I just read an interesting post by Dr. Rod Moser at All Ears about how NOT to get your kids to behave. It reminded me of an incident that happened when I was a student nurse.
I was working in the pediatric outpatient clinic at a major teaching hospital and my next patient was about 4 years old. He'd been in the waiting room much longer than his attention span would bear and was more than a little anxious about his checkup. When I called them back his mom was had a little difficulty getting him to come along, so she took his hand firmly and tried to get him to come. He struggled. His mom said, "If you don't stop that right now, the nurse will give you a shot." Then she turned to me and said, "Won't you?"
I'd heard of this sort of parenting, but it wasn't my mom's style and it wasn't something we'd covered in class. Never at a loss for words, though, I looked at the child and said very firmly, "No. I won't."
Not wanting to totally humiliate the mom, I continued more gently, "When your mom was little, nurses did give shots to bad girls and boys. Your mom just doesn't know that we've stopped doing that. Now we only give shots if you need them to help you get better or to keep you from getting sick. We don't give shots to punish children. I'm not sure what your mom will do if you don't cooperate, though."
Mom stood there with her mouth hanging open for a moment, then closed it and followed me to the exam room. To my delight the boy cooperated with me and with the doctor through his exam. I'm pretty sure the outcome would have been different if I'd gone along with his mom.
Dr Moser says he still hears this type of comment in his clinic. I thought parents had given this stuff up. Apparently I was wrong. Parents, if you aren't sure how to handle your rowdy children, head over to Dr. Moser's blog. He's written some excellent posts on the subject and has links to additional articles with suggestions for positive parenting. As an experienced mom, I can attest to the results. Positive reinforcement works. Scaring your kids with threats of what someone else will do to them simply scares them -- and undermines your authority.
Friday, December 29, 2006
Monday, December 18, 2006
Birth Story
A long time ago, in a hospital not so far away, a woman arrived in the Emergency Room with tiny feet protruding from her vagina. They were cold and blue. No heartbeat could be detected. They rushed her to Labor and Delivery.
Since there seemed to be no hurry, the OB attending decided that this would be a good opportunity to instruct the OB resident in pre-term breech delivery techniques. Since they didn't know when the tiny heart had stopped, they thought it wise to invite the NICU team to the delivery although our presence was not expected to change the outcome.
I was precepting a new nurse, and we went through all the motions of preparing an ET tube and drawing up the resus medications. We talked about the ABC's of neonatal resuscitation while the OB attending instructed his resident. The neonatologist planned to make an attempt at resuscitation, but really didn't expect success.
You've probably deduced by now that things didn't go exactly as predicted. The OB attending talked the resident through a perfect delivery, but what happened next surprised all of us.
The baby cried.
The OB resident quickly clamped and cut the umbilical cord before handing this vigorous, if somewhat bruised, 28 week infant over to us. I don't remember the details of his clinical course - it's been over 20 years - but I'll never forget that completely unexpected, but ever so welcome wail.
Since there seemed to be no hurry, the OB attending decided that this would be a good opportunity to instruct the OB resident in pre-term breech delivery techniques. Since they didn't know when the tiny heart had stopped, they thought it wise to invite the NICU team to the delivery although our presence was not expected to change the outcome.
I was precepting a new nurse, and we went through all the motions of preparing an ET tube and drawing up the resus medications. We talked about the ABC's of neonatal resuscitation while the OB attending instructed his resident. The neonatologist planned to make an attempt at resuscitation, but really didn't expect success.
You've probably deduced by now that things didn't go exactly as predicted. The OB attending talked the resident through a perfect delivery, but what happened next surprised all of us.
The baby cried.
The OB resident quickly clamped and cut the umbilical cord before handing this vigorous, if somewhat bruised, 28 week infant over to us. I don't remember the details of his clinical course - it's been over 20 years - but I'll never forget that completely unexpected, but ever so welcome wail.
Thursday, December 14, 2006
Board of Review
Among my many hats, I am on the Troop Committee for my son's Boy Scout troop. Tonight I had the privilege of sitting on the board of review for 3 of the scouts. Only one of them was fully prepared for the interview.
A few tips for scouts:
It is not a good idea to open with "So how long will this last?" That tends to bring up questions about your Scouting Spirit. It also helps if you sit up straight and look us in the eye when you speak to us. Pick one of us or take turns, but don't look at the wall or the floor when you're speaking. We won't fail you for that, because you might just be nervous, but you should give it a try.
Corollary: the best Scouting Spirit and interview skills will not get you through if you have not read the handbook. We have. The answers to our questions are all in there.
We know you only use the one knot, but we are scouts and we learn the others anyway so we CAN use them. Yes, you really can use that taut-line hitch in putting up your tent. It's much more effective than your square knot. There are actual real-life uses for those other knots too. Your book even tells you what they are.
The big dipper does point to the North Star (Polaris), but if you insist on using those top two stars as guides, you'll never find north. You want the two on the side away from the handle and the line points up toward the top of the dipper.
No, moss does not always grow on the north side of trees. I don't care who told you that, it's simply not true. Moss grows on the side which gets little or no sunlight. Often that is north, but it depends on the landscape and sometimes it's the whole way round.
The N on your compass only points north if you're facing the right direction and have lined it up properly. The compass needle has 2 ends. One of them is red, the other is white. If your compass is functioning properly the red one will point to the north. If you make the red end point to the N, then the N is facing north as well.
Please do not follow your drowning buddy to the bottom of the deep end without first notifying the lifeguard that he's in trouble. Yes, we do expect you to know where your buddy is even if we're not calling a buddy check just this minute.
Yes, knowing how and when to use the Heimlich maneuver is a perfectly acceptable response if you can't remember what it's called. In fact, I'd much rather you knew what to do than the fancy word for it with only limited knowledge of what the word means.
No, we really don't enjoy sending you away without that advancement but we want you to be pround of that rank emblem when you wear it on your uniform. That's why we're asking you to study a little harder and come back when you've learned the bit that's in the section for your next rank. We know you can do it and we'll be happy to meet with you again any time you're prepared.
Please try not to wait until the week before the next Court of Honor.
A few tips for scouts:
It is not a good idea to open with "So how long will this last?" That tends to bring up questions about your Scouting Spirit. It also helps if you sit up straight and look us in the eye when you speak to us. Pick one of us or take turns, but don't look at the wall or the floor when you're speaking. We won't fail you for that, because you might just be nervous, but you should give it a try.
Corollary: the best Scouting Spirit and interview skills will not get you through if you have not read the handbook. We have. The answers to our questions are all in there.
We know you only use the one knot, but we are scouts and we learn the others anyway so we CAN use them. Yes, you really can use that taut-line hitch in putting up your tent. It's much more effective than your square knot. There are actual real-life uses for those other knots too. Your book even tells you what they are.
The big dipper does point to the North Star (Polaris), but if you insist on using those top two stars as guides, you'll never find north. You want the two on the side away from the handle and the line points up toward the top of the dipper.
No, moss does not always grow on the north side of trees. I don't care who told you that, it's simply not true. Moss grows on the side which gets little or no sunlight. Often that is north, but it depends on the landscape and sometimes it's the whole way round.
The N on your compass only points north if you're facing the right direction and have lined it up properly. The compass needle has 2 ends. One of them is red, the other is white. If your compass is functioning properly the red one will point to the north. If you make the red end point to the N, then the N is facing north as well.
Please do not follow your drowning buddy to the bottom of the deep end without first notifying the lifeguard that he's in trouble. Yes, we do expect you to know where your buddy is even if we're not calling a buddy check just this minute.
Yes, knowing how and when to use the Heimlich maneuver is a perfectly acceptable response if you can't remember what it's called. In fact, I'd much rather you knew what to do than the fancy word for it with only limited knowledge of what the word means.
No, we really don't enjoy sending you away without that advancement but we want you to be pround of that rank emblem when you wear it on your uniform. That's why we're asking you to study a little harder and come back when you've learned the bit that's in the section for your next rank. We know you can do it and we'll be happy to meet with you again any time you're prepared.
Please try not to wait until the week before the next Court of Honor.
Monday, December 04, 2006
A New Approach to Theft
I got a phone call this morning.
"Hello, my name is Paul(or so he says). I work for (collections agency) and I'm representing (large radiology practice). It seems that you had a CT scan (details of where, when, and what was scanned) on a date in 2001."
I responded that it was possible, but I couldn't be sure, so much time having elapsed.
Paul assured me that not only did I have the scan on the alleged date, but that the radiology practice in question was out of network for me -- something I knew to be a lie -- and that I owed just over $100 and that he could arrange payment or he could report the alleged debt to the 3 major credit reporting agencies.
When I asked for written substantiation of the supposed debt, Paul informed me that his job did not include written notification.
In that case, I responded, this is not my problem.
After doing a little research, I discovered that there is rather a racket going in collecting previously paid and uncollectible (as in NOT OWED) medical billings. I think it's pretty obvious that medical professionals are not in any way benefitting from these scams.
Then I called the major radiology practice billing department and verified that they do not believe that I owe them any money - from 2001 or any other time. When I suggested that perhaps they had a leakage problem with patient names, dates, etc being leaked to unethical people, the "customer service agent" got a little huffy with me - until I mentioned the name of the agency which supposedly employs Paul. I asked to speak to her supervisor and was informed that all supervisory personnel were at lunch, but that someone would call me back.
OK. Maybe they will. Maybe Paul is a former employee of the collections agency or of the radiology practice and maybe they'll be right on top of this. Just speculating, but he got the information SOMEWHERE.
It's been less than 24 hours, but I think I'll be chatting with the lovely folks at the State Attorney General's office and maybe with the local media as well since this appears to be a well-planned scam which could easily fool someone a little less insistent on paperwork or a little more concerned about her credit rating.
Bottom line, if they won't send you the documentation ON PAPER, presume that you do not owe the money. NEVER arrange to pay a collection agency anything based on a telephone call with no written evidence to back them up -- and particularly if they claim that sending the paperwork isn't their job.
For a quick read on similar scams, check this article titled Debt Collectors often Collect Bogus Debts
And for an even scarier story about actual debt collectors and some unethical practices this Boston Globe report.(registration required) At least my scammer can't actually DO anything to me if I don't let him.
"Hello, my name is Paul(or so he says). I work for (collections agency) and I'm representing (large radiology practice). It seems that you had a CT scan (details of where, when, and what was scanned) on a date in 2001."
I responded that it was possible, but I couldn't be sure, so much time having elapsed.
Paul assured me that not only did I have the scan on the alleged date, but that the radiology practice in question was out of network for me -- something I knew to be a lie -- and that I owed just over $100 and that he could arrange payment or he could report the alleged debt to the 3 major credit reporting agencies.
When I asked for written substantiation of the supposed debt, Paul informed me that his job did not include written notification.
In that case, I responded, this is not my problem.
After doing a little research, I discovered that there is rather a racket going in collecting previously paid and uncollectible (as in NOT OWED) medical billings. I think it's pretty obvious that medical professionals are not in any way benefitting from these scams.
Then I called the major radiology practice billing department and verified that they do not believe that I owe them any money - from 2001 or any other time. When I suggested that perhaps they had a leakage problem with patient names, dates, etc being leaked to unethical people, the "customer service agent" got a little huffy with me - until I mentioned the name of the agency which supposedly employs Paul. I asked to speak to her supervisor and was informed that all supervisory personnel were at lunch, but that someone would call me back.
OK. Maybe they will. Maybe Paul is a former employee of the collections agency or of the radiology practice and maybe they'll be right on top of this. Just speculating, but he got the information SOMEWHERE.
It's been less than 24 hours, but I think I'll be chatting with the lovely folks at the State Attorney General's office and maybe with the local media as well since this appears to be a well-planned scam which could easily fool someone a little less insistent on paperwork or a little more concerned about her credit rating.
Bottom line, if they won't send you the documentation ON PAPER, presume that you do not owe the money. NEVER arrange to pay a collection agency anything based on a telephone call with no written evidence to back them up -- and particularly if they claim that sending the paperwork isn't their job.
