Friday, June 29, 2007

Change of Shift

Change of Shift is up at Nursing Link.

How to tattoo your finger

Recapping is a bad idea. For needles, anyway.

Apparently it's also a bad idea for certain types of very pointy gel-ink pens.

Yes, it hurt. It's been over a week and it isn't going away just yet.

Thursday, June 28, 2007

Learning the Language

The pediatric resident was in his mid 40's. He'd been a professor of pediatrics in his home country, but had to repeat his pediatric residency in order to be board certified in the US. He was a very gentle man and quite knowledgeable about pediatrics, but his grasp of English idioms was somewhat imperfect. He carried a notebook in which he recorded each new idiom and went around singing Christmas Carols he'd learned in his English as a Second Language class. He was determined to be fluent in English before he completed his residency.

After being paged to the ER one evening, he returned to the NICU. He had a question for us. He'd learned a new phrase and wanted to know what it meant. "What means 'f*ck you'?" he asked.

While the rest of us tried to compose ourselves, one of my co-workers took him aside and explained the phrase. He grasped it rather quickly and offered the following explanation.

"I keep getting confused between passed out and passed away."

Wednesday, June 27, 2007

Today is National HIV Testing day

Depending on where you live, local organizations may be offering free testing today. Of course, depending on where you live, that may be true every day. Check with your local health department, Planned Parenthood, etc for details.

HIV testing can help to stop the spread of the disease. One would hope that adults would do what they could to avoid spreading the virus if they knew they were positive, but testing of pregnant women, in particular, can significantly decrease the risk of vertical transmission (mother to baby).

A woman who takes antiretroviral drugs while pregnant significantly decreases the probability of transmission to her baby. Prior to the use of antiretrovirals in pregnancy, the transmission rate was nearly 30% for term babies and much higher for preemies. Now, with antepartum treatment of the mom, followed by six weeks of antiretroviral therapy for the baby, the transmission rate in term infants is 2-7%. This can be reduced to about 1% with elective C-sections prior to labor. Even when the mom doesn't know she's HIV positive until she presents in labor (women with no or very limited prenatal care), transmission rates can be decreased by treating the baby for 6 weeks after birth.

Tuesday, June 26, 2007

I hope they were just waiting for the pediatrician's office to open

Found this in the referral listings today:

Search Words
how do i know if my toddler has a spider bite or mrsa

Doesn't much matter. Either way the toddler needs to be seen by the pediatrician. I hope everything is OK.

Grand Rounds

A very inspirational edition of Grand Rounds is up at Wandering Visitor.

Masche sextuplet update

MSNBC has an on-line article and a 7 minute video update about the Masche family on their web site. It gives more information about Jenny's medical problems and some fascinating footage of the babies and the equipment still in use.

Watch the tops go up on the special intensive care beds being used for some of the babies. Unless you're driving a luxury car, you paid less for it than the sticker price on just one of those beds. They're worth it, though. They save lives. You can maintain a precise level of humidity to protect fragile skin in a micropremie. As demonstrated, you can raise the top for instant access if you need to perform a procedure -- and it converts automatically to radiant warmer mode, so the baby won't get cold while you're working. There are many more features that make life easier for baby, parents, and - of course - NICU staff.

According to the article, some of the babies' nutrition is coming from breast milk banks. We've had a few moms of multiples who could pump enough breastmilk for them - and, we joked, the rest of the unit. That's uncommon with higher order multiples, especially when mom is seriously ill in the immediate postpartum period. Formula is also being used - and will doubtless be a necessity in the future as well.

The neonatologist mentions an "unexpected complication" with one of the babies which will require surgery before discharge, but doesn't elaborate. Overall, mom and babies look really good. It's going to be a long road over the coming years, but the family seems to have lots of support from their extended families and their church.

I'm happy for them and I wish them well. I hope that the 2 additional sets of sextuplets expected to deliver later this summer will be so fortunate. These higher order multiples, even with good outcomes for mom and baby, are considered a failure in infertility treatment, though. The goal is always one healthy baby. Selective reduction isn't the answer either. It's a choice no one should have to make. What is needed is more research and optimum management of infertility treatment.

Monday, June 25, 2007

On Despair and Miracles.

My condolences to the Morrisons. Their grief must be immense with the death of the fourth of their children. The hospital still isn't releasing information about the remaining 2, aside from the fact that they are still in critical condition. I would speculate that they will remain in critical condition for 6-8 more weeks at a minimum - if they survive at all. The family has my prayers for this struggle.

