Sunday, November 15, 2009

Another quiet night in the NICU

Telephone rings. It's labor and delivery. New patient just arrived. She's 28 weeks and she's fully dilated. We remind them to turn up the thermostat in the operating room. How high? We're not sure -- just turn it up. We'll find the policy for you later. We should all know what temperature, but "imminent delivery" can make you forget all but the essential numbers. That baby's probably coming before the temperature gets into the appropriate range anyway. Tropical. Thats what we want.

We check the admission bed, call respiratory therapy to set up the ventilator and check the resuscitation equipment in the delivery area. Must be a quiet night for them. We get 3 RTs. Not complaining. Sometimes you need 3. Tonight it's a good thing to have them all.

Over we go to the delivery area. It's already 72 and the temperature is rising rapidly. I'm not on admissions, but I'm in charge and the admitting nurse can always use an extra pair of hands with a little one. We'll be doing this in the OR to accommodate the extra people and equipment. Check equipment, draw up emergency drugs, measure and cut the endotracheal tube and the feeding tube we will use to give a dose of surfactant to help the baby breathe. Waiting for the OB team to bring in the mom.

Scrub tech has finished setting up for a C-section - just in case.

OB arrives sans mom. The news gets better. Mom had an ultrasound this week. Baby isn't 28 weeks. It's 25 weeks. Call the neonatologist to come in for backup. The nurse practitioner can handle this, but it's policy. No sleep for the neonatologist if the baby is 27 weeks or under.

Mom is FINALLY (maybe 5 or 6 minutes later) in the room and on the OR table.

"Don't push. Let me check her again"

I have my back to the action, double-checking and triple checking. I hear a wet splash and turn around to see the OB and one of the labor and delivery nurses wiping amniotic fluid from their full face masks.

The OB checks the mom again. Prolapse: the umbilical cord has slipped past the baby's head and is in danger of being compressed to the point of cutting off oxygen to the baby. The external monitor is showing a heart rate that exactly matches the mother's heart rate. We hope that the baby is just too far down in the pelvis for the monitor to pick up. There is no time to check with a sono or internal monitor.

Someone asks about fetal heart rate. A voice responds, "Three minutes ago it was 150." Three minutes is an eternity. We'd like to know what the heart rate is now, but there is no more time.

There are only a very few minutes to get that baby to the relative safety of our resuscitation warmer. The room is about 75 degrees now and much hotter for the people surrounding the warmer. Makes me glad I'm just the extra pair of hands, much as my control-freak side wants to have my hands directly involved.

The OB changes gloves as the anesthesiologist "crashes" the mom -- general anesthesia is much faster than other options for emergency C-sections. As soon as the anesthesiologist indicates that the mom is ready, things really go into high gear. An incredibly long few minutes later, we hear a weak cry. At 25 weeks, it's unusual to hear a cry. With a prolapsed cord, it's even more unusual, but it means we can take our time doing what we need to stabilize the baby. It also means that there is much less to do. No drugs. No chest compressions. That weak cry is a truly beautiful sound.

The OB hands the baby to the nurse practitioner who places it in our pre-warmed bed. The baby is covered in plastic from the neck down to minimize heat loss. The baby is working very hard to breathe, so one of the respiratory therapists begins bag-mask ventilation as another hands the laryngoscope and endotracheal tube to the nurse practitioner. In goes the tube and is carefully secured once placement is verified. Too far in? adjust it a little. Breath sounds are equal now and the baby is pink. Time for the surfactant which will help keep those tiny lungs expanded and decrease the risk of damage as we breathe for the baby.

The third respiratory therapist has finished setting up the ventilator on the transport incubator. We transfer the baby into it and off we go to the NICU ripping off masks and OR caps as we exit the OR. We're all hot, but it's worth it. When we get the baby into the NICU admission bed, the temperature is well within the normal range. WIN! But it's really only the beginning. If everything goes well, this baby will be with us until at least Valentine's Day.

Thursday, August 13, 2009

English, please!

Someone keeps leaving comments on one of my posts in a language which I do not recognize. They're not even using an alphabet which I recognize. Give it up, already. I'm not going to publish a comment I can't read!