For a quick read on similar scams, check this article titled Debt Collectors often Collect Bogus Debts
And for an even scarier story about actual debt collectors and some unethical practices this Boston Globe report.(registration required) At least my scammer can't actually DO anything to me if I don't let him.
Friday, November 24, 2006
Grand Rounds
Looking for something interesting to read? There's always great reading on Grand Rounds! This week's excellent addition was edited by Doctor Anonymous
Tuesday, November 07, 2006
New York!
Lady Liberty as seen from the Staten Island Ferry. The view is amazing and the price is right.
My first trip to Manhattan was love at first sight. I don't want to move there, but I want to go back and visit -- often. There is so much to see and do!
Tourist tip: Go visit the Empire State building after dark. The view is fantastic and the lines aren't.
Best bargain: $7 Metrocard that lets you ride all over the city via subway and bus from the first time you use it until 3am the next morning. If you're staying longer, the rates only get better. Maps are free at the information desks and the New Yorkers we met were friendly and helpful when we needed directions.
Pediatric Grand Rounds is up at Tales from the Womb
Pediatric Grand Rounds #15 is up at Tales from the Womb:
SIDS, Autism, Flu Vaccines, Multiple births, and most of my favorite pediatric bloggers.
SIDS, Autism, Flu Vaccines, Multiple births, and most of my favorite pediatric bloggers.
Thursday, October 26, 2006
NPO after midnight
NPO = nothing by mouth. No food. No beverages - not even water. Standard instructions for adults and older children having surgery. As it turns out, that may be rather more strict than is absolutely necessary.
I already knew that pediatric anesthesiologists don't recommend long fasts for NICU babies prior to elective surgeries. I started researching the actual recommendations for adults last summer when my 20-something son was scheduled for elective surgery. 8 days prior to his surgery, almost a full page in the Baltimore Sun was devoted to the subject. The clinical director of anesthesia at University of Maryland Medical Center and several other anesthesiologists were quoted extensively in the article stating that clear liquids can usually be safely consumed up to 2 hours prior to surgery. If a patient asks, these physicians will even say so to the patient.
Not trusting the newspaper to get it right, I went on a hunt for more information and found that the reporter had been accurate. See the links at the bottom for more.
I presented all this to my son and asked what he'd been told, since all his printed information said quite clearly "NPO after midnight" for his 11:30 am surgery. It seems his surgeon was up to speed on the research and had OK'd water or other clear liquids 4-6 hours prior to surgery. My son opted not to take advantage of that information, but he was aware of it.
There is another reason surgeons prefer that their patients fast for longer than the mandatory minmum times. It makes rescheduling that much easier if it becomes necessary. Sometimes it does. While we were in the holding area about half an hour prior to my son's scheduled OR time, we heard another patient very profanely complaining that his procedure had been cancelled because certain necessary records were not available. He wasn't a bit happy. My son's OR time wasn't impacted, but someone else's probably was. I'm sure things like that happen all the time. Maybe not missing records, but changes in the OR schedule for a multitude of reasons.
I would never recommend that anyone disregard his or her physician's advice regarding preoperative fasting. There are too many variables and each case is different. It is worth asking, though, if your procedure is scheduled later in the day, whether it is safe for you to drink water and perhaps other clear liquids. You may be pleasantly surprised by the answer.
Food? Don't even go there! Depending on the reason for surgery and the nature of the food consumed, your stomach may not be empty many hours later. I was kept in the ER for nearly 12 hours prior to my appendectomy many years ago. I still threw up in the recovery room and woke up looking at an X-ray machine. Fortunately I didn't aspirate any of my stomach contents and end up in intensive care. It happens.
If your doctor wants you to eat, he or she will tell you to do that. Don't count on that happening and if you slip up and nibble on something in the morning, for goodness sake, ADMIT IT. Your life might depend on it.
Studies about fluid intake preoperatively:
Evidence Based Nursing 2004: Literature review "evidence is lacking that adults given liquids 1.5-3 hours preoperatively have a greater risk of aspiration or regurgitation than those given a standard fast"
Abstract from British Journal of Surgery on Ingenta Preoperative Fasting Findings recommend 2 hour fast from clear liquids for elective surgery for most healthy adults undergoing elective procedures.
Cochrane Collaboration -- another abstract which clarifies that pregnant, obese, elderly, and those with stomach disorders are more likely to regurgitate, but that healthy adults with none of the above may be able to drink water or other clear liquids up to 2 hours prior to surgery.
I think it's important to note the recommendations from the American Society of Anesthesiologists web site: (emphasis mine)
Some degree of fast is clearly necessary. Fasting from food will almost certainly be recommended from midnight the night before. Ask your doctor his or her recommendations about liquid intake -- and then follow them.
I already knew that pediatric anesthesiologists don't recommend long fasts for NICU babies prior to elective surgeries. I started researching the actual recommendations for adults last summer when my 20-something son was scheduled for elective surgery. 8 days prior to his surgery, almost a full page in the Baltimore Sun was devoted to the subject. The clinical director of anesthesia at University of Maryland Medical Center and several other anesthesiologists were quoted extensively in the article stating that clear liquids can usually be safely consumed up to 2 hours prior to surgery. If a patient asks, these physicians will even say so to the patient.
Not trusting the newspaper to get it right, I went on a hunt for more information and found that the reporter had been accurate. See the links at the bottom for more.
I presented all this to my son and asked what he'd been told, since all his printed information said quite clearly "NPO after midnight" for his 11:30 am surgery. It seems his surgeon was up to speed on the research and had OK'd water or other clear liquids 4-6 hours prior to surgery. My son opted not to take advantage of that information, but he was aware of it.
There is another reason surgeons prefer that their patients fast for longer than the mandatory minmum times. It makes rescheduling that much easier if it becomes necessary. Sometimes it does. While we were in the holding area about half an hour prior to my son's scheduled OR time, we heard another patient very profanely complaining that his procedure had been cancelled because certain necessary records were not available. He wasn't a bit happy. My son's OR time wasn't impacted, but someone else's probably was. I'm sure things like that happen all the time. Maybe not missing records, but changes in the OR schedule for a multitude of reasons.
I would never recommend that anyone disregard his or her physician's advice regarding preoperative fasting. There are too many variables and each case is different. It is worth asking, though, if your procedure is scheduled later in the day, whether it is safe for you to drink water and perhaps other clear liquids. You may be pleasantly surprised by the answer.
Food? Don't even go there! Depending on the reason for surgery and the nature of the food consumed, your stomach may not be empty many hours later. I was kept in the ER for nearly 12 hours prior to my appendectomy many years ago. I still threw up in the recovery room and woke up looking at an X-ray machine. Fortunately I didn't aspirate any of my stomach contents and end up in intensive care. It happens.
If your doctor wants you to eat, he or she will tell you to do that. Don't count on that happening and if you slip up and nibble on something in the morning, for goodness sake, ADMIT IT. Your life might depend on it.
Studies about fluid intake preoperatively:
Evidence Based Nursing 2004: Literature review "evidence is lacking that adults given liquids 1.5-3 hours preoperatively have a greater risk of aspiration or regurgitation than those given a standard fast"
Abstract from British Journal of Surgery on Ingenta Preoperative Fasting Findings recommend 2 hour fast from clear liquids for elective surgery for most healthy adults undergoing elective procedures.
Cochrane Collaboration -- another abstract which clarifies that pregnant, obese, elderly, and those with stomach disorders are more likely to regurgitate, but that healthy adults with none of the above may be able to drink water or other clear liquids up to 2 hours prior to surgery.
I think it's important to note the recommendations from the American Society of Anesthesiologists web site: (emphasis mine)
Why are patients not allowed to eat or drink anything before surgery?
For most procedures it is necessary for you to have an empty stomach so that the chances of regurgitating any undigested food or liquids is greatly reduced. Some anesthetics suspend your normal reflexes so that your body's automatic defenses may not be working. For example, your lungs normally are protected from objects, such as undigested food, from entering them. However, this natural protection does not occur while you are anesthetized. So for your safety you may be told to fast (no food or liquids) before surgery. Your doctor will tell you specifically whether you can or cannot eat and drink and for how long. In addition, the anesthesiologist may instruct you to take certain medications with a little water during your fasting time. For your own safety, it is very important that you follow these instructions carefully about fasting and medications; if not it may be necessary to postpone surgery.
Some degree of fast is clearly necessary. Fasting from food will almost certainly be recommended from midnight the night before. Ask your doctor his or her recommendations about liquid intake -- and then follow them.
Monday, October 16, 2006
Collaborative efforts
One baby in Nursery A and one in Nursery B. I get to guess whose parents will show first and which will need more of my attention, since my bilocation skills are a little rusty. 8 pm and every nurse in the unit had at least 2 babies due.
I was nearly finished with baby B (I'd elected to start with her, so I could spend more timewith family A) when the nurse practitioner appeared to inform me that the parents of baby A had arrived "with attitude" not improved by some bad news she'd had to share with them. Not terrible news, just one more thing they didn't want to hear.
Me: "Thanks, I'll be with them in just a minute. I just need to ....."
NP: "I can do that. What else do you need me to do so you can go take care of that mom in Nursery A?"
No, not wishful thinking. The nurse practitioner did everything I asked AND gave the medication I'd forgotten to mention, giving me the time I needed to soothe the mom who was about to have to go home weeks before her baby would be ready to join her. She could have stayed and talked to the mom until I got there, but she knew that what the mother needed was to hold her baby -- and that I needed to assess him before he came out of the isolette.
One of the things I like best about the nurse practitioners who work with us is that they have all walked in my shoes and they understand what they can do to make life easier for the nurses and for the families. That and they're willing to actually put out the effort when they have the time.
I was nearly finished with baby B (I'd elected to start with her, so I could spend more timewith family A) when the nurse practitioner appeared to inform me that the parents of baby A had arrived "with attitude" not improved by some bad news she'd had to share with them. Not terrible news, just one more thing they didn't want to hear.
Me: "Thanks, I'll be with them in just a minute. I just need to ....."
NP: "I can do that. What else do you need me to do so you can go take care of that mom in Nursery A?"
No, not wishful thinking. The nurse practitioner did everything I asked AND gave the medication I'd forgotten to mention, giving me the time I needed to soothe the mom who was about to have to go home weeks before her baby would be ready to join her. She could have stayed and talked to the mom until I got there, but she knew that what the mother needed was to hold her baby -- and that I needed to assess him before he came out of the isolette.
One of the things I like best about the nurse practitioners who work with us is that they have all walked in my shoes and they understand what they can do to make life easier for the nurses and for the families. That and they're willing to actually put out the effort when they have the time.
Wednesday, October 11, 2006
Homeschooling - Current Events
A friend who is the single mom of 4 boys decided to teach them an unforgettable lesson. She had heard that Fred Phelps -- yes, THAT Fred Phelps would be protesting the funeral of Marine Captain Justin Peterson. She took her sons to the funeral. Here's her story.
Today was the funeral for Marine Captain Justin Peterson. I didn’t know Captain Peterson, but I decided to take the boys to his funeral after we learned that Fred Phelps and his band of misfits intended to picket the Peterson funeral. Captain Peterson was killed in Iraq last week, and I thought it would be as good a time as any for the boys to learn that there are people like Captain Peterson in the world and that they owe him an enormous debt of gratitude for fighting to keep our country safe for them. It was also a good time to point out that although I loathe Phelps more than anyone I can think of at the moment, Captain Peterson died to protect the basic freedoms we all take for granted, most of all the right to free speech, even for people like Phelps. However, we were going to show support for the Peterson family . I don’t agree that Phelps should be using the funerals of servicemen and women as a public forum, so at 6 a.m. we were up and having breakfast so that we could be on the road by 8. More
Thursday, October 05, 2006
"I want you to do everything....."
"I want you to do everything....."
It's something you hear quite often in the NICU in regard to babies who have little or no chance of long-term survival. In my nearly 30 years as a NICU nurse, I can remember many such babies - and the famlies who loved them. They must make decisions that none of us would want to make.
