Suck, Swallow, Breathe

I spend a lot of time feeding preemies -- and teaching their parents to feed them. Often, the parents have the mistaken notion that practice makes perfect. For the adults involved, that may be true. For the babies, not so much.

There is a phenomenon among near-term preemies which demonstrates the issues pretty well for that group. The baby will poke along, choking and dribbling - sometimes failing to breathe as well. One day the baby just gets things together. It's almost magical - as if someone has flipped a switch. I've explained this to countless parents and recently a dad summed it up much better than I could. He said, "I see, it's like walking! He won't be able to do it until he can." The baby's mom was not exactly thrilled with any of us (dad, me, or baby), but she did seem to understand. Good thing. For that particular baby, it was weeks before he managed to pull his act together and nipple all his feedings.

Feeding preemies is much more complicated than feeding healthy term kids. With a term baby, you may have to help them figure out how to latch at the breast (or more rarely on an artificial nipple). Beyond that, the whole thing is pretty much reflex. Preemies have a pretty good suck reflex by 34-35 weeks gestation, but many don't get that swallow part. If they get the suck-swallow, they may not manage to coordinate breathing along with it. Eventually most of them will be able to manage, but it can be very frustrating for the parents while they're reaching that point.

Several things can help. First, don't cold stress the baby. They need to be warm - this often means spending time in an incubator, or at the least being dressed warmly and double-wrapped. Sometimes parents need a lot of education to understand that their preemie simply won't tolerate being unwrapped and passed around the group, especially prior to feedings. If the baby is using excess calories to keep warm, he won't have the energy to nipple or breast feed.

Preemies may not feed well if they are handled a lot or bathed just prior to a feeding. Again, they only have so much energy and need to conserve.

Positioning is important. The impulse is to snuggle the baby in the crook of your arm to feed him. This is a bad idea with preemies for 2 reasons - the baby will probably sleep if you snuggle him, and if he chokes, it will take longer to reposition him to clear his airway.

Choice of nipple can be very important. We have 4 different types of conventional nipples ( and a couple of others for babies with clefts). First is the standard nipple used for healthy term babies. I use that for most preemies as well. Then there is the "orthodontic" nipple which allegedly is more like feeding at the breast. I've never been convinced, but the nipple is quite useful for a subset of babies who choke or dribble, since it places the breast milk or formula in a different spot in the mouth. Another is softer than the others and has a larger hole. It is useful for feeding babies who have the swallow and breathe portions down, but who have a weak suck. Sometimes I use this one to finish a feeding if the baby starts to tire. The last nipple is a "slow-flow" nipple. That one is useful for the babies who have a really strong suck, but are inexperienced with the swallow-breathe portion of feeding.

Breastfeeding has a separate set of challenges in near-term preemies. Most babies take some time to develop an effective latch and suck due to a disparity between baby's mouth size and mom's nipple characteristics. It's hard for the baby to get enough of the areola into the mouth. There are ways to deal with this if the disparity isn't too great.

Mom may need a second set of hands to get the baby positioned and the mouth opened wide enough in some cases. Once the baby latches, mom needs to pull the baby in closer while she (or someone else) presses down gently on the chin to get the mouth open wider. As with term babies, it is important to make sure the lips are turned out, not in. In extreme cases, it may be necessary to use a nipple shield (silicone is best according to our lactation consultants) until the baby grows a little. I encourage the mom to try without the nipple shield first - only for a few minutes if it isn't working.

Dribbling and choking aren't a problem for breastfeeding babies unless the mom has an especially vigorous let-down. That can be managed too. We sometimes have the mother pump her breasts for a few minutes before letting the baby nurse. Estimating intake can be an issue. In most cases, we just weigh the baby's diapers to make sure he isn't getting dehydrated. In special circumstances, the baby is weighed before and after feedings (dressed and diapered). That allows an estimate of intake if that is necessary.

$10.9 Million for the Good Guys

I can't embed the video but it's worth watching.


A federal jury in Baltimore, MD awarded $10.9 million to the family of Lance Cpl. Matthew Snyder. They found that the "protest" by the Westboro Baptist Church wasn't protected speech.

The members of Westboro Baptist Church have the right to their beliefs. They have the right to meet and to discuss them. As Lance Corporal Snyder's father says, they even have the right to express them in public places - in front of courthouses, public parks or streets - yes, even outside the U.S. Naval Academy as they did this week. I really do not believe that funerals are the sort of public venues where they should be able to express their views. I'm glad the jury feels that way as well. This will be appealed, of course and I hope they lose on appeal.

I'm not going to post any links to WBC. They're easy enough to find. I am going to throw in a plug for the Patriot Guard who have been attempting to shield military families from the vitriol of WBC actions at funerals across the nation - with permission of the family. They do this through strictly legal and non-violent means. More recently, they have added Honor Missions to deceased veterans and law enforcement personnel.

Enter the Samurai

This is what has kept me busy all week. The helmet (kabuto) took the bulk of the time with the body armor (Do) a strong second. Lots of duct tape and foam-core poster board went into the armor. It's still missing important pieces for authenticity -- waist, leg, and throat armor to start -- we'll be working on those later. He's really pleased with his wins for scariest and most original in his age group at 2 different contests.

Been a little busy

Armor is as finished as it's going to get. Pictures will be ready by Sunday - 2 costume contests in the meantime and his dad will be there with the camera.

My son is very excited. I'm really pleased with the way it's turned out. We'll be adding to it on an ongoing basis until it's really completed, but it will do for now. Next project, find the local Society for Creative Anachronism because he wants to learn much more about the making of armor, SCA style. And I didn't even tell him that they get together on Sundays to practice archery.

We did learn some things. You can do pretty amazing things with tinfoil and duct tape.

We also learned that it's a really bad idea to put on your gauntlet (forearm armor), which is made in one piece(not at all like authentics Samurai forearm armor), and slide it up over your bicep. Since it was made of posterboard and duct tape, scissors solved that problem. THEN I realized it probably would have come off the way it went on - with his hand straight up over his head. Not planning to test the theory, though. It takes a good 20 minutes to make a new one and I'm running out of patience. Lots of duct tape left, though.

Pictures coming soon

Samurai armor is definitely the most challenging project we've attempted in a while. The helmet is nearly finished and the armor is coming along nicely.

We followed the directions on the Clan Yama Kaminari "How to make armor" page using foam core poster board covered with Duct tape instead of the plastic barrel they recommend. It's easier to cut than the plastic and he'll outgrow it too soon to make it worth going through all that. Also, he doesn't plan to go out and pound on people with sticks while wearing this. They only wear headgear and hand and foot protection when they pound on each other with sticks in his karate class.

Unlike the barrels, foam core poster board isn't flexible, so I cut part way through at 1.5 inch intervals on the side panels before applying black duct tape. This allows the armor to bend in order to fit. Instead of taking the time to lace the panels together, we used red duct tape for the hinges. We will be lacing the upper pieces to the front and back as well as the shoulder straps. Torso armor (Do) should be completed by tomorrow evening. Helmet (Kabuto) shortly afterwards. If we have time, we'll add additional pieces as we have time. Armor should be completed in time for next year's Renaissance festival (or an SCA event if we can find one nearby sooner).

shirt.woot derby #13 - Halloween

Shameless pimp here. My friend has a shirt in the derby and will probably enter more. If you've ever bought anything on Woot or shirt.woot or wine.woot you can vote.

Shirt has been axed twice for technical reasons. Rats. It had moved up to #33 before getting cut this time. They reject many outstanding designs because they'd be too hard to print. This is one of them.

There are lots more choices in the derby, though. You can see the rest of the entries in the derby and vote. There is some really clever stuff there.

Halloween is coming!

My youngest son has designed his own costumes since he was 5 years old. My job is to help implement them. This gets more challenging every year. Considering that his first (prize-winning) costume was a hammerhead shark, that's saying a lot.

This year I may need to swap him off to someone from the Society for Creative Anachronism as he wants to be a Samurai Warrior. With armor. So far, we've figured out how to build the helmet - recycling the Clone Trooper helmet from a few years ago as a base. He's hoping it will look a little like this one:


which we found on the projects page of Clan Yama Kaminari. He wants the whole shebang, so this is going to turn into a long-term project.

Ideas and helpful hints found here

We won't be using the face guard and our helmet started its life as a green military-style helmet which I spray-painted white for use as a clone trooper. It will change color again in this incarnation. He wants it black this time. My plan is to cover it with wedges of black Duct tape so it has a more authentic appearance than simply spray-painting would provide. Also, this makes it possible to construct the remaining part of the helmet in a manner which will match the top. Pictures to be posted as we make progress.

