Thursday, May 31, 2007

IV Therapy Escapades - Part V

It didn't take me long to learn that I wasn't REQUIRED to attend resuscitations in the ER. That didn't keep them from calling me on occasion, though. Little kid with invisible veins? Call the NICU nurse. Yes, the one who thinks feet are good places to start IVs. Call her.

Really, I didn't mind because they always called me while I still had something to shoot for. Mostly they got the IV in one stick and I didn't hear from them. Once in a great while I'd get that page. Sometimes they hadn't tried, but only because the kid had been in a lot and the parents were feeling really stressed. Late evening, I'd finished my routine restarts, I was just waiting around for pages for stick-and-runs anyway.

And resuscitations. Everywhere but the ER. So when the pager went off about the same time as the "Code Blue, Main Lobby" I nearly experienced loss of sphincter control.

I'd been to a few adult codes, but in the lobby? Can't be happening! I couldn't bolt down the steps, because I knew I would need my cart. The one with all the catheters, IV fluids, tubings -- all that stuff. No drugs, though.

The wait for the elevator seemed to take forever. It was probably under a minute, but I needed to get there. Nobody else around when it arrived and, fortunately, it was an express run to the first floor. When I got to the lobby, I was glad to see that the scene was well under control - and that someone had managed to get a crash cart to the scene.

What I didn't expect was the age of the person being coded. He couldn't have been much more than 15. 120 lbs soaking wet (which he wasn't, except for the vomit). He'd been intubated and the IV was already in place by the time I got there, so all I needed to do was stay out of the way while they moved him to a gurney and off to the ER.

I got the rest of story later from someone who'd been one of the first on the scene. He'd been intubated because he wasn't breathing effectively, but they'd never lost the heart rate. His blood alcohol level was nearly 4 times the legal limit of 0.08. Drugs? Tox screen wasn't back yet, but with a blood alcohol level that high, who needs drugs?

He'd been at a party. The friend's parents knew there was booze and thought the kids were safer drinking at someone's house. They hadn't realized how easily adolescents can go beyond intoxication to alcohol poisoning. Nobody wanted to get in trouble, so instead of calling 911 when the kid started looking bad, they called his brother - who pulled up to the nearest door when he started vomiting. Fortunately, someone inside recognized how serious things were and called for help right away or the story might have had a different ending.

You can kill yourself faster when you mix drugs and alcohol, but you can do a pretty good job with alcohol alone. The LD 50 (fatal for 50% of adults) blood alcohol level is considered to be .4 An adolescent who isn't used to drinking can be in a lot of trouble with a blood alcohol level half that. Choking on their own vomit is just one of the ways an intoxicated person can get into trouble. Alcohol can interfere with the part of the brain that controls breathing. Blood sugar can drop to the point that seizures occur. Dehydration and electrolyte imbalances can result from prolonged vomiting.

The kind of rapid binge drinking that can result from dares, games, or hazing can result in very high -- potentially lethal -- blood alcohol levels. Someone who has consumed a large amount of alcohol can die if left to "sleep it off" because they will continue to absorb the alcohol already consumed and the blood alcohol level may continue to increase. If there is a reason to suspect alcohol overdose, call 911.

Fifth in an occasional series

Part 1
Part 2
Part 3
Part 4

Wednesday, May 30, 2007

Practice Makes Perfect

Larger, busier neonatal intensive care units have better outcomes than the very smallest ones.

Surprised? I wasn't. We have slow spells, but overall we're pretty busy for a community hospital. When we orient new nurses, we like to be busy. Not crazy, but busy enough for the orientees to get significant experience before they have to function without someone looking over their shoulder.

Even when they finish orientation, we try not to staff any particular shift with mostly new nurses. It's best to have at least a couple of experienced nurses around in case something unusual comes in the door. We can do that, because we have a large enough staff. Imagine a unit that only staffs 2-3 nurses on a shift. Not nearly so much flexibility there.

Even when we have only experienced nurses on a shift, we bounce ideas off each other. We ask for input from our co-workers and we share what we've learned from conferences and journal articles. It helps us all to be better nurses. It also means that when we send one nurse to a delivery, there is more than one other nurse in the NICU. You just can't be at 2 bedsides at the same time.