We've had 23-24 week infants from singleton or twin pregnancies who were in our NICU for 7-8 months, and rarely longer. Some have been transferred to other hospitals and more commonly to extended care pediatric facilities - not getting home for the first time until as long as 2.5 years after birth. Surfactants and improvements in technology tend to shorten this for many of the survivors, but the reality is that many weeks, often months, and sometimes years of medical attention (inpatient and/or at home) is needed for virtually all babies born so early.

I read an interesting piece on Errant Thoughts from a Disquieted Mind today on the costs of short and long-term care of micropreemies. There are some errors in the first part of the story. She describes the release of even 2 eggs spontaneously as "exceptionally, unbelievably rare" when the actual number is 1 in 80 pregnancies and who really knows how many cycles. Spontaneous triplets are 1 in 8000, which I wouldn't call unbelievably rare either. Relatively minor gripes, those. What you should look at is her estimate of the costs -- in 1994 dollars -- of neonatal care. It is staggering -- and in line with what I know of the costs.

She then goes on to describe what she expects will be the complications. I'd take exception to describing Necrotising Enterocolitis as an expected event, although it's certainly very high risk for such tiny babies. She doesn't say where she gets the numbers for her statistics, but I think they're pretty close. My description of their challenges was described by another blogger as chilling - hers is even more so. Go read it.

In view of all that pessimism, why would anyone even bother to try to save such tiny babies -- or any other desperately ill infant, for that matter? It's because we all know at least one child who has beaten those odds. If you ask anyone who has worked in neonatology for any significant time, they have at least one story. I've already written about one in my post titled Thanksgiving. To me, that child clearly represents a miracle, but I've seen others as well in the 25+ years I've been a NICU nurse. That's what makes it possible for me to do what I do when I don't believe that a baby has a chance. I've been wrong before. I live with the hope that I will be again.

This field requires such a delicate balance. Sometimes neonatologists have to tell families that the hope for survival is very small -- and for intact survival even smaller. Sometimes they must approach families to offer them the option of withdrawing life support when it appears that there is very little hope of recovery. Occasionally it is the parents who approach us when they believe that it is time to let go. Never is it an easy choice, but sometimes it is in the best interests of the baby.

Sunday, June 24, 2007

Baby Boom

Way too many babies in the NICU last night. I think I must have walked 15 miles in our few relatively small rooms. One might go home today, a couple more in the next few days, but most will be with us a while.

I think it's going to be a long summer. Lotsa stories if I'm not too tired to post them, though.

Oh, and I only managed a G rating. I guess I'll have to try harder.

Thursday, June 21, 2007

Explaining the Risks.

I just finished reading about Midwife with a Knife's very busy day. It was fascinating. One of the things mentioned is the difficulty explaining risk to patients. I don't know whether the concepts are just hard for some people to understand, or if it's the stress factor that makes the difference.

Our neonatologists and NNPs have to explain risks and benefits to our patients both prenatally and after admission to the NICU. Time after time, I see them explain something in great detail, ask if there are any questions, answer them (if asked) and walk away. The parents then turn to me and say something like: "So the baby will be OK, right?" (far more rarely they predict a dire outcome)

This is when I insert my statistics speech, in which I basically explain that statistics apply to populations and that their baby is an individual. Chances are whatever they were just told that (good outcome or poor outcome) will apply to their baby, but there are no guarantees - and would they like to talk to the NNP or physician some more? The answer is usually no, not because they understand, but because they are overwhelmed. I always pass that information along so the parents can be counseled a little more when they might be better able to understand.

There is one situation that makes it clear just how hard probabilities are to teach. That is when the parent of an infant with an autosomal recessive genetic disorder for which there is a fairly clear 1 in 4 chance of transmission (Cystic Fibrosis, Phenylketonuria, Sickle Cell disease, etc) has a second second child with the same condition and says: "We knew there was a 1 in 4 chance, but we thought that since the first one had this, the next 3 would be fine."

Tuesday, June 19, 2007

Dear Henrietta

Grand Rounds is up at Code Blog -- with advice from advice columnist Henrietta the Healthcare Columnist. More on that after I actually read some of the wit and wisdom linked there.

Monday, June 18, 2007


Lemonade flavor Gatorade makes it really hard to tell when your kid is puking bile.

Just so you know.

Not sure if other colors are any better, though. I think I need to find a clear flavor.

Oh, and cola syrup does a pretty fair imitation of "coffee ground" appearance. Doesn't do much for vomiting, but apparently doesn't taste much worse coming back up than going down. Unlike the Gatorade.

Yes, it's been a fun day.


A commenter on a previous post asks questions. We've never had quints or sextuplets in our NICU, but I have talked to moms of quads who were offered the choice and opted not to reduce.