I ran into my oncologist today

It's been nearly 2 years since I last saw him and 3 since he discharged me as a patient. I totally blanked on his name. I can't keep my kids straight, so that's nothing unusual. He, however, has a phenomenal memory - even asking if I still worked in the same place (not the hospital where I bumped into him). By name. Amazing.

I need to write a note thanking him for all that he did for me. I provided him with very little excitement in the way of complications of care, but - as with virtually all cancer patients -- more than a little complexity in my need for support.

He and his partners were always upbeat when it was appropriate. One of the partners would periodically pop into the waiting room with a brief comedy routine (always different). Another, who had never seen me, hunted down a test report that came in while he was on vacation.

What I remember above all else is that he wasn't afraid to use the "C" word.

No, not that one. At my first visit to his office, he told me that he thought it very likely that treatment would lead to a cure. Not a word I expected to hear from him for years, if at all.

Since you asked me to......

Hat tip to Fat Doctor who asked (not just) me to pass this monitor cleaner along.

First, put down your cup and swallow.

Then click here.

That one seems to have exceeded their bandiwidth, so you might want to try this one.

"Uncle George is dead. Go see him!"

Taking small children to funerals is always chancy. When the funeral is in another state, you don't always have options, though.

It was 22 years ago in the middle of winter when Uncle George went to meet his Maker. He'd always been a practical joker and insisted on being buried in his favorite red bow tie. His sons and son-in-law had all acquired red bow ties of their own for the occasion.

Having no nearby relatives with whom to leave them, we took our 2 and 4 year old sons with us to the funeral. We joined the family at the pre-service viewing and when the boys got fidgety, I left my husband with his cousins and took them outside. My oldest began greeting the guests with a cheery, "Uncle George is dead. Go see him!"

Uncle George's sons thought it was hysterical, but when one of the other attendees paled in response to the greeting, I thought it might be wiser to take the kids to the nearest McHappy place until closer to time for the service.

At the reception afterwards, they ran and played with Uncle George's grandchildren and visited with the rest of the relatives having a delightful time. When my oldest returned to preschool a few days later, I told his teacher that he'd been to a funeral, but he thought the whole thing had been a big party.

Today we attended the funeral of one of his sons. No red bow ties this time, and there were more than a few tears shed. Overall, though, the tone was one of joy for the deceased, much as Uncle George's funeral had been.

The pastor who preached the funeral sermon spoke of his sorrow for the widow who would be without her husband of 53 years and his sorrow for the friends and family who would also miss him - but of his overwhelming joy for his very dear friend. His joy is based in the promise of the Resurrection - in his belief, shared by most of those present, of a glorious eternity bought for us by the death and resurrection of our Savior.

We will miss our friend and cousin, but we live in the hope of seeing him again one day.

But it Itches!

Poor kid. If he looked sick, I'd have taken him to the doctor. His only symptom was rash that, over the course of a week, spread from his chest to his back, shoulders, and then started to creep down his legs. Tiny bumps (papules) bright pink initially but fading so that you couldn't see them well at all any more. He knew they were there, though.

And they itched. Not that I wasn't sympathetic, but he only seemed to itch at bedtime. So we tried benadryl -- at least he could sleep. He probably itched the rest of the day, but he was too busy to complain. He's always doing something.

Besides, I figured self-limiting, probably viral. Not much point in going to the doctor for that. But it wasn't my rash and he insisted. So we went.

Funny thing is I was only wrong on one point. The pediatrician called it exanthem (aka exanthum) -- IOW, itchy rash, probably viral in origin. He did do a throat culture to rule out Strep, but he thought that was unlikely. Solution, atarax to help control the itching until it goes away in a few more days.

The culture was negative. He's still bumpy and itchy, but at least he believes someone cares. Maybe not his mother, but at least his pediatrician does.

AMATEUR TRANSPLANTS: Anaesthetists Hymn LIVE

Just in case you were wondering

No, we don't do stat paternity tests. It doesn't matter if you're from out of state. Would you like to see the baby? She looks just like you.

Actually, we don't do paternity tests at all. Here's the card. Contact them. They'll tell you how it's done. Yes, the doc will write a scrip if you need one. The company will tell you how much they charge.

No, medical assistance doesn't pay for paternity testing, but hey, the test is cheaper than child support unless the baby-momma has correctly ID'd you. In that case, you might as well skip the test and just pay up. Would you like to see the baby? She looks just like you.

If you really don't want to pay for the test, Maury Povich is recruiting maybe-daddies for his television show. Probably other shows are too. No, I won't be watching.

Memories

Dr. Rob's 10 Reasons to NOT Like Pediatrics reminded me of a time when my older children were very small. It was item #10 if you're wondering.

My middle (then youngest) son was 15 months old at the time. He'd been up at about 2am looking for someone to play with. He didn't whine. He didn't cry. He was very cheerful. HOWEVER, this was a child who made a practice of sleeping through the night while cutting 4 teeth at a time. He NEVER complained about anything.

That and he'd been sleeping through the night since he was 2 days old. Really. Usually 12-14 hours.

So I did what any self-respecting mom would do.

I called the pediatrician and made an appointment to have him examined.

"Dr. Spock's office, how may I help you?"

"My 15 month old was awake last night. I think something is wrong with him."

"Was he crying?"

"No."

"Was he tugging on his ear?"

"No. In fact he was quite cheerful. But this isn't normal for him. Something is wrong."

"You want the doctor to examine your 15 month old because he was up once during the night last night?"

"That's right. Oh, and his brother (of the many ear infections) says his ears hurt, so I'd like to bring them both in."

(audible sigh) "Can you come at 11:30?"

"Sure. We'll be there."

For the record: his brother had bilateral otitis media - and so did he. According to the pediatrician, his ears looked much worse. He was the reason I bought an otoscope (ear-looker thingy) and why the pediatrician educated me in the proper use of it.

Prior to the otoscope, the first ear infection was the only one I caught before the poor kid had pus dripping from his ear canal. He NEVER complained. I got in the habit of checking his ears any time he had a sniffle. A year or so after I bought the "ear-looker thingy" he did ask me to "play check ears" - sure enough, the eardrum was ready to burst again. That was the closest the kid ever came to actually complaining about an ear infection.

That first incident was also the last time the office staff questioned my reasoning for wanting to bring a child in to be seen.

It's mine and you can't have any

By way of Navelgazing Midwife. It's one of the funniest breastmilk stories I've read in a long time.

Warning. If you're the least bit squeamish about breastfeeding, just don't go there.

Driver's Ed

It was many years ago, but some things you don't forget.

My driver's ed instructor was full of useful bits of information:

Buckle your seat belt

He was right, of course. I've only crash-tested one seat belt, but the only damage to me was a bruise where my medic-alert tag got caught under the seat belt. Now the first thing I do after buckling up is find the damn thing and make sure it's ON TOP of the seat belt. Makes one hell of a bruise if you don't.

When parallel parking, back up until the back of your rear passenger door (or equivalent spot in a 2-door) just passes the rear bumper of the car in front of your space before cutting your rear wheels toward the curb (front wheels away). Start turning your steering wheel back the other way shortly before BEFORE your front bumper passes the rear bumper of the other car.

Works. I back in, pull up a little and am perfectly parked every time.

Don't run over ANYTHING, not even a paper bag. There could be a human head in it.

Colorful way of making sure I don't run over paper bags. Can't do it - not even 30+ years later.

If you're on a 2-lane road and someone is coming at you head-on, brake and stay in your own lane. Don't pull to the left or to the right, because the driver who is in the wrong lane will choose one of those most of the time.

I don't know where he got his statistics, but the only opportunity I had to test his theory, the other driver passed me at very high speed on my right - yes, going the opposite direction. I don't want another opportunity. NEVER.

Uber Cool Nerd Queen - that's me

What are you?





I knew I should have kept that Amiga.

Visitor

I don't know whether this bird belongs to a neighbor, escaped from an area wildlife preserve, or has been surviving on his own with the one leg. We've seen lots of raptors around here, but this is the first time I've seen one in the bird bath.

Yes, those are thistle feeders in the background for the many finches who visit our yard. You can't see the "squirrel proof" sunflower seed feeder nearby. We haven't seen any evidence, but I wonder if this one-legged visitor has been snacking at our bird feeders - and not the seeds.