It doesn't surprise me that the death rate for very low birth weight preemies (VLBW) -- under 1500 grams or about 3 pounds -- nearly doubles in hospitals which admit fewer than 10 babies that size in a year. You just don't get enough experience to keep your skills and judgment honed when you are dealing with such small numbers of babies.

Mortality rates for very low birth weight babies is about 18% in level 3 NICUs that admit more than 100 of them every year. NICUs that see 50-100 do nearly as well, with a mortality rate of 20%. I'd like to see morbidity statistics compared, but that will be another study. Still, hundreds of babies are dying who might not in a larger NICU.

The worst statistics are for hospitals which admit 10 or fewer VLBW babies, the mortality rate is 31%. The most shocking thing to me is that size doesn't matter. Gender doesn't matter. Race doesn't matter. These smallest NICUs have a significantly higher mortality rate across the board. That surprised me, because in larger NICUs there are pronounced race and gender differences in survival and the larger, more mature preemies have a better chance.

This is a situation which could be improved by regionalizing neonatal care -- stepping back in time to an era when not every hospital with a birthing center had a neonatal ICU. At the very least, returning to an era when maternal transports were more common so that the very smallest newborns could be delivered in the regional hospital which saw the most of them. That won't be a popular suggestion for hospital administrators who might lose their NICUs, but maybe it's time. The babies ought to come first.

Tuesday, May 29, 2007

Precordial Catch Syndrome - Chest Pain for Kids

"Mom, my chest hurts when I breathe."

Bedtime. These things nearly always happen at bedtime and the temptation is to simply tell him to get his butt back to bed. Something in his voice tells me that this is more than the usual bedtime stall. His voice sounds small, pinched. I can tell that he is in pain.

Reassuring facts:

He is pink. Glowing almost. Clearly whatever is causing this hasn't affected his oxygenation.

His breath sounds are clear and equal and heart rhythm is regular and rate is about 90. Yes. When your mom is a nurse, the stethoscope comes in handy to rule out ominous things like spontaneous pneumothorax (although the pink lips offered more reassurance there) .

I gave him some water to sip and sat him on the couch for a few minutes to see which way this was going to go. Within a few minutes, his voice was back to normal, although he still complained of pain. When he tried to make a play for the TV controller to turn on "Deadliest Catch" I knew he was going to be OK and sent him to bed.

I can remember having similar symptoms as an adolescent. The pain only lasted a few minutes, but boy did it hurt at the time. Once he headed back up the stairs, I got on Google to find out what this is called.

Precordial Catch Syndrome
seems to be the most likely cause of this new symptom. He's the right age, the pain was exactly as described, and the symptoms passed quickly enough. Nobody seems to know what causes it. The pain is exclusively on inspiration (breathing in) and it resolves within minutes. It is possible to break the cycle by taking a deep breath, but I couldn't talk him into that tonight.

He's due for a physical shortly, so if this happens again (likely), we'll discuss it with his pediatrician then. I'm pretty sure he can make a case for sucking it up and taking that deep breath that will break the cycle. If it becomes more frequent, or is accompanied by more worrisome symptoms, we'll make an appointment to be sure this isn't something more serious.

Monday, May 28, 2007

Herbal Remedies: Effective or Risky?

The answer to that question, of course, is "it depends."

It depends on WHICH herbal remedy. It depends on what else you're taking. It depends on whether or not you take the herbal remedy instead of the effective medication your physician has prescribed. It also depends on who you ask. Sanjay Gupta, MD has an article on the TIME web site discussing some of the risks.

A few years ago, a young, healthy baseball player died after taking an herbal supplement containing ephedra to help him lose weight. Ephedra has since been banned by the FDA.

The research on Glucosamine and Chondroitin is less disturbing. It might actually be helpful in the treatment of osteoarthritis of the knee. If it keeps you from needing an NSAID, the risks are probably lower for Glucosamine with or without Chondroitin than for the NSAID as there are very few known side effects. Animal research suggests that it may impair glucose tolerance. I haven't found that to be an issue for me and I have cut way back on my NSAID use -- and I don't really care if this is some sort of placebo effect.