Baby Martin (not his real name) was a full term baby who, for reasons never known to us, had seizures beginning on day 1 of life. It's been a long time, but I don't recall any birth trauma in his history. His NICU stay was relatively unremarkable and he was eventually discharged on anticonvulsant medication only to return to the ER a few weeks later. He'd had a seizure -- one much more severe than any we'd seen in the NICU.
He was admitted to the Pediatric ICU and his seizures, became more and more difficult to control. One study after another left his doctors puzzled and his condition deteriorated. Periodically, he would have a seizure so severe that his heart would stop. Each resuscitation was successful, but eventually it became obvious that the seizures could not be controlled and that his brain had been irreparably damaged. The doctors approached his mother to ask about simply letting him go if it happened again.
"No," she said. "If it is time for him to go, God will take him regardless of your efforts."
Puzzled and frustrated, they continued their aggressive interventions - including periodically resuscitating him.
One night I was floated from the NICU to the PICU. He wasn't my patient, I knew the pediatric resident from his NICU rotations. He had developed a relationship with the mother and was the one who spent the most time speaking to her about the baby's condition and prognosis. He knew I had also gotten to know the mom when the baby was in the NICU and asked for my thoughts on the situation.
"Does she understand what you're doing when you resuscitate the baby?" I asked.
He assured me that he had explained it fully to the mom and believed that she understood. He must have thought more about it, though. He told me later that he had asked the mom to stay for what proved to be the baby's final resuscitation. He had thought she understood. So did she. When she witnessed the actual resuscitation, she decided that this was more than she should be asking of the baby - and the staff. She decided that she would rather simply hold him and let him go.
Parents make choices based on what they believe is best for their child and we try to respect those choices. They seldom truly understand what they are asking when they ask us to "do everything." They must make some of the most difficult choices of their lives based on advice from people they may not know well at all and with limited understanding of the information we try to give them.
It's something you hear quite often in the NICU in regard to babies who have little or no chance of long-term survival. In my nearly 30 years as a NICU nurse, I can remember many such babies - and the famlies who loved them. They must make decisions that none of us would want to make.
Baby Martin (not his real name) was a full term baby who, for reasons never known to us, had seizures beginning on day 1 of life. It's been a long time, but I don't recall any birth trauma in his history. His NICU stay was relatively unremarkable and he was eventually discharged on anticonvulsant medication only to return to the ER a few weeks later. He'd had a seizure -- one much more severe than any we'd seen in the NICU.
He was admitted to the Pediatric ICU and his seizures, became more and more difficult to control. One study after another left his doctors puzzled and his condition deteriorated. Periodically, he would have a seizure so severe that his heart would stop. Each resuscitation was successful, but eventually it became obvious that the seizures could not be controlled and that his brain had been irreparably damaged. The doctors approached his mother to ask about simply letting him go if it happened again.
"No," she said. "If it is time for him to go, God will take him regardless of your efforts."
Puzzled and frustrated, they continued their aggressive interventions - including periodically resuscitating him.
One night I was floated from the NICU to the PICU. He wasn't my patient, I knew the pediatric resident from his NICU rotations. He had developed a relationship with the mother and was the one who spent the most time speaking to her about the baby's condition and prognosis. He knew I had also gotten to know the mom when the baby was in the NICU and asked for my thoughts on the situation.
"Does she understand what you're doing when you resuscitate the baby?" I asked.
He assured me that he had explained it fully to the mom and believed that she understood. He must have thought more about it, though. He told me later that he had asked the mom to stay for what proved to be the baby's final resuscitation. He had thought she understood. So did she. When she witnessed the actual resuscitation, she decided that this was more than she should be asking of the baby - and the staff. She decided that she would rather simply hold him and let him go.
Parents make choices based on what they believe is best for their child and we try to respect those choices. They seldom truly understand what they are asking when they ask us to "do everything." They must make some of the most difficult choices of their lives based on advice from people they may not know well at all and with limited understanding of the information we try to give them.
Tuesday, October 03, 2006
"We've hardly done any schoolwork today at all!"
Words from my youngest after we'd spent 2+ hours researching Aristarchus, ancient Greek astronomer and mathematician who is the first known to have theorized a heliocentric universe. Then we followed "rabbit trails" that lead us through an investigation of why we haven't managed to send any space ships to other galaxies yet. Short answer to that last question: We did. They aren't there yet. We learned that the Voyager I and II missions just reached the limits of our heliosphere within the last year (Scroll down to see the Voyager links)
We changed curriculum providers this year. The current one is called TRISMS. Time Related Integrated Studies for Mastering Skills. We're using the middle school version titled History Makers It's a survey of world history following biographies and achievements of scientists and explorers. We'll be reading some historical fiction and many biographies. When available, we may even look at some primary sources and we'll be checking internet resources -- if only so my son can figure out why those aren't always reliable.
#1 skill on the agenda -- research. Finding answers to your questions and figuring out whether or not they're valid. We start with a list of explorers and scientists, but are encouraged to stray outside the written boundaries of the program. I understand that the high school levels of the program encourage students to find one focus -- music, art, food, medicine, etc. and follow it through the ages as they make their way through the program.
The program incorporates vocabulary, grammar, history, science, geography and art -- most of the middle school agenda. We can incorporate the music of the cultures as well if we do a little additional research. We won't do much of that this year as keeping up with his piano lessons keeps us pretty busy musically.
In addition, we're learning Latin using the Prima Latina program from Memoria Press. It's designed to be used with kids as young as Kindergarten, but works well as an intro for a 6th grader too since it incorporates the Latin Prayers he wanted to learn. His goal is to eventually be able to converse in Latin with the Legionary priests and brothers who assist with the Conquest Club he sometimes participates in.
We changed curriculum providers this year. The current one is called TRISMS. Time Related Integrated Studies for Mastering Skills. We're using the middle school version titled History Makers It's a survey of world history following biographies and achievements of scientists and explorers. We'll be reading some historical fiction and many biographies. When available, we may even look at some primary sources and we'll be checking internet resources -- if only so my son can figure out why those aren't always reliable.
#1 skill on the agenda -- research. Finding answers to your questions and figuring out whether or not they're valid. We start with a list of explorers and scientists, but are encouraged to stray outside the written boundaries of the program. I understand that the high school levels of the program encourage students to find one focus -- music, art, food, medicine, etc. and follow it through the ages as they make their way through the program.
The program incorporates vocabulary, grammar, history, science, geography and art -- most of the middle school agenda. We can incorporate the music of the cultures as well if we do a little additional research. We won't do much of that this year as keeping up with his piano lessons keeps us pretty busy musically.
In addition, we're learning Latin using the Prima Latina program from Memoria Press. It's designed to be used with kids as young as Kindergarten, but works well as an intro for a 6th grader too since it incorporates the Latin Prayers he wanted to learn. His goal is to eventually be able to converse in Latin with the Legionary priests and brothers who assist with the Conquest Club he sometimes participates in.
Sunday, September 10, 2006
Pediatric Grand Rounds!
Pediatric Grand Rounds is up. It's hosted by Shinga at BreathSpa for Kids
Shinga has done a great job and there are many interesting posts to read. Go check it out!
More Pediatric Grand Rounds in 2 weeks at PediatricInfo.com
Shinga has done a great job and there are many interesting posts to read. Go check it out!
More Pediatric Grand Rounds in 2 weeks at PediatricInfo.com
Sunday, August 27, 2006
Near Miss
Never assume ANYTHING. That's one of the first things you learn in nursing school.
NEVER assume anything. Don't forget that.
Never ASSUME anything. As the nursing instructors say, when you assume you make an ASS out of U and ME.
If you're reading this, you've doubtless heard that before, so I won't repeat it again, but don't forget it.
I was under the (mistaken) impression that our pharmacy had a computerized system for calculating neonatal doses. Type in the weight and the dose, double check it, it goes on the Medication Administration Record (MAR) and is printed on the label for every dose. I double-check the pharmacist's math for doses when I'm giving medications, and I had never found an error before. Not one since they started unit dose quite a few years ago. That changed last night.
The order read Gentamicin 6 mg/kg/dose = 7 mg every 24 hours. It was a small increase in the dose (less than 0.5mg), so the nurse practitioner who wrote the order said that no levels would be needed to monitor the change in dose since the baby had grown that much in the 2 weeks since we'd started antibiotic therapy.
What was printed on the MAR and on the dose of Gentamicin in the refrigerator was Gentamicin 7 mg = 1.66 ml. Concentration = 6 mg/ml. I wasn't giving the dose. It was scheduled for 5 pm the next afternoon, but the pharmacist had made a second, fortuitous error. When the new dose was entered, the time was changed on the MAR to 9am. I was checking the MAR and missed the dosing error on my first pass. I just sent a message to the pharmacy asking them to correct the time and reprinted the MAR to reconcile it again.
I looked at the IV flow sheet for the first new 5pm Gentamicin dose. Not 1.6 or 1.7 ml, but 1.1. It didn't match. I don't know whose guardian angel was bugging me about that. My son says they were having a conference, because something kept me going back to the MAR and the flow sheet until I recognized the error.
1.66 ml = 9.96 mg of Gentamicin. Not the 7 mg that was ordered. That would have been nearly 1.5 times the ordered dose. No levels ordered, because the new dose that was ordered was only slightly higher than the previous dose.
You probably thought I wasn't going to repeat this, but NEVER ASSUME ANYTHING. Always double-check the math and the orders no matter who wrote and/or filled them.
NEVER assume anything. Don't forget that.
Never ASSUME anything. As the nursing instructors say, when you assume you make an ASS out of U and ME.
If you're reading this, you've doubtless heard that before, so I won't repeat it again, but don't forget it.
I was under the (mistaken) impression that our pharmacy had a computerized system for calculating neonatal doses. Type in the weight and the dose, double check it, it goes on the Medication Administration Record (MAR) and is printed on the label for every dose. I double-check the pharmacist's math for doses when I'm giving medications, and I had never found an error before. Not one since they started unit dose quite a few years ago. That changed last night.
The order read Gentamicin 6 mg/kg/dose = 7 mg every 24 hours. It was a small increase in the dose (less than 0.5mg), so the nurse practitioner who wrote the order said that no levels would be needed to monitor the change in dose since the baby had grown that much in the 2 weeks since we'd started antibiotic therapy.
What was printed on the MAR and on the dose of Gentamicin in the refrigerator was Gentamicin 7 mg = 1.66 ml. Concentration = 6 mg/ml. I wasn't giving the dose. It was scheduled for 5 pm the next afternoon, but the pharmacist had made a second, fortuitous error. When the new dose was entered, the time was changed on the MAR to 9am. I was checking the MAR and missed the dosing error on my first pass. I just sent a message to the pharmacy asking them to correct the time and reprinted the MAR to reconcile it again.
I looked at the IV flow sheet for the first new 5pm Gentamicin dose. Not 1.6 or 1.7 ml, but 1.1. It didn't match. I don't know whose guardian angel was bugging me about that. My son says they were having a conference, because something kept me going back to the MAR and the flow sheet until I recognized the error.
1.66 ml = 9.96 mg of Gentamicin. Not the 7 mg that was ordered. That would have been nearly 1.5 times the ordered dose. No levels ordered, because the new dose that was ordered was only slightly higher than the previous dose.
You probably thought I wasn't going to repeat this, but NEVER ASSUME ANYTHING. Always double-check the math and the orders no matter who wrote and/or filled them.
Thursday, August 24, 2006
Ritalin, it's what's for breakfast sometimes
I read Aggravated DocSurg's post on Black Box warnings for ADHD medications
I followed his link to Flea's April post on the subject of medicating chilren with ADHD
Then I read the comments which is what started this rant. Just so you know.
The fact that kids with ADHD respond well to firm discipline does not mean that their parents are not providing precisely that. ADHD kids need structure and organization. They need the OTHER children in their environment to be disciplined. Of course they respond to discipline. Usually.
Sometimes they need medication too. I don't believe medication should be the first option, and if I got a "do over" there are definitely some things I'd change.