He wouldn't have to. There is certainly enough road kill around here - mostly squirrels, with the occasional raccoon or 'possum, to keep him well fed.

Pediatric Grand Rounds

The Labor Day Weekend edition is up at Unintelligent Design. Thanks to Dr. Clark Bartram for keeping this going!

Byler Babies arrive

Karoline Byler, of Wesley Chapel, Florida, can finally take a deep breath. Her babies were delivered Saturday, September 1, between 9:00 and 9:03 pm at Bayfront Medical Center in St. Petersburg, Florida. They were taken through the connecting tunnel to adjacent All Children's Hospital. The 2 hospitals have been planning for months and there's a video linked from the All Children's web site that describes the plans. The hospitals have managed many sets of multiples - including quintuplets, so they are understandably confident of their ability to manage the Byler babies.

From the All Children's Web site:

Names and birth weights for the five boys and one girl are as follows:

Brady Christopher - 2 lbs., 8 oz.
Eli Benjamin - 3 lbs
Ryan Patrick - 3 lbs
Jackson Robert - 2 lbs., 10 oz.
Charlie Craig - 2 lbs., 5 oz.
Mackenzie Margaret - 2 lbs., 9 oz.

They describe the babies condition as stable, except for Ryan Patrick who is "receiving airway support" and in serious condition. To me, that means something short of a ventilator because that would generally be described as critical condition. The babies were born at 29 weeks, 4 days gestation. There are certainly risks for these babies, but at 29+ weeks and having come through delivery with apparently no major complications, statistics are in their favor.

The family, with an eye to supporting these 6 additions to their family, has signed an exclusivity contract with Inside Edition reportedly worth $12,000, so you'll have to watch their broadcast if you want to see pictures of the babies today. As the reporters in the video I linked above said, that will buy a lot of diapers.

Update:

I should have anticipated this. 2 of the Byler babies are now in critical condition and 2 others in serious condition. It's quite common for 29 week preemies to have some respiratory issues and I hope that's all that's going on here.

We call that initial period when the baby does so well the "honeymoon" and it last about 24 hours. The babies start running into problems with inadequate surfactant production after that.

If that's the issue, the 2 who are in critical condition probably had to have a breathing tube placed so they could receive surfactants. They'd be kept on the ventilator for a period afterwards. The time frame would depend on how quickly they recover. The 2 in serious condition may need respiratory support short of a ventilator. They may recover without needing a ventilator, or they may need some surfactant replacement within the next day or so themselves.

Breastfeeding - a personal choice

It is well documented that breastfeeding provides many health advantages for moms and babies. The incidence of upper respiratory infections is lower. The incidence of severe allergies, asthma, and type 1 (insulin dependent) diabetes is lower. The incidence of sudden infant death syndrome is lower. Moms who breastfeed even have a lower incidence of breast cancer. There's a myth that the baby weight comes off faster. Many women find that it helps. I didn't find that to be true - and many women don't.

In the US, where we have access to clean water, refrigeration, and infant formula that is virtually always safe if stored properly (there have been a few alarming -- even lethal, but rare -- exceptions), women can choose to feed formula without fear of the risks found in third world countries. They should be informed of the benefits they are giving up. They should be supported with good breastfeeding education and workplace accommodations, but I don't believe in badgering women who choose not to breastfeed.

Some moms have medical reasons for choosing formula. Those vary from a need to take medication not compatible with breastfeeding to breast surgery which interferes with milk production and let-down. In rare circumstances, the baby may have a genetic disorder which makes breastfeeding impossible, due to special dietary requirements.

Some women have psychological reasons. For example, women who were molested as children may find it difficult to even consider breastfeeding. Some women have work schedules which will not accommodate breastfeeding or even pumping. Some have tried with a previous infant and for one reason or another found it too discouraging to even try again. Some women wish to share the closeness of feeding times with the baby's father or other relatives.

Whether or not I agree with their reasons, I don't badger. I educate about options - like partial breastfeeding. I help them research medications to be certain that they have the latest information. If they wish, I can refer them to our social worker for help with other issues. I make sure that they know WIC provides food for breastfeeding moms in addition to formula for babies. Under the right circumstances, I'll even offer them a pump to help deal with engorgement.

In the end, I support their choice. Moms have a hard enough time without people trying to make them feel guilty about one more thing.

Yes, I wish everyone could breastfeed, but that isn't ever going to happen. Moms need to educate themselves and make the best choices for themselves and their babies - and nobody should jump to conclusions or behave in a hostile manner regardless of the way a particular baby is being fed.

Breastfeeding in Public

I did it. I didn't whip it out and show everyone the facilities, but I didn't hide under a blanket, either. I learned to arrange my clothes and the baby so that I hardly ever flashed anyone. My oldest is in his mid-20's so it was a little less common then than it is now.

OK, it was a lot less common and people occasionally made suggestions that the bathroom was the most appropriate place for that sort of activity, because -- it's a body function.


I didn't get nasty with anyone. I just did the same thing I did with other unwanted parenting advice. I ignored them. After all, I didn't see THEM taking their plate into the bathroom to perform that bodily function in private.

We have a serious problem in this country, folks. There are still people who can say with a straight face, "It's a body function and should be private." They think their sensibilities are more important than the health and safety of someone's child.

I simply do NOT understand their problem. I know it's a cultural issue. They were raised to believe that breasts are for sex and that suckling = sex. For babies it equals food. The best possible food for babies - who can't wait until nobody with breast issues is looking.

"Nurse-ins" can be used to demonstrate that it is possible to breastfeed in public without unnecessary exposure - or they can be used as an in-your-face political statement that doesn't do much to further the cause of breastfeeding.

The breastfeeding statistics in this country are abysmal. The good news is that we're getting more than 70% of moms to at least try breastfeeding. The bad news is that most of them don't keep it up. Partly that's lack of support at the outset. Much of it, though, is lack of support - and sometimes outright hostility - when they get home.

FDA Warning for Breastfeeding Moms

Last Friday, the US Food and Drug Administration released a warning for breastfeeding moms and their healthcare providers. A rare genetic tendency to metabolize codeine more rapidly than usual may put infants at risk. One infant death has been reported.

That mom was reportedly taking a relatively low dose of codeine when her 13 day old baby died of a morphine overdose. The mother was not taking morphine. She was taking codeine. It is normal for the body to change some of the codeine into morphine, but this should happen relatively slowly so that there is little risk to nursing infants.

Nursing moms need to pay attention to their babies whenever they are taking any medication or herbal supplement. A change in behavior, especially excessive sleepiness, lethargy, poor muscle tone, or difficulty getting baby to feed can indicate that the baby is getting an unhealthy amount of whatever you are taking. The same is true if the baby becomes very fussy, vomits, or has very tight muscle tone, color change, or increase in respiratory rate. Complicating matters, any of these can also indicate illness in a newborn.

Bottom line, if you are taking a medication, make sure it's approved for use with nursing babies (codeine is, in moderation). If your baby's behavior changes markedly - even if the medication is approved - check with the baby's doctor.

It is always possible to reach someone outside of office hours. If your baby's pediatrician hasn't given you other instructions, call the office phone number and leave a message with the answering service or follow the instructions on the office voicemail about reaching the pediatrician. If for some reason you cannot reach the pediatrician and/or you believe it is an emergency, the ER is open all the time.

Avoiding the problem? Take the codeine if you need it, but if over the counter pain medications like Tylenol or ibuprofen will do, that might be a better choice. Read labels. Some cough medications can contribute to the increasing morphine levels. If you're getting really sleepy after taking codeine, watch the baby extra-carefully.

Don't mix prescription pain medications unless your doctor tells you to. Many contain codeine and you could get a double dose. If you aren't sure what's in the medication, ask your doctor or pharmacist.

Your best source for information about medications and breastfeeding should be your doctor, the pediatrician, a lactation consultant, or a pharmacist, but here is a link with more information on breastfeeding and medications:

Dr. Thomas Hale - wrote the bible on the subject, called Medications and Mother's Milk. Make sure you're looking at the latest edition (12th). It's updated regularly and you shouldn't use a copy more than a year or 2 old. The differences can be huge. Absolutely do not waste your money buying an older edition.

TC has shared an excellent web resource it's called Kellymom.com: Breastfeeding and Parenting a site run by Kelly Bonyata, BS, IBCLC. She sources her information and tells you how current the information is.

