Tuesday, August 16, 2022

Recovery





A year and a half ago, it was my daughter's fourth birthday party, a Zoom with just our family at home, though I had made a ton of appetizers and cake pops and a cake. I was sad that she was having a COVID party, but it was during the early peak of the Delta wave, and we were doing our best to have Kona's (just nuclear family) dragon-themed party with flare. I was of course super busy all day and had made all the dragon eggs and dragon cake pops with Kona's help. We were blowing out candles when my husband, Curtis pointed out to me that my parents weren't on the Zoom. I was just thinking that they had forgotten. He said that I should call, so I called my mom on video chat, thinking my parents could say happy birthday to Kona.

My mom answered, wearing a mask and short of breath. It looked like she was in the hospital. I said aloud, "Mom, do you have COVID?" Half-joking with her. She answered, "No, Megan. Your dad..." She paused. I went to the other room, obviously upset. Curtis saw my face and knew. He decided it was movie time for the kids and didn't miss a beat; they thought, "What a great party." My mom told me she had done CPR at home and gave a rundown, step by step of what had happened and what was going on. She hung up to get more updates. I cried in the corner, then got up and went to hug the kids and sat stunned, not watching whatever movie they were watching, just staring straight ahead, holding onto them. It was Curtis who had the insight to tell me that I was vaccinated and I should get on a plane. It was true. Our family had still been living in its little bubble, isolated except for me being a frontline worker wearing full PPE (finally) at work. (Finally we had enough stores due to a cleaning process of used N95s...Yes, it was still that point in this traumatic chaos.) I was a month out from my first Pfizer, lucky enough as a frontliner to be offered the vaccine first, but also vaccinated to ensure that I could continue to work during a pandemic.

Being the ER doctor that I was, I booked a flight, threw some black flats and a black dress into my backpack for what I assumed would be a funeral, grabbed my Envo (a reusable N95-comparable mask I bought for work), and prepared to get on a plane for the first time in over a year. I was sure there was no way he would survive, knowing cardiac arrest at home has a 10% or less survival rate. It was late January in Georgia, and I forgot that it got cold there. I hadn't even brought a long-sleeve shirt, much less a jacket. I was dazed and also terrified to give my mom or my family COVID by flying on a plane with a bunch of people who were (sorry) stupid enough to be flying on airplanes with COVID numbers so high and at a point where we still didn't have a lot of treatments or many people vaccinated. We hadn't seen my parents in well over a year, not wanting to risk flying and bringing them something. What if the last time I saw my dad was the last time I saw my dad...

My mom somehow had used her RN and NP powers to get into the cardiac ICU with my dad at a time when no visitors were allowed in the hospital due to high COVID numbers across the country. She was sitting by his side while he was being cooled with multiple drips going and a balloon pump. It was a medical miracle and emergency medicine and intensive care in practice. It was medically amazing and beautiful and why we do what we do, for the save. But it was my dad. He was pale and swollen and intubated and having these shivering movements that didn't stop with more sedation. I worried about his brain and how he could recover and if he could wake up. But he was alive.

His nurse for the night was 36 weeks pregnant but wore her N95 and maneuvered sideways around the bed and adjusted his drips and gave meds as scheduled and checked on us. She was wonderful. We waited for the doctor. My mom had probably told the story over and over to everyone that night, just like she continued to do for weeks afterwards, processing the most important code of her life, the code that was actually on her husband. I am so thankful she was there that day and heard him fall down. She said to me so many times when we spent time in the ICU or at home, waiting for the evolution of his prognosis: "I really think I started compressions within the first minute." Amazing. So thankful for her and her unique and unrelenting thirst for medical knowledge because she had kept reading after retirement and knew about hands-only CPR. She started compressions and never gave breaths, confirmed with the 9-1-1 operator that she had put on speaker. She was already doing compressions when they answered her call. God, my mother is amazing. True grit, that woman.

My dad still has no memory of the time he was in the hospital. He remembers the days before when my parents were camping and hiking and biking 15 miles a day and doing all the other long cardiovascular exercises with which they fill their travels and retired lives. Probably some things it's really best we don't remember, and that's why our brains have a way of protecting ourselves and helping us forget. One day he was hiking up a mountain, and the next day he fell on the laundry room floor carrying in groceries. My mom and an incredible EMS team resuscitated him and gave all the right meds, and they had ROSC (Return of Spontaneous Circulation) by the time they arrived in the ER. My parents live out in the country, but a few years ago they were lucky enough to get a fire station 3.2 miles from them, and that fire station just happens to have a supervisor who does all the ACLS (Advanced Cardiac Life Support) training for the state of Georgia. And that supervisor was with the team that day who answered the call. I think back to my own EMS rotation. The way the firefighters tell stories: "One day, I got a call..."

My dad doesn't remember waking in the CVICU and not understanding why he was in the hospital. "I'm fine. I just don't know why I'm here." He didn't believe us when we told him what happened. In the cath lab, prior to getting his balloon pump, his ejection fraction (EF), the amount of blood his heart could pump out to his body had been 15 percent. Fifteen percent. Normal is something like 50 to 75. He had a confident and exceptional cardiothoracic surgeon who found a way to bypass 4 coronaries (blood vessels that supply blood to the heart), and my dad's amazing cardiovascular training had given him enough collaterals to survive the arrest and the surgery. Who knows how long he had had an EF of 15. But the man didn't believe he needed the bypass because he had ICU deliria. I worried he had had a stroke, but it turns out, when you die and come back to life and get cooled for a long time and then rewarmed, your brain really doesn't let you remember all that. And thank goodness. It was enough that the rest of us do.