My 25 year old was diagnosed with ADHD at the age of 3. Kid couldn't sit still to listen to a short book. There were other issues. For example, much of the time he couldn't hear well. Instead of medicating him at age 3, we opted to have his tonsils and adenoids removed (he was having sleep apnea too).
His activity level decreased, in my estimation, by about 50% --- but he still had ADHD. He was still MUCH more active than any other kid in the neighborhood -- all boys. It was an interesting neighborhood.
We enrolled him in an early childhood intervention program. He learned to sit still and listen to stories. I'd love to know how his teacher managed that, when I couldn't one-on-one.
After pre-K, we enrolled him in our parish school where the teacher's discipline style meshed well with mine. She was gentle with the kids, but VERY firm. He thrived. OK, his speech therapist begged me to medicate him, but he did very well in kindergarten.
In first grade, his teacher let him sit UNDER his desk to do his work. He did fine in the classroom, but he was failing lunch. He was totally overwhelmed by the chaos in the cafeteria. He couldn't eat. Since he was already at the 3rd percentile for weight when he started school, this was a very bad thing.
At this point, I approached his pediatrician about evaluating him again for ADHD. The concensus was that he did have ADHD and might benefit from medication. I cried, but decided to try it. On day 1 of medication, his penmanship improved remarkably. So did his spelling. He was already excelling at other subjects, so not much else changed except that sometimes he sat in his chair instead of under his desk. And he gained weight.
Over the course of the next 5 years, we gradually increased his ritalin dose and added tofranil. We took him to a psychologist to be re-evaluated. Diagnosis: ADHD. Pure ADHD, no depression, no OCD, no PDD. Just ADHD.
One of his teachers suggested martial arts, so I started interviewing instructors. The first 2 said they thought they might be able to help him. The third had letters from parents detailing how martial arts in that particular school had helped their children. We signed up. Within a year, he was off tofranil and his ritalin dose had been decreased from 80 mg/day to 40.
If I got a do-over, he'd have started martial arts at about age 3. Maybe 4. It's hard to find a school that takes 3 year olds and does a good job of it.
Then I found homeschoolers on the internet. I had considered homeschooling when I didn't know that anyone else was doing it. The more I read about families dealing with ADHD, the more inclined I was to try it. I presented this option to my son - and he decided he would like to try it.
Homeschooling isn't a panacea. It does allow you to teach academics during the good times and do something else on the bad days. We got him down to 10 mg of ritalin in the morning (for math).
He wanted to go back to school for high school - and had to go back on ritalin 2x/day to do that. He also eventually earned his second degree black belt in Karate and managed to earn an associate degree as well -- with no ritalin for his college classes. He works. He pays his bills - on time. He does his own laundry. He's a fully functioning adult - with no medications. He still studies martial arts.
If I got a do-over, I'd have tried homeschooling him in first grade. It might not have been the answer, but knowing EVERYTHING I know now, I'd have tried it. There was a lot I didn't know then. I don't regret what we did, but I'd have done it differently.
For a while, he talked about having been "turned into a zombie" by medication. I wondered whose life he was remembering, because his memories certainly didn't match mine. We showed him a few home videos and reminded him that from about age 12, he was very much involved in decisions about dosage. He's dropped that line, but I still wonder where it came from.
I'm glad that there are stronger warnings on the stimulant drugs which are the mainstay of medical ADHD therapy. Physicians and parents need to consider all their other options and make as many changes in the environment as possible before resorting to medication. But they shouldn't eliminate medication as an option if it proves necessary.
I followed his link to Flea's April post on the subject of medicating chilren with ADHD
Then I read the comments which is what started this rant. Just so you know.
The fact that kids with ADHD respond well to firm discipline does not mean that their parents are not providing precisely that. ADHD kids need structure and organization. They need the OTHER children in their environment to be disciplined. Of course they respond to discipline. Usually.
Sometimes they need medication too. I don't believe medication should be the first option, and if I got a "do over" there are definitely some things I'd change.
My 25 year old was diagnosed with ADHD at the age of 3. Kid couldn't sit still to listen to a short book. There were other issues. For example, much of the time he couldn't hear well. Instead of medicating him at age 3, we opted to have his tonsils and adenoids removed (he was having sleep apnea too).
His activity level decreased, in my estimation, by about 50% --- but he still had ADHD. He was still MUCH more active than any other kid in the neighborhood -- all boys. It was an interesting neighborhood.
We enrolled him in an early childhood intervention program. He learned to sit still and listen to stories. I'd love to know how his teacher managed that, when I couldn't one-on-one.
After pre-K, we enrolled him in our parish school where the teacher's discipline style meshed well with mine. She was gentle with the kids, but VERY firm. He thrived. OK, his speech therapist begged me to medicate him, but he did very well in kindergarten.
In first grade, his teacher let him sit UNDER his desk to do his work. He did fine in the classroom, but he was failing lunch. He was totally overwhelmed by the chaos in the cafeteria. He couldn't eat. Since he was already at the 3rd percentile for weight when he started school, this was a very bad thing.
At this point, I approached his pediatrician about evaluating him again for ADHD. The concensus was that he did have ADHD and might benefit from medication. I cried, but decided to try it. On day 1 of medication, his penmanship improved remarkably. So did his spelling. He was already excelling at other subjects, so not much else changed except that sometimes he sat in his chair instead of under his desk. And he gained weight.
Over the course of the next 5 years, we gradually increased his ritalin dose and added tofranil. We took him to a psychologist to be re-evaluated. Diagnosis: ADHD. Pure ADHD, no depression, no OCD, no PDD. Just ADHD.
One of his teachers suggested martial arts, so I started interviewing instructors. The first 2 said they thought they might be able to help him. The third had letters from parents detailing how martial arts in that particular school had helped their children. We signed up. Within a year, he was off tofranil and his ritalin dose had been decreased from 80 mg/day to 40.
If I got a do-over, he'd have started martial arts at about age 3. Maybe 4. It's hard to find a school that takes 3 year olds and does a good job of it.
Then I found homeschoolers on the internet. I had considered homeschooling when I didn't know that anyone else was doing it. The more I read about families dealing with ADHD, the more inclined I was to try it. I presented this option to my son - and he decided he would like to try it.
Homeschooling isn't a panacea. It does allow you to teach academics during the good times and do something else on the bad days. We got him down to 10 mg of ritalin in the morning (for math).
He wanted to go back to school for high school - and had to go back on ritalin 2x/day to do that. He also eventually earned his second degree black belt in Karate and managed to earn an associate degree as well -- with no ritalin for his college classes. He works. He pays his bills - on time. He does his own laundry. He's a fully functioning adult - with no medications. He still studies martial arts.
If I got a do-over, I'd have tried homeschooling him in first grade. It might not have been the answer, but knowing EVERYTHING I know now, I'd have tried it. There was a lot I didn't know then. I don't regret what we did, but I'd have done it differently.
For a while, he talked about having been "turned into a zombie" by medication. I wondered whose life he was remembering, because his memories certainly didn't match mine. We showed him a few home videos and reminded him that from about age 12, he was very much involved in decisions about dosage. He's dropped that line, but I still wonder where it came from.
I'm glad that there are stronger warnings on the stimulant drugs which are the mainstay of medical ADHD therapy. Physicians and parents need to consider all their other options and make as many changes in the environment as possible before resorting to medication. But they shouldn't eliminate medication as an option if it proves necessary.
Wednesday, August 09, 2006
Deal with it
"Deal with it." Those were his exact words.
Not exactly the advice I wanted from the orthopedic surgeon I consulted this week. I was hoping for more of a miracle cure.
MRI shows "possible fraying" of the medial meniscus and a ganglion cyst - also medial. Not the source of the lateral knee pain I've been having for the last 4 months. The rest of the news was worse. Turns out the arthritis that's been a relatively minor problem for more years than I care to admit kicked into a somewhat higher gear and by the end of a 12 hour shift the knee hurts like hell. The fact that we've been running an average census of 1.5 to 2 times our typical census might have something to do with that. Especially since we don't often have 1.5 to 2 times as many nurses.
At least he didn't start the conversation with "You're too young to be thinking about total knee replacement. " That's what I heard from the orthopedist I consulted last fall when I smashed the other knee on a rock. I was afraid to go back to someone who brought up the subject of surgery on a body part that wasn't (at the time) causing any significant problems so I found a different orthopedic surgeon.
This one could use a little work on his delivery, but I prefer his attitude toward invasive procedures. He explained why there I wouldn't benefit from cortisone shots or surgery to smooth things out (short term solutions to long-term problems, he says) and recommended a better knee brace and some physical therapy. We might consider those options later if things get worse, but not as an initial approach.
On the positive side, I left the physical therapy facility after the first session feeling better than I have since April. That lasted about 6 hours, but I get to go back tomorrow. No miracles, but I'm beginning to think maybe there's hope.
Not exactly the advice I wanted from the orthopedic surgeon I consulted this week. I was hoping for more of a miracle cure.
MRI shows "possible fraying" of the medial meniscus and a ganglion cyst - also medial. Not the source of the lateral knee pain I've been having for the last 4 months. The rest of the news was worse. Turns out the arthritis that's been a relatively minor problem for more years than I care to admit kicked into a somewhat higher gear and by the end of a 12 hour shift the knee hurts like hell. The fact that we've been running an average census of 1.5 to 2 times our typical census might have something to do with that. Especially since we don't often have 1.5 to 2 times as many nurses.
At least he didn't start the conversation with "You're too young to be thinking about total knee replacement. " That's what I heard from the orthopedist I consulted last fall when I smashed the other knee on a rock. I was afraid to go back to someone who brought up the subject of surgery on a body part that wasn't (at the time) causing any significant problems so I found a different orthopedic surgeon.
This one could use a little work on his delivery, but I prefer his attitude toward invasive procedures. He explained why there I wouldn't benefit from cortisone shots or surgery to smooth things out (short term solutions to long-term problems, he says) and recommended a better knee brace and some physical therapy. We might consider those options later if things get worse, but not as an initial approach.
On the positive side, I left the physical therapy facility after the first session feeling better than I have since April. That lasted about 6 hours, but I get to go back tomorrow. No miracles, but I'm beginning to think maybe there's hope.
Sunday, July 16, 2006
Pediatric Grand Rounds is up at Pediatricsinfo.com
Lots of interesting reading in this week's Pediatric Grand Rounds. Go check it out at Dr. Sethi's PediatricsInfo.com
Dr. Flea will be hosting the next Pediatric Grand Rounds. Send him your nomination.
Dr. Flea will be hosting the next Pediatric Grand Rounds. Send him your nomination.
Thursday, July 13, 2006
Some people will do anything to get breastmilk.
That was the comment from one of our attending neonatologists when he spotted me feeding breastmilk to a baby whose mom had opted not to breastfeed. He's right. If there are no contraindications, I'll do anything within reason to persuade the moms of my babies to provide at least a little breastmilk. The gambit that had him shaking his head was rather more unusual than most.
My biggest ploy is promising the moms that they don't have to keep it up if they don't like it. I do as much educating as possible, but I won't put on the guilt thumbscrews. NICU moms feel guilty enough that their baby was born prematurely, or sick, or with congenital anomalies. Very few of them should feel guilty, and the moms who should generally don't.
We've known for years that breastmilk is the best food for nearly all of our babies. There are a few contraindications: certain medications, many illegal drugs, HIV, and some rare metabolic disorders. Aside from those cases, we know that breastmilk has many advantages. There is evidence that breastmilk helps to promote brain development. It helps to decrease the risk of infection. It has other benefits as well. The neonatologist at Tales from the Womb presents some of the ways in which breastmilk helps to prevent a devastating disease called Necrotizing Enterocolitis. In very simple terms, part of the intestine dies. Often the diseased part can be removed and the baby will survive, but sometimes they end up with short gut syndrome (sometimes called short bowel syndrome). This can make absorbing enough nutrients very difficult. Sometimes they die.
Back to my story. It was a simple one. The mom had opted not to breastfeed. She didn't explain why, but she simply was not interested. She didn't want to hear any more about the benefits to the baby and she didn't want to discuss it -- until the baby was about 3 days old. Her breasts began to fill with milk, even though she wasn't pumping and she wasn't nursing her baby (he was too small). She was in extreme pain and came to me for advice on what to do about the engorgement. I gave her some basic instructions in managing engorgement, then added, "If you like, I can suggest something that will relieve your pain right now."
I explained that it would prolong lactation and she might need to repeat the treatment, but that it would provide immediate relief. I had her interest immediately. She didn't care that she'd continue to produce milk a little longer my way and she didn't care that she would require several repeat treatments. The equipment was just down the hall and she could use it whenever she came to visit her baby.
The magic treatment? A breast pump. I got her a pump kit and showed her how to use the pump. I explained that if she wanted to eventually be able to stop pumping, she needed to pump enough to be comfortable, but not enough to stimulate increased production.
It took her nearly 2 weeks to stop lactating. She pumped twice a day at first and less frequently as her supply declined, but we did have colostrum to feed her baby and, since he was small, several breastmilk feedings each day for a time.
Honestly I'd hoped she would find that it wasn't too burdensome to continue, but sometimes you've got to take what you can get.
My biggest ploy is promising the moms that they don't have to keep it up if they don't like it. I do as much educating as possible, but I won't put on the guilt thumbscrews. NICU moms feel guilty enough that their baby was born prematurely, or sick, or with congenital anomalies. Very few of them should feel guilty, and the moms who should generally don't.
We've known for years that breastmilk is the best food for nearly all of our babies. There are a few contraindications: certain medications, many illegal drugs, HIV, and some rare metabolic disorders. Aside from those cases, we know that breastmilk has many advantages. There is evidence that breastmilk helps to promote brain development. It helps to decrease the risk of infection. It has other benefits as well. The neonatologist at Tales from the Womb presents some of the ways in which breastmilk helps to prevent a devastating disease called Necrotizing Enterocolitis. In very simple terms, part of the intestine dies. Often the diseased part can be removed and the baby will survive, but sometimes they end up with short gut syndrome (sometimes called short bowel syndrome). This can make absorbing enough nutrients very difficult. Sometimes they die.
Back to my story. It was a simple one. The mom had opted not to breastfeed. She didn't explain why, but she simply was not interested. She didn't want to hear any more about the benefits to the baby and she didn't want to discuss it -- until the baby was about 3 days old. Her breasts began to fill with milk, even though she wasn't pumping and she wasn't nursing her baby (he was too small). She was in extreme pain and came to me for advice on what to do about the engorgement. I gave her some basic instructions in managing engorgement, then added, "If you like, I can suggest something that will relieve your pain right now."
I explained that it would prolong lactation and she might need to repeat the treatment, but that it would provide immediate relief. I had her interest immediately. She didn't care that she'd continue to produce milk a little longer my way and she didn't care that she would require several repeat treatments. The equipment was just down the hall and she could use it whenever she came to visit her baby.
The magic treatment? A breast pump. I got her a pump kit and showed her how to use the pump. I explained that if she wanted to eventually be able to stop pumping, she needed to pump enough to be comfortable, but not enough to stimulate increased production.
It took her nearly 2 weeks to stop lactating. She pumped twice a day at first and less frequently as her supply declined, but we did have colostrum to feed her baby and, since he was small, several breastmilk feedings each day for a time.
Honestly I'd hoped she would find that it wasn't too burdensome to continue, but sometimes you've got to take what you can get.
Sunday, July 09, 2006
Spiritual Warfare
Fr. Leo Patalinghug, pictured above, spoke on the subject of spiritual warfare at the Catholic Family Expo this weekend. As you can probably guess from the photo, he's a big hit with the younger crowd -- and the adults. He uses his martial arts expertise to draw a crowd and to make a point - that in the battle of good versus evil, we have supernatural assistance. God's grace. As with martial arts, practice in the weapons of spiritual warfare strengthens us for the fight. The presentation will eventually be available as a CD on the CFE web site. Fr. Leo started off by reminding us of last year's talk and the efficacy of PB&J as weapons in spiritual warfare.
P - Patience. Wait for the Lord -- He will come. Some of the trials we face should help us to develop patience -- think about that the next time you're caught in traffic.
B- Balance. How long do you pray every day? How much time to you spend watching television? Blogging?
J- Joy. He quotes Mother Therese -- Joy = Jesus, Others, You in that order.
After that review, he moved on to this year's addition to the arsenal:
S-O-S:
S - Serious. We must be serious about our faith. It's hard to be serious about things we don't understand, so it's important to study our faith.
O - Oremus - Latin for "Let Us Pray" - us, not me. We, as Christians, NEED to pray together. Praying on your own is necessary, but not sufficient.
S - Sacraments - as Catholic Christians, our sacramental life helps to provide God's grace to strengthen us in the daily fight against evil.
He then uses his martial arts expertise as an object lesson to explain how God's grace will help us to get through anything if we take our faith seriously.
He finishes by explaining the vestments priests wear and the prayers they pray as they prepare to say "oremus" Then picks up his lightsaber (The light will save you) and blesses the audience.
Fr. Leo says he's only invited because he can breakdance and break boards. Those may help to draw a crowd, but it is his message that brings them back year after year. I was curious about the impact of his performance on my 10 year old (in the orange shirt on the floor) and was delighted at the depth of understanding.
I expect Fr. Leo will be invited back to next year's Catholic Family Expo.
Sunday, June 18, 2006
Sunday, June 11, 2006
Evidence based practice
AKA Life in the slow lane, part III
I filled my tank this morning and did the math. 33.27 mpg as compared to my more typical 29-30 mpg. I didn't even remember to keep it at 55 all week - just most of my highway miles. That works out to a 10% discount on gas, or based on the number of miles I drive, about $150/year if I can keep this up -- and if the week was truly typical of my driving pattern.
The benefit appears easy to document, it seems to outweigh the risks of changing my behavior. Keeping it up, that's the issue. I've been driving one way so long that changing my habits more or less permanently will be quite a challenge. That's because the risk of NOT changing my behavior isn't particularly devastating. Not even at $3/gallon. Then there's the time factor. Those 2 or 3 minutes I save on a short trip sometimes seem worth the expense in lower gas mileage.
There are questions about my "study": Was the study sample large enough? Was it consistent with the "control group" in terms of the type of miles driven? What sort of bias was introduced by the sampling technique? The studies we use to make decisions about evidence-based practice in healthcare can have similar concerns.
Sometimes the evidence for change in nursing or medical practice is impressive. Sometimes it isn't. Sometimes it is simply overwhelming. One example that comes to mind is the observation, 24 years ago, that led to the elimination of virtually all benzyl alcohol in products used in neonates.
Some very observant neonatologists noted that patients who received relatively larger amounts of flush solution containing benzyl alcohol as a preservative developed something they called "gasping syndrome". Those who received smaller amounts or none, did not. It was based on a VERY small patient population (16 infants), but the risk of behavior change (elimination of benzyl alcohol) was minimal, and the potential benefit in the elimination of benzyl alcohol toxicity was huge, so they reported to the FDA who quite promptly issued a warning.
As a NICU nurse who was practicing at the time this was published, I have no doubt at all of the validity of the observation. We stopped using benzyl alcohol in our NICU the day our head neonatologist got the word. It was very clear to us that we too stopped seeing benzyl alcohol toxicity in our patients. The babies who were smallest and sickest tended to have arterial lines which we used to draw arterial blood gases - and flushed with solution containing benzyl alcohol. The babies got progressively more and more acidotic and developed clotting problems. Once we eliminated benzyl alcohol, this pattern simply disappeared. I don't know how quickly other NICUs made the change, but evidence of the advantages of discontinuing benzyl alcohol accumulated very rapidly and preservative-free flush solutions became standard practice.
Most evidence-based practice changes require larger groups and double-blind studies. Some changes, like the elimination of benzyl alcohol, merely require careful observation. When the benefits of change overwhelmingly outweigh the risks, it is easier to decide to make a change and to stick to it. When the risks are greater or the benefits less clear, the evidence simply must be better.
I filled my tank this morning and did the math. 33.27 mpg as compared to my more typical 29-30 mpg. I didn't even remember to keep it at 55 all week - just most of my highway miles. That works out to a 10% discount on gas, or based on the number of miles I drive, about $150/year if I can keep this up -- and if the week was truly typical of my driving pattern.
The benefit appears easy to document, it seems to outweigh the risks of changing my behavior. Keeping it up, that's the issue. I've been driving one way so long that changing my habits more or less permanently will be quite a challenge. That's because the risk of NOT changing my behavior isn't particularly devastating. Not even at $3/gallon. Then there's the time factor. Those 2 or 3 minutes I save on a short trip sometimes seem worth the expense in lower gas mileage.
There are questions about my "study": Was the study sample large enough? Was it consistent with the "control group" in terms of the type of miles driven? What sort of bias was introduced by the sampling technique? The studies we use to make decisions about evidence-based practice in healthcare can have similar concerns.
Sometimes the evidence for change in nursing or medical practice is impressive. Sometimes it isn't. Sometimes it is simply overwhelming. One example that comes to mind is the observation, 24 years ago, that led to the elimination of virtually all benzyl alcohol in products used in neonates.
Some very observant neonatologists noted that patients who received relatively larger amounts of flush solution containing benzyl alcohol as a preservative developed something they called "gasping syndrome". Those who received smaller amounts or none, did not. It was based on a VERY small patient population (16 infants), but the risk of behavior change (elimination of benzyl alcohol) was minimal, and the potential benefit in the elimination of benzyl alcohol toxicity was huge, so they reported to the FDA who quite promptly issued a warning.
As a NICU nurse who was practicing at the time this was published, I have no doubt at all of the validity of the observation. We stopped using benzyl alcohol in our NICU the day our head neonatologist got the word. It was very clear to us that we too stopped seeing benzyl alcohol toxicity in our patients. The babies who were smallest and sickest tended to have arterial lines which we used to draw arterial blood gases - and flushed with solution containing benzyl alcohol. The babies got progressively more and more acidotic and developed clotting problems. Once we eliminated benzyl alcohol, this pattern simply disappeared. I don't know how quickly other NICUs made the change, but evidence of the advantages of discontinuing benzyl alcohol accumulated very rapidly and preservative-free flush solutions became standard practice.
Most evidence-based practice changes require larger groups and double-blind studies. Some changes, like the elimination of benzyl alcohol, merely require careful observation. When the benefits of change overwhelmingly outweigh the risks, it is easier to decide to make a change and to stick to it. When the risks are greater or the benefits less clear, the evidence simply must be better.
Wednesday, June 07, 2006
Life in the Slow Lane: Update
I've put about 250 miles on my car since I last filled it up. The tank is still very close to half full. If my gas gauge is accurate, that would mean I'm getting about 10-12% better gas mileage at 55. That would definitely be worth keeping up with gas prices very close to $3/gallon.
Nobody has run me off the road yet, but my son wonders why people keep giving us dirty looks as they flash past.
Nobody has run me off the road yet, but my son wonders why people keep giving us dirty looks as they flash past.
Sunday, June 04, 2006
Life in the Slow Lane
I read an editorial recently suggesting that Americans really aren't paying enough for their gas yet. This was based on the average speeds on our highways. "They" keep telling us that driving 10 mph over the speed limit is like paying an additional $.20/gallon for gas.
I decided to find out. I've been trying REALLY hard to drive 55 (or 65 if that's the speed limit). More typical for me is 10-12 mph over the speed limit on the highway - at least half my miles. I drive a 5-speed Honda Accord that gets about 30mpg on the average when I drive my usual pattern in combined city/highway miles. It got 35mpg at 70-75mph all highway miles last fall on an extended road trip.
I'll keep you posted - if someone doesn't run me off the road in the mean time. I can tell you that the folks around me aren't saving any gas by following my example. More typical is to have someone pull up on my bumper IN THE SLOW LANE and flash their lights at me. Then they get disgusted and fly past me accelerating very rapidly.
