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
Monday, July 30, 2007
Friday, July 27, 2007
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.
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.
Thursday, July 26, 2007
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.
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.
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.
Wednesday, July 25, 2007
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.
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.
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.
Monday, July 23, 2007
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.
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.
Sunday, July 22, 2007
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.
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.
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.
Friday, July 20, 2007
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.
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.
Thursday, July 19, 2007
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.
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.
Wednesday, July 18, 2007
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.
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.
Monday, July 16, 2007
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.
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.
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.
Sunday, July 15, 2007
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
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.
Friday, July 13, 2007
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
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.
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.
Thursday, July 12, 2007
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.
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.
Tuesday, July 10, 2007
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.
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.
Monday, July 09, 2007
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
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
Thursday, July 05, 2007
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.
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.
Tuesday, July 03, 2007
Monday, July 02, 2007
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.
Sunday, July 01, 2007
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
Pediatric Grand Rounds!
Shinga, of Breath Spa for Kids, has the current edition of Paediatric Grand Rounds. There's a little something for everyone - beginning with a photo finish, ending with a review of the autism/vaccine hearings and including a very brief post of mine.
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