Brasstown Bald, Georgia

But here we are, one and a half years later, with amazing labs, a man that would never take medicine before but now has a pillbox, and a complete turn-around on nutrition. My mom is being his life-saving angel yet again by constantly making healthy recipes and altering everything. (Stay tuned for her heart healthy cookbook whenever she has the time to write it.) My dad is hiking mountains again, biking, and fishing with his grandkids. It really is a miracle that we are so happy we can be a part of with him. Our family seems to have a lot of journeys lately, but the recovery is definitely where it's at. We work and live for that recovery, and really there's no looking back.

Gone Fishin'

Thursday, July 7, 2022

Happy July 1st

 

PEM Fellow Graduation 2022

Today I was talking with a physician friend about everyone's nostalgic posts on residency, July 1st, finishing graduations, etc. It occurred to me without realizing it previously that this July 1st is PGY-10 for me. Post-(medical school)-Graduation-Year-10, for those of you confused by all our ridiculous acronyms in this career. Clearly I have taken the road less traveled, and parts of it did hurt, as the Kid President says. It has been an uphill battle a lot of the time, through hurricanes, snowstorms, blackouts, polar vortexes, disaster medicine, bouts with mortality-defining illnesses, births and deaths...and, most recently, being on the frontlines of a global pandemic. I was feeling quite nostalgic saying good-bye this June to the first group of residents that I as faculty had the pleasure of mentoring towards PEM fellowship. It's crazy to look back and see myself in their shoes. They are excited and worried, and most of what I wanted to say to them is to be excited about the journey before you. 

PEM IG Graduating Residents



In honor of ten years of post-graduate training, it seems fitting to look back on what I learned since residency. I hope that some of you will enjoy this post, no matter on what part of the journey you find yourselves. Remember, you have mentors, and you have co-residents and co-interns who will be family for the next 3 to 10 to 20 to forever years, you never know. Even better, the people outside of medicine that stick with you on this journey, that put up with the sleep-deprived and over-worked version of yourself, those are your people. Hold onto them. 

Violet & Curtis visiting me on a 28-hour call
(because I left the hospital too late the night before
to get to see her before bedtime and wouldn't see
her for three days...)










For what it's worth, here are 

7 Residency Truths:


Residency Truth #1: Naps and Strategic Caffeine. 



Dr. Burks at PGY-1 Trip to the Bronx Zoo


My program director, Auxford Burks taught me that residency is all about naps and strategic caffeine. As a shift worker, as a frontliner during this pandemic, and as a nocturnist of the last two years (stay tuned for a blog about how sleep is the ultimate self-care), this advice has served me very well. One of my favorite night nurses and I always joke about how we look forward to our evening pre-work coffee. For me, it often comes after a nap or after getting the kids to bed, even though I already had coffee in the morning. If you don't do coffee, do exercise when possible, even if it's just a walk. Endorphins are endorphins, friends.

 



Residency Truth #2: Hold or feed a baby. 

The best part of NICU was the feeder-growers
and my co-intern, Rushita Mehta, M.D.

Another Auxford Burks original. This may be a bit Peds specific, but it’s hard to feel like life’s problems can’t be fixed, or at least overcome, when you have new life in your hands. If you are lucky enough to have specialized in Peds or OB, you know where the nursery is, and they usually don’t mind if you offer to sit and feed a baby. During the hardest days, our PD said he would just go by the nursery and offer to feed a baby. Endorphins. Cute little life form that you are cuddling. An instant sense of hope for that baby and for you to make the world better for it by continuing to do what motivated you to start this journey.


Residency Truth #3:
Intern Dream Team with Huma & Carly
 Do Something for You.

Maybe holding babies isn’t for you. That’s cool. I learned from my co-resident, Huma Mirza that sometimes self-care and doing something that you are passionate about outside of work is more important than going straight to bed when you get home from the hospital. She said that she would often sleep less so that she could do what she needed to do to be a better doctor when she was in the hospital, even if that was lounging on the couch watching TV. It was her way of not losing herself in all of the sacrifices that this journey requires. When you don't know who you are anymore and have nothing left outside of the hospital, you have no real energy or optimism left for your patients. Never truer words. 

We are altruistic people by nature, but when we give up so much to serve others, we get lost in the process and forget how to be good for our patients. It starts with being good for yourself first. In a similar manner, it is important for parents to take care of themselves, so that they can take care of their kids. No one understands this more than doc-moms and doc-dads; we push the limits every day, trying to fit more in and do more and be more. 


All the Residency Babies

Sometimes it is important just to be there for yourself. As a resident, I was constantly training for triathlons and marathons or going for post-call runs or swims or getting up for a kettle bell workout before a 28-hour call. I was a nutjob. But, I will say, now that I'm older, while I do value those workouts, I never underestimate Truth #1 followed or preceded by a nice long walk. Everything is easier and clearer after a nice long walk. 


Orchard Beach Picnic, PGY-3



Residency Truth #4: Remember where you started. 

Write it down now. Remember why you're in this. It will be December 21st, the darkest day of the year, the longest day of the year as an intern, and you will be wondering. Wondering. You will need a note from your former self... and probably a resident holiday party wouldn't hurt either.


PGY-1 Skit & Holiday Party

 

Residency Truth #5: See the Beauty.

Travel and do Global Health and get out of town or see your town when you can, but there may be a lot of days where seeing the sun out of the hospital isn’t a thing... So, find a window, find a courtyard, find a retreat on a long call. Seek out your own silver linings, even if it’s just bonding with your team doing the silly stuff that gets you through it, ordering on-call food, teaching each other, believing in each other, playing practical jokes. 

