsule formulations.

2. For the dry, hacking, spasmodic cough, the medicine you are looking for is dextromethorphan. It is commonly referred to in cough formulations as "DM." The dosing is 10-20 mg every 4 hours. Again, drink plenty of fluids with this. Comes in liquid and pill/capsule formulations.

I stock all of these medicines in my home, especially during cold season. Is it annoying to take medicines every 4-6 hours throughout the day and night? Sure. But it works, and it's only temporary. If it's really that much trouble, most medicines come in "extended-release" formulations that allow once a day or twice a day dosing; just read the labels.

A lot of people take combination formulas like Dayquil or Nyquil, which usually contain a combo of acetaminophen, pseudoephedrine, guaifenisen, and dextromethorphan. In general, I don't recommend those formulations. If you don't particularly have a mucousy cough, then you don't need the guaifenisen, so it's just going to dehydrate you unnecessarily. Instead, take each medicine separately so you can mix and match what you need. The only exception I would make is for Nyquil, because the active ingredient that makes it a night-time formula, doxylamine, is difficult to find as a sole ingredient. Doxylamine is a good sleep-aid agent, so if you need it, then Nyquil is good. Just be sure to calculate the doses of everything else in there so you know what you're taking.

Maximum doses: Be sure to read the label of each medicine and do not exceed the maximum amount of any medicine in a 24-hour period. Acetaminophen will damage your liver if you take too much; ibuprofen will damage your stomach and kidneys if you take too much. These are potentially serious side effects that should be taken seriously.

Reasons to call your doctor:

- Fever greater than or equal to 101.0. This can signify something potentially more serious, like pneumonia.

- All over body aches and pains. Call your doctor quickly, as this can be a sign of influenza infection, and taking Tamiflu within the first 48 hours can limit the course of infection.

- Shortness of breath or trouble breathing

- Chest pain

- Vomiting or diarrhea, especially if you can't keep anything down and are becoming dehydrated.

- Symptoms that last longer than 10 days. This can be a sign of sinusitis (which would warrant antibiotics), or a post-infectious cough, which can be treated with medicine.

Otherwise, if your sinuses are tender and your head hurts and your nose is stuffy and you have a cough, for two days, DO NOT CALL ME. Take these medicines. A cold can take 7-10 days to resolve completely. As long as you are getting slightly better day by day, just keep doing what you are doing. I will not give you antibiotics. You will get better. It will suck, but you will survive. I know this, because it has happened to me, too.

Bad outcomes

Obstetrics is a weird specialty. We're always super-obsessed (often to my chagrin) with documentation and CYA-type practices. These first couple months on service (since I started on medicine/ICU this year) have had their share of moments of me saying, "But on medicine we didn't worry about this." But I also do know that when things go wrong in medicine, a 90-year-old pt might have a bad outcome, but it's inherently easier to tolerate than when things go wrong with a 20-year old woman -- or a 1-day-old infant. (That doesn't make the loss of someone's grandmother or grandfather any less important, but for the general population, we tolerate the death of a 90-year-old moreso than of a 20-year-old.)

The aftershocks of the death of our post-partum patient from H1N1 pneumonia continues to ripple through the department and hospital. As of this week, the hospital is not allowing anyone under 16 years old to enter the hospital at all (H1N1 is widespread among children). We continue to screen and test our pregnant patients for H1N1, and have a positive test result at least a couple times a week. Tamiflu is a godsend, though; we start our patients on it early and we haven't had any other bad outcomes yet. And I got my H1N1 vaccine, so I feel better that I won't get sick and 1) feel crappy myself and 2) spread infection to patients.

This morning I got to deliver a patient who I admitted the night before. She is a 33-year-old primiparous woman at 36 weeks and 3 days who came into our triage unit for rule out labor. She was contracting every 3 minutes or so for sure, but her cervix was only 1 cm dilated and not effaced. We watched her for a little while because her blood pressures were really elevated, so we wanted to check labs. And 3 hours later, her cervix was still 1 cm and not effaced, but given her high blood pressures, we kept her for more testing. Not in labor. An hour later, the third year resident saw me and asked, "Was Ms. B really 1/long/-3* when you checked her? Because she's 80% effaced for me." And for once, I was really confident in my exam, and I knew she hadn't been effaced an hour prior. Since it was 2 am and my turn to go down for an on-call nap, I went to sleep for 2 hours. And when I got up at 4, the third-year said, "Guess what! Ms. B is in labor! She's 5 cm now."

