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

Home Based

After much traveling, I am finally done - at least for the time being. My ten ophthalmology interviews are done with. I now have the just as, if not more, difficult task of figuring out how to rank these programs. They all will make the cut since it is too ballsy for me to simply not put a program on the list. Some people do it, but I won't after having spent a decent amount of money an all my travels.

Unfortunately for the couple (maybe four) of readers I have, I shan't post publicly any rank list until perhaps immediately prior to January 15th, the date on which I will find out where I matched. It may be nothing more than paranoia keeping from posting such a list, but I know there are people out there who search for this kind of stuff. My list is due on January 8th, just one week before. That means I have less than a month to figure it all out. You wouldn't think it would be hard, but with as many variables as I am trying to consider, the decision seems impossible. I know what ranks 1st, 9th, and 10th on the list, but 2 through 8 remain undecided.

What do I like about the program?

What don't I like about the program?

How's the city it's in?

What's the cost of living there?

And of course within these questions lie many sub questions, if you will. And with the way this matching process works, there is just as good a chance I will get my second or third choice as it is I will get my first. Must choose wisely.

Outside of this, I have the rest of the month to think about it and to do my Christmas shopping. What does everyone want? I think I want a beer. . . . . . . . . . . . .Well, after that I have not much left to say. I would simply refer you to Rachel's Blog for baby info.

Giving the People What They Want ;)

Before I say much else, I have to just congratulate the Razorbacks for their closing win of the season against LSU. What a thrilling game it was. For the second year in a row, AR has beat LSU for the boot and the glory of bringing it home. Not to mention, they did it with a new coaching staff, no McFadden, and with a crap defensive line. Go hogs!

I'm not just a huge football fan, but I have come to like college football at least if not more than professional ball. Less politics, and just generally more entertaining. Since I am more of a casual fan, surely there are more exciting things in my life, right? Right.

With six interviews down, and four to go, it's hard to believe I started on this trail over a month ago. A month? Really? All of my hours and miles on the road over the last month really haven't made it drag by overall. But while on the road, what a drag! I have many miles on the car, and despite an oil change just two weeks ago, I would technically be due for another here in about 500 miles if I went by the 3000 mile rule. The trail has been fun, though. I have the same people in several places. It's nice to know that at each site, I am up against the same group of people, not a whole different 50 applicants. It makes me feel more confident that most of us have a good chance of matching somewhere. Here's the difficult part: every program has rocked my world in some way. SLU has a bunch of cool stuff to do, but the program seems almost too laid back. UTSW puts up excellent surgical numbers, but Dallas is probably just a little too flashy for me and I am sure the program is more malignant than the residents were leading us to believe. UMKC also put up great surgical numbers, but perhaps were a little too much into research requirements. UAB is a very solid program in a neat town, but the first year is in-house hospital call. OU puts up the best surgical numbers I've seen, is in a great city, and I can't find any true downfalls. MU is a solid, hidden program in a good town, but does very little trauma and so I might not get much orbital exposure. I will critique the remaining four programs in a later blog (as much for myself as anyone) and finally announce my rank list. I may not announce my rank list until after all lists are submitted. I can't see any reason why announcing it publicly would effect or hurt me in any way, but better safe than sorry.

Of course, every time I leave and go 300+ miles from home, Rachel gets some reason to be panicked about little Mia. They have all been good reasons, but at bad timing. I leave for Memphis tomorrow, so there better not be any scares Monday morning, Missy.

I put Christmas lights up this weekend since we can't put up a tree this year. We have acquired additional dining room furniture since the last holiday season and thus have no room. Maybe we'll get a little one footer and put in on top of said furniture. I would supply photos of the lights, but anyone who has tried knows they don't photograph well. But new baby furniture does!

The Mona Lisa will probably find a new home when the baby comes, or the trash can as was the initial plan. We decided to hang it in the room because it matched the green, but it doesn't match a baby. Never mind the stacks of diapers piling up, they will get used quick enough.

My room at the
Crowne Plaza Hotel
in Dallas, Texas.


Hello to all from Dallas! Why am I in Dallas? I am currently on my second of ten scheduled interviews. In order:

SLU in St. Louis, MO
UTSW in Dallas, TX
UMKC in Kansas City, MO
UAB in Birmingham, AL
OUHSC in Oklahoma City, OK
MU in Columbia, MO
UT Memphis in Memphis, TN
UAMS in Little Rock, AR
UK in Lexington, KY
U of Cincinnati in Cincinnati, OH

I was in St. Louis earlier this week and am spending today and tomorrow in Dallas. The first interview went pretty well I think. Before you ask, "Do you think they will offer you a spot?" let me just say that them offering me an interview was offering me a spot already. As noted in a previous blog, a rank list is submitted by the program and all the applicants. So now it's just a matter of how applicants rank that particular program and how the program ranks all the interviewees. Of note, St. Louis has a great program, with hospital-paid benefits. The residents were all nice people, and the faculty seemed nice as well. I wasn't sure what to expect at first since many of the residents at UAMS seemed to dislike SLU. I can't figure why since the program seems as good or better than UAMS - perhaps a few less cataract cases. This is not likely to be too important to me since I plan on being fellowship trained one day.

I would really like to add an interview at Duke to this list, but I haven't heard from them yet. I have been denied by three places, two in Boston and the other being John's Hopkins; I have turned down four programs now. That leaves about 13 programs I haven't heard from just yet. Some of them might not ever respond, including Duke. We shall see.

We're having a girl in case you haven't heard! Mia Kathryn Thuro.

I am off from school from now until we return in January. This isn't the case for all of my class, it's just how I have scheduled it. Many of my peers took July or August off. I couldn't do that for obvious reasons - rotations I needed to get done early. Two months off to travel and celebrate the holidays isn't too bad if you ask me. I'll be plenty busy.

I'm not sure what else to talk about right now, so see you next time!