This NICU window was a great reading spot in between deliveries and the viewpoint for many sunsets and sunrises. I can remember it fondly, as well as my team and my seniors that got us through it all.


Residency Truth #6: Expect and accept failure. 

You are going to mess up so much. That's why you have supervising physicians, upper-level residents, nurses, 
pharmacists, and many other people in the hospital to help you and guide you. This is hard for Type A people, but failing is learning. It is the Practice of medicine. It is an art. You did not learn it all in medical school, but you learned some things, so go forth believing in yourself and knowing that it is okay to fail.


<---This tire is a crazy blow-out I had on the way to work one morning. My co-intern said, “Wow, you really don’t do anything halfway, do you?” Nope. Fail big, learn big, folks. You have people to help you.

 

Hermann's Finest

Residency Truth #7: Listen to the people that know it all.

In case anyone is wondering, it's the nurses. They will pull you to the bedside, they will address their concerns with you, they will catch the majority of your sleep-deprived wrong orders that you have placed in the computer. They'll teach you so much about compassion in medicine and about procedures and how teams work. Approach them with grace and thank them for what they do for you in your training and what they do for our patients.


Alright, friends. Congratulations. It's July 1st. Good luck on your journey, wherever you may be.


Monday, January 11, 2021

2021 moving around this merry-go-round'

Not even going to get into the recent national events but a little personal event left me with a new hurdle for rehab, on top of all the mental hurdles many of us have faced in the last year. My insurance isn't paying for physical therapy anymore. Just paying copays was over-budget for us, so I'm not able to do self pay and continue with formal PT. I guess I knew this day would come, but I had just hoped it would be farther away since I'm not even 7 months out from my most recent surgery which was a full-on total knee reconstruction with osteochondral transplants x 2, and also because I've had 6 surgeries in the last 15 months. I think it would be really easy to be angry about it. It would probably make sense to sue my initial surgeon for the post-op infection that led to all this. I am against doing so on ethical principle, but so many times dealing with insurance companies and medical billing and paying bill after bill over the last 15 months I have definitely thought about it. I wasted 2 days on the phone with the insurance company last week and now I'm ready to turn towards self-reliance for a while and just keep moving, as much as possible, as well as possible, which has basically been the goal over the last year+. 

So I am entering a second phase of home, mostly self-designed and definitely self-motivated, PT. The first phase being during lockdown when my PT practice discharged everyone to home PT whether they were ready or not, because the city was shutdown for COVID. Ironically numbers are higher than ever before and we have no ICU beds, but we will just keep everything open and status quo apparently, a whole other story, probably not even one to share on another day.

So here I am with my kiddos doing home PT. It's definitely never the workout I set out to do and there has to be flexibility; much like expectations for regular life days with them, we all just have to adapt! I have been doing about one home session a week with Kona during the holiday break anyway, so she's my go-to workout buddy. Though I know the mental therapy of the workout isn't the same, I do really enjoy the time we have together, just us 2, but lately it has been a group thing and a little more chaotic. PT was really my only self-care and time away from kids where I wasn't napping or working nights in the ED. I think I will miss it. BUT I have so much to be thankful for, including the strength level that working 3 days a week in PT has brought me to~ a point where something like this Magical moment can transpire...

Last week I went for a long park walk with the girls and when my knee started hurting, I suggested doing laps around this one area of the path that is a circle. I timed them and shouted out their times, and they were having a blast racing each other and themselves to get faster at scooter laps. I offered to go with them after resting a while, but Kona was so into it that she said, "No!! You have to be the timer!!!" Two days later when my PT was cancelled we went out again, and I told Kona I would time but would also go with Juno. I started running next to her, only for short intervals, about the amount I can do right now. 

I have never seen a brighter face on Kona. 

"MOMMY'S RUNNING!!" she screamed, and ran towards me with her arms outstretched like we always used to do to give big running hugs. This was my first time running outside since August 2019 and my first time running in front of them for that long too. She said, "We are getting stronger!" hand on her hip and water-bottle-drinking with the other. She then said, "When we get back home, I'm going to tell Daddy that Mommy was running!!" Then of course the first person she told was her older sister, Violet. 

Kona: Violet, guess what !? Mommy was running on the sidewalk!!!

Violet: Mommy, you can run?!!!

M: Only a little bit at a time.

Violet: We need to celebrate!!!

M: I'm so happy how proud you guys are 💜

[Because they know the journey this has been]




Excited for the challenges of the next phase of this journey... because I know with great obstacles come greater transformations.



"The greater the obstacle, the more glory in overcoming it." ~Moliere




Monday, October 5, 2020

the good, the bad, the ugly... & the recovery of a lifetime

Posting this here because though i thought i could write something pivotal and publish in some journal, there are already too many doctor-as-patient pieces out there and i have other projects i need to work on rather than try to edit this and make it beautiful. so, here are my original words without editors and re-writes....

last medal pre-MRSA, May 2019

10.5.2020

A year. A full year since I crutched into hospital where I work, just like I was there for a shift, but instead I was there to say that I thought I needed a work-up and the pain was just too bad. That’s when I start the clock of MRSA septic arthritis, though it had brewed for about 10 days at that point. When I took off my bandage in front of the NP who was seeing me as a patient and not a fellow for the first time, my knee was red and swollen, and pus drained out and pooled onto the floor. Well, THAT looks infected, doesn’t it? It hadn’t looked like that at home, but I had screamed when my daughter barely grazed my leg at breakfast that morning, because the pain was so bad. I had been up several nights in pain, but thought I just had to solider through since I had gone to an Ortho clinic visit that same week and was told it wasn’t infected. In the ED, I waited on my labs, calculated my Kocher Criteria (clinical diagnostic criteria for the likelihood of septic arthritis), and turned to my husband and asked him to go get my laptop from home, so I could do my research project in the hospital because, I told him, “I’m not going home.”

