Monday, December 29, 2008


8pm: Birthing center on the phone: "32 weeker just came in. She's ruptured and 6 cm - 5th baby).

Seconds later speaking to the Nursing Supervisor

"Even with the float nurse you sent, we're down one nurse from our pattern and we're definitely getting one more admission, possibly 2. Can you find me another nurse?"

NS: "I'll call the agencies again."


Phone rings 20 minutes later. "This is the nursing supervisor. I can get you an agency nurse who will be here in 2 hours."

That will be a huge help! Thanks again!

10 pm. Night shift supervisor: "I see we've booked an agency nurse for you at 11. Does that mean I can send the float nurse somewhere else?"

I wouldn't have asked for an additional nurse if I didn't really need one. We're definitely getting an admission within the next hour, there's another potential on the status board and (glancing at the board) OMG there's a 25 weeker on the board now! I know we don't staff for "what if" but I really need to stick to my pattern.

Supervisor: Well, if you REALLY need her....

Yes, I really do - and thanks!

Other units are busy too, so I can't blame the supervisor for trying and I don't want that job for anything. I don't even want to know where else the float nurse was needed. Staffing patterns aren't perfect, but they can sure save a lot of time explaining why additional help is necessary or deciding whether unit staff is "extra" and can be floated.

Sunday, September 21, 2008


The phone rang from the birthing center. "Crash section. No heartbeat. Please send the team."

So I did. And I went with them. An extra pair of hands or three comes in handy when you're trying to do everything at once.

By the time the OB handed over the baby, everything was in place. ET tube cut, drugs drawn up, umbilical line ready to go.

She was beautiful. At least I think she may have been a girl. I didn't really look. I was too focused on what I was doing at the time.

No heartbeat.

Dry the baby. Get her off the wet towels.

Bag-mask ventilation.

No heartbeat.

Chest compressions.

No heartbeat.

ET tube in place. Breath sounds equal. Placement checked with CO2 detector.

Epinephrine down the endotracheal tube while the doc placed the UV line (a tube into the large vein in the umbilical cord).

No heartbeat.

One minute APGAR 0
Two minute APGAR 0 -- no heartbeat. No respiratory effort. No muscle tone. No reflex response. Deathly pale.

Epinephrine via the UV catheter -- "Careful. Don't tug on it."

No heartbeat.

Saline for volume expansion. More epinephrine.

No heartbeat.

Coordination of effort could not have been more perfect. We followed the Neonatal Resuscitation Protocol to the letter.

Including the part that suggests that you should consider discontinuing resuscitation efforts if there are still no signs of life after 10 minutes of "continuous and adequate" resuscitation efforts. I don't much like that part, but I agree with it.

She was a beautiful baby. At least I think she was a girl, but she never had a heartbeat. Not while we worked on her.

On days like that, I don't much like my job. I love the people who work with me, though. I value their expertise and their compassion. I particularly appreciate their ability to support one another and to remind each other that no matter how perfect our efforts, the final outcome is sometimes completely beyond our control.

Wednesday, August 27, 2008

Support our Troops, Packs, and Crews

Just as the Girl Scouts have their cookies, Boy Scouts, Cubs, and Venture Crews sell popcorn. My son's troop has chosen alternate fundraisers because we don't want to interfere with the Cub Pack affiliated with our troop. They raise their entire budget with popcorn sales. We try to support them and they, in turn, support our fundraisers. Since there is a great deal of overlap between the families, we're better off with that strategy.

This year, it is possible to support our military while supporting the Scouts. The order form includes a $25 slot for "Support the Troops" popcorn order. You can support the Troops while you support the troops. I think the Girls Scouts got there first with their cookie sales, but it's still a good idea.

If you have a local Scout unit, please support their efforts - even if you don't eat popcorn. If you don't have a local unit and you'd like to take advantage of the "Support the Troops" option, let me know. I can put you in touch with our Cub Pack and we can get that popcorn out to some young men and women who just might like a snack.

Wednesday, August 20, 2008


The table top and chair above originally had green legs. The table top was badly scarred and the finish had been damaged. I used a citrus-based stripper which eats through old finish (and vinyl gloves) very quickly, but which doesn't have an offensive odor and doesn't strip off skin. Thank goodness.

The project would look better if I'd done what I normally do when finishing furniture, which is to stain first, then add polyurethane as a protective coat. I don't much like the combination product. It works, but it is NOT faster. It is cheaper, proving that you often get what you pay for.

Wednesday, August 13, 2008

Cake Wrecks

I just spent 25 minutes I couldn't really spare reading (and looking at pictures) on a web site called Cake Wrecks. Some of the cakes are funny, some are creepy, some are amazing. A few definitely require a "No eating or drinking while reading" caution.

Contents - 'professially' prepared cakes that have gone horribly wrong.

Tuesday, August 12, 2008


If you're allergic to latex, do NOT believe the nice salesperson at the paint store when they tell you that vinyl gloves will protect your hands from paint stripper. I'm thinking maybe nitrile, but I'm open to suggestions

Odorless mineral spirits aren't. Well ventilated location was definitely a good idea on that one.

Photos to follow when the furniture is finished.

Friday, August 08, 2008


The wedding is in about 16 hours. My middle son will marry his childhood sweetheart.

Actually, they didn't much care for each other the first 10 years, but they first met when they were 7 and 10. Pretty much normal reaction for kids that age.

People keep asking them if they're nervous. They think that's funny, and a little annoying. They know there will be adjustments, but they're looking forward to them with anticipation rather than trepidation.

They found an apartment this week. A little last-minute, perhaps, but it's a good location for both of them, fits their budget, and is roomier than most in that price range. It's also upstairs from the landlord.

I spotted the ad in the local paper last week. It took a few days for them to reach the landlord and make an appointment to check the place out. They invited me to go along, so I did.

Turns out the landlord is a local elected official - one I'd voted for, and will again. She spent some time talking about how folks in this part of town just 'go with the flow', taking things in stride. She even gave examples from her work. She talked some about the stores and churches in the area. We're already quite familiar with those, since we just live a few miles away. Then she mentioned that if my son had any interest in the local Knights of Columbus, one of their most active members is a neighbor.

Oh yes, we know him.