Kava is used to relieve stress or anxiety. It has been banned in several countries (but not the US, yet) because of potential liver toxicity. Any time someone selling a product tells you to use it only 3 days/week and 3 weeks/month, you've got to wonder how safe it is.

St. John's Wort may be helpful for treating mild to moderate depression, but it may interfere with a number of prescription medications such as antivirals for HIV, chemotherapy medications, and cyclosporine (anti-rejection medication for organ recipients). It definitely is not effective for major depression, bi-polar disorder, etc.

The most significant risk of herbal supplements is the risk that people might use them INSTEAD of effective medications. I had cancer several years ago. People I barely knew begged me to try various herbal supplements instead of the chemotherapy regimen recommended by my physicians. I did the research. The herbal supplements they recommended had been investigated by NIH and found to be useless. The chemo regimen had also been studied - in great detail - for many years and found to increase 5 year survival rates for cancer of the type and stage mine was from 55-65% with surgery alone to nearly 90% with chemo and radiation. Sort of a no-brainer there. It was hard for me to believe that people would not be convinced by the statistics, so I shared them with those who recommended herbs instead of chemo. They weren't impressed.

Some herbs are safe, some aren't. Some may help, some definitely won't. Do the research -- it's out there. Look for actual research (peer-reviewed studies) as opposed to pure opinion. Ask your physician. If he or she isn't familiar with the supplement, share your research. If you take prescription medications, make sure your doc knows what supplements you're taking -- and make sure your pharmacist knows too. It might save your life.

Long names can be such a nuisance

Typing them into the computer you get so many more opportunities to misspell them creatively, but that's not the real problem.

I work in a NICU, and NICUs have twins. The patients all have the same first name. Baby. The middle name sometimes changes - some have the middle name Girl, some have the middle name Boy. Occasionally we have one with no middle name, but that's a subject for a different day.

Twins are also supposed to get a letter after their name. A for the firstborn, B for the second. We keep going for the higher order multiples, but so far, triplets and quads have all had short last names, so it hasn't been a problem. The letter comes at the end: Lastname, Baby Girl A or Lastname, Baby Boy B.

The problem is our lab label printer. It only gives you so many characters. We've had twins with long names before, but the parents have usually been considerate and had one boy and one girl, so the labels come out different even without the A or B.

No such luck this time. Identical twin boys. Lab labels both appeared: Longlastname, Baby Boy - no letter. Same birth date too, wouldn't you know. We've had twins born on different days, but not these. They HAD to be born on the same day.

So labs were sent and we get a phone call from the lab:

VERY snotty lab tech says, "Did you really want 2 (insert lab value here) for Baby Boy Longlastname?"

I wasn't assigned either baby, but I knew immediately what had happened.

"Did you look at the medical record numbers?" I asked, "because they aren't the same."

Silence for about 15 seconds.

Greatly chastised voice says "Oh, I guess the letters didn't print. I'll just go run those now."

Yes, someone should have taken a second to write A or B at the end, but snotty lab tech should have taken a few seconds to check MR #'s too.

Sunday, May 27, 2007

Congratulations to the new Grads

Congratulations to all of you who have graduated from the various Schools of Medicine, Nursing, and Allied Health this spring -- and welcome to the wild and wacky world of healthcare.

There's a new addition - and a deletion to my blogroll. No more Homeschooled Med Student. No, not another blog gone silent. She is Dr. Alice now and will be starting her surgical residency shortly. She is moving to a new blog to reflect her new position in life.

Welcome to Cut on the Dotted Line!

Thursday, May 24, 2007

IV Therapy Escapades - Part IV

Dead is dead. I've read that on a couple of other blogs, and it's really true. If your heart stops and there's nobody around who knows how to resuscitate you -- and perhaps not even anyone around to call 911 for a while, your odds of ever having a heartbeat again are really low.

This doesn't stop the EMS folks from trying when they get on the scene - and it certainly doesn't stop the ER folks from trying some more when you get to the hospital. It just means they probably won't be successful. You might even be happier if they aren't.

