A New Academic Year

I have returned to blog. I know you've heard it before, but allow me to apologize for the blogging drought. Been busy you know.

Since my last blog, let's see now. Graduation - it was fun, a big shebang and caboodle about a bunch of peoples' life achievement known as medical school. I have always felt that much of the ceremonial stuff is a bit antiquated, especially if we go to socialized medicine where doctors have no autonomy and can't practice the art of medicine as they were trained (another discussion all together), but I'm sure it is nice for the family and friends to come see it all. Many of them see the whole process and think, "Gosh, I could never do that!" Truth is, most of them probably could. Anyone who spends that many years training to become a member of a profession is gonna know his stuff. Much like a long-time plumber knows his shit. OK, that was a bad one, but here I am sitting in an endocrinology work room bored as hell. Anyways, what else?

Then there was vacation. It was a great reprieve from this year's opening events - you know, the whole Mia situation. Though she is doing great, we needed a break after all. It started with a graduation party at my parents' house. My sister was graduating from high school, my brother from college, and I from medical school. Party worthy? I think so. Then we were off to a cabin hidden away outside of Eureka Springs, AR. It was a 5Bed/3Bath cabin on top of a hill with a great view of the White River, on which I fished a few times. Only one very minor emergency room visit, which could have easily been avoided with a tube of lube. Before you get any ideas, Mia's G-button came out - an extremely common complication with such a device. But a little lube goes a long way in getting one back in, and of all things, that is the one thing we forgot. Got a massage, did a little shopping around, jet skied, and most importantly, relaxed. For when we came back, the move.

The move went without a hitch. A very smooth process. We got back and that very day, we were surprised to find out the previous owners would be gone by that afternoon. So we rented a UHaul and began moving that evening. Within 24 hrs, the rental truck was back at its home base, and 48 hours after that, we were done with the rental house. It was sad in some ways to leave that house - out in woods, total privacy, all the firewood one could possibly want with space to actually burn in outside, great "neighbors," and a very helpful and understanding land lord. But the time was right to buy. We got into a house with essentially no money down with money earned in our pockets. The $8,000 of government money paid the down payment and we still had $2,700 left to spend. Then the fun started.

The roof was in need of repair. To our luck, the insurance company decided to pay for it. But they would only do so if it was a complete tear off and re-shingle job. "OK," we said, "That's even better!" It's what our roof really needed, I would've been surprised if a simple lay-over job lasted 10 years with the condition of that old roof. The guys who came to start the job started on a morning when an obviously ominous-looking cloud was rapidly approaching. And what do ya know, it started raining. Heavily. They already had much of the back side of the roof stripped clean off when it started. But they were too dumb to have A) put new felt paper down over the decking, and/or B) have enough tarp to cover the bare decking in the case of rain. Their solution? Go stand by the car and smoke until the rain stops. WTF?!? Naturally, my wife called me 8:30 in the AM to tell me it was raining on her head - in bed. All three bedrooms, the only carpeted rooms in the house, had rain leaking into them. And plenty of it. I had to call the head roofer (even though he was supposed to be on site at 0530!) to get his ass out to the house with more tarp and a solution to the problem. Then the carpet restoration guys had to dry everything out and clean the carpets. Then the painters had to come and fix the ceilings which thankfully didn't have to be frankly replaced. And the whole time it was nothing but excuses for what happened. Everything was finally completed yesterday, 3 weeks after it all started. Bastards.

Other than that, the house is coming along great. The baby's room was first, followed by the hall bath, then the master bath and bedroom, followed by the living room/entryway/hall. I'm finishing the trim in the hall now. Got a plumber to come fix our obscenely high water pressure and water heater issues. Next we will do the office/future guest bedroom. The kitchen, well that will happen in November if we are very lucky, or next May at the earliest. That's a much bigger, more expensive project to tackle, and I need a stretch of time off to do it since I will be doing the work. No more contractors, thank you. The roofer was one too many. I won't even go into all the yard work I am either doing now or want to do. I refer you to a couple blogs ago for pictures of the house before we changed everything. As much as I would love to post pictures, I am having a difficult time uploading them at this time. Maybe later.

