A Day in the Life

....of a Heme/Onc fellow.

My family often asks what it is I do all day. They know I work ridiculous hours and am ridiculously busy but it's hard for them to understand what the heck I am DOING all day. So here's the play by play:

6am. Time to get up. I check facebook and email since this is the only quiet time I'll likely have for the entire day. I give myelf 5 minutes for this tops.

6:05-6:35. Get ready for work. Scrounge together some assortment of food for "lunch". The quotation marks will become more clear once we near lunchtime.

6:35-7. Drive to work.

I should stop here to explain the structure of the rotation I'm currently on. I'm on the Red service which is the inpatient service for liquid tumors- leukemia, lymphoma and multiple myeloma. Other members of my team include the attending (my boss), a senior resident, one or two interns, and a pharmacist. All of these folks change every two weeks, whereas I stay on the rotation for a month. And the switches are staggered so the team is constantly changing.

My job as the fellow is to supervise the residents and take care of 'fellow' level activities such as writing chemotherapy orders, and doing procedures like bone marrow biopsies and intrathecal chemotherapy injections. I also talk to patients about their chemo regimens, their prognosis and any other cancer related questions.

7-7:30. Prepare for "rounds". I review the past day and overnight events for those w/ active cancer related issues with special attention to the ICU patients since they are sicker and I am the primary oncology presence for them as opposed to the floor patients who have our whole team looking after them. If there's time, I start working on chemo orders or correspondence during this time.

AM: Rounds with the team. This is where we discuss each of our 14 patients in great detail reviewing past events and making decisions about next steps. We also hear about any new patients that were admitted overnight. The interns present this info. I try to stay in the background as much as possible to give the intern and resident independence to learn and take ownership of patient care, but I interject if I think they are missing an important point or making a suboptimal decision. The attending and I also use this as a time to do some teaching about oncology points as they relate to our patients. Then we go see all the patients and relay the plans to them and see how they are doing.

That's the basic structure of the morning. The afternoon is spent talking to patients, families and the primary (outpatient) oncologists, seeing the ICU patients (writing their notes and making recommendations to the primary team), and doing procdures. Oh- and attending or presenting at educational conferences.

Here's a play by play of an actual day:

7:30-9:00 round with the team

9-9:30 bring IT (spinal) chemotherapy over to the other hospital (2 blocks away) to interventional radiology where I inject the chemo via a lumbar puncture.

9:30-10 catch up on what I missed on rounds, continue rounding

10-10:30 I stay back after rounds to talk to a patient and his wife about his relapsed disease in greater detail. We talked about side effects of the chemo we plan to use as well as success rates. We discuss the stem cell transplant process. His wife is understandably very upset. His prognosis is poor and they realize this. I encourage him to take vacations and do all the things he's always wanted to do while he still feels up to it.

10:30-11 catch up on what I missed on rounds, continue rounding

11-12 go over to Feinberg (the other hospital) to explain intrathecal chemotherapy to a young patient just diagnosed with aggressive lymphoma, run back to Prentice to write the chemo orders, bring the orders back to Feinberg and push the chemo

12-1 write chemotherapy orders, talk to attendings about their preferences for certain aspects of the chemo orders

1-1:30 go see our ICU patient. He is very sick and we are making some critical decisions so my attending and I spend time talking to his family and to each other about our chemotherapy options. We decide to continue to hold off on treatment until his other organs improve.

1:30-2:00 write daily progress notes, email updates to primary attendings, answer questions for the interns/residents. sometimes I eat my breakfast cereal at this point, sometimes I don't. Hence "lunch".

2:00-3:00 I learn of a new admission- a guy I know really well with relapsed, impossible to treat leukemia. He's very sick and likely won't make it out of the hospital alive. I talk to him and his wife about goals of care and we conclude that he does not want to go back to the ICU, he'd rather focus on comfort. I reaffirm that he is making a very reasonable decision and that we will do everything we can to keep him comfortable. I inform the nurse, the team, my attending and his primary oncologist about his decision.