I, too, am an NICU RN. I don't understand, but I am open to listening, to those--docs, fertility specialists, OR parents--who think that having 6 babies at one time is a good idea.

The mom of the 30-weekers was in trouble after the birth because she had such a large increase in blood volume to support that pregnancy . . . The kids, even at 30 weeks, are still at risk for developmental delays, learning disabilities, and more.

What would entice someone to take such risks? Please enlighten me.

I don't believe that ANYONE thinks having 6 babies at once is a good idea. People want one baby, maybe two. They find that the less risky forms of intervention either don't work (clomid), are out of their price range (IVF), or violate religious precepts (IVF and/or IUI). They opt for one of the follicle stimulating drugs, perhaps with intrauterine insemination, and find that they are pregnant with way more babies than they'd planned for.

If they choose not to selectively reduce, they may lose all the babies -- or the babies may have multiple challenges as a result of prematurity. If they choose to selectively reduce, they may lose all the babies (miscarriage is one of the risks) or the babies may be born very premature as a complication of the selective reduction. Odds of carrying to term do increase with reduction, but there are no guarantees. Either choice is perilous and heart-wrenching.

There is also the religious objection to selective reduction. If you believe, as I do, that life begins at conception, then choosing to reduce may not be an option. I couldn't do it and neither could the moms of quads with whom I've spoken. Some people do make this choice, in spite of their religious beliefs, because they fear that all the babies will die if they do not.

The reason you hear so much about "miracle pregnancies" and "gifts from God" is that the people who decide to reduce almost always decide to maintain their privacy. I understand that choice - although if they were willing to share their experiences, anonymously or otherwise, it might help people to realize just how big a problem there is with the current state of infertility treatment. Women shouldn't have to make the sorts of choices presented by a higher order pregnancy.

Those who choose not to reduce for religious reasons cannot spend their days worrying. They have to hope that their babies will survive -- and possibly thrive. They must rely on their faith to get them through a very challenging experience.

If anyone would like to share their experiences anonymously, they can email me at tiggersdontjump at gmail dot com. Tell me how much or little you would like shared. I am willing to post a composite or actual experiences.

Pediatric Grand Rounds

Med Journal Watch hosts the latest edition of Pediatric Grand Rounds

Lots to think about, a few things to make you smile.

I love all the health blog carnivals. I find new (to me) bloggers every week. It was a pleasant surprise to find one of my posts had been submitted to this week's Pediatric Grand Rounds.

New on the sidebar:

The Preemie Experiment - Written by a mom who has been there and who has some terrific information and experiences to share.

Breath Spa for Kids - Shinga works with people to help improve their health and change their breathing habits. She writes informative, thought-provoking posts.

Sunday, June 17, 2007

Child of the Heart

His birth mother had been unable to even take care of herself -- and unwilling to release him to be adopted, so he bounced from one foster home to another, never staying more than a year or so in each one. He wasn't the easiest child, but he was usually pleasant and polite to adults, concerned about his friends and at least an average student. He had just graduated from high school and his 18th birthday was rapidly approaching.

I was a chaperone on a church youth retreat. I overheard a casual remark that struck a nerve. He sounded hopeless - possibly suicidal. I didn't know his history yet, so I had no idea why, but I took my concerns to the pastor who was leading the retreat. He assured me he would follow up on it.

Early that evening, they passed out the letters parents had written to their children prior to the retreat. When the young man opened his, a tear trickled down his cheek. He stood and fled from the room before his friends could see him cry. The pastor followed.

He was seriously considering suicide. All he could remember was being a foster child and he knew that once he was 18, the state would no longer issue a check for his board and care. He simply could not imagine that anyone would love him for himself. He had no place to go and no plans for his future.

The letter changed all that. He gave permission for the pastor to share it with the chaperones. I don't remember the exact words, but here is the essence.

My dear son,
You have shared our lives for nearly 2 years. If the state would have permitted it, we would have adopted you, but that was not possible. Soon you will be 18 and the state will no longer have that control. You are our child of the heart and we want to be your family forever.


Thursday, June 14, 2007

Technology. Gotta love it.

NICU nursing is very much about the technology. We have a machine for just about everything. OK, nobody has perfected the baby-butt-patter yet, but pretty much everything else.

I've been a NICU nurse for over 25 years, so I've seen lots of changes in the technology. IV technology, for example. When I started in NICU, nearly all the IV's were started in the scalp with a steel needle called a butterfly. It has little plastic "wings" to help stabilize it, hence the name. Now, we almost always use a tiny flexible catheter. It has a stylet (special hollow needle) in the center, but we take that out once the catheter is in place.