Oh, and my intern year. Yeah, that started too. July 1, 2009. I really don't have a work excuse for not blogging; it's been easy so far. I started in the ER at the VA (except for the first few days and weekend of the month when I got pulled to work on the ward to cover for a foreigner who was not in the least bit prepared to start his internship since he literally got off the plane the day before orientation. I have issues with the sheer number of foreign medical trainees in this country when so many of our own American students didn't match this year. But that's a whole different subject and question of how that even happened). In the ER, I worked 8-5, M-F. No weekends. No call. No overnights. Easy for an intern, right? Other than I had no idea what the hell to do in most situations for at least the first week. Now I am on a consult service. Again, 8-5 (or 4 or 3), M-F, no weekends, no call, no overnights. Again, easy, right? Sure, but here's the problem. We get four "easy" months for the year, 3 of which we can take a week of vacation. I am getting two right off the bat. Any takers on what that means for the future? My September through next June schedule sucks, especially after January. Oh well, I can ease into things only to get smacked around a bit later. I have a week of vacation this month, one in November, one in December/January for one of the holidays, and one in May. That's four weeks in my first year of employment - so I can't complain too much. AND I'M GETTING PAID! Hmm, that's different.

So what about Mia? She is doing great. She continues to see one of her NICU docs on an outpatient basis. He's a great, very nice doctor, but seems a bit hesitant to change certain things. On the other hand, much of what needs to change with her, particularly in terms of her feeding, is dependant on her response to therapy. No one can drive that change but her. (Does that sound too Obamaish?) She has been doing oral and physical therapy for a few weeks now and is making reasonable progress. She starts at a therapy-based daycare on Wednesday, which will be wonderful for her, but perhaps more difficult for her mom. Rachel has enjoyed much well-deserved time off with Mia since April 23rd. That all changes on Wednesday. Back to work, as they say. In the long run, the extra money is much needed for all the improvements we still want to do to the house, and she needs a new car. We'll see how the first month back goes. Pictures below:

TTFN

Signed: Bradley A. Thuro, M.D. Sorry, I had to. I'm really not cocky, rather modest actually. You won't see that every time, I promise

High Time

Mia on her play mat - so close to a social smile yet so stubbornly far away.





First, allow me to apologize. To what use is a blog when its writer never blogs on it? That's right friends, none. I haven't blogged since March. Sure we've been busy since then - bought a house, brought a baby home, graduation plans, restoring the rental house back to its original condition, etc. But there is no excuse for me to use explaining why I haven't taken a half hour here and there to write a little.

So let's begin with Mia, of course. We brought her home on April 23rd. It was a day worthy of celebration, but we were so tired from the previous night and day that not much was done. When we roomed in with her at the hospital, we were adding food to her bag every two hours, I was on call with a pager that went off every hour, and we were trying to sleep on chair beds. It just wasn't working out. The next day, we met with her various therapists (speech, occupational, physical) to learn activities to work with her on. She had a few physical exams done, discharge stuff really. Dietitians came to talk with us. The nurses who frequented her bedside came to say goodbye. I had to run out to get a second car seat which better fit her - not sure to this day why the first one didn't as it was a convertible "infant" seat. And then - we took her home.

What an adjustment. Suddenly her food, her meds, her daily needs were all in our hands. Her meds were easy enough - four of them, just stick them in her G-tube and be done with it. Her therapies are also pretty easy, but she hates them for the most part. Her feeds were different. We were told that since she has thickener in her formula, we could only mix two hours at a time otherwise it would sit and turn to concrete and the pump wouldn't be able to handle it. After a few nights of being up every couple hours at home even, we decided that just would not do. See, she's on a feeding schedule that says five hours on the pump, one hour off, then repeat. She's essentially on the pump 20 hours a day, and off four. We decided to see what happened if we extended her amount to three, and five hours worth of food in the bag. The pump did fine, for the most part. After a few alterations in how we mixed the formula and thickening agent, we got it down. Now, we successfully fill the bag with five hours of food without any clumps and no turning into concrete - that last condition was a myth, I think. It surely was a matter of her food not getting mixed up well enough while at the hospital. I'm not doubting the nurses' abilities, just that with enough times doing it, we got the perfect order and method down.