It’s so hard to accept it when you, as a physician, become a patient. The journey of the last year is not one I would repeat. I got a post-op infection from an outpatient knee scope. I hadn’t had a normal knee to begin with, after a congenital bone disease, playing college ball after I had been told I couldn’t play sports at age 13, and then going on to do Ironman races. I had been beating up on that knee for a long time. But it had kept going and just needed a little meniscectomy and loose body removal to get back to regular life, which is for me very active. The cost of it all, of going at such a fast pace and never taking care of myself or slowing down, was MRSA, a resistant bacteria. Maybe MRSA was just the 1 in 1,000 complication of surgery, and I was the lucky one who got to have a real life-check that day and every day for the next year. That, or it turns out you really can’t work like a resident forever, be a mom of 3, and race endurance races without sufficient rehab and strength training. Oh, and sleep. You can’t do it without sleep, at least not for long.

I don’t do anything halfway, and my body and MRSA were no different. It took 3 open knee surgeries with washouts to sufficiently clean out the joint, prior to IV antibiotics for 8 weeks and 2 more weeks of oral antibiotic. My ESR, a laboratory marker of inflammation, stayed high, over 100, for a long time. I had so many adhesions that I needed another surgery, towards the end of my course of IV antibiotics, just to get my knee moving again; I couldn’t bend past 20 degrees. I had spent 2 months in excruciating pain, unable to tolerate even my daughter or husband bumping against the bed or chair my leg was propped on. I could never sleep, waking every hour or two in pain. I also lost the majority of my muscle mass, about 30+ pounds from the nausea and abdominal pain caused by the antibiotics. I couldn’t eat and took multiple other medications to be able to tolerate fluids. I was anemic from surgical blood loss and weak. I fainted a lot, which led to more time not moving around, and more weight loss. The infection and the treatment became one big spiral of loss, not even considering the toll it took on my psyche. The worst of it was that the inside of my knee was so friable, that I actually tore my ACL and had a severe tear of the meniscus that had been frayed prior to the infection. Because I was medical and a fellow in the ED, my Ortho Trauma surgeon showed me video of him ranging my knee in the OR and how the meniscus just flopped off in the joint, back-and-forth, barely attached to anything. He said it was similar to the incision they made to repair tibial plateau fractures. Cool, I thought. Then, man, that sucks.

Maybe that wasn’t the worst. The worst was a tie between being away from my kids for 11 days and being an adult inpatient. As someone who has spent the last 10+ years in the field of pediatrics, I obviously love kids and value the way we pediatricians care for our patients. It’s not that internists and adult surgeons don’t care about their patients. It’s all just different. Maybe more adult wings should have Child Life. Just putting that one out there. I had good nurses and not-so-good nurses. I had techs that I was so very thankful for and truly valued the pride they took in their job, the professionalism with which they helped debilitated folk like myself do demoralizing things like pee and poop on a bed pan or just try to move enough to get sheets changed in the hospital when any movement of your body causes excruciating, mind-numbing pain. I definitely asked for an above knee amputation multiple times, and the Ortho residents were really good about not rolling their eyes at me. I logically thought that it would be great weight-reduction for racing with a blade later, and a good way to end the pain...until I mentioned it to one of my favorite trauma nurses overnight and asked her about amputees and phantom limb pain. She said that they have to treat their pain with opioids, but then they also beat on the stump and say, "I end here, I end here, I end here," over and over again to learn that they don't have their limb anymore. I guess for me that was a moment of remembering all the horrible traumas we see and knowing that I don't end here, even though a lot of our patients do. I followed in the Ortho Trauma clinic, so I saw even more of the repercussions of what we manage in the ED. Eye-opening to say the least.

When someone sees you with your PICC line and crutching on a walker and having to stop to rest, that person with hardware in one leg and one leg missing as well as a splinted hand is sure to give you words of encouragement and tell you their story, too. I went through a lot, but many of our patients go through more with less resources and more obstacles. As a medical professional, I knew how to advocate for myself, but it wasn’t easy. In the hospital, I remember desperately trying to do so but being too groggy on pain meds to think straight. I couldn’t sleep from pain and from being woken up for vital signs and various rounds. I was febrile and septic and nauseated from all the general anesthesia that I got in one week’s time. The day I found out that I had torn my meniscus (I didn’t know about the ACL until much later, and we still aren’t sure when that happened.), I was really down. Non-weight-bearing for 6 weeks sounded like one more hurdle that I didn’t have time for, which is now hilarious, because I was on crutches for months and months due to the infection and the pain. In that moment, however, I was upset that I would have a harder time being a PEM fellow and being a mom of 3 on crutches for 6 weeks. Little did I know the journey I had in front of me. 

I was deflated. I missed my kids. I was crying alone in my hospital room. The floor environmental services (EVS) lady came in as chipper as always to clean my room and saw me tearful. She gave me a pep-talk. My EVS lady! She has no clue how much those words helped me. I still think about it to this day, even though I don’t even remember her exact words, I remember how she lifted me up during a very dark time. You better believe, especially now during the time of COVID, I thank every EVS person I see, every shift. I like to think I would do it anyway, but after what happened to me, and what they do for us and everyone in the hospital now with COVID, I feel a deeper sense of gratitude. They are keeping us all safe, and they do such a thankless job in the hospital. If nothing else from this whole experience, I appreciate my perspective on that. I appreciate how being a patient made me see and feel the way all our medical provider decisions come to light and how important ancillary staff are in caring for patients and helping patients feel actually cared for. I always try to sit down with families and play with my kid patients in the ED or hold babies and talk directly to them. I want them to know I care, but I also just love kids, and that's why I'm a pediatrician. I now realize that those moments of humanity are even more important to families during their difficult times in our hospitals.