I was a new IV therapy nurse. I knew I was supposed to show up for all stat pages and for all resuscitations. My job was to make sure the patient had some kind of IV access.

One evening, my pager went off for a resus in the ER. I hurried down to find the patient on the gurney, CPR in progress and an ER nurse on each side attempting to start an IV in the patient's arms. The EMS crew had been unsuccessful in the field and the ER nurses hadn't had any better luck by the time I arrived. (Note -- this was quite some time ago -- the patient would arrive with an intra-osseous needle in place these days)

Since the patient was very clean, down to the polished shoes and fresh socks, I asked the ER doc how he felt about accessing the saphenous vein (the large vein just above the ankle bone on the inside of the leg). There are a lot of good reasons not to start IVs in foot or leg veins in adults - but they don't apply when the patient doesn't have a heartbeat and you can't get any other access.

"Any place you can get me a line," was his response.

I quickly stripped off a shoe and sock, cleaned the site, and placed the catheter. Someone handed me a primed IV tubing. I connected it, gathered my supplies and headed toward the door to handle the rest of my pages.

As I was leaving, the ER doc said, "Thanks. Now we can push the drugs and call this code."

I didn't stick around to see if the medications had any effect. The team didn't expect that they would and I didn't want to know.

I don't know how long the patient had been without a pulse. I don't know how long he'd been without a pulse before the EMS people arrived on the scene. I know that there had been a great deal of effort - it was evident from the supplies, equipment, and personnel in the room. They knew the chances were very low, but didn't want to give up without doing every last thing possible

When I got back to the IV therapy office later that day, I told the nurse manager about my experience. That was when I learned that I wasn't expected to answer resus pages to the ER. Then she said, "I'm glad you got the line. The ER may appreciate us more."

Fourth in an occasional series - from my days as an IV therapy nurse several years ago.

Part 1
Part 2
Part 3

Tuesday, May 22, 2007

New Math

Original problem:
4 - 8x = -20

use the commutative property to reverse the 8x and the 4*
8x - 4 = -20
Add 4 to both sides
8x = -16
divide both sides by 8
x = -2


It's easier that way, mom.

Clearly we need to work on the commutative property in regard to subtraction.

For those of you who haven't done Algebra in a really long time, the solution should actually look like this:

4 - 8x = -20
*Since the commutative property applies only to addition and multiplication, we can't use it here.

Add 8x to both sides, add 20 to both sides:
4 + 20 - 8x + 8x = -20 + 20 + 8x

24 = 8x

Divide both sides by 8:

Use the symmetric property:


Sunday, May 20, 2007

RIP Emilio

Emilio Gonzalez, the 19 month old whose family contested the Texas law which would permit hospitals to discontinue life support they consider futile, has died. According to news reports, Emilio died in his mother's arms. I am very sorry for her loss, but not sorry that Emilio will no longer suffer.

Emilio was thought to have Leigh's Disease, a rare neurological disorder which typically appears between 3 months and 2 years of age. Children sometimes live to their mid-teens with supportive care, but those with the most severe form seldom live more than a few years.

End of life decisions are never easy, and when they involve a child they can be excruciatingly difficult. Unfortunately, choices about whether to continue or withdraw life support are not as uncommon as one might hope -- even in the Neonatal ICU. Sometimes the infant is critically ill as a result of a congenital anomaly or syndrome. Sometimes it is a result of extreme prematurity. Always the parents are devastated and look around them for support in the terrible decision they must make.

Occasionally we resort to help from the ethics committee. They examine the facts of the case and make recommendations. I work in a Catholic hospital, so we must follow the precepts of the Catholic Church as well as the laws of our state. Catholic teaching on the discontinuation of life support is that it is not ethically different than never starting it at all. That may be true, but emotionally, the impact is quite different. Helping the parents to fully understand the choices isn't easy either.