The dates on many of the other links I found were nearly 10 years old. NOT ACCEPTABLE, in my opinion. The science on this changes. Yes, some medications are quite well studied, but you may drop a perfectly safe medication or "pump and dump" unnecessarily - or even put your baby at risk - if you don't have the most current information. Feel free to share any good CURRENT information in the comments.

Search terms - sometimes they make me laugh. Sometimes not so much.

"premature babies with blood on their brains, what do they do"

This one made me sad. They probably mean intraventricular hemorrhage (AKA interventricular hemorrhage). Bleeding into the ventricles can be relatively insignificant if there is only a little blood - but that depends on the location of the bleeding. Many babies with grade I or grade II IVH are completely healthy with no significant developmental delay - but not all.

Larger amounts of bleeding (grade III and grade IV) are more commonly, but not always, associated with developmental delays and cerebral palsy.

Sometimes there is so much blood in the ventricles that not enough fluid flows out of them. This causes increased pressure within the brain (hydrocephalus), which can also increase the risk of developmental delays. If the fluid persists, the baby may need a ventriculoperitoneal shunt placed. With the smaller babies, serial lumbar punctures (spinal taps) may be used to postpone shunt placement until the baby is large enough.

Sextuplet update

Actually, no news is good news at this point - and there isn't much. You won't be seeing the irate bloggers talking about litters for at least a few more days. Hopefully closer to 2-3 weeks.

Karoline Byler (more here) was admitted to the hospital over 2 weeks ago and is 28+ weeks now. The docs hope to get a few more weeks with medical management and bed rest, but the survival rate at 28 weeks is pretty good.

The Sodani family has been quiet, too. They should be about 27 weeks by now. The last update on Brian and Gracie's web site says that she's in the hospital - no date, but it's been there for a month or so.

The Masche's are all home and doubtless too busy to do much in the way of updates. I don't even see any new pictures in their photo gallery.

There hasn't been an update on the remaining Morrison baby. He was still in critical condition at the last update, nearly a month ago. He may well be in critical condition for another month. Possibly even longer. He was tiny and it takes a long time for those tiniest babies to outgrow their respiratory and feeding issues.

The families all still have their "how to help" links on their web sites. I hope they're getting what they need. I won't be contributing to any of the sextuplet families. There are plenty of families in need in my own community.

I also found a web site called MOST - Mothers of Super Twins.

This is how they describe themselves:

MOST is a network of families with triplets, quadruplets and more that provides information, resources, empathy and good humor during pregnancy, infancy, toddlerhood and school age

If I had the resources to donate outside my own community, I'd support their adopt-a-family program. With the upsurge in higher order multiples, people with 3-5 babies at a time just don't get the publicity (and the assistance) that they did a few years ago.

Is it possible to disagree about religion without calling names?

From a comment on a previous post:

your own child you would be willing to sacrifice to make a religious point.

To me, that is religious fanaticism.

Throughout the ages, people have been willing to die for their beliefs -- and yes, to allow their children to die also. I wouldn't call someone a religious fanatic simply because I disagree with them. To me a fanatic is willing to have someone over whom they should have NO control or responsibility die for their beliefs. Religious wars through the ages, some of the current terrorist acts, and many of the deaths during the Inquisition fall under that heading.

I am responsible to my God for my children. They are gifts from Him and I must answer to him for choices I make in raising them.

I realize that other people do not consider embryonic stem cell research to be evil. I believe that it requires destroying a living human. I would no more accept for myself or my child the results of that research than I would accept a donor heart from a living, breathing fully functioning human being (we're not talking brain death, here).

As I stated in a comment to that prior post. To me, the difference between the Jehovah's Witness believe about the proven benefits of transfusion and my belief about any theoretical benefit of embryonic stem cell research is that nobody dies when they donate blood. The rest is very much about our responsibility to God as we understand Him. I respectfully disagree with their position on blood transfusion, but I would not call them fanatics.

I also believe that our focus should be on the already successful cord blood stem cells and adult stem cells. That research has been beneficial already and should be expanded.

Religion and Healthcare - how much freedom should we allow?

I have given transfusions to children of Jehovah's Witness children. Virtually all of the parents consented tacitly by not opposing the court orders we obtained in order to give the transfusions. I never felt bad about that until I visited a web site which refers to JW teaching on the subject as "moronic"

That made me more uncomfortable than you might think, given that I believe they are misinterpreting the scripture.

Why?

Because I can see a battle coming. If ever there is any successful treatment from embryonic stem cell research, I would refuse that treatment. I would refuse to allow my child to have that treatment - even if it meant that my child would almost certainly die. I believe very strongly that life begins at conception and that destroying embryos for research purposes is a great moral evil.

I still think that the Jehovah's Witnesses are misinterpreting the scripture. If a child's life is in danger, and if we can get a court order for a transfusion, I'll still give it. I will have a great deal more sympathy for those parents, though.

Religious beliefs in the NICU - Jehovah's Witnesses

My first experience as a NICU nurse with a Jehovah's Witness family was in the 1970's. The baby had severe hydrops fetalis because his mother was Rh negative and had developed antibodies to the baby's Rh positive blood. This sensitization very likely occurred prior to the introduction of Rhogam.

The baby was so critically ill and so unlikely to survive that our neonatologist opted not to request a court order to permit him to transfuse the baby. He felt that it would cause unnecessary pain for the family without any benefit to the baby.

Since then, I've had the opportunity to discuss blood transfusion with several families who are Jehovah's Witnesses. Their responses vary.

The very young moms who have been raised in the faith tend to say, "I can't give consent, but you can get a court order, can't you?" Not always the case, but they often have to balance their concern for the baby with their relationship with relatives.

The physician's answer is always the same. "We'll try to avoid transfusing your baby, but we can get a court order if needed." Care for those babies isn't significantly different than for our other preemies. We try to avoid transfusions in all of them if we can. The one difference is that the babies for whom we need a court order get an appointed guardian who has to approve any transfusions. It's not simply left up to the physician once the court order is in place. The guardian, who is generally a hospital administrator, has to be convinced of the need. I've only seen one transfusion refused, but the guardians take their responsibility very seriously.

Older Jehovah's Witness families don't always have the hard-line belief that all transfusions are prohibited for all members of the faith. Some believe very strongly that transfusion is always wrong. Others believe that it would be wrong for them to have a transfusion, but that their baby is not yet in a position to make that choice. They, like our appointed guardians, want to be convinced that each transfusion is actually needed, but they will sign the consent form themselves. Retaining control is probably an important part of choosing that path.

While doing some background reading for this post, I discovered a web site titled Associated Jehovah's Witnesses for Reform on Blood. The site says that they have members who are or have been elders or members of Hospital Liaison Committees. They disagree with stated positions of the Watchtower on the use of blood and blood products and say that they hope to educate Jehovah's Witnesses on what they call inconsistencies in doctrine.

I don't share the Jehovah's Witness belief that it is a sin to use blood or blood products, but I do appreciate the technological advances that have resulted from medical and surgical attempts to minimize or avoid transfusions. Transfusions save lives, but they're not free of risk.

And one more thing

I know the nurses who took care of my husband must have been glad to see us go home. He's a notoriously poor historian with a couple of significant allergies. He remembers the one about the shellfish, usually, and nearly always forgets to tell them about the peanuts. At least the peanut allergy isn't an issue until they start feeding him. Then he remembers and they ALWAYS want to know what else he's forgotten. Can't blame them.

He can't remember the name of the drug that made his platelet count drop to 30,000.

And neither of us thought it would be a problem to simply give them a list of his medications without a list of "not allergic, but do not give" meds. We were trying to figure out which medications he'd been given prior to discharge and which he might need to take when he got home. Plavix, check. Toprol, check. Aspirin, check. Zocor. Yes, he got Zetia and Lipitor.

"Wait. He got Lipitor? You can't give him Lipitor...."

and then I remembered we hadn't told them about the whacko liver function studies when he was taking Lipitor. And he'd referred every single one of them to me to review his medications and history -- well, everyone except the house doc who wrote the orders and the nurse who'd given him the Lipitor without telling him the name of the damn pill. He'd have remembered if he'd been told the name of the pill.

One isn't going to kill him, of course, but it is aggravating - both that we forgot and that he had a nurse who couldn't be bothered to tell my husband the names of the pills he was handing out.

I need to do a little training: "Yes, honey, you need to ask the name of EVERY SINGLE PILL. I don't care who is giving it to you. Don't put anything in your mouth until you know its name."