The landlord made it clear that she had other prospects to interview, but stood outside and chatted with us for another 20 minutes or so. While we were standing there, the neighbor stopped to wish my son and his bride-to-be congratulations on their upcoming wedding.

When the landlord told my future daughter-in-law they'd been chosen, she said that the other couple, much decorated tattoo artists, frightened her and would likely frighten the neighbors. It's got to be easier to 'go with the flow' in your office than in your home -- and the personal reference from the neighbor certainly didn't hurt.

Then there were all the moms, grandmoms, and friends who have been asking St. Joseph to intercede on their behalf. I don't think the other couple had a shot.

Thursday, July 24, 2008

Slow Learners

A friend told me that she just got her first speeding ticket -- 2 months after replacing her older, rattly car with a newer, smooth-riding model. Steep learning curve, that one. Not as steep as some people find when they get to traffic court, though.

A few years ago, I accompanied my son to traffic court. He had lost control of his car - we think due to a mechanical malfunction. He was uninjured. His car was totaled - and so was the guard rail that had kept him from spinning into oncoming traffic. The Trooper told him he had to write a ticket so the state could bill our insurance company to replace the guard rail, but that he shouldn't worry about it. When his case was called, the Trooper declined to testify against him and the judge threw him a big enough hint that he realized he should plead not guilty.

Most of the rest of those who appeared before the judge that day fared better by pleading guilty - often guilty with an explanation. The judge lowered fines and points all around. There were a few slow learners in the crowd, though.

The same State Trooper had written citations for about half the crowd in the courtroom that day. For speeding violations, he started his testimony pretty much the same way:

At X time on X date using equipment that I calibrated at the beginning and end of my shift, I recorded a speed of (20- 50 MPH above the posted limit)..........

Most people accepted the Trooper's measurement of their speed, but one defendant wasn't so bright. He started his 'defense' with "Your Honor, I don't know exactly how fast I was going.."


Down came the gavel and the judge said "You may not know how fast you were going, but I have the sworn testimony of an officer of the law using calibrated equipment. He measured your speed at (40-50 mph above the posted speed)." No mercy for that defendant -- maximum points AND fine.

It was hard not to snicker at that one, but 4 or 5 defendants later, another man tried the same stunt -- with exactly the same results. I was glad we were sitting in the back of the courtroom, because I really didn't want to get caught snickering at him.

The third time it happened, only fear of being found in contempt of court kept me from laughing out loud. I can't imagine being stupid enough to try that story the FIRST time if I was caught on radar, but I truly do not understand what defendant #3 could possibly have been thinking.

Thursday, July 17, 2008

Enter the Collective

We're rolling out a new computerized charting system and I was conned into being a "superuser". Flattery will get me to do too many things against my better judgment, and so here I am.

In order to learn the new system, I had to orient on one of the floors already using it. An adult medical floor. My preceptor was a very knowledgeable and very upbeat nurse who'd been using the system for nearly a year. She loves it. She's sure everyone will.

Resistance may be futile, but some days, it's my middle name. Eventually we will all be assimilated.

I have seen and toyed with the system. She's right. We will eventually come to like most aspects of this system. It has a few flaws, but overall it's pretty well designed.

The first part of the system we'll be using is the medication administration record (MAR), so off we went to find, administer, and document medications. Generally this went smoothly as there's no stopping to locate labs before you give medications. Coumadin? Click a button and there's your INR so you know whether it's safe to give the dose. Insulin? The blood sugar is there too - and you have to prove that you read it by entering it as you enter the insulin dose. The system even includes a spot for the second nurse to co-sign insulin and other meds which require that.

Most of the meds given, we were off to see her last patient. She pulled up his MAR and scanned his ID bracelet and the medication. They matched.

"Mr. Jones, we're here to give you your medications."

"What did you call me?"

She knows this patient. He's been on her floor for several days, but she did not simply ignore the question.

"Sir, what is your name?"

"I don't know."

"Do you know where you are?"


"Do you know what year it is?"


To me, "You ask him his name" (so I did)

Again, "I don't know"

To me, "I'll show you his diagnosis later. This isn't unexpected."

To the patient, "Mr. Jones, I have your medication."

"What's it for?"

"It's for your stomach."

"What's it called?"

"Protonix, it's for your stomach. For the acid."

"Why are you giving it to me?"

"Your doctor prescribed it. It's for your stomach."

"I don't know if I'm supposed to be taking that."

And on for several more minutes before she simply asked him to open his mouth, which he did. She placed the pill in his mouth and spent the next several minutes coaxing him to swallow.

THEN she told me that she'd thought about working in the NICU, but didn't think she could do what we do. Right. Those of you who care for confused elderly patients have my undying admiration. I could probably learn to do what you do, but I'm not sure I could learn to love it like she does.

Tuesday, July 15, 2008

Beats the heck out of me

My youngest son asked me a question today. At first glance, it seemed to be a very simple question.

Do you breathe out the same amount of air that you breathe in?

I explained that the volume of individual breaths varies, but that my first thought was that average inhalation must be the same as average exhalation -- because if it wasn't you'd either end up with a vacuum or overinflated. Then I remembered that you actually absorb molecules from the air and return others in the process of respiration. I'm not sure that the quantity is measurable, but I'm not so sure that you exhale the same amount over the long haul as you inhale. So I told him that.

His response?

Why don't you blog about it and see what other people think.

He'll nag me if you don't comment. Facts would be nice, but we'll settle for opinions if that's all you've got.

Monday, July 14, 2008

APGAR 0, 0, 0, 2

The neonatal resuscitation protocols include suggestions for when to discontinue efforts:

Infants without signs of life (no heart beat and no respiratory effort) after 10 minutes of resuscitation show either a high mortality or severe neurodevelopmental disability (LOE 5).106,107After 10 minutes of continuous and adequate resuscitative efforts, discontinuation of resuscitation may be justified if there are no signs of life (Class IIb).
That suggestion wasn't included in the original protocols. Children like Edie are the reason that suggestion was added to the protocol.

Her mom had a normal pregnancy and most of her labor was uneventful. Unfortunately, she delivered in a small hospital which did not, at the time, have in-house anesthesia coverage for emergency C-sections. Something went terribly wrong and he had no heart rate at delivery.