So in 3 hours, she went from 1 and long to 1 and 80% to 5 and 90%. Off to L&D she went, and got her epidural. And an hour and a half later, she was complete and +1 station, and ready to push! And I was there and able to do it! So we started pushing and she did really well, and in about 30 minutes she was ready to deliver. The head delivered nicely, and at first I didn't feel a nuchal cord. But then we saw a nuchal cord -- a tight one. Both my attending and I tried to reduce it, but couldn't get it at the first pass, and as I was trying a second time, my attending told me to stop, and grabbed the clamps, and we ordered the patient to stop pushing while we clamped and cut the nuchal at the perineum. The rest of the baby delivered fine. It gasped for breath as usual, and I suctioned the mouth and nose, and handed the baby up to mom's belly, just like normal. And then the nurse grabbed the baby and brought it over to the warmer, and while I was collecting cord bloods and cord gases, it all of a sudden hit me: I hadn't heard the baby cry yet. Gasped, yes. Cry, no. And the mom realized it, too.

So the pediatricians rushed in and did their thing (I couldn't see it; I was busy doing my thing), and while we delivered the placenta and repaired mom's tears (the shoulders busted out all at once, so she had a couple little ones), the silence in the room was overwhelming. A nurse called out the time. "Seven minutes." As in, seven minutes without a cry. I start feeling sick.

And then, finally, the baby cried. Everyone breathed a sigh of relief, myself included. But I'm anxious to go to work tomorrow to see how the baby's doing.

And while I gripe, I know why we document up the wazoo. Because when a 90-year-old woman with multiple medical comorbidities dies, chances are you won't get sued. But when a 23-year-old woman dies 1 week after delivering her baby, or a baby ends up with a bad outcome, everyone is going to be scrutinizing what you did over and over. We scrutinize it, and try to learn from it. And we hope we won't be scrutinizing it in court.

Why couldn't I have gone into a less stressful field?

Balsamic Vinegar

Yum! I used it a lot this past weekend, with great results. Here's a recap:

Saturday, dinner with my friend and bridesmaid Karen, her husband Jake, and their 2-year-old daughter, Lily:

Brushchetta as an appetizer: Tomatoes, diced onion, fresh basil, a splash of good balsamic vinegar, a drizzle of EVOO, and salt and pepper. Serve with a good loaf of bread -- we got a baguette from the Asian grocery store down the street (Vietnamese cuisine has a lot of French influence, remember).

Balsamic-glazed grilled chicken:

Make a marinade using balsamic vinegar, olive oil, some lime or lemon juice, some dried oregano, salt and pepper, and minced garlic. Mix to combine, and pour over chicken parts. Marinate for a couple or few hours. Grill, basting with the marinade.

Cut up some peaches (it's peach season!) and put on the grill. Slice some onions into thick slices (I used yellow onions because I have a bunch of them right now, but red onions or Vidalias would be even better, I'm sure!), give them a swipe of olive oil, and add those to the grill, too. While everything's grilling, mix up a balsamic vinaigrette: good balsamic vinegar, salt and pepper, dried oregano, a sprinkle of sugar, and some fresh chopped herbs (I used basil). Whisk while drizzling in extra virgin olive oil, until it reaches the right consistency. I used a bagged mixed greens salad from the grocery store, topped it with tomato wedges from my garden, the grilled peaches and grilled onions, and poured the vinaigrette over the whole thing. Serve alongside the grilled chicken.

For a few reasons, I have started to buy different versions of certain oils and vinegars. For marinating and sauteeing, I use regular olive oil. I save the EVOO for salad dressings, bruschetta, and other preparations in which we'll be eating the oil in its raw and pure form. The regular olive oil is cheaper, and I save the good stuff for when it matters. The same goes for balsamic vinegar -- I use a run-of-the-mill balsamic for marinating and reducing into sauces, and save the sweeter, better, and more expensive balsamic for pure/raw preparations like vinaigrettes and bruschetta. If you're trying to make your dollar stretch farther, this is a great way to do it while still being able to use quality ingredients when it counts.

Sunday, dinner with some friends and an excuse to use up more chicken and peaches:

Same chicken marinated in the same balsamic marinade, but this time, served with a grilled peach and corn salsa, recipe courtesy of Mark Bittman's How to Cook Everything. Cut 2-3 peaches in thirds or halves and grill. Also grill a couple ears of corn. Let cool until able to handle, and then cut off the corn kernels and dice up the peaches and put everything into a bowl. Add about 2-3 tablespoons of chopped Thai basil (regular basil or mint would also work well), and half of a jalapeno, finely diced. Squeeze some lime juice into the bowl and season with salt and pepper. Serve warm over the chicken. We've been eating it cold ever since as a salsa with chips, but it was really best warm over the grilled chicken. The spiciness of the jalapeno in the salsa is cut by the lime and Thai basil, and it all goes wonderfully well with the sweetness of the balsamic glaze on the chicken.

To use up the jalapenos and banana peppers I've been growing, we also made jalapeno poppers. To make them, slice your peppers in half lengthwise and scoop out the seeds and white rinds. Mix shredded cheddar cheese with cream cheese, and spoon into the peppers. Wrap the whole thing with half a strip of bacon and secure with a toothpick. Grill for a few minutes over semi-direct heat until the bacon is cooked through, and eat warm. Very yummy. I thought about using a more interesting cheese instead of the cheddar, like Monterey Jack or Colby, but decided the heat of the jalapeno would negate any subtle taste differences, and I think I was right. That said, if all I had was Jack cheese, I wouldn't bother going to get cheddar for this recipe. We stuffed ourselves with jalapeno poppers and then ate the chicken with the corn and peach salsa, and it was plenty of food.

