Friday, March 30, 2007

The Cable Box

Every time I drive past that cable box, I think about Michael. I wonder how he's doing. If he's in college or working (or both).

I met Michael near that cable box one late fall day. I was driving home from somewhere - no idea any more. The first thing I noticed was the small group of cars on the opposite side of the road. Then I saw the skid marks heading into the woods - and the car. It was upside down, windshield out. I pulled over, grabbed my cell phone and hopped out of the car.

As I stepped out, Michael stepped out from his side of the road. "Do you have a bandaid?" he asked. "I need a bandaid."

I glanced at the trickle of blood on his arm, then tried very hard to control my facial expressions as I spotted the bone protruding a few inches below the elbow. Deep breath.

"Sorry, I don't have a bandaid." He started to walk back across the road.

I spotted a friend, Linda - another nurse - who had also stopped. "Anybody call 911 yet?" I asked.

"My husband drove up to the fire station." she responded. It's only a few blocks away and cell service is spotty out here, so that made sense. I tucked my phone in my pocket and turned toward Michael.

Another vehicle approached and Michael started out in the road again. My friend and I reached for him simultaneously. "I need a bandaid." he said again.

Trying to keep my eyes on his face, I repeated that I didn't have one. He whipped off his t-shirt and wrapped it around the arm. Good. He doesn't seem to notice the bone.

We steered him to the side of the road and helped him to sit on the cable box. Fingers lingering on his wrist, I wished I had my watch with me, but his pulse was strong and slower than mine. No obvious trauma to his chest or abdomen.

"Was anyone else in the car with you?" I asked.

"No. I was going to see my girlfriend. My parents are going to kill me when they see the car."

My friend Linda diverted his attention and assured him that they would not. She tried to calm him with stories of her own experiences. He suddenly remembered that his homecoming dance pictures were in the car and tried to get up to retrieve them. Linda distracted him again and I went to see if I could locate the pictures.

I approached the car cautiously, remembering the warnings I'd gotten from my EMT son about the risks in any serious crash. No signs of smoke. No gasoline odor. I glanced in the windows and spotted a backpack in the pile resting on the interior roof of the car. I wondered again how he managed to escape more serious injury. He insisted he hadn't been speeding, but the skid marks told a different story. Thank goodness he'd been wearing his seatbelt. Air bags had deployed too.

I lifted the backpack, hoping the pictures were inside. They were under the backpack. I showed them to him and asked, "Is this your girlfriend, she's very pretty?"

"That's my girlfriend, but those aren't the homecoming pictures."

They were clearly from a dance - and from the decorations seemed to be the homecoming dance. I began to wonder about head trauma and decided that it might be a good idea to get some information from him in case he started to deteriorate. Name, phone, parents' names and contact information.

Sirens, finally!

The paramedic approached and I quietly informed her of the compound fracture he'd hidden under the T-shirt. She asked him again, "Who was in the car with you?"

Same response, nobody.

I watched as they assessed him and packaged him for delivery to the local hospital - collar, full backboard. Unwrapped his arm and re-dressed it. Started an IV. The whole thing couldn't have taken more than 5 minutes. Teamwork - quiet, calm.

Michael kept insisting that none of this was necessary. He'd be fine. Yes, the paramedic responded. You'll be fine. We'll just call your parents to meet us at the hospital. You won't be able to drive your car anyway.

I handed over the contact information and asked what I should do with his backpack.

Last thing the paramedic said to me before getting in the back of the ambulance with Michael. "I'll take that. This isn't going to get him out of doing his homework."

Thursday, March 22, 2007

Lies, Damn Lies, and Statistics

Screen after screen of tables flashed across the screen. Here and there an asterisk appeared beside a bar graph or table. "You know what that means," exulted the speaker. "That means this difference is statistically significant. It means that every time you repeat this study, you'll get the same results."