In one case, the baby had to be resuscitated repeatedly. The mother was offered the option of a DNR order -- to simply stand by the next time the baby's heart stopped and let the mother hold her child as he died. She was ushered out of the room for each attempt. The doctor had explained to her repeatedly the steps in resuscitation and was growing increasingly frustrated with the mother's belief that when it was time for the baby to die, we would be unable to save him. Eventually he asked that the mother be permitted to stay in the room during the next resuscitation. When she witnessed the resuscitation, she decided that she did not want her baby to go through that experience again.

Other parents have not had the same response. One became terribly agitated when it appeared that we might not be able to resuscitate the baby. The doctor running the resuscitation felt physically threatened by the response. The baby was successfully resuscitated that time, but when the baby coded for the last time, we were relieved that the parents were at home.

It is incredibly draining to care for children whose parents are not ready to acknowledge that they are dying. Many of the interventions are uncomfortable and some are downright painful. It is one thing to hurt a baby with the intention of saving his life. It is another thing entirely to inflict pain in the process of delaying death for a few days or weeks. It is the most difficult part of my job - this fending off the inevitable in order to allow the parents time to accept it.

Saturday, May 19, 2007


Good thing I love technology. As a NICU nurse, I see plenty of it. I usually work nights, so there's one piece of equipment I don't see often. That's the machine used for echocardiograms -- ultrasound pictures of the heart. Sometimes the tech comes in early in the morning before I leave. If I have time, I love to watch the echo technician at work.

The first time I saw an echocardiogram in progress, I couldn't make out a single thing in the grainy screen. As time passed and color was added, I could see the flashes of color that signified blood flow -- and that showed the abnormal blood flow from cardiac defects. I still couldn't make out structures, though.

One recent morning, the echo tech rolled in a machine I'd never seen before. It was huge. The screen was larger and the machine looked very new. I had a few extra minutes, and a good vantage point, so I watched fascinated as she pointed out valves, ventricles, major blood vessels. It was amazing. The images actually looked like the structures -- finally. I'd never have been able to name them without her help, but the tour was fascinating.

As I watched, I appreciated the advances in imaging available to us, but what struck me more than anything else was the courage of those pioneers in pediatric cardiac surgery who didn't have access to any of this technology. I was overwhelmed with the magnitude of the decision to make that first incision.

Friday, May 18, 2007

Thoughts on Lowering the Price of Gasoline

No, this isn't one of those stupid emails telling you not to buy gas on May 15. Apparently a lot of people paid attention to that one, because there were no lines at the cheapest station in the area when I went in to buy gas that day. Price went up a lot of places around here on the 16th. Probably just a coincidence, don't you think?

That sort of idiocy won't lower the price of your gasoline. The sellers know you'll be in the day before or after anyway. They know that because most of you are unwilling to change your driving habits in any meaningful way.

Oh I know you think you are UNABLE to change, but for 99.44% of you that is simply a lie. Virtually everyone can conserve just a little -- and that's really all it should take.

Last fall, I did a little experiment. I drove the speed limit for most of my trips around this area. You probably can imagine the sort of road rage this engenders. Really amazing, when there are anywhere from 1 to 3 other lanes available how thoroughly pissy some people can get. I do my bit to save a little gas and some fool wastes 3 times as much riding my bumper until they figure out I'm not going to speed up and then accelerate rapidly to 20 or so miles over the speed limit.

At a 10% improvement in gas mileage, I'm saving $3.50-$4.00 every time I fill up. I save more by combining errands and scheduling sports and music lessons close together. I've worked things out so I only have to fill up every 2-3 weeks, so that's not as big a deal as it might be for some of you.

Make sure your car is in the best possible mechanical condition -- tires inflated properly, oil changed regularly, clean air filter, tune-up when needed. All of those can add varying amounts to the distance your car will go on a tank of gas.

If a hefty enough percentage of the driving population managed to conserve 5-10%, that ought to be enough to actually make a difference in gas prices.

Can't drive slower? I understand. You're afraid someone will blow you off the road. You don't have to slow all the way down to the speed limit. Just knock off 3-5 mph.

Plan ahead -- you may not be able to choose the schedule for your appointments or your children's lessons, but surely you can cut out one short trip every week. It's not that hard, really.

Carpool - even one day a week would make a huge difference if 25% of the population did that.

Even better, use mass transit if it's available. Give some serious thought to walking or riding a bicycle.

You might not see a difference at the pump right away, but if you conserve just a bit, you'll still see a difference in the total that you are paying for gas.

*If it looks like a statistic, I made it up for dramatic effect. I keep hearing that the increasing prices are related to demand. If that's true, decreasing demand is the best way to decrease prices. For the record, I believe that a significant part of the increased price is gouging.

Thursday, May 17, 2007

Whatever happened to common sense?

I signed up for the Consumer Product Safety Commission's recall list. It's full of gems like dishwashers that can catch fire (didn't buy that model, thank goodness) and children's accessories that are full of lead.

Today's offering had me rolling my eyes.

The headline says:

 (Store name here) Recalls Children's Capri Pants Due to Choking Hazard;
I thought they must be infant, or at least toddler sizes. Nope. The smallest size is 4. These are girls' size 4-8 pants and the buttons are ON THE INSIDE. They are stitched to the waistband and there is an elastic strip for adjusting the waist.

I suppose younger siblings may be chewing the buttons off. Heaven knows my sons chewed buttons off their shirts at this age, but pants? and inside, no less.

Why not just check to see if the buttons are loose and re-stitch them if they are. That's what I did with my sons' shirts. Of course I wasn't likely to sue myself.

Oh, and if you want to know what else has been recalled, you can sign up for the daily emails at  

Monday, May 14, 2007

Spider Bite

"Do you think I need to see a doctor about this?"

I hesitated briefly and my sister, also a nurse, jumped in, "Yes! That's ugly."

Ugly is an understatement. It was about 3cm (1.5 inches) across and elevated by nearly a half inch. Fiery red with a scabbed center, my hesitation was not about whether it should be seen, but how soon. ER or private physician?

"How long has it been there?"

"Yesterday. The spider bit me yesterday. It itched and I scratched it."

We also learned that it had oozed a thick, white, substance that was described as resembling yogurt. We learned that the pain was quite localized in the area of the lesion which had doubled in size since the previous day AND that the person had NO intention of changing plans for the evening which did not include the ER. I hope it doesn't do more than double again before it's treated.

I'm betting on CA MRSA - community acquired methicillin resistant staph aureus. Nasty bug, that one, and increasingly common. I hope I'm wrong. Better that than a brown recluse spider bite, though. Those cause significant tissue damage. The person did not think the bite was from a brown recluse, just a fairly large house spider and that it got infected after being scratched. If there had been a necrotic center, I'd have pushed for an ER visit that evening, but it was scabbed over, not necrotic, and not oozing.

In case you're curious, here are some links to MRSA infections and nasty spider bites:
Warning, they're all ugly.

Brown recluse bite -- note the necrotic area in the center. It's red, but not elevated.

Another brown recluse bite -- really ugly one on a hand. As an anonymous person says in the comments, this may or may not actually be a brown recluse bite. If it is, it's likely infection that has done most of the damage rather than brown recluse venom. Check out this link (no pictures) on the UC Riverside entomology site.

MRSA skin abcess -- very similar to the abcess I saw, but with no center scab -- and a little smaller

Spider bites can get infected, whether they're from a dangerous spider like the brown recluse, or a house spider. It is also possible, and doubtless more common, to have an infected hair follicle, or other skin lesion. The link above to the article about CA-MRSA includes a list of risk factors for otherwise healthy people which includes "close skin-to-skin contact, openings in the skin such as cuts or abrasions, contaminated items and surfaces, crowded living conditions, and poor hygiene."

Friday, May 11, 2007

No Prenatal Care

I tell you, it's enough to strike terror into the heart of a NICU nurse when those words appear on the monitor screen that connects us to the birthing center.

No Prenatal Care.

That means no labs, unless mom's labor lasts long enough for us to get them, but that's not nearly common enough.

We don't know if the baby needs to be treated to prevent HIV - and won't for at least 24 hours. The medications aren't risk-free, so we can't just give them to everyone. They're most effective if mom was treated antenatally and the treatment continued for weeks after birth. Delay in treatment can increase the risks. When an HIV positive mom is treated during the pregnancy, and when she has good prenatal care and the pregnancy can be carried to term -- and when the baby receives the full course of prophylactic treatment, the transmission rate is about 1%.