One of the things I particularly loved about cooking this weekend was being able to use so many items from my own garden and from the local market. One of my own tomatoes went into the bruschetta; I used my own basil for the bruschetta and Thai basil for the corn and peach salsa. My own jalapenos and banana peppers were the basis for the jalapeno poppers -- I definitely would not normally have made them if I didn't have an abundance of peppers I didn't know what to do with.

And the Italian market is definitely my favorite place to shop. I got 3 pounds of perfectly ripe peaches for $1, which went into the salad on Saturday and the salsa on Sunday; fresh Jersey corn for the salsa; amazing slab bacon -- for much less than the grocery store charges! -- for the poppers; and great whole chicken breasts to go with the dark meat I already had in the refrigerator. The butcher offered to split the breasts for me, but I chose to do it myself; it was a good lesson in chicken anatomy, and it gave me the opportunity to save all the little extra trimmings and bones to freeze and make stock with later. The only downside to the market is that everything closes down around 5 or 5:30 so it's hard for us to get there during the week.

As exhausted as I am from working, I am really enjoying cooking this summer. I hope the weather doesn't cool down anytime soon -- we need to keep grilling!

Less depressing stuff

Last week we had a patient who came into the ER with chest pain. 33 years old, otherwise previously healthy, though with a significant family history of cardiac disease. Chest pain, and in the ER, he went into V-fib, and was shocked back. It doesn't happen all that often, but what made it even more exciting was that because he had no other comorbidities, he was a candidate for our hypothermia protocol. I had never heard of it before, but lo and behold, a day after we dropped his body temperature to 33 degrees Celsius, I saw this article on CNN.com: Cooling is catching on for cardiac arrest patients. (No, I do not generally get my medical news from CNN; however, I was post-call and just doing some fluff reading on the Internet.)

Our patient did great! He was cooled for 24 hours, then rewarmed slowly. He slowly came to and did well neurologically, and we transferred him from the ICU out to a regular floor bed later that day. The other night I was walking through the floor units and saw him -- sitting in a chair outside his room reading a book. Totally normal. He's definitely shaken by what happened -- imagine waking up in a hospital having no idea why you were there, and being told that not only did you die for a minute, but that your body was then frozen (OK, not really frozen Austin Powers style, but you know...) and rewarmed. Crazy! He'll do fine physically, but I hope he follows through with his emotional/psychological counselling, because boy, will he need it. In any case, I thought you'd enjoy a slightly more happy story from the ICU.

And here's a Can You Believe It story: I have an 87-year-old woman who is on a ventilator because she developed respiratory distress the other night. She's a sick woman, and when it came time to think about intubating her, we needed consent from someone, and since she was unable to give consent due to her respiratory distress, we called her son, who consented over the phone, saying she would want to be intubated. So she was intubated. The next morning, another son contacted us and said he was her healthcare power of attorney and she did NOT want to be intubated. Uh oh! The first son, when approached with that information, maintained that there was a newer document in which HE was named power of attorney, and she DID want to be intubated. And when we told him to go home and get the papers, he came back and said he couldn't find them. Hmmmm. And of course, it turns out the two brothers don't talk to each other. So we scheduled a family meeting and waited. And in the meantime, one of the nurses found out the scoop: The first brother, the one who initially consented to the intubation, is apparently $1.5 MILLION in the hole from gambling debts. And he continues to gamble. He has multiple sclerosis and lives with his mother, and he uses her social security money to continue to gamble! So of COURSE he wants to keep her alive and on the ventilator -- he wants her money! Juicy, juicy.

In the end, papers were found at the lawyer's office, in which the patient had checked off that she did want to be resuscitated and did want to be intubated, so we will continue to treat her. But I can't look at the son the same way anymore. The gall!

And finally, I walked home today via the Italian Market and stopped to pick up a couple lemons and some bread. Dinner plans tonight are for chicken scallopini and bruschetta (home grown tomatoes ripened yesterday!). Sarcone's was sold out as usual (they sell out first thing every morning!), so I walked down to Talluto's, where I've also gotten bread before, about 10 minutes before they closed. Alas, the bread bin was empty, but the woman behind the counter said there was some at the register. I peered into the large brown bag full of rolls and as I asked for a couple short rolls, the woman shoved the whole paper bag into a plastic grocery bag and pushed it toward me. "Oh," I said, a little confused. "How much for the whole bag?" "Have a good day," she replied. And when I looked even more confused, she explained, "We don't sell day-old bread so we won't sell them tomorrow, so you can have them." Wow! What luck! Yay for the Italian Market.