3-3:30 There's a big hullabaloo about trying yet another chemo agent on the guy mentioned above. It has little to no chance of working; he is very sick. I think he's actively dying. At his outpatient attending's request, I present the option of the medicine to the patient. He declines. I'm relieved because I know another medication will not help him with comfort, which is his primary goal. (Post script- he dies peacefully 36 hours later.)

3:30-4:00 Talk to the team, run the list with my attending. ("Run the List" or RTL, means we touch on key issues that are worth talking about- we don't talk about everyone every time- just the most active high level stuff)

4:00-5:00 start working on signouts for my covering co-fellow because I have the next day off. Taking a day off is hard work. I write a document with all the patients, their cancer history and the important active issues to give to the covering fellow. I ask the housestaff to put in orders they may have missed as I review the patients. Try to find something to eat, hopefully I brought something from home because I can't spare the 15 minutes to go to the cafeteria.

5:00-5:15 walk over to the outpatient building to get a signature on chemo orders, call a recently discharged patient to let him know his bone marrow was clean (no disease) though, in his case, this doesn't change the prognosis.

5:15-5:30 go over chemo orders for a new patient with the attending.

5:30-6:00 walk back to Prentice to drop off the chemo orders (they literally have to be walked over). Get a call from Pathology that another patient's bone marrow is NOT clean (meaning there is still disease). This also doesn't change her management. Final check in w/ housestaff before I leave.

This particular evening is "day-off eve" meaning I can sign my pager out since I have the next day off. Therefore I don't have to keep the pager on at all times, and I won't get called in the middle of the night. Day off eve is a good night.

That's a pretty typical day. Lots of running back and forth, procedures, diffucult patient conversations, lots of discussions about patient management. Usually there are some bone marrow biopsies thrown in for good measure. Two days a week I have clinic in the afternoon so all my daily work has to be done by noon. That's always interesting:) At least two days a week I give a lecture to the housestaff to teach them about heme/onc. I often spend time looking up research articles and reviewing new literature as it comes out. So much to learn!

To my family: Does this shed any light? Or are you only more confused? ;)

2nd Annual Bison Family Turkey Trot

I am proud to say that for the second year in a row the majority of my immediate family members participated in the Bison Family Turkey Trot! While I knew there was no way this way would top last year's celebratory trot, I still wanted to do my part and get a run in! So as soon as we found out I'd have Thanksgiving off, Adam and I signed up for the Lincoln Park Turkey Trot 8k. I wore my "HappyThanksgiving2007!" shirt from a Rockford Turkey Trot a few years back and let me tell you, I understand why folks don't run in cotton. I was somehow hot AND cold the whole run!

Overall it was a good run, but nothing special to report. It was a very crowded course- no big PRs here (though I did technically get a PR but only because my last 8K was years ago)- but I expected that. Adam and I ran together at a nice easy pace for the first 3 miles, but just before mile 4 he informed me that when we got back on the wider street he was going to speed up. I gotta say, I wasn't excited about that. I was planning on this being a fun run, not a race, but there's no way I could let Adam run ahead without making some kind of effort to keep up!

As promised, at Mile 4, he took off like a bolt of lightening. Ugh. I let him go for a few seconds, then joined in the fun. Fun is the wrong word. The last 2 miles were anything but fun. Well, Adam says he had fun but we ran waayy faster than was comfortable for me. Anyway I'll spare you the gory details about the right side of my brain throbbing (I'm thinking due to lack of oxygen) and my surefire way to get people to move out of your path by breathing like you are about to die (I think I was). In the end we finished 20 seconds apart. I forgot my Garmin so I have no idea what kind of splits we had for the last 2 miles- probably sub-8 minutes based on how bad I felt.


And don't worry, I didn't forget the bison!