There were so many ups and downs on this journey, and they keep coming even now. I definitely had moments of being more positive than my doctors about my condition. At my first ID (infectious disease) follow-up appointment, I told my ID doc that my nights were like having a newborn because I woke up every 1-2 hours, except instead of breastfeeding a crying baby, I was screaming out myself in pain. He was worried about my inflammatory markers because my CRP was 79 at that first visit. I mentioned to him that in the ED it had been 256 and that it was trending down. I said, "Maybe you need to be a more glass-is-half-full kind of guy." That was the good and the bad of it. The ugly was that I still couldn't bend my knee. Even after another surgery to lyse adhesions (scar tissue from so many surgeries and the healing from the infection itself), I still had such a swollen knee even a month out from that surgery. My knee was just angry. Part of me was, too, but with so many obstacles, you really have to look on the bright side and celebrate the small victories, like putting shoes on without wincing in pain, washing your own hair, or being able to walk. My Ortho doc drained 100cc of fluid off at my first post-op visit from surgery #7, the lysis of adhesions, and we both looked at each other, thinking the same thing—he said to me, "At least it's not pus." Maybe that's my mantra for life after this. At least my knee isn't full of pus.  

I have COVID, but at least my knee isn't full of pus. 

Still getting medical bills, but at least my knee isn't full of pus. 

 I'm so behind on life, but at least my knee isn't full of pus. 

 I think I tore my rotator cuff, but at least my knee isn't full of pus.

I look back at pictures over the past year, and the saddest part is how much I feel like I missed of my kids’ lives. Forget that I spent a year not running, a year in pain, months wondering if I would ever walk again, AND that I’m still wondering if I can ever be a triathlete again or can run for my mental and physical health, something that was once so intrinsic to me being me. I missed a gap in my girls’ lives that I won’t get back. I read to them, I watched movies with them, and I tried to sit and watch them play, but none of those things could I do for very long without breaking away to cry in pain. I couldn’t take care of them the way I normally would for months. I was groggy and weak and depressed.

CPM cuddles and my PICC line is finally out.
Things are starting to look up. December 2019.

We all had an emotional journey together. Just as I had to accept my disability and lack of control over the circumstances of my life, and search to maintain my sense of identity and self, they also had to find their mom in the disabled person that I was. My 3-year-old would tell me, “Mommy, soon your leg will get better, and then you will be back to being Mommy again.” Even still, she talks about the activities we will do when I am better. They had regressions and progressions this whole time just like I did. I just had my 8th knee surgery in June, an osteochondral transplant, ACL reconstruction, and meniscus repair. I told my kids ahead of time what to expect. My baby made me the happiest by actually wanting to cuddle with me this time around. When she was 13 months old last year, she didn’t want anything to do with me because I couldn’t go anywhere with her, and it broke me. This past summer, just shy of 2 years old, she would sit with me while I ranged my knee in the CPM, and her two older sisters would sit as close to me as possible. Somehow, the continuous passive motion machine and my crutches, surgical sleeve, and brace had become our normal. They know what physical therapy is. They know about crutches and walkers. They know that Mommy needs to ice. But none of them remember when Mommy used to go running, and that’s what bothers me the most when I think about the new direction my life might take now.

Post-op surgery #8, June 2020

Over the last few years, I had a goal to do an Ironman as a mom. I ran through most of my pregnancies, and I even pushed Kona in the jogging stroller for runs when pregnant with Juno. As a second-opinion Olympic Team orthopedic surgeon told me when she recommended I give up on my knee and look toward a total knee replacement, “You’ve always been an athlete.” I was only doing short races during fellowship and was just getting back to running after baby 3 when I got my MRSA. I spent so much of the last year in the worst pain of my life, and I am still healing and rehabbing. Now I’ve had time to reflect. Do I really want to prove this to myself, one more Ironman? And would the person I am even stop at one? Do I want to prove that I can do the scheduling and the lack of sleep and the strategic nutrition that training for an Ironman while being a full-time doc and mom to 3 growing girls would take? Do I want to be gone from them for that long? My new orthopedist, one of the top in the country (My knee and I don’t mess around anymore.) seems to think that I could do as much as I want after the 12 to 18 months of rehab that this most recent surgery takes. I’m on month 4, by the way. I am 8 months away from even contemplating the start of an Ironman training schedule.

 

CPM snuggles with my June Bug

Like so many athletes now, though, I am in limbo, and not just due to my injuries and rehab. Who is to say we will have a return to normal sports any time soon with the COVID-19 pandemic? It’s hard to say what returning to my sport would be for many reasons. Maybe my knee couldn’t do the training, maybe the newly diagnosed arthritis in my shoulder would mean I have to give up the zen of swimming and therefore triathlon, too. Maybe I had my heyday in the sun and now it’s time to move on. Perhaps the only racing any of us will be doing is virtual, and then maybe conflicts with kid and work schedules won’t even be an issue anyway. Well, where’s the challenge in that?