Vaccine, Autism, and Statistical Nonsense

Since Med Journal Watch has comments turned off, I'm going to comment here.

He's right on nearly all his points, but he missed a BIG one.

The discussion of Autism related to the alleged prenatal exposure to Thimerosal from Rhogam requires a visit to the Rhogam web site

Since at least 2001, THERE IS NO THIMEROSAL IN RHOGAM. Scroll down. You'll find it.

Once again, statistical nonsense which totally ignores reality. Thimerosal must cause Autism, according to the anti-vaxers, so there must be thimerosal in Rhogam.

Even when there isn't.

Update: See Christian's comment. The only thing he missed was the date when the Rhogam (or similar product) was given. The study subjects were prior to the exclusion of Thimerosal.

I haven't been able to access the full text of the study yet. I'll keep trying, but I did a little investigation of the researchers. Christian, of Med Journal Watch, is quite right to be suspicious. The researchers definitely have a dog in this fight. Dr. Mark Geier is a paid professional witness in anti-vaccine trials. He has had his testimony stricken on at least one occasion because he did not have the necessary credentials to be an expert witness in that case.

Additionally, Dr. Mark Geier has been cited for attempting to breach confidentiality and had a different study suspended for that reason.

For some very interesting information on the Geiers, see this post on the Neurodiversity Weblog.

As an Rh negative mother of a young adult with ADHD (too old to have gotten prenatal thimerosal), I'd be interested in research that truly shows a higher incidence of any type of developmental issue in children of Rh negative women. The study population was only 53 and it truly was not a prospective study in the way I understand prospective studies. Further research would be interesting, but I'd want it done by someone who doesn't have anything to gain other than knowledge.

Making a difference

Abbie Armstrong comes from a family with a tradition of changing lives. She's carrying on the tradition - even before she graduates from nursing school.

While still in high school, she was invited to fill an empty seat at a fundraising dinner. The dinner was to benefit the people of the island of Sumba, a small island in Indonesia. No, I never heard of it before I read the story either.

The pictures Abbie saw at that dinner weren't the pretty tourist pictures on the first link. They were the pictures of the indigenous people of the island. The people who have very little in the way of health care - and often not much in the way of clean water or protection from malaria.

Abbie's life was changed forever that night. She decided that she must visit Sumba - and it was arranged. She decided that she could not go empty-handed, so she invited friends and family to donate money, not knowing how it would be spent before she left home. The rest of her story is truly inspirational. Abbie's life has been changed, but not only her life. Read the article to see how one person can make a difference - if they are willing to make the effort.

Surviving childhood -- your children's

My friend Pippa, of Pippa Said is having a little trouble with her youngest child. Said child likes to play in the street. And is being encouraged by the older siblings. Pippa could use some advice. Mine would be along the lines of "Have a glass of wine."

Drinking won't help, of course, but when your kids act like that, the neighbors already believe that you do. I should know. I have boys. 3 of them.

My oldest was fond of playing in the street. I didn't exactly encourage it, but blink and he was out there. It was the one infraction for which I routinely spanked - accompanied by the admonition, "If a car doesn't hit you, I will. Every time."

To which my son would respond, "That doesn't hurt!"

Kid never knew how close that put him to death. He did survive - his excursions into the street and his mother's wrath.

He's the only one of my kids I never put the "Mother's Curse" on -- you know, "I hope you have a kid just like you!" I was too afraid he'd ask me to babysit.

Want to know what life was like when he was little? I once told a co-worker that nobody who'd read Ransom of Red Chief, by O. Henry, would ever consider kidnapping him.

Part of his problem was that he had a significant speech delay. At age 3.5, I could only understand about half of what he was saying. This was quite frustrating for both of us. Only after his speech improved did I realize that it was actually a mixed blessing.

I also learned of the hazards of teaching small children the correct names for their body parts.

By age 3 3/4, after only a couple of months of speech therapy, he could very clearly (and very loudly) ask, "Mom! Mom, does that man have a penis?"

Loud. Every time he saw a man standing still in a public place.

I knew it was really about the attention, so I'd try to ignore him, because shushing just didn't work. So of course he'd ask again -- louder.


Eventually, I took a chance.

"I don't know, honey, why don't you ask him?"

To my everlasting relief, he did not.

Tiny Turtle update

Most of tiny turtle's meals consist of Romaine lettuce. He gets a little tomato, little bits of fruit, and as a special treat a tiny cricket to hunt or a bit of shrimp. We're still having a drought here, and worms are mighty hard to come by.

The turtle prefers his lettuce leaves large. He crawls underneath and nibbles from below. We're all entertained by the moving lettuce leaves. With most other foods, he hides until he thinks we're gone before he will come out to eat. With the shrimp, he just doesn't care. He'll eat in front of whoever happens to be around. He looks damp in the picture because I had just misted his terrarium to keep him from having a drought in there too.

He's grown a little. His shell is now 38 mm wide and 41 mm long. He seems to be healthy. He's quite active in the early mornings when there aren't many people around. His skin looks clean and his eyes are shiny. He's quit hissing at us, so I think he's getting used to us. He still likes to hang out in his little pool, but never when I'm looking. I can tell by the little turtle footprints he tracks into the water.

More to read!

Pediatric Grand rounds Volume 2, Number 8 is up at Highlight Health with a Harry Potter and the Deathly Hallows theme.

Thanks for including my post on the challenge of teaching something I do almost without thinking.



Change of Shift: Volume 2, Number 3 appears in a very colorful format at Musings of a Highly Trained Monkey

and finally, Grand Rounds appears on Health Business Blog

Vacation Bible School

This week, in addition to my other entertainment, I assisted at my parish Vacation Bible School -- with a western theme - Wah-Hoo!

My part, fortunately, was very scripted. I don't think I could have managed otherwise.

Day 1. The story of Rahab, who hid the spies sent by Joshua from the King's army. Joshua, chapter 2

We had the "spies" hidden under a sheet and when the soldiers came, I tossed more sheets over the kids to hide them too. The soldiers were actually voices on a CD and I only had to read my part and poke the kids with "swords" and "spears" through the sheets. Before I uncovered the kids, the "spies" (also on the CD) gave me a red cord to hang from my window so I wouldn't be killed when Jericho was destroyed.

Day 2. Joshua's Army crosses the Jordan river. Joshua, chapters 3-4. The river is flooded, but when the priests step into the river carrying the Ark of the Covenant, the waters are parted and the army crosses on dry land.

We put several thick towels on a tarp and soaked them. Then we had the kids take off their shoes and cross the "marshy ground" to approach the river (blue sheets held up to look like a flooded river. When the kids approached the river they could feel the spray from the flooded river (my partner had a spray bottle) and when the "priests" touched the river, it dropped away revealing rocks on the "river bed".

Day 3. The walls fall down. Joshua, Chapter 6

I was at the hospital with my husband, but my co-teacher had this under control. He had the children marching around the "walls" he'd set up and when they stopped and sounded their "horns", he had a pull-down video screen that rolled up like a window shade - causing some of the kids to bolt out of the room. I'm sorry I missed that one.

Day 4. The resurrection. Mark 15-16 I missed that one too, but my co-teacher had about 30 balloons blown up and hidden. When it was time to announce the resurrection, he pulled them out of hiding and tossed them around the room. The kids won't forget that any time soon.

Day 5. Naaman is cured of leprosy. 2 Kings 5: 1-14

We set up by the "Jordan River" again - this time with pots of water. We rubbed onion on the kids to give them an idea what it would be like to have leprosy. Some were upset. Some said they thought it smelled good - at first. By the time we cleaned the smell off, they were all glad to be rid of it.

Believe it or not, you can take the smell of onion off fairly quickly by rubbing the skin, under water, with the back of a stainless steel spoon. I have no idea how that works, but it does.

Afterwards, I dabbed vanilla extract on the back of each hand and invited them to "let God be in control" of their lives. That was a big hit after the onions.

Finally, it was back to the parish hall for the closing and traditional pizza party. I asked some of the kids if they plan to come back next year -- and got a resounding YES! from each one.

The program we used is Avalanche Ranch by Harcourt and each part of the program is scripted so that the teacher can just follow the program. You can choose your own crafts, but theirs come in kits and fit into the program themes. Our director of religious education opted to purchase a CD with all the music for each of the kids. It's well worth it. The kids who attended last year's camp still have their CD's and still sing the songs - whenever their parents can stand it. The music is peppy and upbeat. Some of it they already know, the rest written for VBS by PROFESSIONAL musicians.