Later in the day, I was happily surprised to learn that my parents participated in the Bison Family Turkey Trot as well even though they were far away in North Carolina. They went for a run with my niece on the bike. I was very happy to hear that. I think we've got a strong tradition started. Maybe next year we'll get some matching T shirts, make it a real event:)

While I don't have a picture of the formal run my family did, I do have this great shot of my Dad chasing my niece playing football. What a great shot! I think she's going to be a runner:) No pressure, G:)

Hope you all had a great Turkey Day!

Recipe for a Great Long Weekend

Ingredients:

• 1 dear friend, imported from California

• 1 supportive husband who enjoys quality time with my friends

• 5 bottles of red wine (Syrah and Zin are best)

• 3 games of bowling with new friends (the kind with retro music from the 90's are best)

• 1 tasty French-Mexican fusion meal at Mexique

• 4 runs, 1 with 4 x400m intervals at sub-7 minute pace

• 1 game of 'Celebrity' with old and new friends at The Happy Village

• 1 bag of White Cheddar Cheez-Its

• Tons of laughs

• 15 hours of work (a necessary evil)

• 1 jazz and champagne brunch with a Boston import

• 1 simultaneously emotional and hilarious meal at West Town Tavern

• 103 minutes of Stick-it

• Roughly 2 hours too few of sleep each night

•  4 naps to make up for the above

• 2 amazing homemade meals from Chef Adam including the famous Skillet Cheese Toast!

Instructions: Joyously celebrate the arrival of the California import. Start off with a quick run (the FAST one) followed by a glass of wine and some laughs. Next, leisurely enjoy the meal at Mexique. Mix in a dash of work. Next, mix in the bowling and the game of celebrity at The Happy Village. Keep laughing until you can't laugh anymore. Consume the Cheez-its. Stay awake until you absolutely can't keep your eyes open anymore.  Sleep in and then meet the Boston import for brunch. Nap again. Enjoy both homemade meals from Chef Adam, best if consumed on the couch while watching Stick-it. A dash more of work. Another run. And then the West Town tavern meal. Laugh until you cry. Cry until you laugh. Finally, sprinkle the bottles of wine throughout the weekend. Enjoy!

 

My Optimistic Bathroom Door

This is the back of my bathroom door. Swimsuit, swimming coverall, another swimsuit. When was the last time I swam? Might have been in 2010. At least not since last spring. But do I put my swimsuit(s) away in a more logical place like a closet or drawer? No. Because I know one day I will get into swimming because one day I will do an Ironman. It's just that today is not that day. And tomorrow probably isn't either. But one day I will work less than 10 hours a day, less than 6 days a week and I will swim. And leaving my suits hanging on that door where I see them every time I leave the bathroom makes me look forward to that day and reminds me that it is coming soon. Who knew a little hook on a nondescript bathroom door could be so motivational?

First Sign of Aging: There Goes My Cementum!!

Yesterday I went to the dentist because I have had intermittent tooth pain since July. Yes, July. Five months later I was finally able to coordinate my schedule with the dentist's schedule and get in to see him. The nurse took an x-ray and the dentist came in a few minutes later, sat down next to me, and calmly said, "You're getting old".  I'm very well aware I'm getting old since the price of all my dermatologic interventions (creams etc) is rising in direct correlation with my slowly advancing wrinkles. So this was not news.  I'm willing to accept that things aren't going to work as well over time, but I wanted to know if there was something dental hygeine-wise that I should do differently.

First, some background on the tooth pain. One of my upper right molars hurts ONLY when I eat super concentrated sugar. Like Skittles. But baked goods and chocolate are okay. The inside of Nutri-Grain bars is not okay. The pain is pretty sharp but only lasts for a few minutes, then goes away completely. Back in July, I decided to brush more aggressively and often (three times a day instead of two) and lay off the sweets (not that I eat many anyway) and see if I could improve things on my own. Well, the pain stayed away because I didn't eat sweets but when I tried again....OUCH!

Apparently, this is due to the age-related degradation of my cementum. No joke. So the outer-most layer of the surface of our teeth is a one to two cell layers of a substance called cementum that covers the roots of our teeth. Over time, this layer can erode. Mr Dentist assured me that I have excellent teeth and no signs of decay, this can be just a natural part of aging teeth.