If I can be selfish and truly honest for a moment, I just miss the mental high and clarity that comes from running. That sense of inner calm and focus that I have for the whole rest of the day. The last 2 weeks in physical therapy I have been increasing my Alter-G percentage, the amount of body weight and therefore impact on the joints that I do while running. This fancy treadmill that blows up like a balloon holds you suspended in spandex that zip into the bubble, just as weightless as you set the machine. Running at 70% makes me feel like an astronaut in space. Like Flo-Jo flying down the track, or Steve Prefontaine doing "an easy 10", I feel like I could run for hours. Then, last Friday, I ran three one-minute intervals at full weight-bearing on the regular treadmill. I hurt (more than usual) for several days afterward. That was my first run in over a year. After knee surgeries 1, 2, and 5-7, I never really expected to run again. I have made miracles happen on this knee so many times, but I have spent the last year thinking that I need to retire and give up the one thing that makes me me. I know now that I am more than a triathlete, and I know that I can get good workouts from low-resistance exercise, but there’s something in me that still wants to run. I wanted an amputation to run. I just underwent one of the most intense reconstructive surgeries with the longest rehab in the hopes that I might still run, even though it meant putting myself and my family through all those regressions all over again. Somedays I can hear, “You ARE an Ironman,” in my head and actually think about making it to the finish line of another one. And some days, I feel the weight of it all, and all the pain and sacrifices don’t seem worth it. The “anything is possible” slogan might have to refer to the fact that I can be as active as I want with my kids and stay in shape with low-impact exercise, instead of being the athlete I was before. Time to find another sport?

 

 


                                                        Alter-G:  First Run in over a year!


Everything is a process, and I know more about rehab, mental toughness, and chronic pain than I ever wanted to know. Each little milestone meant everything to me and was celebrated in some small way~ bending my knee past 20 degrees, lifting my leg for a straight-leg raise without tears, getting my PICC line out, crutching all the way upstairs for the first time, washing my own hair, putting on pants without sitting down, and now bigger ones like going down stairs faster than Juno! (I can finally alternate feet going downstairs and she is still doing one leg down and both together, like I basically did for the last year until recently.) I had to learn to walk again, which was literally the hardest step of this journey. Now I have to learn to run. My physical therapist mentions that the next step is cutting and jumping, something I gave up on a long time ago when I chose to be a triathlete as my next athletic career after college basketball. I thought I had done my major athletic journey back when I did 6 weeks of non-weightbearing in college and 5 months of intense rehab to finish out my career and play my senior year, following a meniscus repair and loose body removal surgery. I did another year of rehab after college before endurance racing and triathlon seemed possible. How simple and easy that all seems now! I tell my PT at Ironman TMC now that I don’t care if I can ever jump or cut again; I just want to run. But, maybe I do need to jump and cut, though. Violet’s favorite sports now are tennis and basketball. You better believe I’m going to be out there on the court with her when all is said and done.

 





Sunday, October 4, 2020

La Vie en Rose: Lessons in Endurance Training_4.17.19

Holy smokes, folks! Has it really been almost 3 years since I last blogged on here? A few things have changed- Violet will be turning 5 in a few weeks, and she has 2 younger sisters! I am wondering why I haven't written in so long, but then I look down at the fact that I am writing this with the Haaka on one side and Juno on the other, in a post-run post-breastfeeding high, thinking I only have another hour on this day off before it is time to start dinner and pick up the hooligans (our loving name for our older children that keep us laughing and grounded and crazy all at the same time), and I realize that reflection and also research on health topics haven't necessarily been high on the priority list lately.  I started a career in PEM (Pediatric Emergency Medicine), moved to Texas, started fellowship, and we added to our already growing family here. Now with 3 kids + fellowship, a 3-year blog hiatus sounds small. 

Juno is here! 8/2018


BUT, as I am back to semi-endurance training again, almost 8 months post-partum from 3rd kiddo and 2 weeks out from the Indy Half-Marathon, it occurred to me that I had some things to say that were too long for one of my rambling Facebook or Instagram posts, so a blog seemed like a good idea. During my 5-mile pace run today, I was realizing that though there have definitely been some lulls in training for high-risk pregnancies or post-partum knee rehab, I have actually been an endurance athlete for 10 years now! I was thinking today about how mind-clearing running is for me and how it really is an act of personal kindness and intellectual wellness. Today while I found my stride for the first time since starting to train for this race 2 months ago, these are the tips I was thinking about that I have learned during the crazy journey that has been my re-return to fitness over and over again over the last 10 years.


Family trip with rose-colored glasses


1. la vie en rose
Seeing the world through rose colored glasses. The title of this blog comes from a moment the other day with my girls when Violet was trying on my sunglasses inside (while we were trying to eat breakfast and get off to school nonetheless), and she told me, "Mommy, do you know when you look at the light through these, it's pink?" She was right. My cheap drug store sunglasses that are now all scratched from being around these kiddos do have a pink tint to them that I had never noticed before. I played the song "La Vie en Rose" for them and we pretended we were eating at a French cafe, and we talked about seeing things in a positive light. There is nothing more important in endurance training or in life than staying positive. I am honestly so bad at this, but I am working on it. There are so many setbacks and obstacles in training, and you will help yourself out by not letting yourself get bogged down by one bad mile, one bad run, one off week, etc. My Numa sports glasses that I have actually been wearing for racing for the past 10 years are rose tinted sunglasses. How funny that just now I am seeing the symbolism in that and hoping it will keep me positive and not allow myself to be my toughest critic.


