Generic Medications. Sometimes they work......

When a generic is available, I'm generally open to trying it. I've had very few bad experiences overall.

One medication gave me migraine headaches in its generic version, but not in the brand name -- migraines are a known side effect of this medication in both forms, so maybe I just got lucky with the brand name. In that case, the generic was consistent, so I was pretty sure it was responsible.

More recently I switched from a brand name blood pressure medication to the very recent generic equivalent. My blood pressure had been pretty stable since I'd started on the brand name version several years ago so I foolishly failed to check my blood pressure more frequently when I made the switch. I'd been checking it about once a week. I picked up the new prescription on a Friday and had an appointment with my physician the following Wednesday. By the time I arrived at the office, my blood pressure had reverted to my pre-medication levels. Not a good thing at all.

I've had an issue with intermittent white-coat hypertension with this doc. ONLY this doc. Every one else gets normal readings. As one of her partners says, "She's so intimidating."

NOT. She's very soft-spoken and I have no idea why this happens. She asked me to start checking more often at home and let her know the results. I kept taking the generic version for about another week with blood pressure readings that were inconsistent. One day 116/60, the next 140/70.

Finally the light bulb went on. I called the pharmacist who offered to replace the remaining generic tablets with the brand name version. 2 days later I haven't had a high reading. That's not long enough to be certain, so I'll be monitoring daily (at least) for the next month or so. If my blood pressure stays down, I'll have to assume that the generic just doesn't do the job for me.

Update: It's not the generic. It's not the doc. I'm pretty sure it's not the meter. Rats. God bless the pharmacist for letting me try though.

Drive-by

He only has 2 speeds - dead run and unconscious. Typical boy. Typical of my sons anyway.

He's growing very fast these days and body parts keep getting banged on things that used to be in a different position, relatively speaking. He occasionally complains, but not much. We go through a lot of ice.

He was flying into the car and his knee collided with something that used to hit him about thigh height. He immediately tried to assume a fetal position -- with the one leg sticking out. Not good, but not particularly distressing (to mom). Then I saw the tears. He doesn't do that often. Must really sting.

"You OK?"

"No." (sounds more sulky than injured).

"Sorry to hear that. We'll go home and ice it."

Then he moved the knee while trying to buckle his seatbelt. I heard the whimper. Not good. He doesn't do that often at all. He reached forward to grab the ever-present video game and I saw another tear trickle down his cheek.

"I'm OK. It only hurts a little"

I touched the knee very lightly. Another whimper. Kneecap doesn't feel like it's quite in the right place. Doesn't move freely. Definitely not good. At least it feels like it's all in one piece.

"Do we go home and ice it, or do we need to go to the ER."

I get the answer I expect.

"Home."

He starts to play the game and I hear a whimper every time I take a corner. If the game doesn't distract him, it must hurt.

"It really hurts when I move it, mom."

"Do we need to stop by the ER?"

This time he surprises me.

"I guess so."

I usually err on the side of waiting until morning, but it's early evening - weekday, how busy can they be? If the pediatrician's office was open, I'd call him instead. I probably should anyway, but the whimpering is starting to get to me.

I pull up in front of the ER entrance and dash inside for a wheelchair. When I come back out, a security officer has pulled up in front of me - waiting silently. I help my son out of the car. He stands, straightens the injured leg and smiles.

"I can walk on it! I don't think we need to go in."

"What happened?"

"I felt a pop and then it felt a lot better." (big smile)

"So we go home and ice it? "

"Please?"

"You're sure?"

"Yes."

"OK. Get in the car"

I smile at the security officer and say, "We may be back later."

No whimpering on the way home. I'm not quite sure what happened there, but he's walking without a noticeable limp. The knee is purple and it still hurts. It looks a little bigger than the other, but the ice pack seems to be helping. His pediatrician may get a call in the morning, but I'm pretty sure we won't be going back to the ER tonight.

The Circle Game

Earworms - those songs or fragments that just get caught in your head and stick until you can play them all the way through or replace them.

I couldn't remember the name and couldn't seem to get the lyrics straight. No time to google. I was too busy. Sometimes being on admissions means a dull night. Sometimes it means admitting a preemie to the NICU and following through. Sometimes you just feel like you're running around in circles -- hence the earworm.

"Can you get this kid over to newborn? He's 4 hours old - slow transition. They said he could come over after they get report."

"No problem. I'll call and see when it's convenient.... 20 minutes? I'll just make sure his documentation is together and grab a set of vitals."

The folks in the newborn nursery were glad to see he'd already been bathed and most of his admission paperwork completed. Back to the NICU, I started feeding one of my patients and the phone rang.

"It's the Birthing Center - high risk delivery in 4. Oh, you're busy. I'm free, I can cover this for you."

15 minutes later: "Sharon wants you to know she's bringing the baby back. Just for observation."