Scalp veins are still the largest, most stable veins in a newborn, but if the baby has hair, you end up shaving and that's disturbing to the parents.

Also disturbing to the parents is the thought that the baby could be injured by the catheter. They know we use a needle to place it, and some of them either forget or don't know that the needle comes out and only a flexible tube is in place. More than once, I've been asked about the risk of "that needle" getting into the baby's brain. That wasn't a problem when we DID use needles, and it certainly isn't a risk with the catheters. Scalp vein placements don't bother the babies, but they do bother parents, so we try to avoid them if possible.

New babies who are seriously ill or very tiny may have a conventional IV, but they will also have some sort of central venous catheter as well. The easiest to place are the umbilical catheters. It's not exactly a simple matter, but when things go well, it's possible to have a catheter placed in the umbilical vein and one of the 2 umbilical arteries fairly quickly. Those give central venous and arterial access without making any incisions or even puncturing the skin.

We use the umbilical arterial catheter(UAC) to measure blood pressure and to take blood samples to measure oxygen and carbon dioxide content in the blood as well as acid-base balance. We also get the majority of our blood counts and blood chemistry samples from the arterial line.

The umbilical venous catheters (UVC) are used primarily to provide fluid and high calorie IV feedings. One of the most important advances for the UVCs is the double-lumen catheter. It has 2 separate tracks and that allows us to give 2 totally different fluids at the same time. When there isn't a UAC, we can get blood samples from the UVC, but this is much less common. UAC and UVC have been around NICU's longer than I have, but the technology has been upgraded.

Another huge step forward was the development of the neonatal-sized PICC - percutaneously inserted central catheter. This is a longer, flexible catheter placed through a fairly large peripheral vein. It is long enough to reach the large blood vessels in the chest that flow into the heart. It can be left in place for weeks, unlike the conventional IV catheters which usually have to be replaced after a few days (when we're lucky). Those come in single-lumen and double-lumen catheters as well. The physician or nurse practitioner decides based on the length of time the baby is likely to need the PICC and the reason she needs it.

June 14 - World Blood Donor Day -- and so much more!

The theme for Change of Shift at Nurse Ratched's Place is the different reasons to celebrate June 14. Go check it out -- then make your appointment to donate.

Wednesday, June 13, 2007

Sextuplets still in the news

The Masche family has been permitting updates and I was pleased to hear that all 6 babies are off their ventilators and breathing room air, according to their dad. That is excellent news. They will doubtless have some challenges, but are well on their way.

The Morrison family has asked for no further news releases and the hospital is honoring that request. Those babies are still in critical condition and I know from experience that there will be a lot of ups and downs for them. I hope they do well. The family doesn't need microphones in their faces while they are dealing with the stress of having 6 tiny babies in the NICU.

There are 2 more sets of sextuplets pending (hat tip to NICU 101 for tracking down the web sites)

The Soldanis - in California - are 16+ weeks now. According to Gracie's blog, they had a scare a couple of days ago, but things are progressing well now. She hopes to stay out of the hospital for a little longer -- and pregnant for at least 12-14 weeks more.

The Bylers live in Florida. Unlike the other parents of this year's crop of sextuplets, they already have one daughter. They're trying to minimize the impact on her and are already seeking advice from other families with multiples. They're hoping to reach 28-30 weeks (mid to late August) before delivering in order to give the babies the best possible chance.

After my first post on the Morrison and Masche sextuplets, I experienced a big jump in readership. Looking at where the new readers came from, I discovered a message board for people who are interested in multiples. It's called Quintland and according to regular posters, the Dilley 6 (now 14 years old) pop in from time to time. There are parents, multiples, and folks who are just curious. In order to discourage lurkers, you have to post several times in the newbie area before being admitted to the rest of the board.

I also found this link with survival statistics at various gestational ages. It's from a South African hospital, but it looks pretty much like the US statistics. They do point out that most babies below 23 weeks aren't resuscitated, due to the low survival rate and poor outcomes. At my hospital, we very seldom resuscitate babies below 23 weeks -- and of the few we've managed to get to the NICU, not one has survived.

Vitamins can do that?

NEW YORK (Reuters Health) - Women who take multivitamins before and during pregnancy apparently reduce the chances that their offspring will develop certain types of childhood tumors, researchers report.

The study shows a 36% reduction in childhood leukemia and a 47% drop in neuroblastoma -- decreases in other childhood brain tumors as well. It's all very interesting and one more reason to feel guilty if you were tossing your cookies through the first trimester and couldn't keep crackers down, much less prenatal vitamins.