2. Don't expect perfection
This lead me to my next lesson- don't expect perfection. Not out of yourself but also not out of your training. As someone who has had Ironman races cancelled for hurricanes and done marathon training in thunderstorms, racing and training is never perfect. Don't plan your training schedule or your life too much. Go with the flow

Running at 30 weeks pregnant pushing my Kona Bean in 103 F Houston heat



3. Don't be embarrassed by your pace
Everyone is running a different race, has different obstacles, has different goals. You don't need to compare yourself or push yourself beyond reason. I am the worst at this. I want to be a better version of me- the doctor me, the mom me, the wife me, and the athlete me. Dude, something's gotta give. I finally accepted that I am going to run this race at a pace that is embarrassing to me, but I also could very easily be not training at all or waiting for the right time to jump back in, and honestly folks, with that mentality, it may never come. Maybe I'm never going to have an endurance pace of 9-minute-miles (I used to lust after 8 or 7-minute-milers.), but I'm out there getting my runner's high, and that in and of itself is really enough right now. Because I finally accepted my pathetic pace, I had a really strong pace run today because I wasn't chasing a pace the whole time that was too much for me. Getting faster is something I will do after this race. It's okay to set these kind of goals for ourselves, especially when you haven't been racing. You aren't going to be able to do endurance and speed training in your program unless you're already up to snuff. This is my first time running postpartum without knee rehab first. Mistake? Not yet anyway. :-\
Juno likes my Camelbak! Post-run, sweaty cuddles


4. Treat your allergies and wash your hair after workouts! - 
Flonase. It's class C in pregnancy, which I guess is why I haven't used it in so long, but my life is forever changed from starting this medicine again 3 weeks ago. Turns out not blowing snot rockets your entire run is very uplifting. Bad allergies? Take Zyrtec, Singulair, and Flonase. Works great for asthma, too, since Zyrtec and Singulair work synergistically in allergic asthma, and flonase has been shown to improve asthma as well.
Wash your hair. This is so time consuming and annoying, especially busy parents and others who find themselves barely having time to fit in the run much less the shower, but washing the allergens off after running including getting them out of your hair and nose (Neti pot or Sinus rinse anyone?) is key to ensuring that you don't sleep in a carpet of pollen on your pillow that will keep you stuffy all night and into the next day. Curly hair? Use a cleansing conditioner so you don't dry out your hair! I love Amika :) 


Stay tuned. I imagine this blog will evolve since I'm PEM now, but we'll come up with some good topics or just random life updates on whatever race or obstacle is next! :-P

Wednesday, April 20, 2016

Tips for Spring Training

I know I owe everyone some really good blog articles on fun sports and medical topics, BUT I realized that I haven't found the time to write something for you since January, so this means a quick blog to get us started and then hopefully some more research-based things coming up soon. All of my research writing time has gone into actual research and not blogs lately, go figure!

Tips for Spring Training -

1. Embrace the Awesome
having a blurry fun time and ready
for spring swimming!!!!
This spring weather makes everyone go park and exercise crazy. One of my new favorite catch phrases is #embracetheawesome. (I thought I made it up and was so excited, but when I wrote the hashtag, I realized a bunch of other people have already used it. Oh well.) At any rate, still Embrace The Awesome. This spring and sunny weather has you gliding on air and ready to spend every last bit of daylight out enjoying the essence of spring...then go with it! Use that boost to get yourself back to being active again, pump up your bike tires, dust of your running shoes, grab your tennis racket, make it happen!

2. Stay hydrated
This goes without saying, but you may forget how much hydration you need to bring with you for workouts or how to replenish afterward. With warmer weather, there is more sweating, more salt loss, and hydration and rehydration become even more important. A good rule of thumb is that your pee should be clear prior to your workout (concentrated urine that looks darker is a sign of dehydraton). More than an hour of strenuous exercise in the heat means an electrolyte replacement drink after, and  you should have a protein and carbohydrate meal/snack within 30 minutes of endurance training if possible, to maintain muscle mass and properly replenish glycogen stores.

3. Don't Forget the Sunscreen
Athletes are the biggest culprits of not using sunscreen. You think you have a base tan, you think you want a base tan, you think you don't burn easily...well you're all wrong!
Watch this enlightening video with an ultraviolet camera, showing how sun exposure affects your skin.

Dandelions on the soccer field? Those are ok...right, Violet?
5. Check field conditions
This should be up to the schools and the coach for youth sports, but sometimes things are getting revamped when they need to be. Make sure things are up to snuff before your kid heads out on the playing field. Adults, you should know better when you are playing sports later in life.



     6. Check equipment


Wondering where her sun hat is while playing ball.
   If you are like me, you haven't pumped your bike tires since you last did an outdoor ride or oiled your glove since last fall or summer.
I am so bad about leaving my bike on the trainer and letting the front tire go totally flat, and then as soon as the weather turns nice, I get frustrated when it takes me an hour to get everything ready to go for an outdoor ride. BUT, it is definitely worth it to pump the tires, check air pressure, make sure your flat kit has everything you need, and that everything is functioning properly since your last time out. This goes for every sport, especially for kids. Make sure they have the right equipment to help prevent injuries.


7. Consider body type and any changes
That bike is too big for you, Violet!
This is especially important for youth sports, but it applies to adults as well. Adults may not be in the same shape they were the last time they decided to play a certain sport or enter a certain level of training. Even elite athletes need to recognize physiologic changes and hormonal differences since the last season or big event. For ladies even menstrual cycle can affect training, as well as adaptation after pregnancy or miscarriage, premenopausal changes, etc. For men, different amounts of muscle mass or endurance training can affect testosterone level and athletic performance. So please talk to your health professional or your experienced trainer or coach about these when setting your goals and training regimens. For kids, especially around the time of puberty, parents and pediatricians need to consider the stage of puberty and the growth velocity that has occurred over the last year. I will write another blog specifically on this topic, but being at a younger bone age or a younger stage of puberty compared to other kids in the same grade can put a child at a disadvantage not just for athletic performance but for athletic injuries. This is most important for contact sports. Talk to your doctor and make sure a check-up happens to see where your child is with regard to Tanner Stage (or SMR Sexual Maturity Rating). Yes, that means putting on a gown and getting your private parts checked. All pediatricians should be doing it with the annual health maintenance exam. Parents please ask if they are not.