By 1 minute, his APGAR score was still zero - no heart rate, no respiratory effort, no reflex response, poor muscle tone, blue or pale. By 5 minutes, still no heartbeat. At 10 minutes, the pediatrician was still desperately trying to save the baby -- but still no signs of life. Finally, sometime between 10 and 15 minutes, Edie had a heartbeat -- and nothing else.

Edie was a beautiful baby, but she never moved spontaneously. A month later, she might gasp when disconnected briefly the ventilator for suctioning, but generally she didn't even do that. Her parents visited every day. They held her, talked to her, took pictures for their memory book. They hid their pain from most of the staff -- to the point that many believed they were in denial. Those of us who had quit trying to 'orient' them were privileged to share their pain, though. They knew it was just a matter of time and were determined not to waste their precious moments with this child crying at her bedside.

A few months later, Edie got septic and her parents agreed that resuscitating her if her heart stopped would not be in her best interest. She died, more or less peacefully, a few days later.

The other babies I've seen with 0 APGAR scores at 10 minutes survived only a few hours or days. I don't remember another who survived even a week.

It's very difficult to make the decision to stop resuscitating a full term, or near term baby, especially if the mom was in the hospital being monitored so we know the time that the heartbeat stopped prior to that emergency C-section . I've seen many babies respond to the Neonatal Resuscitation Protocol and go on to do very well. Those babies virtually all have had APGAR scores increasing by 5 minutes, and the rest definitely had signs of life by 10 minutes.

That suggestion to consider discontinuing resuscitation if it has been unsuccessful after 10 minutes makes a lot of sense to me as I sit here typing. In the adrenaline-laced atmosphere of a neonatal resuscitation, it's hard to put it into practice. I'm always grateful that the final decision is not mine.

Thursday, June 05, 2008

Welcome to the NICU, let me show you around - Part II

Why do I have to wait so long to come see my baby?

Parents may be asked to wait 30 minutes to an hour - occasionally longer - as we admit the baby to the NICU. Other units may have different policies, but we find it easier to provide urgently needed care if we can explain it to the parents when we've finished, rather than during the procedures. Some of them can be frightening if you've never seen them before. If the mom arrives at the hospital several hours (or days) prior to delivery, our physicians or nurse practitioners will spend some time explaining the NICU admission procedures and what we expect for their baby. Unfortunately, we don't always have this opportunity.

A-B - Airway & Breathing. If the baby is having difficulty breathing, or maintaining an adequate oxygen level, we'll have to deal with that. Sometimes the problem is so severe that we need to place a breathing tube in the delivery room. Sometimes the baby just needs some supplemental pressure or oxygen.

If the baby just needs a little oxygen (bigger babies who are simply slow transitioning), we may use a nasal cannula -- just like the ones used for adults, but smaller. Humidified, and sometimes heated (depending on the flow) oxygen is provided. We use a device called a blender to mix it with air to provide just the right concentration for each baby.

Babies who need more help breathing may be placed on Continuous Positive Airway Pressure -- which we call CPAP (pronounced See-pap). Humidified, heated air mixed with oxygen (again, a blender) is delivered at a higher flow to a nasal mask which covers the nose or soft "prongs" that fit inside the nostrils. This is similar to the equipment used by adults with sleep apnea.

Babies in severe respiratory distress will have a breathing tube placed. The tube is called an endotracheal tube or ET tube and the procedure is called intubation. Babies who are intubated usually receive surfactant. Surfactant is the substance in your lung fluids which decrease the pressure needed to expand the lungs -- and decrease the effort needed to breathe. We use a natural (animal derived) surfactant rather than a synthetic surfactant because studies have shown better outcomes with the natural surfactants.

Once the baby's airway is stabilized - with one of the above - we'll need an xray to check the extent of lung disease and the placement of that ET tube.

C - for Circulation. If the baby requires full resuscitation at delivery, we will provide chest compressions and possibly some fluid in the delivery room. Most babies don't need that degree of resuscitation at birth, but it is far more common for babies to have abnormally low blood pressure for many reasons which can range from blood loss due to placental separation prior to birth to septic shock from infection. We may start an IV in the baby's arm or leg, but if the blood pressure is very low or if the baby requires an ET tube to breathe, we'll probably place catheters in the baby's umbilical cord.

The doctor or nurse practitioner will tie a sterile cord around the base of the cord to keep it from bleeding. Then they will place a flexible tube into the umbilical vein and one of the umbilical arteries. This gives us a place to provide needed fluid, a way to obtain blood samples without using needles, and a way to monitor the baby's blood pressure more accurately. Again, an xray will be needed to determine the placement of those catheters. On a good day, we get one xray for ET placement and line placement at the same time.

Babies who aren't so sick will have a thorough physical exam and some basic lab work, possibly an IV placed in an arm or leg, and an xray. Families of those babies usually get to visit within about a half hour. If things seem to be taking an unusually long time, the nurse from the delivery room can call the NICU to find out what is holding things up -- it may be an emergency with another baby. Occasionally we admit 2 or even 3 babies at the same time -- and that's not counting the twins and triplets. Larger NICU's in hospitals with busier delivery suites are likely to be even busier.

Once the baby's condition is stabilized and the urgently needed procedures are completed, we let the nurse in the delivery suite know so the family can come visit the baby.

Sunday, May 11, 2008

A Scout is Reverent

There have been many changes since the restructuring of our troop a few months ago. Some are larger than others. I was chatting with the father of our Senior Patrol Leader a few weeks ago. He mentioned that the troop he spent his Scouting years in had begun each meeting with the Lord's Prayer in addition to the Pledge of Allegiance and the Scout Oath, Law, and Motto our troop was already saying.

I liked the idea. I thought it appropriate, since our parish is our sponsoring organization so I mentioned it to another leader, who replied, "We should take that to the Troop Committee."

I told the Scoutmaster who responded, "The committee can't tell me how to run the meetings."

These exchanges were overheard by one of the younger scouts who said, "We don't need anyone's permission to pray. I'll ask the other Scouts what they think."

And so it was done.

Wednesday, April 30, 2008

Welcome to the NICU, let me show you around

Only occasionally do families of NICU babies have enough advance warning to get a tour of the unit where their precious child will spend the next few days, weeks, or months. The baby is often whisked out of the OR or birthing room before the parents get more than a glimpse and it may be up to 2 hours before the baby is stable enough for them to be permitted to visit.