Grand Rounds!

Grand Rounds is up at Dr. Val and the Voice of Reason on Revolution Health.

Your choice of versions: Immediate Release -- just the facts
Extended Release -- gives a little more information about the posts

Something for everyone: Sad posts, Happy posts, Hot buttons, Helpful tips, Case Reports, and Everything Else

Then there are those bonus posts specially selected by Dr. Val

Monday, June 11, 2007

Sextuplets -- times two.

More than one baby per pregnancy means increasing the risks -- increased risk of prematurity (we have several sets of twins in our NICU currently), increased risk of complications for mom and babies.

Within the last 24 hours, 2 sets of sextuplets were born. One set has a pretty good chance of having a normal life, the other not so much. Neither set is in the NICU where I work. I've seen many babies at both gestational ages, though.

The Masche sextuplets

Jenny Masche gave birth at 30 weeks, 4 days. There are risks involved in having 6 babies, but the survival statistics for preemies born at 30+ weeks are pretty good. 5 of the six need help from ventilators to breathe. The 6th may yet. Sometimes the little ones tire out and need some help. It's also possible that they will all be breathing on their own within a few days.

If they need a lot of help breathing, they'll get surfactant to help keep their lungs expanded. They may get some high calorie IV feedings before they're ready for oral feedings. Those first feedings will be by a tube placed through the mouth or nose via the esophagus to the stomach.

They will be watched very closely for all the possible problems that go with a pre-term delivery.

Apnea of prematurity
will probably show up by 2 or 3 days of life (or whenever they are off the ventilator). At just over 30 weeks, the probability is very high that the respiratory center in their brains will be immature and they will take breaks from breathing periodically. Their nurses will watch closely to see if they start breathing again spontaneously. If the heartrate drops precipitously, or their oxygen levels fall significantly -- or if they just wait too long to take that breath, someone will gently stimulate them to get them breathing again. If that doesn't work, the nurse will use a bag-valve-mask resuscitation device (self-inflating, or anesthesia-type bag) to breathe for the baby until he or she recovers.

They may stay on the ventilators for a short time or a longer time. Once they're maturing and breathing more on their own, they'll be placed on a CPAP or SiPAP device to help keep their lungs expanded and decrease the work of breathing. This helps decrease the apnea. They may also be given medication to stimulate the respiratory center.

With all that respiratory support, it will be important to keep a close eye on the oxygen saturation levels -- the percent of the hemoglobin that is actually carrying oxygen. Too low and the baby won't do well, but too high and the risk of Retinopathy of Prematurity (ROP) increases born at less than 32 weeks is a risk factor, but oxygen use increases the risk. About half of babies weighing less than 1700 grams will have some degree of ROP.

The babies will have frequent eye exams to watch for early signs of ROP because it can be treated. Laser surgery and cryosurgery are both effective if used before the ROP is too advanced.

There are other possible risks for the Masche babies, but nothing like the risks faced by the other set of sextuplets.

The Morrison sextuplets

Brianna Morrison's babies were born about 8 weeks earlier than the Masche babies. Just over 22 weeks gestation. As far as I know, only one baby has survived at that gestational age. She was a single baby and should have been larger and better nourished than the Morrison babies as a result.

These babies weigh between 11 ounces and 1 lb 3 ounces. They're about 1/3 of the weight of the Masche babies. Their skin is gelatinous with no subcutaneous fat. It is incredibly fragile and great care will have to be taken to simply avoid tearing it. They will lose so much fluid through their skin by evaporation that it will be a huge challenge to keep them hydrated and keep their electrolytes in balance.

The blood vessels in their brains are even more fragile than the 30+ week Masche babies. There is a significant risk of bleeding into the brain.

Their digestive systems are immature and they may not tolerate oral feedings for many weeks. This means they will have to receive IV feedings for longer - and this can be very hard on those tiny livers.

Their risk of ROP is even higher than for more mature babies. The probability of long-term lung problems is very high.

The challenges faced by these babies are huge and I wish them well, but I do not have much hope for their survival.

TRiPS: Protecting the troops from themselves

It's been quite a while since I was a 20-something, but I haven't entirely forgotten what it was like. I was a cautious driver - still am. I never got a speeding ticket, except for that one time when I wasn't speeding and the officer stopped the wrong car (really-- even the judge believed me). I see a lot of crazy driving when I'm out running around though, and I read an article today that helped me make more sense of it.

The story is in the Baltimore Sun, which means you'll only be able to read it by logging in on their site -- and probably only for a week or so before they start charging money. If I can find a more open source, I'll link it.

Bottom line, the style of driving that keeps you alive in a war zone can get you killed when you get home. Avoiding IEDs requires driving at high speeds down the middle of the road. Makes me wonder if I have a neighbor who goes to Iraq on weekends, but that's not the story I want to tell.

Since 2003, nearly 600 active-duty soldiers have died in the US in personally owned vehicle crashes (cars and motorcycles). Add to that the number who have left the service and deactivated National Guard and Reservists. Nobody is counting them.

The Army has implemented a program to try to help prevent motor vehicle deaths of troops who've returned from combat zones - particularly Iraq and Afghanistan. There are restrictions on driving for those most recently returned and there is the TRiPS program -- an on-line form that soldiers are required to fill out before leaving for trips over a certain distance (varies depending on their post). It's designed to encourage safer driving. I hope it works, but I have some doubts.

They have to say that they'll stop and take a break every 2 hours. I do that now, but only because I have arthritis and literally wouldn't be able to get out of my car at the end of the trip if I didn't. When I was 20-something, it was nothing for me to drive 5-6 hours without stopping. My 20-something sons can easily drive 4-6 hours without stopping if I'm not in the car with them. Safer to take a break? Doubtless. Is it going to happen? I don't think so. Making the troops lie about something that basic probably doesn't help their appreciation for the rest of the system. Maybe it will remind them to take a break when they're getting tired or losing focus - and that would be a good thing.

They have to outline their trip plan -- destination, planned stops, etc. I think that's a good idea. Nobody should head out for a trip longer than a couple of hours without SOMEONE knowing where they'll be and when they expect to be back. Someone should have a clue where to start looking for you if you don't turn up. Can they lie on this part of the form? Yes, but if they get caught, there will be some 'splainin' to do.

It asks about seatbelt use, alcohol use, types of roads, weather, etc. Again, it's a simple matter to lie, and I don't think the more experienced drivers really need this, but it's probably a good reminder for the youngest troops.

They're required to read descriptions of fatal accidents. Can't make me. Can only make me let the computer sit on that page long enough to pretend. Even if I read the descriptions, I don't believe that will happen to me -- and I'm a cautious driver. My 20-something sons still have that immortality complex that goes with being young. I can't imagine that someone who has survived combat will believe that he or she can die on the highway -- but maybe it will convince someone to wear a seat belt. OTOH, if the quality of the writing approaches Ambulance Driver's or Lawdog's, it might just get their attention.

Driver safety classes -- Properly run, I think those are probably the most useful aspect of this course. I have a friend who has taken a civilian version which included some behind-the-wheel experience in emergency situations on slick roads and under adverse circumstances. I'd like to sign up for one of those. I don't think that's what they're offering, but I hope the classes are helpful. One local post offers a 30 minute "local hazards" class that covers our state's driving laws and a longer class for all soldiers under 26.

This is a subject that concerns me deeply. My sister was left to raise 2 small children when her active-duty husband died in a single-car accident some years ago. The military has always treated her well, as befits the widow of a member of our armed forces, but that death was preventable. He was driving too fast, too late at night, without rest. He wasn't wearing a seatbelt. I expect the only break he took in his 400 mile drive was when he saw the flashing lights in his rear-view mirror. There was a blood-spattered speeding ticket found in the remains of his vehicle. My mother wrote a thank-you note to the officer who had tried to slow him down.

Sunday, June 10, 2007

Absolute must read!

From Rickety Contrivances of Doing Good:

In the days of our ancestors, the volunteer chaplain went forth to be trained in the hospital. And lo, the first and most important rule in the hospital -- aside from the Commandment to Obey HIPAA -- was the Sacred Ritual of the Handwashing. The Sacred Ritual was to be performed before and after every patient contact: for lo, the Sacred Ritual of the Handwashing was the Universal Precaution, and the best defense against the dreaded hospital-acquired infection.
read more

Do overweight patients ignore overweight doctors?

I followed the link from #1 Dinosaur's post to an article which suggests that overweight doctors aren't very effective at counseling their overweight patients. #1 Dinosaur disagrees. So do I, but for different reasons.

OK, and some of the same ones, but I really think it boils down to respect. I can see myself having a productive visit with #1 Dinosaur -- or Fat Doctor(no longer blogging, I fear), for that matter. Both admit to being calorically enhanced (as I am). But that's not why I'd listen to them. From reading their blogs, I have concluded that they treat their patients with respect -- even the crazy ones. That is what makes me believe that I could benefit from having either of them as my personal physician.