Monday, April 27, 2009

Day 14

My youngest son overheard a conversation I had with a friend about the Varicella (Chickenpox) Vaccine. He didn't much like what he heard. We were discussing the CDC recommendation for a second dose of vaccine - and the probability that further boosters would be needed for those who had been immunized. He was immunized at age 6. Late for the current recommendations, but I had waited until his pediatrician was willing to enthusiastically recommend it. When he immunized his grandchildren, we chose to immunize our son.

A few days after that conversation, my son learned that a friend's younger brother and sister had just come down with chicken pox. We had an extended discussion about the risks of chicken pox at age 13 vs as a young (or not so young) adult. We discussed the symptoms he might experience and the one potential benefit of actually contracting the disease instead of getting the booster. He's never been a weenie about needles, so I'm pretty sure his decision was based on his awareness the longer immunity he would likely receive if he caught chicken pox. I was very careful not to pressure him one way or the other, although I did tell him that he was rapidly approaching an age where the risks of the illness would significantly outweigh the benefit of longer term immunity.

After checking with the mother of the poxed children, we stopped in for a 45 minute visit. That started the countdown. About day 3, he started having symptoms. I was able to convince him that it was far too early and that the chances of contracting chicken pox weren't nearly 100%.

I did forget to give him my statistics lecture in which I say that statistics only apply to populations and that for him this will be 100% or 0.

Today was day 14. He has been complaining of a mild headache and scratchy throat since yesterday. He had found something he thought was a tick on the top of his head. Visualizing it through his incredibly thick hair was tough, but I managed. Definitely not a tick. It was a tiny red bump that looked like he'd scratched it. He suggested that maybe it was a chicken pox lesion. I countered with the suggestion that he ought to have others on his torso if that was the case. So he took off his shirt. There they were. About a half dozen red bumps on his chest and another 10 or 12 on his back. If he's lucky, that's all we'll find, but if this is chicken pox (and they do look like chicken pox), he can keep popping out with them for the next few days.

The incubation period for Chicken Pox is 10-21 days, but the average really is 14-16, so he's right on time. Now I need to figure out who to notify among the many people he's been around for the last few days.

They were desperately short of altar servers for the First Communion services at our church on Saturday. He was the only altar server at 2 of the 3 services - took a break during the third. He was also assigned to serve at the 9 am Mass Sunday morning. He was fine then, so he did that too. AND he went to Sunday School -- without complaining at all. He even went to his karate class before we dropped him off at a friend's house so we could go to our Boy Scout Troop committee meeting. Fortunately, same friend where he was exposed to Chicken Pox.

If you hear about a major chicken pox outbreak in the Mid Atlantic states, that will be our fault.

Tuesday, April 21, 2009


It rained this evening and the roads were slick. My youngest son and I were waiting on the parking lot that is usually a 45-50 mph 2 lane road - the only one into the peninsula where we live. I thought it might be a perfect time to discuss driving safety, since he'll be that age before I care to think about it -- and since he was trapped beside me in the front seat.

Oh, and he started it.

"Mom. Why are there more crashes on rainy days?"

"Why do you think there are more crashes? What is different about driving in the rain?"

"The roads are wet."

"OK. They're wet. What difference does that make?"

"They're slippery."

"What else is different?"

"It's raining."

(Trying very hard NOT to roll my eyes)
"So what else does that change?"

"How far you can see?"

"Exactly! So what do people do differently when they drive in the rain?"

"Nothing." (smarter than I thought)

"And what SHOULD they do differently?"

"Drive slower and leave more distance."

"Very good!"

We saw a flatbed/tow truck pass by in the opposite direction and traffic began to move as if someone had pulled the drain plug in the sink. Just as he said, very few people were paying attention to the road conditions in their haste to make up for lost time. Sigh.

When I got home, I noticed that my oldest son had not yet arrived -- he should have beat us by 30 minutes or so. Neither vehicle involved in the crash looked at all like his, so I wasn't too worried, but he usually lets me know if he's going to be late.

He had good reason not to this time.

He was much closer to the crash than we were.

He told me that he noticed the car in front of him starting to fishtail, so he backed off to give the driver space to recover -- or at least not to involve him in what was about to happen. She bounced off the road, over the curb, and started to slow down. He thought she was going to stay off, so he sped up slightly and passed her safely. He glanced in the rear view mirror in time to see her spin back onto the road and crash into the vehicle just behind him.

"So you narrowly avoided the crash?" I asked.

"No, mom. It was at least 2 car lengths behind me."