Sometimes the mother is so sick that it is days before she can leave the birthing center or ICU herself. These can be some of the longest moments of a parent's life.

Babies generally start their stay in some kind of radiant warmer bed. If the NICU is well funded, it may be something like this one:

The bed pictured above has many features which make life easier for the NICU staff, for parents, but most importantly for the tiny infants who need those features to make their lives safer and more comfortable.

Starting at the top:

The bed has a radiant warmer component hidden in the clear shield at the top. It opens when the top is lifted and closes when it is closed. In the open position, the radiant warmer unit can provide enough heat to keep a tiny baby warm in an average-temperature room. The tiniest won't stay warm for long, even in this environment, because they lose heat as body fluids evaporate directly through the skin.

Fortunately, the top can be closed at the touch of a button to make a closed, humidified environment for the baby. Closing the hood shifts the bed to heating by gentle currents of warmed and (optionally) humidified air which are designed to form a barrier between the baby and the exterior.

A sensor probe is attached to the baby's abdomen, armpit, or occasionally side or back to let the bed know exactly how much heat to provide to maintain the baby's temperature.

Not all units have the option of a monitor attached to the ICU bed as this one does, but all babies requiring this type of bed will be monitored (to be discussed later).

Because NICU babies are weighed frequently, a scale has been built into the bed. This allows the baby to stay in his/her warm environment while being weighed. The bed can keep a log of weights and graph them.

The sides have portholes for use when the bed is in its closed position and the sides fold down to permit more access for delicate procedures when the bed is open-- or once the baby is more stable, to allow him/her to be removed without opening the top.

The unit can be lowered so that family members can sit beside the bed to visit or raised enough for the tallest staff member to work comfortably.

More on NICU equipment and admission procedures to come

Friday, April 25, 2008

Captain Barbecue hangs a chicken

Neumed left a comment on a previous post in which he mentions cooking a chicken on a string. That sounded like too much fun, so I had to go looking and found Captain Barbecue. What a hoot!

I also found William Rubel who has written an entire book about hearth and campfire cooking. Now I know what to ask my kids to buy for Mother's Day.

It does look fun -- and quite tasty. Most Boy Scout camping areas don't permit open fire cooking any more, but there are a few places left -- including a local park with fire rings. I'll be passing this along to our troop Quartermaster and cooking instructor.

As a side note, parts of the Captain Barbecue web site might be considered naughty. Not quite R naughty, but definitely PG-13+ naughty.

Saturday, April 12, 2008


My 12 year old is officially a Star scout. He completed the requirements a couple of months ago, but the Court of Honor was this week. He's worked hard to get here and is raring to go on with the requirements for his next advancement. He "only" needs 2 more merit badges from the required for Eagle list - and 2 months more in his leadership position - before he is eligible for the Scoutmaster conference and board of review which will determine when he has earned the Life rank. I believe the merit badges may take longer than he thinks. Some of them can be quite challenging.

We have other scouts advancing and our newest recruit will bridge as soon as he completes his Arrow of Light in the Cub Pack. He's been visiting troop meetings and seems to fit in well with the troop. He's looking forward to camping with the boys - and they've been working with him on his Arrow of Light requirements.

Baby gets a pacemaker

Little Liam King was only 5 days old when he became the youngest patient ever to receive a pacemaker to regulate his heart rate. Depending on which version of the story you read, his parents were told he'd only live 15 minutes, 15 days, or 15 months without the surgery. I'll be looking for the story to be published in one of the medical journals to find out which.

Liam was born with a heart defect which affected the electrical system in his heart. This is called heart block. The heart's electrical system is supposed to coordinate the contractions which pump blood through the heart. In heart block, the blood vessels are often normal, but the electrical signals don't get to the right place to cause the ventricles (lower chambers) of the heart to contract. There are 3 types of heart block.

First Degree -- the signal gets through, but not as fast as is typical. This type of heart block usually does not require any treatment.

Second Degree -- Most of the signals get through, but there is an occasional missed beat. Depending on the frequency, this type may cause enough symptoms to require a pacemaker.

Third Degree -- also known as complete AV block. This is the type baby Liam has. No signals get through to the ventricles. The ventricles have their own electrical signal which will cause them to beat at a slow rhythm, but which may not provide enough blood flow - especially for a baby. Individuals with third degree block are at risk of sudden cardiac death and will need an implanted pacemaker.

The images of baby Liam on the icWales site show just how large the pacemaker is in comparison to this fairly small infant. It covers about half of his abdomen. As he grows, the pacemaker will have to be periodically replaced and repositioned. He seems to have done very well in his hospital stay. He was delivered 6 weeks before his due date and released from the hospital only a little over 4 weeks after his birth. There are more than a few 34 week preemies who would still be hospitalized even without the cardiac complications and surgery.

Update: See the comments - Liam's dad dropped by to let me know they were actually told he might only survive 15 minutes. Amazing how differently the various news sites reported this.

Wednesday, April 09, 2008

The Pope is Coming!

I have tickets to stand on the lawn and watch him drive by. Probably the closest I'll ever get to the Vatican, though.

It's been crazy busy here. Work is busy, homeschool co-op is busy, the Scout troop is going to make me totally crazy. Being secretary and treasurer when you're married to the Scoutmaster is probably not the best idea. Refusing to have check writing privileges -- definitely a smart move. Sorry, honey. You'll have to go to the committee for the money. When I get caught up, I'll write a review of Troopledger. It has some very useful features and some which could be improved. Overall, it's a positive, though.

Friday, March 28, 2008


Midwife with a Knife wrote an interesting and thoughtful post on one of the consequences of noncompliance in pregnant diabetics. Sometimes their babies die. Sometimes that happens very close to their due date. She writes about the challenge of speaking with these women about how their behavior contributed to the stillbirth of their baby. Not an easy conversation to be sure but they need to know that following the doctor's advice in future pregnancies will significantly improve the next baby's chances of survival.

Stillbirth (fetal death) isn't the only negative outcome when a pregnant diabetic fails to follow her OB's advice in regard to diet, blood sugar testing, medication (often insulin) and monitoring. The surviving infants are very likely to end up in the neonatal ICU. When someone tells you that their baby weighed more than 9 pounds and was born more than a month early, think non-compliant diabetic. That's usually the case.