I decided to find out. I've been trying REALLY hard to drive 55 (or 65 if that's the speed limit). More typical for me is 10-12 mph over the speed limit on the highway - at least half my miles. I drive a 5-speed Honda Accord that gets about 30mpg on the average when I drive my usual pattern in combined city/highway miles. It got 35mpg at 70-75mph all highway miles last fall on an extended road trip.
I'll keep you posted - if someone doesn't run me off the road in the mean time. I can tell you that the folks around me aren't saving any gas by following my example. More typical is to have someone pull up on my bumper IN THE SLOW LANE and flash their lights at me. Then they get disgusted and fly past me accelerating very rapidly.
Tuesday, May 30, 2006
Frequent Flyer
Last time I was in the ER with one of my kids I told them I wanted frequent flyer miles. They laughed. They thought I was kidding.
5 times in the last 10 months I've spent my evening in the local ER. Most were good experiences, as such things go. I won't be upset if I don't get to visit them again any time soon, though.
One recent visit resulted from an unexpected reaction to SOMETHING UNKNOWN by my middle son. He'd had a cold, but seemed to be recovering. He had a coughing spell and suddenly was just not moving air well at all. He was moving just enough air to wheeze and to manage about a 400 on my peak flow meter. Not too good for an athletic, non-smoking, 6'tall, 20-something male. More typical for him is the normal range of 650+. Yes, he's played with peak flow meters before, so he knows.
Since he'd just returned from dinner at a local restaurant, I asked about any new or unusual foods - just chicken and rice, not likely culprits. I seriously considered using my epi-pen and calling 911, but he threatened violence if I tried. I wasn't sure he was kidding, so I talked him into taking 50mg of liquid benadryl and off to the ER we went.
Sudden onset respiratory distress gets you triaged pronto and even a "breathing treatment", but not much more. The triage nurse and the RT were happy with an Oxygen saturation of 95% post treatment, even though it had been 98% pre-treatment. "See, he's not wheezing any more," they both said.
"You have to move air to wheeze," I pointed out - to no avail, so off to the waiting room we went.
A very long half hour later we were escorted to a room. My son introduced his nurse as "one of the good ones." The (new) respiratory therapist was appropriately concerned by the decline in O2 saturation, the respiratory rate of 30, and the lack of response to the initial treatment. After a brief consultation with the ER doc, he returned with a different type of nebulizer and spent 20 minutes explaining why the first treatment hadn't worked and how my son could alter his breathing to make this one more effective. One more treatment and we were ready to leave, prescriptions in hand.
One of the RT's I work with in the NICU at a different hospital explained that not many hospitals in our area use the breath-triggered nebulizer that was so effective for my son. They're more expensive. I don't know how much more expensive, but I'm fairly certain that without that nebulizer, the next step would have been IV steriods and possibly an admission. That makes me think having them around as a back-up would make for possible significant cost savings.
5 times in the last 10 months I've spent my evening in the local ER. Most were good experiences, as such things go. I won't be upset if I don't get to visit them again any time soon, though.
One recent visit resulted from an unexpected reaction to SOMETHING UNKNOWN by my middle son. He'd had a cold, but seemed to be recovering. He had a coughing spell and suddenly was just not moving air well at all. He was moving just enough air to wheeze and to manage about a 400 on my peak flow meter. Not too good for an athletic, non-smoking, 6'tall, 20-something male. More typical for him is the normal range of 650+. Yes, he's played with peak flow meters before, so he knows.
Since he'd just returned from dinner at a local restaurant, I asked about any new or unusual foods - just chicken and rice, not likely culprits. I seriously considered using my epi-pen and calling 911, but he threatened violence if I tried. I wasn't sure he was kidding, so I talked him into taking 50mg of liquid benadryl and off to the ER we went.
Sudden onset respiratory distress gets you triaged pronto and even a "breathing treatment", but not much more. The triage nurse and the RT were happy with an Oxygen saturation of 95% post treatment, even though it had been 98% pre-treatment. "See, he's not wheezing any more," they both said.
"You have to move air to wheeze," I pointed out - to no avail, so off to the waiting room we went.
A very long half hour later we were escorted to a room. My son introduced his nurse as "one of the good ones." The (new) respiratory therapist was appropriately concerned by the decline in O2 saturation, the respiratory rate of 30, and the lack of response to the initial treatment. After a brief consultation with the ER doc, he returned with a different type of nebulizer and spent 20 minutes explaining why the first treatment hadn't worked and how my son could alter his breathing to make this one more effective. One more treatment and we were ready to leave, prescriptions in hand.
One of the RT's I work with in the NICU at a different hospital explained that not many hospitals in our area use the breath-triggered nebulizer that was so effective for my son. They're more expensive. I don't know how much more expensive, but I'm fairly certain that without that nebulizer, the next step would have been IV steriods and possibly an admission. That makes me think having them around as a back-up would make for possible significant cost savings.
Thursday, April 20, 2006
MRI and other torture devices
I never thought I had issues with claustrophobia. I've been in some pretty small places for extended periods of time with no adverse effects. They had to wake me after my PET scans (both of them). I was a Cub Scout den leader for a total of 6 years, so it certainly can't be the volume that got to me. I think it was the pitch - one particular pitch, a pitch that even determined Cub Scouts can't quite manage.
Lack of confidence in the tech didn't help either.
"Does this" she said, indicating inch high red letters stating LATEX ALLERGY, "mean that I need to find some different gloves?"
It was all I could do not to say "Well duh!" Instead I said "Maybe I should just get out my Epi-pen now." She got the gloves.
"Ok, lie down on the platform and put your head in the cradle. We'll be putting a helmet on your head."
It's not exactly a helmet, folks. It's more like a cage. With bars. VERY close to your face.
The first scan took 20 minutes.
The first 18 minutes wasn't too bad. I made the mistake of opening my eyes on the way in. Bad idea.
After that, I kept my eyes closed and focused on breathing. In. Out. In. Out. In. Out. Slower. Slower. Don't hold your breath.
It wasn't too bad until the frequency of the sounds changed, along with the vibration around and under me, I experienced about 2 minutes of sheer panic. There was an overwhelming urge to scream. I'd been warned not to lick my lips. The only thing that kept me from screaming was fear that they'd have to repeat the whole thing if I did.
The tech didn't plan to pull me out between the first and second scans. She just wanted me to stick out my arm so she could inject the contrast. We compromised. I didn't move, but she hauled me out so I could open my eyes and look at the ceiling until I stopped hyperventilating. THEN I stuck out my arm and let her inject the contrast.
Other things I wish I'd known: as with many types of contrast, this one caused an odd metallic taste sensation. It passed within a few minutes, but I hadn't expected that and it was disturbing. It also made my tongue feel thick - but only briefly. That's scary when you're deep in a narrow tunnel and can't even talk because talking would mess up the scan.
Oh and the scan was essentially normal. A few "age-related" scattered ischemic areas, but aside from that, nothing to worry about. Back to the ENT for the diagnosis which is.......Meniere's
Could be MUCH worse. This is treated with diuretics (but I don't tolerate the drug of choice) and a low sodium diet. I whined at first, but since I haven't had any episodes of vertigo since I started cutting back on sodium, I've decided I need to give that up.
A friend helped me locate some low-sodium cottage cheese - funny what you miss when you're told you can't have it. Now if I could just find a low-sodium Caesar salad dressing to go with that, I'd be really happy. Recipes appreciated.
Lack of confidence in the tech didn't help either.
"Does this" she said, indicating inch high red letters stating LATEX ALLERGY, "mean that I need to find some different gloves?"
It was all I could do not to say "Well duh!" Instead I said "Maybe I should just get out my Epi-pen now." She got the gloves.
"Ok, lie down on the platform and put your head in the cradle. We'll be putting a helmet on your head."
It's not exactly a helmet, folks. It's more like a cage. With bars. VERY close to your face.
The first scan took 20 minutes.
The first 18 minutes wasn't too bad. I made the mistake of opening my eyes on the way in. Bad idea.
After that, I kept my eyes closed and focused on breathing. In. Out. In. Out. In. Out. Slower. Slower. Don't hold your breath.
It wasn't too bad until the frequency of the sounds changed, along with the vibration around and under me, I experienced about 2 minutes of sheer panic. There was an overwhelming urge to scream. I'd been warned not to lick my lips. The only thing that kept me from screaming was fear that they'd have to repeat the whole thing if I did.
The tech didn't plan to pull me out between the first and second scans. She just wanted me to stick out my arm so she could inject the contrast. We compromised. I didn't move, but she hauled me out so I could open my eyes and look at the ceiling until I stopped hyperventilating. THEN I stuck out my arm and let her inject the contrast.
Other things I wish I'd known: as with many types of contrast, this one caused an odd metallic taste sensation. It passed within a few minutes, but I hadn't expected that and it was disturbing. It also made my tongue feel thick - but only briefly. That's scary when you're deep in a narrow tunnel and can't even talk because talking would mess up the scan.
Oh and the scan was essentially normal. A few "age-related" scattered ischemic areas, but aside from that, nothing to worry about. Back to the ENT for the diagnosis which is.......Meniere's
Could be MUCH worse. This is treated with diuretics (but I don't tolerate the drug of choice) and a low sodium diet. I whined at first, but since I haven't had any episodes of vertigo since I started cutting back on sodium, I've decided I need to give that up.
A friend helped me locate some low-sodium cottage cheese - funny what you miss when you're told you can't have it. Now if I could just find a low-sodium Caesar salad dressing to go with that, I'd be really happy. Recipes appreciated.
Tuesday, April 18, 2006
Grand Rounds
Grand rounds are up at Fat Doctor She's done a terrific job of organizing and all the links work. I'm impressed, but not surprised.
Thursday, April 13, 2006
IV sites
The largest, most stable veins in infants are in the scalp. Lots of babies are virtually bald, too, making those veins even more inviting when you’re looking for a place to put the IV that your tiny patient needs RIGHT NOW. Unfortunately, parents often find scalp IVs rather intimidating. This leads to somewhat less than positive interactions at times. Usually the parents will take my word that it not only is in the baby’s best interest, but that there really isn’t another option. Other times, I’m just as happy to leave those discussions to the physicians.
One night I was called to the pediatric unit to place an IV in one of their smaller patients. The only veins I could find were in the scalp. The patient’s nurse wanted to ask the mom’s permission prior to placing the IV in the scalp. I’m generally in favor of involving parents in decisions – when it’s appropriate. This time there was only one acceptable answer. No point in presenting options that don’t exist. Mom didn’t seem upset when I explained why I had chosen that scalp vein and assured her that it wasn’t causing the baby any pain. I headed back to the NICU and missed Act Two in which the baby’s father arrived and demanded that we “take that needle out of my baby’s brain.” He wouldn't listen to the baby’s nurse, but the pediatric resident was able to convince him that it 1) wasn’t in the brain, and 2) wasn’t coming out until the baby was better hydrated.
Sometimes we have issues in the NICU too. The day shift nurse had placed the scalp IV in my patient. Mom and grandfather had been in and had seen it. Nobody said anything to the day shift nurse, so we were caught off guard when mom phoned that evening. Fortunately for me, one of my favorite pediatric surgeons happened to be making rounds on his NICU patients when mom called. He asked to speak with her and she apparently passed the phone to her father. This is the half of the conversation I heard:
“Actually, there’s no needle, just a flexible tubing.”
.....
“No, it’s not in the brain.”
.....
“The skull and some tough membranes are between...”
.....
“Those veins are the largest and most stable veins. The IV will stay in longer there.”
.....
“I told the nurse to put the IV in the baby’s head”
.....
“When my grandson had surgery, I insisted that they put the IV in his head.”
I don’t know if his grandson ever had surgery, but this seemed to be the answer that satisfied the baby’s grandfather as the conversation went on from there to other details of the baby’s condition. The statement that most impressed me was his claim that he had told the nurse to put the IV in the head. I doubt he’d had any such conversation, although he would have if she thought she needed to ask. We loved him because he cared for his patients so much – but also because he made the nurses feel like a valued part of the team. He has since retired. I am happy for him, but we all miss him.
One night I was called to the pediatric unit to place an IV in one of their smaller patients. The only veins I could find were in the scalp. The patient’s nurse wanted to ask the mom’s permission prior to placing the IV in the scalp. I’m generally in favor of involving parents in decisions – when it’s appropriate. This time there was only one acceptable answer. No point in presenting options that don’t exist. Mom didn’t seem upset when I explained why I had chosen that scalp vein and assured her that it wasn’t causing the baby any pain. I headed back to the NICU and missed Act Two in which the baby’s father arrived and demanded that we “take that needle out of my baby’s brain.” He wouldn't listen to the baby’s nurse, but the pediatric resident was able to convince him that it 1) wasn’t in the brain, and 2) wasn’t coming out until the baby was better hydrated.
Sometimes we have issues in the NICU too. The day shift nurse had placed the scalp IV in my patient. Mom and grandfather had been in and had seen it. Nobody said anything to the day shift nurse, so we were caught off guard when mom phoned that evening. Fortunately for me, one of my favorite pediatric surgeons happened to be making rounds on his NICU patients when mom called. He asked to speak with her and she apparently passed the phone to her father. This is the half of the conversation I heard:
“Actually, there’s no needle, just a flexible tubing.”
.....
“No, it’s not in the brain.”
.....
“The skull and some tough membranes are between...”
.....
“Those veins are the largest and most stable veins. The IV will stay in longer there.”
.....
“I told the nurse to put the IV in the baby’s head”
.....
“When my grandson had surgery, I insisted that they put the IV in his head.”
I don’t know if his grandson ever had surgery, but this seemed to be the answer that satisfied the baby’s grandfather as the conversation went on from there to other details of the baby’s condition. The statement that most impressed me was his claim that he had told the nurse to put the IV in the head. I doubt he’d had any such conversation, although he would have if she thought she needed to ask. We loved him because he cared for his patients so much – but also because he made the nurses feel like a valued part of the team. He has since retired. I am happy for him, but we all miss him.
Tuesday, April 11, 2006
Sometimes it's not what you say.....
Last Wednesday I saw the ENT about those vertigo episodes I mentioned. Interspersed within the following condensed conversation, there was discussion of history, symptoms, etc, but note the focus.
Dr. M: The ENG report is basically normal. So how long has it been since you've had an eye exam?
Me: About a year, I think. (Thinking "About time to call the doctor, I suppose")
Dr. M: You really should have an eye exam. (looks at report again). How long did you say it's been since you had your eyes examined?
Me: A year. No, wait, I fell down twice in 3 days last fall and thought it was because of my bifocals, so I went to one of those optical places to get some plain distance vision glasses for walking. I had an eye exam in October. (Thinking: "OK, I'll call tomorrow and see my regular Optometrist.")
Dr. M: Well, I think you really should have your eyes examined again. We'll get an MRI of your head to make sure there's nothing wrong in your ears that we've missed, but I think everything is fine. Here's the order
Me: Couldn't hurt. (Wondering now if I should call the Optometrist I've been seeing or make an appointment with an Ophthalmologist)
Dr. M: Let me see that a minute (takes the MRI order back and writes "To be read by Neuro radiologist only". Underlines Only. Twice. Then hands me the chart to carry out to the desk)
OK, so what would you do? The ENT told me 3 times in less than 5 minutes that I needed an eye exam even though I'd had 2 in just over a year. Me? I flipped open the chart on the way out and read the ENG report. I don't pretend to understand those things, but under "impressions" the words "potentially ophthalmic/retinal in origin" leapt out at me.
Then I did what any self-respecting hypochondriac would do. I called the nearest internationally reknowned eye center and made an appointment for the following Monday.
The eyes are normal. The Ophthalmologist at the internationally reknowned eye center was very understanding. He didn't snicker once. He was VERY reassuring, but I have a feeling that when he wrote down the chief complaint it went something like this:
"Acute hypochondria, exacerbated by referring physician."
So is there a tactful way to tell the ENT he needs to tone down his style a little? I understand that some patients need the extra encouragement to make follow-up appointments, but it is possible to scare the pants off the rest of us.
Dr. M: The ENG report is basically normal. So how long has it been since you've had an eye exam?
Me: About a year, I think. (Thinking "About time to call the doctor, I suppose")
Dr. M: You really should have an eye exam. (looks at report again). How long did you say it's been since you had your eyes examined?
Me: A year. No, wait, I fell down twice in 3 days last fall and thought it was because of my bifocals, so I went to one of those optical places to get some plain distance vision glasses for walking. I had an eye exam in October. (Thinking: "OK, I'll call tomorrow and see my regular Optometrist.")
Dr. M: Well, I think you really should have your eyes examined again. We'll get an MRI of your head to make sure there's nothing wrong in your ears that we've missed, but I think everything is fine. Here's the order
Me: Couldn't hurt. (Wondering now if I should call the Optometrist I've been seeing or make an appointment with an Ophthalmologist)
Dr. M: Let me see that a minute (takes the MRI order back and writes "To be read by Neuro radiologist only". Underlines Only. Twice. Then hands me the chart to carry out to the desk)
OK, so what would you do? The ENT told me 3 times in less than 5 minutes that I needed an eye exam even though I'd had 2 in just over a year. Me? I flipped open the chart on the way out and read the ENG report. I don't pretend to understand those things, but under "impressions" the words "potentially ophthalmic/retinal in origin" leapt out at me.
Then I did what any self-respecting hypochondriac would do. I called the nearest internationally reknowned eye center and made an appointment for the following Monday.
The eyes are normal. The Ophthalmologist at the internationally reknowned eye center was very understanding. He didn't snicker once. He was VERY reassuring, but I have a feeling that when he wrote down the chief complaint it went something like this:
"Acute hypochondria, exacerbated by referring physician."
So is there a tactful way to tell the ENT he needs to tone down his style a little? I understand that some patients need the extra encouragement to make follow-up appointments, but it is possible to scare the pants off the rest of us.
Monday, April 10, 2006
"The good news is that I don't think you have a brain tumor."
The bad news was that the doc didn't know exactly what was wrong.
The worse news was that a brain tumor wasn't even on MY differential diagnosis until he made that smart-ass remark. I was 21 and a nursing student, so I suppose he can be forgiven for presuming that it was. Don't all student nurses self-diagnose? Don't most of us eventually self-diagnose with something terminal? Guilty, but not that time. I was just thinking maybe I had Meniere's I was having dizzy spells that came on with no provocation that I could identify. I wasn't experiencing tinnitus, and the hearing loss was intermittent, not progressive and it was associated with upper respiratory symptoms.
Nine months later when the doc still hadn't come up with a diagnosis after putting me through a boatload of tests, I was really worried that I might have a brain tumor. He ordered one last flurry of tests and a diabetic friend gave me the diagnosis before the doctor came up with the same answer: Hypoglycemia. The high point on my glucose tolerance test was a fasting sugar of 70. It was all downhill from there -- 4 hours worth with a low of 40. It was probably a good thing they quit after 4 hours. No symptoms, but my blood sugar was still on a downward slope. It was still headed down and I had become symptomatic by the time I bumped into my friend. She gave me a snack and her diagnosis. I was able to keep the blood sugar under control by altering my diet and the dizzy spells were history.
I doubt that the doctor EVER made another flippant remark about brain tumors to another patient. I wasn't very gentle when I presented him with my friend's diagnosis for his confirmation. I made sure that he understood just how frightened I had been when he took so long to figure out the actual diagnosis after his off the cuff remark. To his credit, he listened to my entire rant and apologized with convincing sincerity.
Last July I had an episode of vertigo that lasted about a week. My internist didn't find anything to be overly concerned about at the time and prescribed Meclizine to slow things down. It's happened twice more since then. Both subsequent episodes lasted 4-5 days, so at least they're getting shorter. The third episode started the same day I was scheduled to see my ENT about something entirely different. I'm back on the medical carousel trying to figure out what is causing the intermittent symptoms. One thing leads to another and I still don't have a clue what's wrong. My ears check out. So do my eyes, not that visual problems cause vertigo, but the balance test (called an ENG or electronystography) showed a borderline signficant irregularity that was "possibly opthalmic (retinal) in origin", so I was off for an eye exam (normal) this morning. I'm no closer to an answer, but at least this time, thanks to that PET scan I had in December, I'm the one making the smart-ass remarks about being pretty sure there's no brain tumor.
I have an MRI scheduled for Wednesday and another visit to the ENT the following week for the results which will probably be normal. I've determined that my blood sugar and blood pressure are normal during these episodes, so that eliminates a few possible causes. The current ENT wants to see me when the vertigo recurs. I'd just as soon it never did even if that means the puzzle doesn't get solved. I'm determined not to engage in Googlology. I'm afraid I'll find out that there are things I really should be worried about and I just don't have the time for that.
The better choice is to make an appointment with my internist and let her put the rest of the pieces of this puzzle together. If there's an answer, I'm sure she'll find it.
The worse news was that a brain tumor wasn't even on MY differential diagnosis until he made that smart-ass remark. I was 21 and a nursing student, so I suppose he can be forgiven for presuming that it was. Don't all student nurses self-diagnose? Don't most of us eventually self-diagnose with something terminal? Guilty, but not that time. I was just thinking maybe I had Meniere's I was having dizzy spells that came on with no provocation that I could identify. I wasn't experiencing tinnitus, and the hearing loss was intermittent, not progressive and it was associated with upper respiratory symptoms.
Nine months later when the doc still hadn't come up with a diagnosis after putting me through a boatload of tests, I was really worried that I might have a brain tumor. He ordered one last flurry of tests and a diabetic friend gave me the diagnosis before the doctor came up with the same answer: Hypoglycemia. The high point on my glucose tolerance test was a fasting sugar of 70. It was all downhill from there -- 4 hours worth with a low of 40. It was probably a good thing they quit after 4 hours. No symptoms, but my blood sugar was still on a downward slope. It was still headed down and I had become symptomatic by the time I bumped into my friend. She gave me a snack and her diagnosis. I was able to keep the blood sugar under control by altering my diet and the dizzy spells were history.
I doubt that the doctor EVER made another flippant remark about brain tumors to another patient. I wasn't very gentle when I presented him with my friend's diagnosis for his confirmation. I made sure that he understood just how frightened I had been when he took so long to figure out the actual diagnosis after his off the cuff remark. To his credit, he listened to my entire rant and apologized with convincing sincerity.
Last July I had an episode of vertigo that lasted about a week. My internist didn't find anything to be overly concerned about at the time and prescribed Meclizine to slow things down. It's happened twice more since then. Both subsequent episodes lasted 4-5 days, so at least they're getting shorter. The third episode started the same day I was scheduled to see my ENT about something entirely different. I'm back on the medical carousel trying to figure out what is causing the intermittent symptoms. One thing leads to another and I still don't have a clue what's wrong. My ears check out. So do my eyes, not that visual problems cause vertigo, but the balance test (called an ENG or electronystography) showed a borderline signficant irregularity that was "possibly opthalmic (retinal) in origin", so I was off for an eye exam (normal) this morning. I'm no closer to an answer, but at least this time, thanks to that PET scan I had in December, I'm the one making the smart-ass remarks about being pretty sure there's no brain tumor.
I have an MRI scheduled for Wednesday and another visit to the ENT the following week for the results which will probably be normal. I've determined that my blood sugar and blood pressure are normal during these episodes, so that eliminates a few possible causes. The current ENT wants to see me when the vertigo recurs. I'd just as soon it never did even if that means the puzzle doesn't get solved. I'm determined not to engage in Googlology. I'm afraid I'll find out that there are things I really should be worried about and I just don't have the time for that.
The better choice is to make an appointment with my internist and let her put the rest of the pieces of this puzzle together. If there's an answer, I'm sure she'll find it.
Monday, March 13, 2006
Unexpected findings
Five years ago this month I completed my treatment protocol for colon cancer. A few months later, I was reviewing the latest CT scan with my oncologist. Chest, abdomen, and pelvis. He apparently hadn't read it - or at least not more than cursorily - before I entered the office, because when he flipped to page 2 of the report, he started to laugh.
"You have to see this," he said, as he handed me the report.
Normal findings, except for an enlarged prostate. "Funny they never found that on any of the umpteen previous CT scans, isn't it?" I said. "I wonder what my Gyn will say when he reads this."
The oncologist made a quick phone call to the radiologist's office and found that the Gyn had already called. The whole report had already been re-done by a second radiologist and would be faxed to him immediately. I heard from the Gyn's nurse that he'd had a great deal of fun at the radiologist's expense - but she wouldn't tell me more than that. I've known the Gyn a long time. I can just imagine. His nurse doesn't use that kind of language.
I laughed about that report for years, although it did worry me a little that the radiologist could have made such a whopping error in reading the scan. Turns out he probably didn't. My sister used to type medical reports. She told me that an error of that magnitude in a report would have to be committed by a transcriptionist of exceptional skill. Someone the radiologist really trusted. Someone whose work wasn't routinely proofread, because he or she simply didn't make many mistakes.
She then explained how this almost certainly happened. Experienced transcriptionists tend to type essentially the same report over and over when the results of a scan are normal, because the doctor will dictate more or less the same report in the same order so that nothing is overlooked. In doing large volume, the transcriptionist may save time by calling up the previous normal scan and making the few required changes instead of typing the whole 2-3 page report over again.
It seems likely that the previous normal scan called up by the transcriptionist was of a male with an unremarkable scan, except for that enlarged prostate. Oops.
I have copies of both readings. The first, which will stay with the report, because the radiologist signed it, was a more than adequate reading, except for that enlarged prostate. The second is the most thoroughly documented normal CT scan report you could ever hope to find. The second radiologist not only had to read the scan, he or she had to prove that said scan was on the same patient as all the previous scans in the folder.
None of this would have happened had I paid more attention to other unexpected findings. Over a period of 2-3 years, I ignored some very intermittent, very minor rectal bleeding. I occasionally mentioned it to my internist or one of her partners, but none of us was overly concerned. I also had some problems with constipation and had absolutely no family history of any kind of cancer. Besides, I was way too young to have colon cancer. By the time Katie Couric aired her on-camera colonoscopy, I was 45. She got my attention. I still believed the GI doc would only find internal hemorrhoids, but I wasn't willing to bet my life on that, so I scheduled the colonoscopy. Talk about unexpected findings.
March is national Colon Cancer awareness month.
Trust me, you're not too young to have colon cancer. Having no family history offers no protection. If you have symptoms. Get checked. If you're 50 or over, get checked whether or not you have symptoms. If you have a family history of colon cancer and are within 10 years of the age at which your youngest relative was diagnosed - get checked!
If you've had negative flexible sigmoidoscopies, but never had a colonoscopy, don't think you're safe either. My mom did, so it took over a year to browbeat her into having a colonoscopy. Fortunately her cancer was very small and limited to the distal portion of a polyp which could be removed during her colonoscopy. Now she jokes about her "little cancer" and nags her friends into having colonoscopies.
Your turn!
"You have to see this," he said, as he handed me the report.
Normal findings, except for an enlarged prostate. "Funny they never found that on any of the umpteen previous CT scans, isn't it?" I said. "I wonder what my Gyn will say when he reads this."
The oncologist made a quick phone call to the radiologist's office and found that the Gyn had already called. The whole report had already been re-done by a second radiologist and would be faxed to him immediately. I heard from the Gyn's nurse that he'd had a great deal of fun at the radiologist's expense - but she wouldn't tell me more than that. I've known the Gyn a long time. I can just imagine. His nurse doesn't use that kind of language.
I laughed about that report for years, although it did worry me a little that the radiologist could have made such a whopping error in reading the scan. Turns out he probably didn't. My sister used to type medical reports. She told me that an error of that magnitude in a report would have to be committed by a transcriptionist of exceptional skill. Someone the radiologist really trusted. Someone whose work wasn't routinely proofread, because he or she simply didn't make many mistakes.
She then explained how this almost certainly happened. Experienced transcriptionists tend to type essentially the same report over and over when the results of a scan are normal, because the doctor will dictate more or less the same report in the same order so that nothing is overlooked. In doing large volume, the transcriptionist may save time by calling up the previous normal scan and making the few required changes instead of typing the whole 2-3 page report over again.
It seems likely that the previous normal scan called up by the transcriptionist was of a male with an unremarkable scan, except for that enlarged prostate. Oops.
I have copies of both readings. The first, which will stay with the report, because the radiologist signed it, was a more than adequate reading, except for that enlarged prostate. The second is the most thoroughly documented normal CT scan report you could ever hope to find. The second radiologist not only had to read the scan, he or she had to prove that said scan was on the same patient as all the previous scans in the folder.
None of this would have happened had I paid more attention to other unexpected findings. Over a period of 2-3 years, I ignored some very intermittent, very minor rectal bleeding. I occasionally mentioned it to my internist or one of her partners, but none of us was overly concerned. I also had some problems with constipation and had absolutely no family history of any kind of cancer. Besides, I was way too young to have colon cancer. By the time Katie Couric aired her on-camera colonoscopy, I was 45. She got my attention. I still believed the GI doc would only find internal hemorrhoids, but I wasn't willing to bet my life on that, so I scheduled the colonoscopy. Talk about unexpected findings.
March is national Colon Cancer awareness month.
Trust me, you're not too young to have colon cancer. Having no family history offers no protection. If you have symptoms. Get checked. If you're 50 or over, get checked whether or not you have symptoms. If you have a family history of colon cancer and are within 10 years of the age at which your youngest relative was diagnosed - get checked!
If you've had negative flexible sigmoidoscopies, but never had a colonoscopy, don't think you're safe either. My mom did, so it took over a year to browbeat her into having a colonoscopy. Fortunately her cancer was very small and limited to the distal portion of a polyp which could be removed during her colonoscopy. Now she jokes about her "little cancer" and nags her friends into having colonoscopies.
Your turn!
Saturday, February 25, 2006
Just what part of "She's not here" do you not understand?
Ding-dong! (NICU doorbell - at 3am)
Me: "Can I help you?"
Him: "I'm looking for my sister, she's in labor."
Me: "This is the Neonatal ICU. Your sister isn't here."
Him: "Where is she, then?"
Me: "She's probably in the birthing center, turn around and go to your right."
Him: "I can't get in there."
Me: "Do you have a visitor pass? You need a visitor pass to open the door."
Him: "There's nobody at the desk." (He must mean the front desk. There's nobody there after midnight)
Me: "You'll have to go to the Emergency Room to get a visitor pass. The security desk in the ER."
Him: "I didn't come in that way. She's 8 cm dilated and she's going to have the baby any minute."
Me: "Is this her first baby?"
Him: "Yes. Can you let me in?"
Me: "I think you have time to go to the ER to get the visitor pass. Besides, she's not in here. This is the Neonatal ICU. We only have premature babies in here. She's probably in the birthing center."
Him: "Where is the birthing center?"
Me: "Turn around and go to your right, but if you don't have a visitor pass, you'll have to go to the ER to get one. I can't open that door from here."
Him: "You're being insensitive to the situation."
The conversation went on for a few more minutes in the same vein and he finally figured out that arguing was getting him nowhere. Or maybe he finally was fully awake. Whatever. I can be pretty darn insensitive some times. I still can't open the door to the birthing center from the NICU no matter how many people ask or how nicely.
Me: "Can I help you?"
Him: "I'm looking for my sister, she's in labor."
Me: "This is the Neonatal ICU. Your sister isn't here."
Him: "Where is she, then?"
Me: "She's probably in the birthing center, turn around and go to your right."
Him: "I can't get in there."
Me: "Do you have a visitor pass? You need a visitor pass to open the door."
Him: "There's nobody at the desk." (He must mean the front desk. There's nobody there after midnight)
Me: "You'll have to go to the Emergency Room to get a visitor pass. The security desk in the ER."
Him: "I didn't come in that way. She's 8 cm dilated and she's going to have the baby any minute."
Me: "Is this her first baby?"
Him: "Yes. Can you let me in?"
Me: "I think you have time to go to the ER to get the visitor pass. Besides, she's not in here. This is the Neonatal ICU. We only have premature babies in here. She's probably in the birthing center."
Him: "Where is the birthing center?"
Me: "Turn around and go to your right, but if you don't have a visitor pass, you'll have to go to the ER to get one. I can't open that door from here."
Him: "You're being insensitive to the situation."
The conversation went on for a few more minutes in the same vein and he finally figured out that arguing was getting him nowhere. Or maybe he finally was fully awake. Whatever. I can be pretty darn insensitive some times. I still can't open the door to the birthing center from the NICU no matter how many people ask or how nicely.
Tuesday, January 03, 2006
Thanksgiving
If you read my previous post, you may be wondering why we try so hard in what seem like hopeless circumstances. We believe in miracles. We've seen them.
Thanksgiving eve, in a community hospital many years ago. A tiny baby lay very still in his intensive care warmer bed. The night before he had been active, but no more. I hadn't seen any movement in hours. His fontanel was bulging. His pupils were fixed and dilated. His heart rate should have been over 120, but it was in the 80's - and had been for hours. His limbs cooled, despite the heat of the radiant warmer and it seemed that nothing we did would ever make a difference to this tiny child. The IV pumps continued to drip fluids into his tiny veins. The ventilator forced oxygen into his tiny lungs. None of it seemed to matter.
The neonatologist had been fighting this losing battle since early evening and finally decided to go home about 4am to get a little sleep before approaching the family about terminating life support. He was just coming in as I was leaving - about 7:30 that morning.
I shocked my youngest sister by expressing my hope that he would not be there when I got back to work that night. I couldn't see any hope for him at all. If he survived - which seemed impossible - surely he would be profoundly brain damaged.
When I arrived at the NICU that night, I heard the story: The doctor had been unable to contact the parents. He tried repeatedly, but there was no one at home. This was in an earlier era - no cell phones, no voice mail, not even answering machines. Nobody was home.
About 11am, the family arrived, but there was no consideration of terminating life support. Yes, the baby was still there. At about 10, he had started to move again. His pupils began to react. His heart rate returned to normal - and so did his fontanels. There was no evidence of his brush with death. He looked like a typical preemie again.
Where were the parents when they couldn't be reached? They were in church, giving thanks to their Creator for all the gifts they had been given - but especially for this very tiny child.
Thanksgiving eve, in a community hospital many years ago. A tiny baby lay very still in his intensive care warmer bed. The night before he had been active, but no more. I hadn't seen any movement in hours. His fontanel was bulging. His pupils were fixed and dilated. His heart rate should have been over 120, but it was in the 80's - and had been for hours. His limbs cooled, despite the heat of the radiant warmer and it seemed that nothing we did would ever make a difference to this tiny child. The IV pumps continued to drip fluids into his tiny veins. The ventilator forced oxygen into his tiny lungs. None of it seemed to matter.
The neonatologist had been fighting this losing battle since early evening and finally decided to go home about 4am to get a little sleep before approaching the family about terminating life support. He was just coming in as I was leaving - about 7:30 that morning.
I shocked my youngest sister by expressing my hope that he would not be there when I got back to work that night. I couldn't see any hope for him at all. If he survived - which seemed impossible - surely he would be profoundly brain damaged.
When I arrived at the NICU that night, I heard the story: The doctor had been unable to contact the parents. He tried repeatedly, but there was no one at home. This was in an earlier era - no cell phones, no voice mail, not even answering machines. Nobody was home.
About 11am, the family arrived, but there was no consideration of terminating life support. Yes, the baby was still there. At about 10, he had started to move again. His pupils began to react. His heart rate returned to normal - and so did his fontanels. There was no evidence of his brush with death. He looked like a typical preemie again.
Where were the parents when they couldn't be reached? They were in church, giving thanks to their Creator for all the gifts they had been given - but especially for this very tiny child.
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