For preemies of untreated moms, it's considerably higher -- even with medication after delivery.

We don't know if the baby needs to be treated to prevent Hepatitis B.
On weekdays, we can generally get the labs back in time to prevent unnecessary treatment, but on weekends our only option is to give Hepatitis B Immunoglobulin in addition to the Hepatitis B vaccine. This is an avoidable injection -- and an avoidable expense. If only the mom had prenatal care. At least we can usually keep the baby from getting Hepatitis B - which is critical, because infants who contract Hepatitis B have a greatly increased risk of becoming carriers. That puts them at higher risk for cirrhosis and primary liver cancers.

We don't know if the mom is colonized with Group B Strep.
This can lead to otherwise unnecessary admissions to the Neonatal ICU. You can pretty much pay for the whole nine months of prenatal care - for at least one woman - by eliminating just ONE otherwise unnecessary NICU admission. When we don't know the mom's GBS status, we are much more likely to admit the baby to the NICU to start 3 days (minimum) of antibiotic treatment for symptoms we might observe in the well-baby nursery and follow with serial CBC's. Sick babies get admitted regardless, but certain variations from normal are much more likely to end up in the NICU if mom is GBS positive -- or if we just don't know.

The baby is at greatly increased risk of being small for dates.
Babies who are significantly smaller than expected for their gestational age are guaranteed a NICU stay and an expensive workup. We've had an epidemic lately of 1400 gram FULL TERM babies. That's just a hair over 3 pounds. None of the moms had prenatal care.

Those babies are at increased risk of developing necrotizing enterocolitis - a serious condition which can be life-threatening, can require surgery - and at the very least, requires weeks of IV feedings and antibiotics. None of our recent little ones has had NEC, but they all get really hungry before we feed them. Depending on the birth weight and the mom's choice of breast or bottle, that can be as much as 5 days after birth presuming there are no symptoms of NEC. They need IV feedings which are phenomenally expensive. 5 days of TPN c0uld cover 9 months of prenatal care AND food supplements for several women.

The babies are at increased risk of a variety of developmental delays and congenital anomalies.
This is because of undiagnosed maternal factors (diabetes, poor nutrition, substance abuse, hypertension, viral illnesses, etc). Many of these, if managed prior to and during pregnancy do not need to lead to negative outcomes.

You have no idea of the gestational age.
With ultrasound imaging - possible if mom does not present fully dilated - you at least have an idea of the size of the baby and can be prepared for that. Size alone does not help much in determining gestational age. Small for dates infants are more mature than you would guess from size alone and infants of diabetics may be large, but premature.

Undiagnosed multiples.
Yes, we're prepared for all possible outcomes, but the very last thing you want to hear in the delivery room is, "I think there's another one in here," when you had no reason to expect twins. It's not pretty - and ultrasound imaging has virtually eliminated that scenario, but if a mom comes in fully dilated and crowning, there just isn't time.

Prenatal care is available for FREE in many areas and at greatly reduced cost in others. It's a worthwhile investment. Not only does it reduce costs to the point that it pays for itself - just in reduced NICU admissions and maternal morbidity, but it pays for itself in reduced long-term problems for the babies. It's not just about the money, of course. Improved outcomes for the babies is the most important thing, but the money isn't unimportant. We have a finite number of health care dollars and saving dollars while saving babies just makes sense.

Tuesday, May 08, 2007


Mom learns more than the kid some days. Today I learned that electricity can be dangerous in the hands of 11 year old boys. Even battery powered electricity.

I can hear you out there. Someone just said, "No kidding!"

That was the polite comment.

My first mistake was not asking why he wanted 4 batteries instead of the 2 he'd been using.

He's been experimenting with a small Snap-Circuit set for a couple of years and the big one arrived today. It's the really flashy one with 750+ experiments, some of them involving the computer. My computer. I'm not so sure about that now.