I can't wait to see what they'll have for us next year.

Men

Could someone please explain to me what part of "Take it easy for a few days" would lead a man to believe that his doctor had given him the OK to go out and clean the swimming pool the day after a cardiac cath with stent placement.

I'm not sure I'm going to survive this. I really need a nap, but I do not dare go to sleep before he does.

Adoptaplatoon.org

One of my co-workers told me about an organization called Adopt a Platoon which matches deployed troops with individuals, families, and organizations in the US who send letters and care packages. She's been doing it for a while.

They're very careful to protect the identities and addresses of our troops, so it can take a while to get cleared by the organization. I got home from the hospital last night to find my acceptance notice from them. The first letter will go out in the mail today. The first care package will go early next week. After that, letters at least weekly and care packages at least monthly.

They have lists of suggested (and prohibited) items so I'll have a clue where to start - and in case our troop isn't able to let us know what he or she really needs. I plan to send a check list in each package with a self-addressed envelope that simply lists the contents with a spot to check "send more soon, send more later, and send something else instead." I hope he or she will not worry that our feelings will be hurt by checking that last one, because I'd much rather send things that are wanted or needed. I want to keep it really simple, because his/her free time can be better spent writing home than writing me.

There are tips on the web site I'd never have considered - like newspaper not only makes good cushioning material for care packages, but may serve double duty as reading material when it gets there. That means my local newspaper would probably be a better choice than the larger city paper to which I also subscribe, except perhaps for the city paper's comics.

It was a long day, but not a bad one

They took my husband to the cardiac catheterization lab at about 12:30 and told me the procedure would take 45 minutes to an hour. 3 hours later, he finally made it to the recovery area. At least he's consistent. He never makes any procedure easy for the physician who has to perform it. Thanks to the nurse who came out every 45 minutes or so, I was kept up to date on the progress and knew he was doing as well as could be expected.

I have only good things to say about this visit so far - from the valet service to the medical and nursing staff. Everyone has been wonderful. I'd love to know how they jam cell phones, but there was always a telephone around I could use when I needed to contact family to let them know how things were going.

I was concerned about leaving him for the night -- until I met his night nurse. The nurse is a former Scout leader, so they hit it off right away. After watching him work for a little while, I had no worries about the quality of care he'd get either.

Yes, I took names, and yes, they'll be going in a complementary letter - along with a thank-you to all the cheerful, but nameless faces who made the day more pleasant.

Vaccines lead to age-related diseases

I had an interesting conversation recently with a friend who made the above allegation. I promptly went into defense mode and gave my rant about people misunderstanding vaccines.

Turns out my friend had no such misunderstanding. She simply meant that, prior to immunizations, most people died before they had the opportunity to experience such ills as arthritis, heart disease, cancer, type 2 diabetes, and all those other diseases we may experience on the far side of 40.

Informed consent?

My husband has a cardiac cath scheduled for Wednesday to check a couple of relatively small areas with decreased perfusion after exercise. 9 minutes on the treadmill and he was having no chest pain or shortness of breath when they did the scan. If he was less active, he'd never have known he needed to get this checked out. His only symptoms were some dizziness and shortness of breath when he spent 20 minutes on a stair climber at the gym last month. That and if he mows the lawn when the temperature in the 90's he gets a little winded. I'm glad he's paying attention. Lots of people would think that was normal.

It sounds like he may need a couple of stents, but that there hasn't been any damage done - yet. I listened as the cardiologist explained the procedure - in very simple language. I watched as he explained the risks and asked if we had any questions. I was the only one asking questions and those were mostly "When and where?" As soon as the cardiologist left the room, my husband looked at me and said, "So is there any danger that the procedure could trigger something?"

Well, yes, but not much and it's safer than not doing it.

The interventional cardiologist will review all this with him again on Wednesday, but I expect that the conversation will be the same. He will have no questions for the doctor and lots for me as soon as the cardiologist walks out of the room. Good thing these cardiologists explain things so clearly. I know the vocabulary, but this sure isn't my area of expertise.

Preceptor -- learning to teach heel stick blood draws

I occasionally help orient a new staff member or precept a student. I really enjoy this, because it makes me think. They always have questions. The one that makes me really think about how I'm performing a technical skill is "Why does this work for you and it doesn't for me?" -- could be blood draws, could be getting a preemie to eat. Could be something more technical.

When I get asked that question, I realize that I failed to properly explain the skill. I have to think through every single step of an action which has become so ingrained that I barely know how I'm doing it any more. Only by watching someone do what they think I've told them and what they think I've demonstrated do I learn the subtleties of finger placement so I can explain a little better the next time.

One thing that is exceptionally easy to do, but hard to teach is heel stick blood draws. Everyone does this a little differently, so in addition to demonstrating my technique, I encourage the student or orientee to observe other nurses and adapt the various differences in technique until something clicks.

There are some basics, though.

Prepping the skin is simple - clean with antiseptic (alcohol for most heel sticks), allow to air dry. I watched a new resident prep skin for a blood culture once. He went through the routine and then BLEW on the site. No. I didn't let him draw the blood until he'd re-cleaned the area.

We use an automatic safety lancet designed for heel sticks. Placement is important -- on the side of the heel, not in the center. Choice of inner or outer side depends on the baby's position and whether the nurse is right or left handed. It also may depend on just how badly damaged the skin already is.

Those things are easy to teach. Much harder is teaching just how hard to squeeze a given baby to get the blood you need without damaging the baby's skin or leaving a bruise. Most people are too gentle at first and have to be encouraged to squeeze just a little harder. With the smaller preemies, it's important to keep your fingers from slipping so that you don't tear the skin. With all of them, technique has to be adjusted to the gestational age and the baby's general condition.

It's important to get a free-flowing specimen for CBC's (blood counts) and electrolytes. If the blood isn't flowing freely, the CBC might clot and give false readings (or be rejected by the lab) and with electrolytes, the serum potassium can be falsely elevated if the blood cells are hemolyzed. Warming the heel prior to sticking helps. So does wiping off a drop of blood after every 2-3 that you collect. It's also important that the blood flows into the microtainer instead of being scooped off the skin. Scooping picks up micro clots which lead to bigger clots or which contain hemolyzed cells.

The objection I hear most often to wiping those drops is that the new nurse or student doesn't want to "waste" blood. It wastes more blood if the specimen is rejected due to a clot or gross hemolysis.

The microtainers we use have lines to let you know when you've collected enough blood. Some tests require that the container be filled to the top line, some just to the bottom one. For CBC's, it's important to fill to a level between the 2 lines so that there is enough blood for the test, but not too much for the EDTA that keeps the blood from clotting before it gets to the lab. Inverting the tube a few times (after capping it) helps to mix the blood with the EDTA so it doesn't clot. It also gives you the opportunity to examine the specimen for clots before sending it to the lab. If you can see a clot, toss the specimen and try again. There's no sense wasting the lab's time by sending an obviously clotted CBC.

Once you've collected the specimen you have to get the baby to stop bleeding. That can be as simple as placing a bandaid or gauze and tape on the area - or applying pressure for a couple of minutes. If the baby has a low platelet count or other bleeding issues, it can be much more difficult. Since a preemie has about 100 ml/kg total circulating volume, you want to avoid any unnecessary blood loss. The tiniest preemies have skin that is too fragile for bandaids or tape, so I generally apply pressure until the bleeding has stopped.

Breathe

The cardiologist called while I was napping Friday in preparation for work. He talked to my husband, so I STILL don't have the whole story. Apparently, the Thallium stress test was normal, but there was something on one of the other tests he didn't like. Something about a couple of those things they fixed when they did the bypass (I'm quoting here). I gather the blood flow through 2 of his 5 grafts isn't as good as it was on the last echocardiogram. Good thing he had some urgent errands to run after he told me that, because I hyperventilated for about 30 minutes. I don't think it would have helped him much to watch me panic.

The good news is that I don't have to wait until the bills come to find out what tests were done. We have an appointment at 11 on Monday. This time I'm not sitting in the waiting room.

Overheard in the Cardiologist's Office

My husband had a marathon appointment today. He hadn't been in 3 years so they did the WHOLE workup. He wasn't sure what some of it was, so I guess I'll find out when the bills come. At least the cardiologist didn't stop him at the door and tell him to go straight to the hospital.

So I sat in the waiting room with and without him for over 3 hours while the testing was done.

Secretary (on the phone): "You have some tests scheduled for Monday. I have just a couple of questions for you."

"How tall are you?"

