Consequences

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.

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.

Snips and Snails and Puppydog tails

Cunning Blood, a post on ImpactEDNurse.com 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.