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.