"How much do you weigh?......No, I can't write that down. I need a number - it will be just between you and me.........No, I won't post it on the internet. Have a nice day."


And later - conversation between 2 of the front desk personnel:

Secretary 1: "Oh, my face just went numb. It isn't drooping or anything is it?"

Secretary 2: "No. It looks fine."

S1: "It's gone now. I guess it was a TIA."

S2: "Let me look at your eyes. Your pupils are equal. It wasn't a TIA. You'll be fine."

Alrighty then. I think if I worked in a cardiologist's office, I'd want an opinion from someone with just a smidge more medical training than the front desk folks. I'm sure they pick up a lot from hanging around the office, but I'm anal like that.

Some people sure are gullible

There's a "children's book" being discussed in several places on the internet. It allegedly has the title Thanks for Dying Jesus and subtitled This Candy Sure is Awesome.

The folks who posted the image to their web sites apparently failed to notice the web site in the lower left corner of the image. It's called somethingawful.com Articles, reviews, images, video. It's all awful.

Don't click if you're easily offended or if there are children in the room. There are 10 pages of "Children's Books" and the Thanks for Dying isn't even the most offensive. Most of the others are funnier, too. You'll find those and lots more under the Photoshop Phriday link

If you google that title, you'll find a host of web pages apparently taking it seriously. Even I'm good enough at photoshop to have managed that one. Some of the others, maybe not.

Training

Babs, RN has some interesting discussions going on in the comments section. One of them reminded me of my 30th birthday.

My husband had never missed a birthday, to that point. Hasn't since, I might add. I always know he's remembered because I wake up to cards and flowers. EVERY birthday.

Except for the 30th.

Nothing. Not a card. Not a flower. I knew he'd forgotten. I was a little disturbed, so I decided I'd take a lesson from him. He's fond of the expression, "Don't get mad, get even."

So I went to the large wall calendar in the kitchen and wrote, "Judy's Birthday" on the calendar. And didn't say one word about it when he phoned that afternoon - or when he came in from work. Empty handed.

He checked the calendar and allowed as how he'd forgotten an important errand. Right.

When he returned an hour or so later, he had gifts, flowers, a card - and had arranged a sitter for a dinner date.

I told the story to other people for years before I finally admitted to him what I'd done. He didn't have a clue.

Anniversary? He hasn't ever missed one. I had that date engraved on the inside of his wedding band. Prior to the wedding.

Summer of Sextuplets

The Mache sextuplets last update was 10 days ago. At that time, the babies were 2 lbs, 7 oz to 3 lb 7 oz. Babies that size gain 10-30 grams/day (1/3-1 ounce), so it's possible that one or more is over 4 lbs by now.


The Morrison 6 are down to 2, but according to a regular poster at Quintland, those 2 are growing and tolerating their feedings. It sounds like they are probably still "critical" and there is no news yet on the Morrison6 web site.

There are 2 more sets of sextuplets whose families have chosen to publicize their pregnancies:

The Soldani's, in San Jose, CA, are a little over 21 weeks. They're hoping to make it to at least late August, when they'll be closer to 28 weeks. Single babies born at 28 weeks have about a 75% chance of surviving with no major handicaps. If they can hold out to 30 weeks, like the Mache's, that increases to about 85%. The linked article is worth a read - the Soldani's are about halfway down, but it starts with a set of quads and there is some discussion of couples who have made the choice to reduce or to limit the number of embryos implanted.

The Bylers, in Florida, are 22-23 weeks gestation. They are at the cusp of viability and hoping to hold off delivery until September.

I work in a 20+ bed level III community hospital NICU. A parent recently asked me how we'd manage sextuplets. I told him I didn't think we'd ever have to. There are several larger (40+ to 70+ bed) units within an hour of us. It would make much more sense for quintuplets or sextuplets to deliver at one of those hospitals.

There is no reason for a hospital to be surprised by sextuplets (or quints, quads, or triplets for that matter). Women who are expecting higher order multiples know about it ahead of time and most of them are admitted to the hospital days or weeks before the babies are delivered. One reason is that it's very difficult to eat enough to support that many babies and some moms are supplemented with high calorie IV feedings. The other reason is to monitor the babies and the mom. There are significant risks to both with these higher order multiples.

We've managed quads with relative ease, but the babies were 28-32 weeks and the deliveries were elective -- and in daylight. We prefer our triplet deliveries to be elective too, but we've managed them emergently several times - and anywhere from 23 weeks to 35 weeks. We don't get too stressed about triplets any more. We just put on our roller skates and kick it up a notch.

So how does a NICU prepare for higher order multiples? I can't speak for everyone, but I know how we do it. As soon as we know that triplets or quads will be delivering at our hospital, we start making contingency plans. That means casual lists of nurses who are willing to be called in on short notice for that particular delivery. They might not be willing to give up sleep or a scheduled event for just any busy night, but they're willing to make the sacrifice for what, to us, is a relatively unusual occurrence. They're hoping not to get that call. The nursing supervisors on each shift check in with us about those contingency plans and keep lists of personnel in-house they can send us if anything changes before we can get our own personnel in.

We also make sure that we have the appropriate number of baby beds available for the delivery and for the admission to the NICU. They may not actually be IN the NICU until we know that the delivery is imminent, but we'll make sure they're "dressed and ready" (stocked with the basics for an admission).

We hope that the delivery will be elective -- a scheduled C-section with all of the necessary staff pre-scheduled, the beds set up, and all the little details in place. That doesn't always happen, of course, but it's the ideal. The larger units have proportionally larger staffs with more nurses scheduled on any given shift. They'll have their own contingency plans, too. I'm sure they still prefer to have their higher order multiples delivered electively, though.

So how do you stress a NICU nurse?

"Oh. There's another one in here" The mom had no prenatal care and arrived crowning - a true OMG moment. Fortunately baby #1 was doing fine, because there was NO time to get a second team into the DR.


Updated to delete links that are no longer relevant.

Free Books! (well almost)

Thanks to and these Thy gifts for pointing out BookMooch - a web site for swapping books.

Then there is also paperbackswap.com

More than paperbacks on both sites for the cost of postage - you pay for those you send out those sending to you cover the costs of their postage. I've been on paperbackswap for over a year now and have been very pleased. I'm looking forward to BookMooch now.

IV Therapy Escapades - Part VI

In which I learn the importance of clearly differentiating unresponsive vs napping.

In real life, I'm a NICU nurse. However, I spent a few years filling in a shift here and there as an IV therapy nurse. I learned many things in that job.

I was frequently laughed at because I talked to ALL the patients the same way - except maybe the little kids. I explained everything to everyone. Even the comatose. You never know if they can hear you.

I started a lot of IVs on unresponsive patients. Most were quite elderly, most were noticeably debilitated. Not all of them. This man was in the age rage of most of the unresponsive patients I'd seen. He didn't respond at all when I spoke to him and gently shook him. He didn't flinch when I placed the #22 catheter in his arm and secured it. Not even a little bit. Not a sound. Not a twitch.

OK. Move to the other arm to remove the old IV. Gently start to peel back the tape from one rather hairy arm. Yes, I was careful to go with the direction of the hair, so as not to leave a bald spot. I even used alcohol to loosen the tape before I started peeling. I leaped back out of the way as the tape tugging on his hairy arm brought him from unconsciousness to snarling almost instantly.

"Can't a man get a little sleep after surgery?"

After I apologized and he realized that he'd slept through the restart, he let me finish removing the tape and the old IV catheter. That's how I learned not to be so gentle when trying to rouse "unresponsive" patients.

Part VI of an occasional series

Part V
Part IV
Part III
Part II
Part I

Pediatric Grand Rounds!

Pediatric Grand Rounds is up at Parenting Solved. As always, there are many links to fascinating posts. Thanks for including my post as well. They're looking for people to host PGR, so if you're looking for an opportunity to read lots of submissions and put together an upcoming PGR, contact Dr. Clark Bartram.

Turtle Safe

Tiny Turtle seems to have settled into a routine. Eat, sleep, hide. Mostly hide.

We've had a drought around here and catching worms is more of a challenge than I care for. I priced some night crawlers at the bait shop and decided that shrimp was a better bargain, given how little this turtle actually needs to eat. The humans here will be finishing up the rest of the pound of shrimp after he chows down on his quarter of a small one.

Usually I clean his rock, put his food on it, pull him out from his hiding place and show him the food. He hisses at me, hides, and comes back later to clean off the rock. Today he hissed at me, but then chowed down. It's the first time we've actually seen him eat.