Other than that, she's only had to go to ACH for a follow up general discharge appointment, ophthalmology appointment (she has no remaining retinopathy - good thing!), another dilation (Rachel wrote about that experience here), and a high risk newborn clinic appointment. A home health service comes by once a week to assess her growth and overall well being since she was a preemie, but that will likely stop after next week. She is adjusting well, I think. She is starting to realize that we are in fact her parents and the ones who are here to comfort her and take care of her every need. She is still a relatively fussy baby, though. It's hard to now if that's just how she is, or if it is related to being in the NICU away from home for so long. She showed signs from day one of having a low-threshold temper, so who knows? I'm sure there is a component of both views.

To the house. We have closed on it, or Rachel did anyway. After all the numbers were crunched and all the lenders called, it was decided it was best to leave my name off the mortgage and loan application. But since we are married, there is an inherent interest in the property held in my name. And, the closing costs were essentially paid by the government, and the monthly payment will be paid by me. Does any of that matter, though? No. It will still be her house to decorate. That's OK, because I am going to redo the kitchen. I need to master my remodeling skills somehow. Of course, there will still be the heavy weight of her input to consider. I think I will enjoy every minute of it nonetheless. Now all I need is tools. We don't move until the second week of June. Gives us plenty of time to pack, paint, and relax. I only have one bedroom left to paint, Mia's, and patchwork painting to do in the living room and kitchen. Luckily, our landlord is happy with the color in the living room and kitchen, so I don't have to paint all that back to white. Every single other room, however, required a layer of primer followed by paint. Even at back to white, it looks far better than when we moved in, simply because it's a fresh coat of paint, which wasn't done back then.

And then, graduation. What a big year for them. My little sister graduates from high school this month. My brother graduates from college this Friday and will continue with classes towards his CPA in a year or so. I am graduating from medical school with convocation on Friday and commencement on Saturday. Convocation is what matters - it's privy just to our fellow students, as opposed to commencement when the entire class of 2009 between the colleges of medicine and pharmacy, nursing students, graduate students, etc. walk across the stage for a piece of paper. At convocation, we get hooded, get our special awards, etc. Unfortunately, my parents can't make it to convocation, but all in good reason as it's my brother's graduation day. Wish him well. I have filled out most of my contractual paper work. The only remaining things are an ACLS card, a couple official things, and insurance paperwork. Finally, Rachel will have insurance! I start doing residency related things in the last couple weeks of June.

Well, that's all for now. Time to relax some more. The real relaxation will come with our trip to a cabin in Eureka Springs in a couple weeks. A week, hidden away, no doctor appointments, no work related duties - just family and quiet time. Oh wait, this is the Minyard family - scratch the quite time. ;)

The Latest

After another one-month hiatus, I will write about what's going on in life.

As always, first thing's first - Mia. Since I last wrote, she has actually had her surgery. To every one's benefit, the surgeons were able to put the ends of the esophagus together. The passage is tight, and it will never be normal, but it's finally there nonetheless. She had a rough first couple days - requiring blood pressure support, and suffering from massive swelling. A little over a week after surgery though, and she was almost her normal size and ready to be extubated. That's when the real trouble started. The day after extubation, she was having a lot of wheezing. After a bad chest x-ray and a bad blood gas several hours later, the decision to reintubate her was made. When we went in the following day, we got the full story from the neonatologists. Her right lung, without the aid of the vent, was incapable of moving air appropriately, and was unable to stay fully inflated. With the kind of surgery Mia had, one in which people go messing around the middle of her chest, there is always an inherent risk of damaging one or both of the following nerves: those that control the diaphragm, and those that control the vocal cords. It would seem that the nerve serving her right diaphragm was in some way damaged - stretched, bruised, or lacerated - who knows? While flat out having cut it is less likely, it's not a zero chance.


None of this is the end of the world. As long as the nerve wasn't grossly separated, the function will return. However, nerves grow very slowly, like a millimeter a week. If it starts to appear as though several weeks are going go by without improvement, there is a short-term solution. Another surgery. They would go in and tack down her diaphragm to help keep her lung open. She would just have to learn to use all of her accessory muscles to breathe - they do this when necessary and babies do just fine. The real problem is that we just don't know how much waiting will be involved. Depending on how she does, she may just have to remain on the vent for an undetermined amount of time. This throws a huge pipe wrench in the idea of getting her home by April 1st, now only a week away. And when they do get her off the vent successfully, however that may happen, she will still need an undetermined amount of time to learn how to swallow well enough to go home. She's nearing 100 days old, and still not home. I can't really talk about it any more.


In other news, we are getting a house. We found a house put up for sale by a graduating resident. It's in an optimal area, still in West Little Rock (though not near as far west as we currently are), and at an excellent price. We first saw it the same day Mia had to go back on the vent. Then, this past Saturday, we just had to have a second look. After this, we decided to make an offer. And after learning that three others had done so the same day, we were glad we did. Because of his profession, and my rapidly approaching one, he was more willing to do whatever it took to work with us above the other bidders. I guess it helps to be in the medical profession where one can draw upon many connections and then get even more. At any rate, we won the bidding war fairly easily and are still getting a great deal on the house. Pending a good inspection and appraisal, we close on May 1st. Since he doesn't finish residency until June, we won't move in until June 7th or so. But I still think we'll be OK. He will just pay us rent between closing and when he is able to leave. Below are pictures:


























And finally, the match. I, of course, matched into my intern year here. But that's really no surprise since it was a guaranteed spot. At any rate, the match stats were difficult to swallow this year. Out of 22,000 available spots, 30,000 applicants filled most of the spots. There were over 1,000 US seniors who didn't match. This is scary, considering there are only 15,000 US seniors for those 22,000 spots. Too many foreign medical graduates - end of story. More and more students are graduating every year, with great jumps in numbers yet to come. And yet, there aren't more and more residency spots since the Medicaid system is broken. This means nothing but doomsday for future graduating medical students. Sorry guys - I have nothing to suggest. Apply widely, and more importantly, apply yourselves before that point even comes. Then - you should have no problems. Oh yeah - and don't keep your expectations for yourself too high - you'll only disappoint yourself.

Stay posted, if you will. Keep thinking. Keep praying.

A New Month

So Sunday brings to us a new month, and in it, could be many big things.

First, Mia. After much waiting, it is likely we will find out sometime late next week or early the following week what kind of surgery Mia can have and when. We had initially been told it would be today, but alas, we found out last week it would be more than 3 weeks from the previous procedure. Oh well. I can't say I'm terribly surprised. Don't get me wrong, I want her home in our arms in our rocking chair as much as everyone else, but I think I have seen how the system works a thousand times over more than everyone else. Especially in academic medicine. Initially, one plan gets spit out - then, after whatever specialty team has a moment to get together and discuss a complicated case, like Mia's, they decide as a group when a better time would be. I imagine this is what happened; that and coordinating OR schedules between the surgery folks and the ENT folks. Either way, it's still aggravating, but there's no one to blame. At any rate, no one has been able to give us any indication as to whether her esophageal gap is too long for repair or not. There just hasn't been sufficient visualization of the lower part of the esophagus. We know the ends have "grown," but how far is not so obvious.

Otherwise, Mia is doing quite well. She hit the 6 pound mark the other night, and is probably a few ounces more than that today. By her due date, she will most certainly be of average birth weight. She's still on oxygen, and we're not sure why. Whoever is responsible for weaning babies off vents, be it docs, respiratory therapists, APNs, etc., didn't do a good job weaning the vent this last time after her procedure. And she has had trouble being without it since. There seems to be a possibility she will need home oxygen. It is hard to know for sure if the two are related. And while it's like it would be the end of the world, we're tired of dealing with things attached to her other than us. Her eye exams have also been fairly reassuring. One worries about retinal damage in premature babies, especially when they're on oxygen too long (but this is more related to being on the vent at high O2 levels and high pressure, which she hasn't had). While her retinas are premature as expected, there is no irreversible disease to be seen.

In other news, my "rank" list for my intern year was certified. Not that any of this matters, because it's a guaranteed spot for me anyway. It's tough to see all my classmates at their current level of stress. Now that their rank lists were due yesterday, they have to wait three weeks before the result of the match is known. Three weeks! There is no known reason why it should take that long. Everything is computerized, and Lord knows it couldn't more than a minute or two to run the list. And to top it off, it's not like they accept late rank lists. So where the hold up is, no one knows. And it's not like the NRMP will ever speak a peep of why they take three weeks to do it. My match was less than 1 week after the list was due. Of course, I had other things to worry about at the time, so I didn't really get too nervous about the whole thing.