8. Know your stuff!
This is supposedly going to be a great website for parents especially to check what sports need what prep prior to gearing up for spring training or any season, for that matter. However, right now it is still under construction. Check back later and see what info they add: stopsportsinjuries.com.

9. Try something new
A great way to cross-train is to keep yourself doing some different sports at different times of year. Yes, we all have that sport that we love the most, but getting better sometimes means a little time of from it, and this gives you time to enjoy something else! This is also a good way to avoid over-use-injuries. We should probably have a couple blogs on those coming up.

10. Be inspired
I was running recently and saw two women running with reflective jackets. One read “Guide” and the other “Blind-Deaf.” So these two ladies deserve a super shout-out because they were moving fast! Total inspiration. I spent some time on my run wondering what it would be like to run a race and not be able to hear any of the fans cheer. It makes you think you are pretty fortunate to have what you have, and it also makes you applaud these ladies for getting out and running and exercising their ability to stay fit, despite life’s obstacles. Great job! You better bet I will be thinking of them in some of my upcoming races, trying that much harder because I can hear and see people cheering for me and know how special that gift is.

We love animals and we love running! Help us support
the Bronx Zoo!!!!!!! :-D
I find that sometimes signing up for even a small race is a good way to enjoy the nice weather and get yourself exercising when you otherwise wouldn’t. Our family signs up for the Indianapolis Mini Marathon every year, and I definitely wouldn’t have been running much recently without having this race on my calendar. I have been taking a training break, which means running a half-marathon only this year lol. Violet and I also decided to do her first race at the end of this month- a run for the Bronx Zoo. I think it’s a win-win. We get to go to the zoo, Violet gets a ride in the Enterprise (our jogging stroller), I get exercise, and the zoo gets some financial support from the fundraising. If you are local and interested in joining us for the run, check out this link. If interested in donating, go here.


References:
Von Duvillard et al. Fluids and hydration in prolonged endurance performance. Nutrition. 2004 Jul-Aug;20(7-8):651-6.


On deck:
-Back Pain (I am not forgetting you, Charles! we Will try to do this one next)
-Overuse Injuries
-Neurodevelopment and Youth Sports Training
-Ankle exam and injuries for providers
-Knee exam and injuries for providers

Friday, January 8, 2016

Intoeing Part II: The Pluses and Minuses of Pigeon-toed Anatomy in Athletes

Last blog we went over the different causes of intoeing in kids. Now we review what intoeing means for athletes.

Studies have shown that low to normal thigh-foot angles and intoeing while sprinting correlate with sprinting ability. Meaning, if your anatomy is such that your thigh-foot angle is low and makes you prone to intoeing and you continue to intoe while you sprint, you may be a better sprinter than those who don’t! Or, you may just be overcoming your anatomy and sprinting well despite your intoeing. It is hard to say which the case is. Have observational studies shown more sprinters who do well because they are pigeon-toed, or do sprinters just happen to have some pigeon-toers who sprint well? Usain Bolt has been noted not to intoe while sprinting. Andre Agassi and Michael Jordan, two athletes who have excelled in sports that require lateral movement (i.e. tennis and basketball) are pigeon-toed. Biomechanically speaking, lateral movement is easier when done with toes turned inward. Is this the case with sprinting?
Violet can't figure out if her rain/snow
boots make her intoe more or not.
She runs pretty fast in them!

The theory to explain the mechanism based on biomechanics and physics from the leading exercise physiologists goes something like this – runners land on the outside of the foot and roll their foot inward from heel-strike to toe-off. People with intoeing have less of this maneuver because they already land partially rotated due to their anatomy. They have less give in the foot and ankle joint when they strike, and the stiffer foot means less energy is absorbed and more energy is dissipated. Running speed is increased when an athlete’s body has the capacity to handle the impact of the forces that occur when the foot strikes the ground, forces that are 3 to 6 times bodyweight. A stiffer foot enables the athlete to absorb these forces and quickly accelerate in the opposite direction.

Some folks propose that intoeing, associated with having flat feet (pes planus) and bow legs, may lead to being faster, but it also leads to more ankle, knee, and hip injuries. The theory being that intoeing feet don’t cushion the force, so even though they are faster, the musculoskeletal system incurs the consequences of that impact. A recent literature review actually showed that there is a low association between pes planus and lower extremity musculoskeletal injury. I haven’t found anything that directly reviewed intoeing with lower extremity injuries, but since the theory is based on the association between intoeing and pes planus, I think we can safely say that there is low evidence to support it. So, dream on, athletes, for those pigeon-toes.
Violet checking out a runner's gait
and trying to decide if they are
hyperpronating or not. There's a lot
less entertainment during winter jogging
stroller runs because fewer people and
fewer animals are out. Why aren't they
as crazy as us, sweet girl?


References

Budt et al. The relationship between foot posture and lower limb kinematics during walking: A systematic review. Gait Posture. 2013 Jul;38(3):363-72.

Feigenbaum et al. The association of foot arch posture and prior history of shoulder or elbow surgery in elite-level baseball pitchers. J Orthop Sports Phys Ther. 2013 Nov;43(11):814-20.

Fuchs R and Staheli L. Sprinting and Intoeing. Journal of Pediatric Orthopaedics. July/Aug 1996: 16;4 – 489-491.

Tong et al. Association between foot tye and lower extremity injuries: systematic literature review with meta-analysis. J Orthop Sports Phys Ther. 2013 )ct;43(10):700-14.


Zafiropoulos et al. Flat food and femoral anteversion in children—a prospective study. Foot (Edinb). 2009 Mar;19(1):50-4.