Not that I'm ready to trade in my slim, athletic internist for anyone just yet. I always feel that she treats me with respect. She's frustrated with me at times -- and deservedly so. She empathizes, though. Her husband is a diabetic who shares many of my issues with managing diet and controlling weight. It helps her to understand me - and I think that I (and patients like me) help her to understand her husband. She is my cheerleader when things are going well and she offers well-considered advice and encouragement when they are not.

I've seen her partners too. One of them (also slim) gave me some of the best diet advice I've ever gotten. He looked at the weight I'd gained over the previous few years and noted that the calories in ONE extra slice of bread per day added up to those pounds. One slice of bread. When I'm actually THINKING about the food that goes into my mouth, it makes me realize just how little I have to change in order to lose weight. It also gives me the incentive to spend that extra couple of minutes at the gym when I go. Bottom line, he respected my intelligence and gave me information that has helped me to focus better on how I eat. There are many other factors involved, but that advice helps.

I'll be replacing my Gyn, though. There are many things I like about her, but her approach to weight management is to tell me that she wants me to lose X pounds and have my HbA1C at a specific number before I go back. It's not there. Oh, the HbA1C is, but not the weight. I don't feel like listening to another patronizing speech, so she gets fired. Dumb, maybe, but I really don 't feel like being patronized by someone 20+ years younger than me who has NEVER had a weight problem. There are other respect issues as well. I'd go into them, but it would turn into a real rant. (like this isn't?). I don't feel that respect from her. I don't feel the empathy that #1 Dinosaur mentions. She's good at what she does, but sometimes that's just not enough.

Sumdood makes an appearance

Warning to anyone who might be standing on the corner minding their own business. Sumdood is tough.

Actually, I've only watched him spar, I've never seen him in serious action. I expect that's the story those 2 guys told when they got to the ER. Just standing on the corner, minding my own business, when Sumdood smacked me around.

His side of the story was a little different. According to HIM, he was just walking down the street minding his own business when 2 mouth-breathers about his size (not small) approached him and demanded his wallet. He said he only had a couple of dollars in it and was afraid they'd just be pissed if he gave it to them. So he said, "No." and kept walking. He was in a public place with people nearby, and it was daylight, so he figured they'd just move on.

Nope. Mouth-breathing type #1 shoved him up against the wall of the adjacent building and again demanded the (nearly empty) wallet. He backhanded MB#1 and kept walking. I'd have thought the man could feel the muscle behind the backhand, but I suppose he was adequately self-medicated and didn't notice.

MB#1 took offense at being denied twice and swung. Block, crunch & MB#1 was sitting on the sidewalk whimpering.

Next, MB#2 decided to swing. Rinse and repeat. Definitely felt crunch of ribs fracturing that time. Result: 2 mouthbreathers sitting on the sidewalk whimpering. He's pretty sure their story when they got to the ER was that they'd only had a couple of beers and they were standing on the corner, minding their own business..........

No. He didn't call 911 for them. Not his town and he didn't feel like explaining. They were breathing - rather loudly - when he left them. It was daylight, and there were people around.

Thursday, June 07, 2007

Conjoined twins

The Dogaru twins have been in the news a lot lately. The most recent news was that yesterday's surgery was stopped due to swelling in Anastasia's brain. They had planned a staged procedure and this means they'll have to reassess and make new plans. I'm fascinated by the whole process. Conjoined twins aren't something you typically see in a community hospital NICU.

We did get one set. It was back in my early days as a NICU nurse. Before prenatal ultrasounds were so common. Before the equipment gave the sort of clear images widely available now.

Preterm twins. I don't remember how premature, but something between 30 and 35 weeks. It was a maternal transport from a small hospital in a distant part of the state. The only thing we knew initially was that they were twins and preterm. When the mom was re-scanned, the verdict was "hugging twins" and almost certainly conjoined. The state of the art in prenatal ultrasound was nowhere near what it is now.

Ideally, the way to move these babies would be in utero, but by the time she reached us, the mom was very actively laboring and moving her again wasn't an option. The regional neonatal transport team was notified to be on standby and we got ready to admit the babies to our NICU for stabilization.

Unlike the Dogaru twins who are joined at the head (cephalopagus), these twins were joined from the top of the sternum to just above the umbilicus (thoracopagus). This is the most common form of conjoined twins, and the heart is always involved. It was obvious that this was the case for these twins once they were admitted - they always had the same heart rate.

There were a number of interesting challenges.

First, positioning the babies to intubate them so they could be placed on ventilators was a challenge. It had to be done very quickly so that they could both be ventilated. One baby had to be held up out of the way so that the other could be intubated, then the babies had to be flipped without dislodging the tube so that the second twin could be intubated.