Umm. Not exactly. At least not when I studied statistics. I know it's been a long time and what the hell, I took statistics for Psych majors, not statistics for nurses, but it can't be that different, can it? They accepted the credit when I transferred.

Oh, and the Chi Square was 0.1, so it really means there's only a 10% probability that the results were due to chance. Given the nature of the study, I'd say there's a hell of a lot more probability than that. They didn't appear to control for much more than the one element they were trying to prove was significant.

I very nearly raised my hand again to correct the speaker, but I'd already done that twice, so I settled for rolling my eyes and figuring she's either not as smart as she looks, or she's bought into the whole big pharma promotion of this particular product.

At least I got a good dinner out of the deal.

Thursday, March 15, 2007

Fear in the NICU

Image from Feebleminds

The day shift nurse is new. She doesn't know me and apparently doesn't listen much to gossip, so she was puzzled when I laughed at her question: "Do you mind helping breastfeeding moms?"

While I was trying to come up with an answer that wasn't sarcastic, she went on, "I can get L to help you if you're not comfortable with it." By this time, L was trying not to snicker too. She knows my reputation. She's watched me work. We both assured the day shift nurse that I could handle it.

They give me the hard cases - the ones where you simply cannot laugh while there are visitors in the NICU; the moms who need 3 people to get one baby latched and who bring ALL their visitors over to watch while they do it. I love taking care of the tiniest, most critical babies, but I enjoy the challenge of helping new moms learn to breastfeed too.

A NICU admission, even of a term baby, can create truly challenging circumstances for learning to breastfeed. That's especially true if mom lacks experience, has flat or inverted nipples, damage to one or both nipples prior to the NICU admission due to the baby's nursing style which in this case was Great White Shark.

Some babies have difficulty latching because the suck isn't strong enough. Others have such a strong suck that if they aren't latched perfectly, they can damage a new mom's nipples in a relatively short time. The hungrier and more frantic the baby, and the more inexperienced the mom, the greater the potential for damage. Issue mom a breast pump with inadequate instruction and you have a setup to absolutely sabotage breastfeeding.

Round 1:

Enter the Nipple Nazi: I'm usually not, but this case required extreme measures. The day shift nurse had phoned the mom while I was getting report on my other patient. She asked her to PUMP before coming to the NICU. Mom arrived with nipples tender from pumping, about 6 ml of colostrum in a bottle, and an entourage. I like to have mom's support person around when I'm helping a new mom learn to breastfeed, because I've found that the support person (often the baby's father) is able to quickly learn how to assist in positioning and evaluating the latch. Adding an audience tends to distract the mom and her partner and to add confusion. Especially when the audience wants to help. Double that when they have very little idea what they're talking about. At least this entourage was very pro-breastfeeding.

Step 1: Make the mom as comfortable as possible. Comfortable chair, check; footstool, check; screens, "No thank you, it's too hot in here." Mom strips to the waist. Uh-oh. Potential problem. Not for me, I've certainly seen enough breasts not to develop twitch when I see one, but there was another dad in the room and many of our ancillary personnel (housekeeping, laundry, etc) come through in the evening and they're not all comfortable with that much exposure. Fortunately, L heard the exchange and set up screens to give the other dad some privacy so he could pay attention to his own child instead of the performance across the room. Unfortunately, the screens weren't placed to do much for the gentleman from the laundry who entered the room eyes averted and one hand blocking out the view.

Step 2: Evaluate mom's technique: She requested (and was given) a syringe to feed the colostrum. She was concerned about nipple confusion, but apparently missed the point that ANYTHING which encourages the baby to suckle incorrectly will contribute. Give me a bottle any day over an incorrectly used syringe, finger, spoon, cup, etc.

Step 3: Try to get the baby to latch. 6ml of colostrum just wasn't taking the edge off the baby's hunger and every time the baby got close to the breast she lunged. And mom cringed and pulled away - making her nipples even more tender. The lactation consultant had been in earlier and left 2 different styles of nipple shields, so we tried those. And I spent a LOT of time repeating "Don't pull the nipple out, put your finger in the corner of the baby's mouth to break the suction."

Nipple shields can be helpful, but when the challenges include a tendency not to open the mouth wide enough, an incorrectly used nipple shield can make this much worse. We were eventually able to get the baby to latch and nurse on one side with the nipple shield. There was a lot of off and on behavior, though. Between the nipple shield, the fight to get a good latch, and the slow flow from the recent pumping, baby was getting more and more frustrated.

So we switched and the baby had a total meltdown. It was Shark Attack in the NICU on side 2. The baby lunged, missed the nipple and latched above it. This is quite painful and mom was becoming more anxious by the minute. Baby lunged, hitting closer to the target this time, but with her mouth not wide enough, so that she only got the tip of the nipple. Mom shrieked and pulled away, causing even more pain.

I showed her how to soothe the baby with a finger, making baby open WIDE before allowing her to suckle. By this time, mom was so gun-shy, she seriously asked if the baby wouldn't be satisfied with what she'd gotten so far and the finger.

Grandpa chimed in at this point, "She wants steak"

I had to laugh and responded, "Yes, and she's trying to get it from mom."

Mom looked at me and asked, "Don't you have some kind of nippley thing you can use to give her some formula?"

I said, "Yes, it's called a bottle."

Mom: "We didn't want to use bottles."

Me: "I don't want to give her a whole feeding, just give her enough to take the edge off so she stops acting like a shark."

Mom: Laughing (finally), "OK. Let's try that."

Out comes the orthodontic nipple and the formula. I take the baby and let her suck about 4 times, making sure that her mouth opens wide before I pop it in and making sure that her lips are turned out, not in. The baby relaxes and we're finally able to get her latched comfortably on side 2.

Baby sleeps for 4 hours. Hopefully so does mom.

Round 2

Baby is alert and rooting, but not crying. This is the point at which the NICU admission becomes a real problem. I call mom and 35 minutes later she makes her way to the NICU. By this time, baby is SCREAMING and frantic. Mom didn't pump before she came this time, but she had pumped after leaving the last time and her sore nipple is now cracked and bruised.

I ask mom's permission and we start with colostrum and 5 ml of formula by NUK again. Baby immediately latches strongly but not painfully on mom's less sore breast. We have a very long chat about breast pump use and how this is only about nipple stimulation and NOT a contest to see how much colostrum she can extract. I explain that "It didn't hurt that much" is NOT the goal and "It didn't hurt at all" is the only acceptable goal, so don't turn the vacuum up so high this time. Mom isn't able to offer the sore side at all at this feeding and baby isn't satisfied after nursing 20+ minutes on the available side, so we give 10 ml more of formula and tuck baby in. She sleeps for 3 hours. Mom pumps the sore side and sends 5 ml colostrum back with dad for later use.

Round 3

NICU interference again: Morning blood work gets baby totally frazzled so we need to use the bottle trick to soothe her, but this time she doesn't take more than 2-3 ml before she's calm enough to latch. 20 minutes on the not sore side and mom is off to pump the damaged side. Baby is satisfied with the 5 ml colostrum from the last pumping and the 20 minutes of nursing. She's still sleeping 1 1/2 hours later when I go home.

I have no idea why, but I also have a reputation of being "nice". Totally undeserved, really. Before the day shift arrives, I slip out to the nurses' station to talk to the day charge nurse. I make sure that our orientee has my assignment. I leave to the preceptor's sincere "Gee thanks!"

It's not so bad as all that, really. The lactation consultant will be available and mom should have all her visitors around to help too.

Tuesday, March 13, 2007

Everybody lies (if only by omission)

I could subtitle this "True Confessions of a NICU nurse" or "Things I Never Told my Children's Pediatrician"

Nurses worry about their kids, sometimes more than non-nurses, sometimes less. Some worries I've shared with the pediatrician, others not.