Dentinal tubules

The next layer of our teeth is called dentin. It underlies the enamel and surrounds the nerves of our teeth. Dentin is sensitive to touch and other stimuli. And dentin is holey, like swiss cheese. The holes are called 'dentinal tubules' and they connect to odontoblasts that connect directly to the nerves. This was news to me-our teeth are naturally holey?  Once the cementum is gone the dentin and the dentinal tubules (holes) and thus the nerves, are exposed to the elements. These holes generally cause no problems but they can if the odontoblasts move and irritate the nerve. Odontoblasts are particularly sensitive to fluid movements. Mr Dentist said that the sugar isn't directly hurting my teeth, rather the osmotic pressure of highly concentrated sugar is drawing water from the roots of my teeth which irritates the ondontoblasts and it is the pain of this osmosis that I am feeling. As soon as the sugar dissolves so does the pain. He described the root of the tooth as a little man whose head was being pulled into the pores of the tooth whenever I ate sugar and the pain was his head getting stuck. Who knew?
  

I was mighty happy to not have a cavity. I happily declared, "fine I just won't eat concentrated sugar!" to which he responded, "No need to do that, as long as you can just deal with the pain". I guess I'm really not causing my teeth any harm, it's just more of a nuisance, but I'm going to lay off the pain-inducing sugar nonetheless- who gives themselves pain on purpose??!!??

So my teeth aging turns out to be an inconvenience rather than a health-issue or even an expense. I hope the rest of my body ages as gracefully (yes, laugh lines I'm talking to you- GO AWAY!!!)

:)

Hiking in the Smokies

Adam and I did two day long hikes while in the Smokies. The first was the Rich Mountain loop near Cade's Cove which we soon learned is the most popular part of the park. Luckily we only saw three other people on the 8.5 mile hike- the ridiculous hordes of people spent the vast majority of their time in their cars. It was a nice hike- lots of pretty fall color and we saw an elk, but not a must do.

 

 

 

 

On the cliff.

Winter and fall at the same time. See the snow on the top trees?

Our last day in the park we did the Alum Caves hike on the recommendation of the guy who topped off our anti- freeze at the Volkswagen dealership. Seriously. We figured he was a local so knew his rocky mountain hikes. It was a really great hike. There were a few other people but there were enough points of interest and stunning views to more than make up for it. the hike starts out along a creek, very pretty with nice sound effects. Then we hiked through a cave. Then there was a nice cliff overhang at about the half way point to the peak. Most of the other hikers turned around at the cliff. It had snowed the night before so for the second half of the hike it was a winter wonderland. Very pretty. A lot of the hike was on rocky cliffs so there were wire handrails drilled into the rocks to hold on to. With all the ice we definitely utilized those!


We could not see a whole lot from the top of the mountain due to fog but that was okay. We had a quick snack then headed back down. On our way down the sun came out and it started to warm up to the point that all that snow and ice started to melt. It suddenly became spring! So we experienced fall at the beginning of the hike, winter in the middle and spring at the end. It was pretty darn cool. I definitely recommend this hike.

Winter on the way up.

Snow starting to melt on the way down.

For more pictures from our trip, check out the slideshow I added to the blog homepage. Just click on it to make it bigger.

Chicago Monster Dash 1/2 Marathon Race Report

Saturday I ran the Chicago Monster Dash 1/2 mary for the 2nd year in a row. Walking to the race, I thought how funny it is that I now associate all holidays with a race. Thanksgiving is Turkey Trot day, Christmas is a Santa or Rudolph themed race, Halloween is the Monster and I traditionally do a solo long run on the 4th of July- it makes the cook-out food taste that much better:) And for my birthday, I run mileage that= my new age (with a decimal in b/t the two numbers, age 33=3.3 miles).