I am also on the hunt - for houses and for day cares. With Rachel working, and I on a couple easy few-hour months at school, it is reasonably up to me to do all the leg work on these fronts. As a freshly starting doctor, I can qualify for pretty much whatever home loan amount I want. Granted, we don't need a $250K house, but we could be approved for that. I think $150K or less is fair. And with today's market, one can get a house listed at $175K for that amount. I have some good neighborhoods in mind - ones I need to drive Rachel around in. Better yet, these are hoods that are nice, big, clean, close to work, and supply potential buyers with tons of options. I'm overly excited about the process, but I know it will be cumbersome. I have done much reading about buying a first home. I plan to talk to a broker within the next week or two, get pre-approved doing whatever I need to, find a buyer's agent, and find a home. While a lot of this depends on Mia's condition on discharge, we should know some of these answers soon. And if things go optimally, the ground work will be done and we can hit it running, getting most everything taken care of before the baby comes home, except of course actually moving. As far as daycare - what a depressing search. I have only found about four out of several that I would put my baby in. Two of these are actually quite good. I would also like to take Rachel to see these places. At least their waiting lists are reasonable, not the six months or more I was warned they would be. I guess that long of a list typically applies more to church-associated day cares. Anyway, as I said before, at least the difficult parts of the searching will be done before Mia is home.

If you've made it this far, I thank you for paying attention. I don't blog just very often, and so when I do, I go quite long. Hold your remarks, honey : ). And Dr. G, if you ever read this, which you won't. Stay tuned as the next month brings much news.

Writer's Block

I haven't really posted in awhile because I haven't had much to say. Everything there is to know about Mia is on Rachel's blog. Everyone's asking when Mia will get to come home, as if there is hope it will be very soon. I'm not being pessimistic, but it won't. Even if she were to have surgery next week, she would need plenty of time to grow more and heal and eat and breathe better. I give her at least two weeks beyond surgery before she comes home, but that's just my unprofessional guess. My AI ended without a going away party. Didn't really learn much other than how to get patients out the front door of the VA. My primary care month in the internal medicine clinic started on Monday. It's pretty cush - I see one or two patients a day, and the best part about it is that when I'm not seeing anyone, I don't have to sit around with nothing to do. I can actually leave if I wish. I went back to the gym today for the first time since well before Christmas. I was somehow still able to run three miles, very close to my usual four, without trouble. We shall see how my legs feel tomorrow or the next day. I made a fair amount of money on call at the eye bank last week, more than I ever have before. This is only party because I submitted my days and referrals from the last time I was on call the week Mia was born since I never submitted anything then.

I thought I would have more paramount things to say when I started this blog, but I guess I just don't.

An Announcement

Now whose tiny hand is this?

So, you already know about Mia, what else could there be? I matched in ophtho. . .At UAMS. . .My top ranked program. That means no more interviews! The intern year at UAMS is a guaranteed spot - no interview or other bs required.

Details will follow.

A Precious Promise Kept

This is Mia Kathryn Thuro, born on January 1, 2009, at 8:29 in the evening. She weighed 2 pounds and 14 ounces, at a length of 15.75 inches. And let's just say that, for being just shy of 30 weeks in the womb, she is doing splendidly. Rachel, I'm sure though I have not read it myself, has written a wonderful blog detailing her experience and feelings surrounding the event. But here are mine.

She was born with us being full aware that there was a problem ahead of time. From the very first official ultrasound, no pictures beheld a stomach. At first glance, this simply means waiting for the baby to swallow some fluid and the stomach will appear. However, after many repeated attempts, everyone failed to visualize her little stomach. This could only mean one thing - the connection between her esophagus and her stomach was missing, if not at least defective. It is known as esophageal atresia; and although it isn't terribly rare, not too many babies are born with such an ailment.

What this meant for Rachel from early on was the high possibility of early labor. The baby while in the uterus constantly swallows amniotic fluid, digests it, and re-secretes it through the kidneys. It is also resorbed through the blood and placenta. If a baby can't swallow, the fluid inevitably builds up in excess within the uterus. Too much fluid, in a very thin amniotic sac, leads to only one kind of outcome: premature rupture of membranes, aka POP!