Folks, I'd have needed a change of underwear if I'd been that close. I'm very proud of my son. Not only was he unfazed by the crash, but he stopped to offer assistance (no injuries, thank goodness), waited until the tow truck had hauled off the wreckage and gave one of the drivers involved a ride home.

Tuesday, February 17, 2009

My mother doesn't curse

I don't remember what prompted my 13 year old to say that, but he did say it to someone I'd never met before.

Without thinking, I said, "He's never been to work with me."

It's true. I don't curse at home. I very seldom curse at work either. Some of my co-workers are of the same mistaken opinion as my son. Most of the docs are.

I don't swear in front of families. That would be unprofessional.

I don't even swear at the people who elicit the most foul language - almost always the folks in the lab. It doesn't do any good. Occasionally I'll write an incident report or three (in the same night), but I wait until I hang up the phone to say what I really think. It can be quite colorful.

NOTHING makes me angrier than being told one of the BIG LIES about a blood sample I've just extracted painstakingly from the tiniest infants.

Lie #1: The sample was QNS (quantity not sufficient).
Don't tell me there's not enough blood in the microtainer when I obtained the sample myself. I filled it to the top line when you should only need me to fill it to the bottom line, and I know the patient's hematocrit is on the wrong side of 30. Tell me you spilled it or that the machine malfunctioned. Either will make me far less angry.

Lie #2: The viscosity of the blood kept the machine from working properly.
Do you think I don't know what that word means? Maybe you think I don't know the patient's hematocrit. Maybe you just need someone to teach you how to use the (expletive deleted) machine.

Lie #3: The sample was clotted.
Oh I know that samples sometimes clot, but if I have a heelstick sample clot twice in the same year I'm having a bad year. If it came from the heparinized arterial line. Just tell me you dropped it, OK?

Occasionally a family member will push me over the edge, but I maintain control until they are out of sight (and hearing):

The day shift nurse told me that the mother wasn't quite getting the message about how sick her 530 gm 23 week baby was. Intubated, high ventilator settings, barely maintaining temperature. Electrolytes totally out of whack. She just couldn't hear the painful message that her baby was critically ill and in danger of dying due to extreme immaturity of all systems.

The baby was born years ago, before we allowed any visitors other than parents and grandparents. There were vast numbers of extended family members and the mom wanted them ALL to see the baby. From the window.

Unfortunately, the plastic wrap we were using to help maintain the baby's temperature in the radiant warmer was blocking their view. I explained repeatedly what she'd already been told, that the baby needed the protection of the plastic wrap and that I couldn't take it off for each of her visitors.

No, I couldn't lift the baby (and his ET tube and his chest tube and his umbilical lines up to the window so they could see better. He was too fragile.

She asked if I could take the baby to the door so they could have a closer look.
"He'll die if I do that" was my response.

She FINALLY got the message: The baby is tiny and fragile. It will be a long time until he goes home -- if he does at all. She finally heard that. I hated to be so blunt, but she was quite literally endangering his life every time I moved away for any reason.

Her behavior changed instantly. Instead of asking for him to be handled, uncovered, carried to the door, she started questioning the necessity of each intervention. She wanted the day shift attending to come back. The night shift attending might not know the baby well enough. On and on it went for the better part of an hour after my blunt explanation. Finally she became too exhausted to continue and retired to her room.

I decided I needed to take a very short break while she was gone and headed for the conference room. The night attending had decided it would be a good place to complete her charting, so she was sitting at the desk in the corner. I'm pretty sure I enhanced her knowledge of English slang and profanity as I expressed my opinion of how the last couple of hours had gone. I never raised my voice, but I turned the air quite blue while expressing my thoughts. After about 5 minutes or so, the charge nurse opened the door, listened to my ongoing rant, and said: "You know we can hear every word you're saying in the nurse's station.

That was BIG LIE #4. Fortunately she couldn't keep a straight face once she'd said it.

Saturday, January 31, 2009

Spare me O Lord!

I know that I live in a part of the country where racism of the more genteel variety flourishes. Beatings are rare and the more genteel racists deplore them. Out loud. I generally bite my tongue and change the subject, because enlightening the ignorant seems to be pretty much impossible.

If, however, the statement is too egregious then I tend to lose control of my mouth and say something along the lines of "You know, that's just ignorant"

"No, really. I mean that your statement is simply not true. You don't have the facts. