Sunday, August 27, 2006

Did you know that Pediatric Grand Rounds is at Milliner's Dream this week?

It is! It's chock full of interesting tidbits this week too.

Go read it!

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.

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.

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.