On the not shared list:

1. Pediatrician: "Does he spit up very much?"
Me: (thinking Not for a kid in my family) No, not really.
Truth: The child spewed after every feeding to the point that I carried towels for burp cloths.
Why not tell? He was my first. I didn't know the pediatrician well enough then to know that as long as the child was gaining weight, he wasn't likely to insist on any unnecessary tests.

2. Breastfeeding 2 day old choked and turned blue with letdown when my milk came in. I never bothered to share this with the pediatrician because the baby had stopped choking by our first office visit 5 days later. I had thoroughly assessed him to be sure he didn't have a murmur or any evidence of aspiration, pneumonia, or other respiratory issues. Also, we'd only had well-child issues with the first one at this point and I didn't fully appreciate the pediatrician's ability to diagnose based on a history and physical exam. IOW, I was still leery of unnecessary testing.

3. Calls to poison control. I can't remember, many years later, whether poison control asked for the pediatrician's name. I expect they did and that he got a report. All 3 times should have given him a good chuckle, they certainly amused the folks at poison control. More on those in a separate post.

4. Child with a history of swallowing objects swallows yet another one. Pediatrician hadn't been impressed by previous events and had simply instructed me on what to watch for. This was one time I should have called. When I eventually mentioned the event to him, he was more than a little unhappy with me. Seems wires from orthopedic equipment are in a different class than small buttons or springs from pocket knives, but he didn't see any point in ordering studies by the time I told him.

I'm sure there are more, but you'll have to wait until they pop into my head.

Wednesday, March 07, 2007

Stress Reduction?

Authorities called in the bomb squad early Tuesday and diverted a flight to Las Vegas after Los Angeles International Airport security screeners found hidden wires and other objects in a body cavity of a Philadelphia-bound passenger.

I bet you can guess which body cavity. The man said he did it to reduce stress. Somehow I don't think his technique worked very well - not for him and not for any of the folks involved in the investigation. Maybe he should consider medication next time.

Heart-healthy Mac & Cheese

OK, it's still high sodium, but you can't have everything.

8 oz Velveeta light
8 oz fat free shredded cheddar
1/4 cup low fat (or fat free if you can find it) parmesan cheese
3/4 cup skim milk
1 pound of your favorite pasta shape

Cook the pasta according to package directions. Drain. Add the milk and cheeses. You can melt everything on the stove or put it in a microwave safe dish and nuke it for about 5 minutes. Serves 8 (main dish size servings). My sister says the secret is the Velveeta. She calls it the universal solvent.

Nutrition information:

Using traditional pasta (healthier with whole wheat - and pretty tasty)
336 calories, 50 g carbohydrates, 5 g fat, 23 g protein. Sodium 750 mg - more if you add salt to the water while you're cooking the pasta.

Questions you might not want to ask

If the patient in the bed is wearing a wedding band and holding her husband's hand and her chief complaint is "threatened abortion" (miscarriage) AND the pregnancy test was positive, you might just want to skip the question on the history "Are you sexually active?"

Barring that, don't look so freaking puzzled when her response is more than a little sarcastic.

Yes, the patient in the bed was me, but it was a long time ago. Funny how things pop into your head, anger intact, many years later. I wouldn't recognize the resident if I met him on the street. That might be a consolation to anyone who's been on the receiving end of a sarcastic response to an ill-timed question. The OB resident in question graduated from medical school in the era prior to role-playing "patients". I realize that "Are you sexually active?" is a question that needs an answer in a typical office or clinic setting and in many ER situations as well. It shouldn't be one of the first questions asked, though, because you need to develop some sort of rapport with the patient. If the patient's private physician is on his way in, it might best be deferred.

The Blog that Ate Manhattan has a great post on the various permutations this can take even in a private practice setting - and the often unhelpful responses. #1 Dinosaur shares his experiences with this rather touchy question as well.