Today's salad consisted of the aforementioned quarter of a small shrimp, quarter of a small grape, quarter (maybe less) of a grape tomato, and Romaine lettuce all chopped small for a small turtle. He's ripping through it as I type.

On the back of the shrimp package in bold red letters it says

TURTLE SAFE

We got a good laugh from that. My first thought was, "How do they know what we're doing with the shrimp." Then I realized that they meant none of his relatives were put in danger for this meal. I think I need a nap.

Sextuplet Buzz

A lot of hits here are people looking for updates on the Masche and Morrison Sextuplets. The Masche family updated their web site last week. It's on the newsletter link (left side of the page). They have new photos of the babies as well, if you're curious. In the photos, I see that the babies are still in incubators - no surprise, given the sizes listed in the newsletter. They're growing, but still small. They have feeding tubes and monitors, and according to the newsletter, Cole will need some sort of surgery on his colon - no details given. The family requests that the pictures not be forwarded, but they've been very generous in posting pictures on their web site and it must have enormous bandwidth to still be up at this point. They expect to start bringing home the most stable babies in 2-3 weeks, or shortly before what would have been the due date for a singleton pregnancy. The Maches have huge challenges ahead even if the babies have no developmental delays or other issues related to prematurity.

I haven't found any updates on the remaining Morrison Sextuplets, but their photographer friend had posted a short note on July 5th stating that there would be an update soon from the family. Your best bet for news about them will probably be the Morrison6 web site. I'm sure both families will appreciate your ongoing prayers.

More to read!

Grand Rounds is up at Aetiology and Change of Shift makes an appearance at NursingJobs.org

Pancuronium = Pain relief? For whom?

Kevin, MD pointed out this story of death in a UK Neonatal ICU.

A British medical consultant (the equivalent of a neonatologist in the US), was treating 2 very pre-term babies whose condition had become hopeless - or nearly so. With the parents in agreement, he removed the babies from their ventilators in order to permit them to die. I don't have any issues with this part of the story. It's something that is done more frequently than most people know. It is not ethically different to withdraw life support than never to start it - more difficult for the families, but not different ethically.

The babies were given morphine to help keep them comfortable -- again, the ethical choice. Suffering should not be permitted in the course of dying if it is in our power to prevent it. The dose was not too large. If anything, he gave too small a dose, because the babies began agonal breathing. Gasping. If they were adequately sedated, they wouldn't be uncomfortable, but there is simply no way for them to tell us, so their parents were understandably disturbed by the gasping.

The physicians choice, apparently, was not to administer more morphine, but instead to give a drug called pancuronium (Pavulon) which paralyzes the muscles. It doesn't provide ANY relief from any sort of distress. It stops the breathing and almost certainly speeds up the dying process. Death by suffocation.

The article does a fairly good job of laying out the realities of dying infants and the distress of their parents. I have a great deal of sympathy for the parents. I am horrified at the physician's choice - not so much because it hastened death, but because of the mechanism. Imagine being paralyzed, but fully aware. Just as we have no way of knowing if those babies were suffering before he gave them the Pavulon, we have no way of knowing if they had any relief from suffering. They may have been totally aware of being unable to breathe. Worse than gasping? I don't know, but it's not something I'd want to find out.

He may have been treating the parents' distress, and possibly his own, but he did NOTHING for that baby by giving the Pavulon.

I have friends who were present when a neonatologist suggested using Pavulon when a baby was taken off the ventilator. The nurses in the room made it quite clear that this was not an acceptable course of action, and he prescribed morphine in doses adequate to keep the baby comfortable instead. I wasn't present, so I don't know how much gasping occurred, but the parents were assured that the baby had enough medication to be comfortable in spite of any gasping. Death was not immediate, but did not drag on for hours either, according to the nurses present.

I would love to know what conversation took place between the British physician and the nurses there. Did they try to persuade him to take another course of action, or did they simply watch and then report him afterwards? I sincerely hope it was the former and not the latter.

So what is Pavulon used for? It is used - with the patient intubated, ventilated, and under general anesthesia or very heavy sedation - to achieve complete muscle relaxation - paralysis, if you prefer, because it prevents voluntary muscle movement. When the patient is under general anesthesia or heavily sedated, this can be theraputic. It is necessary for many kinds of surgery and it is beneficial when there is no other way to ventilate a patient who is struggling in spite of heavy sedation. Without the anesthesia or sedation? It's called anesthesia awareness, and adults who've been through it are traumatized.

For more on the subject, see Geena's post at Code Blog and another by Kirsti Dyer, MD at NICU Parent Support Blog. Finally, read Dr. Crippen's thoughts at NHS Blog Doctor.

I don't think so

You paid attention during 100% of high school!

85-100% You must be an autodidact, because American high schools don't get scores that high! Good show, old chap!

Do you deserve your high school diploma?
Create a Quiz

Paid attention in high school? Not. If I had, I wouldn't have scored nearly so high. Most of what I know I learned by paying attention to life - and reading good books.

I did pay attention in Band, though. Mr. Pindell wouldn't tolerate anything less.


Hat tip to Shoe Money Tonight for the quiz.

Slow news day. I went back and "corrected" my answers until they were all wrong - including the ones about age and gender. Those apparently get marked right no matter what you put, so the lowest possible score is 17% - and the comment for that one is:

17-33% I hope you don't vote, because that would be irresponsible. You know high school education is free in America, right?

New on the Sidebar

And way past time. I've been reading them pretty much every time they post for quite a while:

Trauma Queen - EMS on the other side of the pond. I'll feel much safer knowing he's about if I ever get over there. Great stories too.


The Lawdog Files - a peace officer somewhere in the US who really knows how to tell a story. It's generally advisable to swallow before you start reading.


Crass-Pollination -- ER Nurse Blog

Hope

"Please, just tell me that it's not hopeless."

The dad had walked up just as the echocardiogram technician uttered the words, "Bad. That's very bad."

I'd caught his expression at the time, but he just walked away without saying anything and saved his request until she left. There wasn't much I could say.

The tech had showed me the defects she saw and it looked pretty complex, but I really didn't have any information that would be helpful to him. The cardiologist hadn't even seen the echocardiogram yet - it was still being transmitted to the world-class pediatric cardiology center (WCPCC) where we were planning to transfer the baby.

I took a deep breath and said a silent prayer. How to leave him with at least a little hope, but no promises? It's never easy.

"I can't promise you anything. Even the cardiologist at WCPCC can't give you answers until she reviews the echo, examines the baby, and maybe not until she does a cardiac catheterization or other studies to find out exactly what's going on. I can tell you that we're sending your baby to the hospital where I'd want my baby to go in this situation -- and that they can fix things now that nobody could fix 20 years ago. Your baby was born at the right time, in a part of the country where we have several nearby cardiac surgery centers. Your baby is going to the best one. It's not hopeless."

Then I watched him walk over to his wife and promise her that everything would be fine. I wondered if I'd said the right thing.

The transport team arrived shortly afterwards to take the baby to WCPCC. The next evening, we heard that the baby did have a correctable defect. She would require several surgeries before her heart was completely repaired, but it was definitely not hopeless.

Grand Rounds

A special edition for July 3 is up at Over My Med Body.

Tiny Turtle

My son found him in the back yard this morning. The shell is 36mm wide and 40mm long. He gets to stay with the understanding that my son keeps a journal and does most of the maintenance work involving the turtle - that means he'll have to do some serious reading on the subject.

The last turtle we found was about half this size. We kept that one healthy until he got too big for the 10 gallon aquarium where he spent most of his time. He was about 4x6" at that point. A friend invited us to release him on his many acres of land, which included a strawberry patch and a pond. In a couple of years, this one may get to join him.

One thing we learned about turtles the last pass is that they absolutely love ant larvae. No shortage of those around here.

Supporting the families of the troops

A friend of mine is sponsoring an effort to support the families of deployed Marines. She's organizing an effort to send care packages to moms of babies born while their dads are deployed.

Operation Marine Corps Kids will send care packages to the families of deployed troops when babies are born. The packages might include a hand-crafted baby afghan, cap or bonnet, booties or toy. With sufficient resources, we'll also be able to include a handmade toy for other kids in the family. It's a small, but significant, gesture of love and support for those who keep the home fires burning alone.

I'll be adding them to the side bar as well. Donations of hand-crafted items or hand-made toys very much welcome. More information on the Marine Corps Kids web site