It isn't fun or easy to check your blood sugar 4-6 times/day, follow a fairly rigorous meal plan, and maybe even give yourself multiple doses of insulin. I know how hard it can be - I was diagnosed with diabetes just prior to my last pregnancy. I was spared the insulin, but my fingers certainly were sore and I met with a dietitian monthly to make sure I stayed on track. I might not have done so well, but that was the year we admitted one after another 9+ pound 34-36 week gestation infants of diabetics. They nearly all were so sick that they required ventilators and ALL of them needed huge amounts of IV glucose solutions to manage their blood sugar issues. The experience made me obsessive about doing everything necessary to keep MY baby out of the NICU. It also made me much more sympathetic to the moms who weren't able to stick with the program. It's hard. Really hard. The results are worth the effort.

Babies whose mothers aren't able to keep their blood sugar under control during pregnancy are very likely to be larger than normal for their gestational age. This often leads to pre-term delivery with resulting respiratory distress. They are also at significantly higher risk for birth defects - particularly cardiac anomalies.

Another problem for infants of poorly controlled diabetics is hypoglycemia. When mom's blood sugar is high, the baby produces large amounts of insulin in response. When the baby is born, the insulin production continues - resulting in dangerously low blood sugars. It isn't uncommon to need a 15 or even 20% sugar solution to stabilize the blood sugar in these babies. Once we get the blood sugar stabilized, we can slowly decrease the amount of glucose we give and wean the baby off IV fluids. This can take several days.

Discussing the cause of their baby's admission to the NICU can be almost as challenging as MWWAK's discussions with the moms of stillborn infants. It isn't uncommon for the women to lie to their OB's.

One woman had told her OB that her blood sugars were essentially normal -- all 6 times the was testing each and every day. She had even managed normal fasting blood sugars when those were tested by the lab. I don't have a clue how she managed that last, because each and every urine specimen tested at her office visits had been 2-3+ positive for glucose. That's pretty significant.

I didn't bother pretending that I believed she'd stuck to her diet and checked her blood sugars. I simply told her that many women found it hard to follow a diabetic meal plan and unpleasant to test their blood sugar. She burst into tears and confessed that she'd given up testing her blood sugar and found it too easy to hit the drive-through when she was hungry. I'm sure her OB had given her what MWWAK calls the "dead baby talk" - and that she'd likely left the office and had a hot fudge sundae on the way home to console herself. We had a chat about how things could turn out differently next time if she followed her OB's advice. I also recommended that she see a dietitian - preferably beginning PRIOR to her next pregnancy so she would have a better chance of following that advice. I don't know if any of that had a long-term impact on her. I do know that we never saw another baby of hers in our NICU.

As if I don't have enough gray hair already!

I went away for the week to visit family in another state, taking only my youngest son with me. On day 2 of what SHOULD have been a relaxing week, I received an email from my middle son entitled simply "Bad news"

Something more descriptive would have saved me serious agony for the brief time between seeing that flash across my screen and opening the email. I envisioned all sorts of ACTUAL bad news. I nearly laughed when I read the email.

"possible meningitis exposure" -- so much less dire than the possibilities which had flashed through my mind.

The staff in the ER at his hospital had joked that, given the number of people potentially exposed, they should just take over a floor and take care of each other.

Meningococcal Meningitis is certainly nothing to laugh about. According to the World Health Organization, 5-15% of patients die, often within 48 hours of diagnosis and 10-20% of survivors have some serious sequelae. It's not exactly a rare disease - the CDC reports an incidence of 0.3-1/100,000, with the majority of cases in infants.

Meningitis symptoms include sudden onset fever, headache, stiff neck, nausea, vomiting, and frequently a macular rash (flat red spots). It is diagnosed by taking a sample of spinal fluid to the lab for testing. Normal spinal fluid is clear. Spinal fluid from a person with bacterial meningitis will almost always be cloudy.

Good son that one. He had showered and tossed his uniform in the washer as soon as he got home from work. He really just wanted to know if he needed to stay away from his father and brother until he knew whether he'd actually been exposed. Since the incubation period is 2-10 days for meningococcal meningitis (average is 4) and since he would have preliminary results in under 24 hours - plenty of time for prophylactic antibiotics - I assured him that he didn't need to worry about them. Better news for all concerned, the patient tested negative.

Wednesday, March 19, 2008

Recycling fundraisers -- advice please

My husband has settled in as Scoutmaster of our son's troop. I've been tagged as both secretary and treasurer. All the other parents have at least one job/committee position. You can see that we need to do a little recruiting so we can share the wealth.

Speaking of wealth, I understand that upwards of 70% of inkjet cartridges and nearly half of laser toner cartridges end up in the landfill when they could be recycled. We're working on getting collections started in various places (especially our parish, where we have access to the largest number of potential donors).

If anyone has dealt with an ink jet/laser recycling company, I'd love to hear about your experiences. They all claim to pay postage, although a few want to reimburse rather than paying up front. I'm inclined to stay away from them. All suggestions welcome.

Second recycling effort: we've been invited to collect and recycle brass from a local gun club range. I've been told that it's worth upwards of $50/5 gallon bucket. I'm afraid to let the scouts help with that project - fear of live rounds as well as concerns about lead.

The reloaders take their brass home with them and we're welcome to the rest. It's currently all over the place. Plan is to put out buckets with signs asking people to toss just the brass, no trash, into the buckets. I still expect to have to pick up a fair amount of it. Again, comments welcome. I need to locate a local metal recycler who will accept the brass. Anyone with advice on how best to accomplish that please comment.

Monday, March 03, 2008

Snips and Snails and Puppydog tails

Cunning Blood, a post on made me laugh - and reminded me of an incident involving one of my sons.

He'd been admitted to the hospital to have his tonsils out. His surgeon had ordered a bleeding time test prior to surgery. This involved pricking the arm with a special lancing device and timing how long until the bleeding stopped. It's not terribly painful, and on an older child or adult, is quite a simple test.

Not so with this child. A simple finger-stick in the pediatrician's office generally required 3 adults. The pain didn't phase him, it was the loss of blood. His language delays made it impossible for him to explain WHY he was so distressed by the loss of even a drop of blood, but he had no difficulty communicating his utter dismay.

I tried to explain this to the phlebotomist, but she simply did not believe that 2 adults (her and one nurse) could not manage one small child.

Consequence: she learned just how far a few drops of blood can travel when projected by a panicky 3 year old. He shed nowhere near the 10 ml of blood impactEDnurse describes, yet he managed to thoroughly spot his sheets, the nurse, and the phlebotomist.

Thursday, February 28, 2008

How to get rid of your discipline problems

Not at home. I haven't figured that out yet. I did learn quite recently that if you make some people mad enough, they'll just go away. Mind you it can be really annoying while they're actually leaving, but if you suggest that someone's child is less than perfect and that perhaps discipline might be warranted within a Scout troop instead of the "boys will be boys" attitude, you might just get rid of the majority of your discipline problems.

They angrily tossed in their letters of resignation and declared that the troop would cease to exist without them. Funny just how much they underestimated the group that was left behind. We got custody of the bank account, the summer camp reservations, the troop flags, the majority of the useful equipment and pretty much everyone above the rank of Second Class. We also got to keep the newest scouts and the only OA members who hadn't aged out of the troop.

They also forgot that the new Scoutmaster was a Scoutmaster when they were kids and knows everyone of any importance in the District -- and has the total respect of District and Council executives. Those nasty emails the former leadership (and I use that word very loosely) sent to all and sundry have come back to bite them in the butt and will continue to do so for some time.

Wish I could claim I did it all myself. My major contribution has been in helping craft some very helpfully unhelpful emails to the former leadership. And adding many people to the bcc list so they can see the petty namecalling coming from them and the civil and rational emails coming from the new scoutmaster. Attaching BSA official forms and including links to BSA policy which makes the other group look ignorant, at best, is a source of entertainment as well.

I'm really not the person you want to mess with. I don't generally curse and I try really hard not to raise my voice, but I play mind games with the best. My daddy would be proud.

Friday, February 15, 2008

Happy Valentine's Day

We celebrated St. Valentine's day at our homeschool co-op on Thursday. At lunch, the kids went around the hall passing out valentine cards and candies. After several such deliveries to my table, I received my very favorite valentine of the day.

A tiny child approached me with a sticky, crumb-covered lollipop in her hand. She wished me a happy Valentine's day as she handed it over. Her generosity was touching. Her mother's horror, melting into helpless laughter -- priceless.

I wish I'd saved it so I could share a photo.

Tuesday, February 12, 2008


I'd heard that there might be a lot of people choosing that date for their weddings. I don't know about that, but I do know about one.

I'm going to be a Mother-in-Law

To a young woman I've known for almost 15 years. She consented to marry my middle son some time back and they have FINALLY set a date.

Yes, I am very happy about the upcoming nuptials.

Wednesday, January 30, 2008

Just Don't Ask!

I got a frantic phone call tonight from someone I know who takes a lot of medication. A mind-boggling number of prescriptions. She'd gone online and entered them all in some database that pops up all the potential drug-drug interactions and wanted my opinion.

"So how many different pharmacies do you use?"


Good answer. "OK. The pharmacy should have a database that will give the pharmacist a red flag for drug interactions."

Stuff I didn't understand from the database.

"You know I only give about 3 different kinds of medications in the NICU, don't you? I really don't know about all those grown-up drugs."

More stuff from the database I don't understand.

"No. Really. Most of this stuff came out a long time after I graduated from nursing school."and it was after 1 am by then and I REALLY didn't want to look it up.

Long QT interval

"What makes you think you have long QT interval? Didn't you have an EKG recently?"

Oh, that's right!

"Well, if you're worried, you could take that mind-boggling list of scrips to the doctor to see if you really need all of them."
Repeating myself for the umpteenth time

Well, maybe THESE two.

So then I had to look up Long QT interval. And email it to the individual, because as it turns out there are medications which can trigger it - but there was that normal EKG recently. And the fact that none of the current symptoms are on the list of LONG QT Interval symptoms. Only question. Was the EKG before or after the last meds were added to the list.

This is why I generally tell people "If you weigh more than 10 pounds and you're not pregnant, I can't help you."

To which most of my family responds, "Don't ask Judy. She'll only tell you to call the doctor."

That really isn't true, though. Sometimes I tell people to ask the pharmacist.

Monday, January 28, 2008

New Record

I looked over at the charge nurse and said, "It's really quiet in here tonight."

When the pediatric resident sauntered in to talk to the nurse practitioner about a baby who needed to be transferred from the well-baby nursery I looked at the clock.

"Almost exactly 20 minutes, wasn't it?" was her response.

She let me take the admission.

Sunday, January 27, 2008

NICU Nightmare

Flames in the bed? A Minnesota newborn was badly burned, especially about the face and neck when a fire started in his oxyhood. The baby was already experiencing respiratory distress and likely has heat injury to the airways as well. How awful for the baby and the family! Only quick reaction on the part of the nurses in the room spared the baby further injury.

The original story linked to this post is no longer available.

An oxyhood is a fairly simple device which consists of a Plexiglas or plastic "hood" which encloses the baby's head and allows an oxygen enriched, humidified environment to be provided to an infant.

The baby's head stays inside the "hood" with the large opening over the neck. Oxygen is introduced via the hollow tube in the left of this image - generally by way of a corrugated plastic tubing. In some models, the lid can be removed to allow access to the baby without losing all the oxygen (much of it, but not all). In others, you have to remove the entire "hood" to reach the baby's face.

We used to use oxyhoods quite often, but have gone over to nasal cannulas instead (ease of use, ease of cleaning, the ability to provide enough flow to help stent the airways among other reasons). Fear of fire is NOT one of the reasons we switched. Quite honestly, it never occurred to me that this could happen -- that it is technically possible, yes. That it could actually happen - no.

The last 2 times I've used an oxyhood in the NICU, it was only to provide humidity with no added oxygen. AND it was in a radiant warmer bed which could potentially be described as an "open topped bassinet under a warmer." There are many brands and styles of warmer beds as well.

I hope that the hospital where the fire occurred will share the results of their investigation. I have a personal theory about how this might have happened and it would not be specific to the brand or style of oxyhood or warmer bed. In fact, an oxyhood wouldn't be needed at all in my personal nightmare theory. Speculation is useless, though.

Facts are necessary - not only to avoid any possibility of a repeat, but to ensure that a useful piece of equipment isn't needlessly discarded. If we believe that warmer beds or oxyhoods are the problem and discard either (or both) we may not eliminate the actual risk. If we presume that an equipment malfunction (or misuse) is to blame, we may not take appropriate precautions either.

Saturday, January 19, 2008

Neonatal thrombocytopenia - a puzzle

The nurse in the newborn nursery had noticed petechiae and bruising which had not been present when the baby was admitted a few hours earlier. She notified the pediatrician who transferred the baby to the NICU when he received the result of the platelet count -- 17,000, instead of the normal 150,000+ . If the count had been low, but not life-threatening, the pediatrician might have opted to repeat the test to rule out lab error or to look for a trend. 17,000 is in the range considered life-threatening, so a NICU admission during the workup isn't optional.

When the baby arrived in the NICU, she looked, aside from the petechiae and bruises, perfectly healthy. She was pink, breathing easily, and eagerly rooting. Muscle tone was excellent and she was unhappy at having to wait to be fed. All these signs are encouraging, because one of the most common causes of thrombocytopenia (abnormally low platelet count) in a term newborn, sepsis, would almost certainly result in abnormal behavior or appearance in at least one area if the baby were sick enough to have a platelet count that low. Most of the congenital syndromes which can cause severe thrombocytopenia are associated with fairly obvious characteristics and were quickly discounted. Other possible causes were considered and ruled out.

Because sepsis in a newborn can quickly be lethal, cultures were obtained and IV antibiotics started. The risk of discounting sepsis as a possibility is simply too great and far outweighs any risks of the antibiotics used.

Sepsis really wasn't near the top of the list of suspects, so blood was drawn and overnighted to a distant hospital for extensive testing to determine exactly which anti-platelet antibodies were causing the problem. The neonatologists believed that the low platelet count resulted from an incompatibility between the mother's blood and the baby's platelets. A platelet count below 20,000 in the absence of indications of sepsis is most commonly caused by Neonatal Alloimmune Syndrome.

The neonatologists suspected an alloimmune cause for the low platelet count. They considered it possible, but unlikely, that an autoimmune process was the cause, because the mother's counts were normal. IVIG - IntraVenous Immune Globulin - was given and a very brief increase (to 30,000) was achieved.

Platelet transfusions were given, to no effect. Our blood bank can "pedi-pack" (divide) platelet units in order to decrease the number of separate donors, but because the platelet count didn't rise after the first transfusion, the neonatologist requested a new unit of platelets from a different donor for each transfusion. He spoke at length with the blood bank technologists, a hematologist, and eventually the blood bank director about specific characteristics he wanted for the donors.

By the time the second platelet transfusion had had no appreciable effect, the neonatologist was convinced that we were dealing with an alloimmune incompatibility and, pending results from the distant hospital, contacted the Red Cross to have them locate donors who were most likely to match the baby while preparing to gather platelets from the mother.

One interesting observation was that the baby never had any excessive bleeding from heelsticks, IV sites, etc., and that several specimens sent for blood counts clotted before reaching the lab. A donor was located and within a very few days, the baby's platelet count rose to a safe level and she was discharged.

The lab results confirmed a diagnosis of Neonatal AlloImmune Thrombocytopenia - which occurs in 0.05-0.1% of live births - one per 1000-2000 infants. There are several antibodies associated with the condition, so finding the perfect donor is essential - and the mom may be the best choice.

According to the Institute for Transfusion Medicine (1996 numbers) mortality rate was 1-14% with first babies being most likely to be severely affected since the mom can be followed during subsequent pregnancies. 10-20% of affected babies may have intracranial bleeding with about half of bleeds occurring before birth.

Second and subsequent pregnancies can be carefully monitored. Delivery is usually elective cesarean section if the baby is affected and appropriate platelets are on hand in case the baby is symptomatic.

Friday, January 18, 2008

Mother of the year. Again.

Actual conversation:

9:00 pm: "Mom, can I watch Mythbusters, it's a new one."

"I suppose so, but you have to go to bed right after."

10:00 pm, "Mom, I think I'm going to throw up."

"Do it upstairs"

7:40 am next morning "Mom, I don't feel so good."

"You were well enough to turn on the television after breakfast. Get in the car. We have homeschool co-op today."

8:15 am - child flies out of chapel and shortly afterwards reports that he did in fact throw up. I'd have been skeptical, but by that time he was also complaining that his legs were "vibrating" and he was several shades paler than when he'd gotten in the car.

Monday, January 14, 2008

Children, (do not always) Obey Your Parents!

I've taught first aid to quite a few classes of Cub Scouts over the years. I pretty much go through the Readyman activity section in the Webelos book. It is written at an age-appropriate level and is easy for the kids to understand.

It covers the major emergencies an 8-10 year old can be expected to understand:

Heimlich Maneuver (choking)

Always stand near a wall when in the presence of Cub Scouts who have learned the Heimlich Maneuver. ALWAYS. Especially if you have food or drink in your hand. If you cough, even a little, one of the Cubs will promptly "rescue" you. EVERY time. It takes a while for them to learn to ask whether or not you are actually choking.

Serious Bleeding

They are fascinated with blood. Some to quite a disturbing extent, but you can't fail to get their attention if you use fake blood when you demonstrate how to stop bleeding. I decided to use Bob Amick's "B" recipe for my demonstration. As he says, it flows well. You can tint it darker for venous blood and brighter red for arterial.

The Cub Scout handbook doesn't discuss arterial bleeders, but I decided to include it in the demo because it really gets the kids' attention -- and because I managed to puncture an artery in my ankle when I was about 7 years old. It was a very small, but well-placed laceration and the blood flow was quite impressive.

I always start with the demonstration of venous bleeding, because it's included in their books. Also because it pales in comparison to arterial bleeding. Most Cubs have already learned the concept of direct pressure by the time they get to my demonstration. For venous bleeding.

Their jaws just drop when I demonstrate arterial bleeding by pulsing the "blood" using a relatively small syringe and small-bore tubing. I tell them about my injury and assure them that a relatively small arterial bleeder really can shoot blood 4-6 feet. I'm not sure they believe me when I assure them that it is possible to at least slow down the flow of a small arterial bleed using direct pressure.

I'd like to be able to tell them that I stayed calm and handled things myself, but the truth is I started screaming at the top of my lungs panicked. Fortunately, our teen-aged paperboy had some first aid training. He was able to control the bleeding before my mom saw it. She's never been very good with blood.