This was of course a scary moment. We had only just finished watching Ocean's 13 when I decided to take a shower. No longer than I had shut the bathroom door, I hear a small shriek from the living room, thinking Rachel was laughing at something - two sounds which are sometimes surprisingly similar through two closed doors. I came back out to see what was so funny only to see first hand what it meant to have one's water broken - not to mention the fact that there was more than usual to begin with. We quickly dressed and rushed off to the L&D triage center at UAMS. There she was hooked up to a monitor and to our great relief, a baby's heartbeat was present and normal.

We were told at that point that Rachel would be in the hospital until she delivered - be that one day, or one month. It didn't matter. Once one's amniotic sac is ruptured, the risk of infection to the baby and mother is too great to let one go walking around. We were moved into a labor room and awaited greetings by a neonatologist (doctor who specializes in newborns), the obstetrician, and the anesthesiologist. They all got their words in, but the anesthesiologist ended up being of no help. Her water broke at around 2:30 in the afternoon, and she was dilated 1 cm around 3:30. A couple hours and one sedative dose later, she had progressed to 3-4 cm. A few hours later, and in the middle of the anesthesiologist talking to us about epidurals, she was dilated to 10 cm. Buy buy to that doctor, and hello to about three others and a few nurses. Before another 30 minutes passed, Mia was out and whisked away to be stabilized.

An hour passed with great emotion and anticipation. I got to see her briefly in that time, but eventually, when she was safe and sound in her incubator with the Angel One Transport team, she was brought to us. For a few short minutes, we gently touched her hand, and she was then taken to the premier place for sick children in the state - Arkansas Children's Hospital, only twenty minutes from our house.

She was stabilized on the ventilator, and she remains so to this day (1/6/09). The story of her atresia is like this: there's a good part and a less good part. Optimism here. There are five different types. Importantly, the most common is when there is a connection between the lower part of the esophagus and the trachea, or wind pipe. This is not her kind. Mia's is much less common - the kind where no connection exists between the esophagus and the trachea. There are three other even less common variations, but I won't discuss those. With Mia, the lack of a connection to the trachea is a good thing. With a connection, air is drawn into the stomach with each breath. This inflates the stomach, pushing up on the diaphragm, decreasing room for the lungs to expand. This requires higher ventilator pressures to inflated the lungs constantly, which is much more damaging to such premature lungs. So she can now tolerate low vent pressure, and will hopefully wean off of it easily. The unfortunate thing is, when there isn't a connection, the gap between the closed ends of the esophagus is often much bigger, making a repair more complicated or impossible.

So here's what we do. We let her grow for a while. She has had a tube put into her underdeveloped stomach so that she can be fed breast milk, and so that we can get her stomach and lower esophagus to expand. After 4 weeks of waiting, x-ray contrast studies can be done to see how close the ends of her esophagus are to one another. If close enough, the repair will be scheduled. If almost close enough, we wait another four weeks and then schedule the repair. If nowhere near close enough, which is fortunately often not the case, her esophagus is made to drain out the side of the neck and a bigger tube is put in her stomach. Then, at age 6 to 9 months, long after she has come home, they do an esophageal replacement with either stomach parts or intestinal parts. We hope for a repair at 4 or 8 weeks, much more so than a replacement.

Many other things have been checked out on her to ensure that no other accompanying defects had gone unnoticed. To every one's fortune, no other problems have come up yet. There are many times one or several of a list of other problems that can occur with esophageal atresia, but we've been fortunate.

As of now, she remains on the vent, but an attempt to remove the vent will be undertaken tomorrow morning. They will watch her throughout the day to make sure she can hold her own, so to speak. We pray that she can. If she can, then it won't be much longer before we can hold her. Few of you may, but most of you have no idea how hard it is not be able to hold your newborn child for a week or more, no matter how beautiful she is. But we visit her everyday, many hours out of the day, nonetheless. She holds our hands and grips with her toes. She is pretty calm though as she is sedated since she is on the vent and has suction constantly to keep her upper esophagus free from pools of saliva. We don't want her to inhale that stuff and get a pneumonia. But, believe you me, when we get to hold her, you will hear about it.

Other aspects of life have been subsequently inconsequential. I started a work intensive rotation yesterday, but I don't even care. I match into ophthalmology in nine days, but I don't even care. I'd like to find a house we like, but I don't care right now. Some things have just become more important.

A Promise

I promise, I will soon post a blog about our new baby girl, Mia. Not only has that been a huge time investment since 1/1/09, but so has school as I started my acting internship yesterday.

Best Wishes - BAT