"OK. This one is finished eating. I'll be right over."

Sometimes even term babies are sick at birth. Rarely they're born with an infection or congenital heart disease Much more commonly they are simply slow transitioning to extrauterine life. Usually they just need a little time to clear the amniotic fluid, but it's not always easy to tell the difference in the first moments of life.

If a baby doesn't appear to be adjusting well, we do what we can to help them transition in the birthing room. Most of the time, all that is needed is to dry the baby and perhaps stimulate him. If necessary, we provide oxygen and suction secretions.

A very small fraction will actually require resuscitation - those babies usually are admitted to the NICU, but some will recover in time to stay with mom in the birthing center.

If a baby is breathing, but obviously working hard at it, or continues to require oxygen beyond the first minutes of life, he'll get to come back with us to the NICU for continued observation. If he doesn't transition very quickly there, we will almost certainly do some lab tests(blood count, arterial blood gas), get a chest x-ray, and possibly start more aggressive treatment if that's indicated. Many of these babies will complete the transition within an hour or two and we'll be able to return them to their moms either in the birthing center or by way of the well-baby nursery.

That's how my shift went. Over and over. As I was cleaning the bed for the third time in less than 4 hours, one of my co-workers remarked, "I think I'd pick another bed. That one's unlucky."

"Unlucky?" I responded, "Nope. Just busy. I think I'll stick with this one."

Running in circles isn't always a bad thing.


And the seasons they go round and round
And the painted ponies go up and down
Were captive on the carousel of time
We can't return we can only look behind
From where we came
And go round and round and round
In the circle game

Joni Mitchell -- The Circle Game

Photographs and Memories

The last couple of months have been pretty rough. The census has been at least 50% above our usual and people are tired of the overtime. Even with nurses floating in from other units and external agency, it's been pretty rough some days. I go home aching and wonder if it's all worth it.

It is, of course, and we keep a reminder very near the nurses station. The bulletin board with the photos and letters is supposed to be there to inspire the parents of our current patients - to let them know that there is hope. It helps the staff too. One picture in particular has been my inspiration lately. She was only 23 weeks, barely a pound.

Her course was rocky, as might be expected, but she eventually went home. That was 18 years ago. Her smiling face is posted on the board - her senior picture. She'll graduate from high school this year and go to college in the fall - athlete and honor student. Her parents are rightfully proud of her. So are her nurses -- and my step is just a little lighter this morning.

News from the Starving Artist Front

I'm visiting relatives in NC this week and found, to my delight, that one of my favorite artists has decided to increase his production. I've admired his work for a long time and he's finally going more public with it -- as in his own web site which is FoggArt.com He also makes trips to art fairs in Central NC (dates listed on the web site) and sells on Ebay. He makes fantasy creatures and alien life forms . He also paints and makes poured cement and hypertufa sculptures. All of his work is unique. The artist is a friend so I know he's honest. His photos don't really do justice to the artwork, but you'll get the idea. If you don't see what you want on the web site, contact him and ask. He can probably make what you want.

Futility

Born too early and nothing is going right. Systolic pressure hasn't been above 20 in 8 hours despite dopamine and dobutamine. Hematocrit and platelet count are still dropping in spite of multiple transfusions. There was a brief resus earlier in the day - only one round of epinephrine needed to bring back the heart rate, but it really isn't looking good.

I glance up at the monitor above me and see one QRS complex on the left side of the screen. Our monitors are all interlinked and when an alarm goes off, everyone can see where the problem is. I hear, "Can someone get me an epi?" Calm voices, no anxious shouts, just a request for assistance. Most of us have been doing this a long time and we work well as a team. She has the epinephrine in her hand by the time I reach the bed seconds later.

The heart rate is still in the 30's so I start chest compressions and she draws up the epinephrine. Someone else picks up a clipboard and starts recording. The nurse practitioner asks for bicarb and another nurse has it in her hand, drawing up the dose.

6 rounds of epinephrine, at least 2 rounds of bicarb, 20 ml of saline for volume expanders. Hemoglobin is in single digits now. The blood pressure is better, but only with chest compressions. There has been no response at all to the resus drugs. I feel like I'm making a depression in the chest and realize that the baby is rapidly becoming edematous -- leaking all the volume expanders into the subcutaneous tissue. The blood pressure monitor on the arterial line shows a decline in the blood pressure although I have been very consistent with the chest compressions. 10 minutes into the resus, someone calls the neonatologist at home. He's on his way.

A blood gas to see how things are progressing - base excess of -20, pH so low there's clearly no point in continuing, but we can't stop until the neonatologist arrives to call the code. There's an occasional complex on the screen now, but when I stop compressions, there is no pulse. No audible heartbeat. It's pulseless electrical activity. I resume compressions and we wait. When the neonatologist arrives I stop for the last time.

Too little. Too immature. He never had a chance.