Once that was accomplished, placing lines for access to do blood gases and provide fluids was the next challenge. At least the babies could be kept in a side-lying position so no acrobatics were required, just the usual challenges of placing umbilical lines. We had to settle for lateral (side) views on the xrays since positioning the babies for any other view would have been more of a challenge than we wanted.

Each baby had his own nurse and they had to coordinate their care so as not to be in each others way. Medication dosages had to be calculated, and since the circulation was connected, what one got, the other did as well.

We were glad to see the transport team when they arrived. It was a fascinating experience, but the babies could only receive definitive treatment at a center with more advanced capabilities.

Extra shift tonight - really lazy food

2 lbs chicken tenderloins. Cut into bite sized pieces and browned if you're feeling ambitious. Otherwise, just toss into the crock pot.

1 large vidalia onion, sliced. Also in the crock pot.

Add 1 large or 2 small chicken bouillon cubes

one 6 oz can of orange concentrate (thawed)

and anything else that looks good -- sliced carrots, maybe.

If you want to add tomatoes, do that at the end, just before serving.

Cook on low for 5-6 hours. Serve over rice or noodles. I'm partial to rice, myself. I start it in the steamer when I start the chicken and it's all ready at the same time. Steam some broccoli while setting the table and Voila! Dinner.

Wednesday, June 06, 2007


My youngest has been taking lessons for nearly 5 years. He still gets nervous on recital nights, but his playing has definitely improved. The students were all quiet and respectfully attentive for each other - as were most of the parents.

Coolest event of the night: one of the other moms came up to my son after the recital and told him how much she looks forward to hearing him play. It really made his night!

Monday, June 04, 2007

Save a Life, Give Blood!

"Blood Bank."

"I need platelets for baby Anemic. Do you have any for her?"

"No. Sorry. I'll have to get those for you from the Red Cross."

"How long will that take?"

"At least 4 hours."

"Oh. Let them know the platelet count is 35,000"

"Didn't come up much after the last transfusion, did it?"

"No. Looks like it's going to be a long night. Can you send me some packed red cells while we're waiting for the platelets?"

"Sure thing. I'll have those ready in 15 minutes and I'll call when the platelets come in."

"Thanks. I'll send someone down for the blood in a few minutes."

The conversation could happen pretty much any day in any busy Neonatal ICU -- or adult ICU, for that matter. Platelets are one of the blood components responsible for clotting. There are many illnesses and traumas that can make the platelet count drop precipitously. Packed red cells (PRBC) are the cells in blood that carry oxygen. Babies, and to a lesser extent, adult ICU patients, often need transfusions simply because we have to take so much blood out for lab testing. We try to limit the draws, and we only take tiny amounts, but in a critically ill patient it adds up.

Babies can lose blood as a result of surgery, hemorrhaging into the brain or the intestine (usually a result of necrotizing enterocolitis). Blood cells can be destroyed by infection, and rarely as a result of Rh incompatibility. It's rare, but it still happens. Transfusions can be our only option.

When transfusing a newborn, we can't just use any blood. The blood has to pass all the screening tests used to test blood for adults -- and one more. The blood has to test negative for Cytomegalovirus (CMV). 50-85% of adults in the US test positive for CMV, so we are seldom able to use directed donor blood. The families who request directed donation are upset at first, but once we explain the potential devastating effects of CMV infection in newborns, they realize that we are only trying to protect their baby. CMV can cause profound neurological damage in people whose immune system isn't working properly -- and especially in premature infants because their immune systems are immature.

With 50-85% of adults testing positive for CMV, we sometimes have to wait for safe blood for our babies. In the summer, when donations drop off, that is much more likely. While you're planning your summer, please give some thought to scheduling time to donate blood whether you're CMV negative or not -- someone is waiting for it.

Images shamelessly stolen from the World Blood Donor Day web site.

Update: Since posting, I've discovered that there is a whole list of people who need CMV negative blood. The list includes prenatal transfusions (slaps head), transfusions for CMV negative pregnant women, organ and bone marrow recipients (unless they or the organ are CMV positive). There's a longer list below that one on the same page of people who might benefit.

Pediatric Grand Rounds

Awesome Mom has done a great job with this week's edition of Pediatric Grand Rounds.

Lots of good reading from old favorites and new (to me) bloggers.

Sunday, June 03, 2007

2 Beers

On the ER blogs, I keep reading that the intoxicated patients (and family members) have only had 2 beers.

Mystery solved (5L mini-keg). 2 of these should explain most elevated blood alcohol levels.