Last year, I dressed up as- what else?- a bison. This year, my cousin was using my bison suit so I went as Santa. I felt a little sheepish since I basically just used the beard, hat, and shirt that were given away at the Santa Shuffle last year, but it was actually a hit! Kids liked it, adults kept cheering 'go santa!'.... until I lost the beard 1/2 way through (too uncomfortable) and then the hat in the last 2 miles (too hot). Then I was just a woman in a funny red shirt holding a hat:)

Since I just ran the Louisville Marathon less than 2 weeks ago, my plan was to take it easy and enjoy the costumes during this race. However, that plan changed pretty early on. The start was ridiculously crowded. In fact, most of the race was uncomfortably crowded. I realize this is pretty standard for most of the big Chicago races. I try not to complain because the popularity of these races just means that more people are running, but the longer I run the more I like to run with space in front of me. I don't like to be cramped. In terms of a race review, I'd say, don't run this to PR. It's a good race, worth doing, but do it for the costumes and the festivities.

I was running alone, and after plodding through the first 3 cramped miles (9:56, 9:19, 9:38), I was getting kinda bored. I didn't like the idea of staring at the backs of the same people for 13.1 miles. I feel the same way about driving. I don't need to be driving super fast but I just don't like having people in front of me! So as tiny breaks in the pack opened up I jumped through them and found myself speeding up whenever I had the chance (8:40, 8:43, 9:04).

At about the halfway point I glanced down at my Garmin and noticed that I was on pace to get a sub-2. Now I've run sub-2 half marathons before in training and even during marathons but I've never had a formal sub-2 half marathon result. So I decided today was the day to knock that out. I figured the back half of the course would be more thinned out so if I just stayed at a comfortably hard pace, I'd be set.

The below graph shows miles on the x axis and pace on the y. It gives a good view of how much faster I was in the 2nd half than the first:

Miles 5-6 and 8-9 were a bit tight which explains the relatively slower paces.

Well, comfortably hard became uncomfortably hard a little earlier than I would like and the last 45 minutes weren't fun. The last 5K was really hard. The last mile I had to fight, fight, fight to not stop running. I kept looking at the Garmin to see if a sub-2 was still possible because the moment it was no longer possible I was going to take a walk break. Funny thing about keeping running- I stayed on pace so never allowed myself a walk break. I rolled in at 1:58:29.

 

This race was a good experience for me. Because the first 3 miles were so slow I had no choice but to negative split the race. So I had to run faster than was comfortable to make up for the slow miles, making the race way more painful that if I had kept a nice 9:09 pace all along. Honestly, I think keeping an 8:45-8:50 pace would have been pretty comfortable too. It was just the xx xx miles that we're pushing it a bit for me. Especially 2 weeks after a marathon.

I'm glad that I PR'd. That's always a good thing. But it was more of a formality. I'm more proud of the way I ran the race after I decided to go ahead and push it. I committed with 1 hour of running left to go for it. That's a bit early to make such decisions. But I stuck with it even though I really was darn uncomfortable. I kept telling myself running uncomfortably for an hour is excellent training for Boston. Because even when I'm optimally trained, I'm thinking my BQ run is going to be full of discomfort!

Now I have the racing bug. I want to find a less crowded 10k, 10 mile or 1/2 marathon and just run like stink. I have no idea what I'm capable of and I'd love to find out!

In terms of a review for those considering doing this race next year, a few points. Like I said above I would recommend running this for fun, not for a time (though obviously that is easier said than done for some of us..ahem). The course is nice- along the lakefront, though Lincoln park, but tight pretty much the whole way. The folks who were supposed to stop traffic near navy pier made us stop and wait for a bus to pass (2 years in a row, NOT COOL!), so there are some organizational problems that need to be fixed. Water/gatorade stops are plentiful. The post-race is well-organized. The race shirt is nice. The results were already posted by the time I got home which I LOVED. The costumes are great and it's overall a fun race. So I'd recommend doing it for fun with a friend. And don't forget to dress up!

** runnerd: a person who does not conform, often highly intelligent but socially rejected because of their obesssion with running. A runnerd will run in any condition and is either running, constantly thinking about running, or talking about running.