Stopped Breathing

Basic rescue breathing is all the Cubs learn. Some Webelos learn CPR and virtually all Boy Scout troops require it. Mostly I stress calling 911 - to get help and because the operators in our area are trained to walk people through CPR if it's needed.

Internal Poisoning

Again, call 911 - and round up any containers.

Heart Attack

I review this one in much more detail. I have the kids list the symptoms. They're surprisingly good at that. Then I tell them that there is one more symptom they've missed. After a little guessing, I tell them that denial is very common and that they need to be aware that an adult having a heart attack will probably insist that they are "fine" or "just having indigestion" - or some similar explanation for their discomfort.

I tell them that sometimes it is important to disobey an adult and this is one of those times. If the adult looks sick enough to frighten them - and especially if the adult is having symptoms on the list for heart attack - they should call 911. No matter how insistent the ill adult is, they should call anyway.

Inevitably one of the Cubs asks if they won't get in trouble for calling when they've been told not to. I assure them that the paramedics will back them up. Even if the adult isn't having a heart attack - even if they aren't seriously ill -- any adult who looks that sick needs to be evaluated by someone other than a child.

Every single time I have done this, someone in the group shares a story. One dad survived because a member of his family had disregarded his assurance that he was "fine". One of the Cubs shared that a grandparent had survived a heart attack because one of the adults present had disregarded his refusal of care. The saddest story was from a young man whose grandfather had not survived. The boy wasn't alone with him, but the adults in that instance had hesitated to call. It might not have made a difference, but he will always wonder.

Tuesday, January 08, 2008

Aspirin - not for babies, no matter what the package says.

I was stunned to read this article in Advance for Nurses about a local grocery store which was still selling low-dose chewable aspirin labeled as "baby aspirin" or "children's aspirin"

The author details her experiences treating a child with Reye's Syndrome (strongly linked to aspirin use in children and teens with viral illnesses) and her efforts to get the product off the store shelves.

It's a worthwhile effort, but I believe her efforts are misdirected. If it was just one grocery chain, going after the chain management might be effective. It's not just one chain.

She found "children's aspirin" in Food Lion. I went to my local Giant store this week and found "children's aspirin" there as well. It's manufactured - and labeled - by several very well-known companies. We need to go after the companies who mislabel their low-dose aspirin. They need to recognize the risk they present to children and to re-label their product as "low-dose" aspirin rather than "children's aspirin".

Children should only take aspirin if their pediatrician recommends it. Mine NEVER has. Not once. I'm sure there is still some reason to give aspirin to a child, but parents shouldn't make that decision without consulting their pediatrician. The risk of Reye's syndrome is just too great. Parents still make the mistake of giving aspirin for fevers - the first sign of many viral illnesses. It's just not safe.

The FDA should act on this, and the author of the article is lobbying for that as well. However, I think that a grass-roots effort by healthcare professionals and parents could effect a change much faster. Next time you go to the pharmacy or grocery store, look at the pain-reliever aisle and particularly the children's medication section. You might find "children's aspirin" in either place. If you find it, take a minute to challenge the manager of the store -- probably useless, but worth trying. Then make a note of at least one brand that is inappropriately labeled and write them a letter explaining why they need to change the packaging.

I'm going to start with Bayer. The name is almost synonymous with aspirin - and yes, they are one of the offending companies. Their web site says "low dose" and "for adult aspirin regimens" but the package inappropriately says "baby" or "children's" aspirin.

Monday, January 07, 2008


About 8 months after my husband's bypass surgery he complained of "indigestion". I don't "do" adult nursing, but I've taught first aid to Cub Scouts long enough to know that indigestion isn't always indigestion.

Shortly after his initial complaint, he became very pale. His skin was cool and clammy and sweat started pouring off his forehead. Over his objections, I picked up the phone and called 911.

We were joined very shortly by our local version of Ambulance Driver and his rookie partner. My husband was still feeling pretty rocky, but I started to feel better as soon as they arrived.

Within moments, they'd checked his BP - a little high, but not scary.

His pulse - 50.

Blood sugar - 83.

EKG - "Did he have these Q waves on his last EKG?"

I didn't know. "Not a problem. We can find out when he gets to the hospital."

At that point, my husband started insisting AGAIN that it was only indigestion - and that he didn't need to go to the hospital. Oh, and I remembered that I needed to call the NICU to let them know I wouldn't be in to work that night.

The paramedic didn't bother to argue with him. "Mr. S. do you think you can walk out to the ambulance with us?"

I understand that walking to the bus isn't always the best plan if there's a possibility of cardiac problems, but leaving him at the house wasn't an option. He kept protesting that he didn't need to go, but his feet just walked him out the door and to the ambulance.

By the time I parked my car and joined him in the ER cubicle, he was pink and looked perfectly healthy. The ER doc entered, looked from him to the paramedics to me and basically asked why we'd dragged him in since my husband kept insisting that he only had a little indigestion. The doctor's tone changed after he heard the history and saw the CABG scar. A quick call to the cardiologist and my husband was admitted for the night and the million-dollar work-up scheduled for the morning.

Which showed that he had reflux.

Not that I'm complaining or anything, mind you.

Wednesday, January 02, 2008

Legos! We got Legos!

Legos coming out our ears -- and more on the way.

My youngest son is enthralled by them and wants to display his models. The problem? Finding reasonably priced shelves that are deep enough to hold them all. Some of them are pretty big.

I did find shelves that are deep enough - and not terribly expensive, but the shelf is basically an open grating with holes bigger than 1 inch across. Not the best place to store Lego figures. They'd just fall through.

To solve this problem, I bought poster board and something called Magic Cover (think Contact Paper). It is marked in inches, centimeters, and half-inch squares. I cut the poster board to cover the holes in the shelves, piecing it to make it cover the holes.

I joined it with clear packing tape, then topped it with the Magic Cover cut about 3 inches longer and wider than the poster board (about 1.5 inches on each side). This pattern is called Granite Silver.

Magic Cover, like other self-adhesive plastic products is tricky to handle. You need to peel back about 3/4 inch and fold back the backing. Line it up and stick down the uncovered part, then VERY carefully pull off the rest of the backing slowly, smoothing it in place as you go. Next we assemble the shelves and my son gets to gather his Lego models from all over my house.