It has 2 battery holders - for a total of 3 when you count the parts from the first kit. That's 2 batteries per = 6 batteries. Good thing he couldn't find 6.

He got out both sets and built something very much like the photo above, only with 4 batteries, 2 electric motors and 2 spiffy red fans. It was blowing quite a bit of air what with the sliding switch he'd installed to regulate the power.

My second mistake was turning my back on him.

First I heard an alarm - 0ne of the assortment of noisemakers provided -- and an amazingly loud whirring sound. Then something whizzed past my ear.

The next thing I heard: "I guess I won't do THAT with 4 batteries again."

You betcha. He knows that was a close call. Couple of inches closer and he'd be banned from science experiments for quite a while -- or worse, sentenced to write a report. That's the worst possible punishment around here - writing a report on what went wrong and why.

Right now he's trying to figure out whether reversing the polarity on the electromagnet will toss out the iron rod instead of sucking it in. I don't think it's going to work, but I can tell I'm going to have to insist on protective gear for future experiments.

Friday, May 04, 2007

First Class!

He's not quite 12 yet and he's nearly as proud of himself as his parents are of him. My youngest has been a Boy Scout for a little over a year and just earned the rank. He's very enthusiastic about scouting and is planning his next merit badge and how he'll meet his requirements for the next rank.

He loves the camping. He loves the meetings. He loves the challenges and the action. He even loves helping the older scouts with their Eagle projects -- 2 completed since he bridged, another one scheduled for next month.

Mom is enjoying the more relaxed role of troop committee member instead of Den Leader.

Wednesday, May 02, 2007

Interesting Statistic

I finally figured out how to see what sort of Google searches led people to my blog. Nothing shocking or even entertaining there. I suppose that means I'm pretty bland.

The interesting thing about the statistic was HOW MANY times a particular search had led people to my blog. 27 of the last 100 clicks were search engines, mostly Google. 8 of those were queries about childhood immunization. I find that fascinating in view of Shinga's observation In December 2006 about the number of anti-vaccine links vs the number of pro-immunization links and their relative importance in the search engines. Immediately afterward I linked to the first few of Flea's posts on the subject. I need to modify that post, because I failed to keep up with Flea, but I strongly encourage you to link to Flea's posts -- or to similarly well-written posts on the subject of childhood immunization. It seems to have a positive effect on the search engines, if not on the searchers.

Necrotizing Enterocolitis vs ........

Both babies were significantly small for dates -- about 1400-1500 grams (around 3 pounds) even though they were 34-35 weeks gestation. They were IUGR (intrauterine growth retardation) which is a significant risk factor for NEC (Necrotizing Enterocolitis).

Both presented the same way: Essentially normal vital signs, active bowel sounds, minimal residuals before feedings, no vomiting, no obvious blood in the stools. However, both had tight shiny bellies - potentially a symptom of NEC which can be lethal in these small infants.

We weren't overly worried, because we knew that even if this was NEC, we'd caught it early. The neonatologist ordered an xray and a CBC.

We get the xrays back first. Baby 1's xray was clearly benign -- full loops, but no pneumatosis (gas bubbles in the intestinal wall - a conclusive sign of NEC) . Diagnosis FOS*

Baby #2's xray was terrifying. It looked like virtually the entire colon had been impacted. The neonatologist headed off to phone the surgeon as I prepared to start an IV and give the ordered antibiotics. I opened the incubator portholes my nose told me there was another problem to deal with first.

I opened the stinky diaper and called the neonatologist over to examine the contents.

"No, it can't wait until after you call the surgeon. Just come look at this. Really, you want to see it before you make that call."

No. The diaper wasn't full of the feared "currant jelly" stool. Currant jelly stool is blood and mucous which is a sure indicator of intestinal bleeding and very commonly a surgical emergency. Instead, the stool looked almost exactly like the xray image of the intestine. It was frothy and full of bubbles. I don't remember what the final determination was on the frothy stool, but the baby definitely didn't have NEC. Again, diagnosis for that night was FOS*

*FOS - full of stool. Preemies often have sluggish GI motility and this FOS diagnosis isn't uncommon - but it's always a relief.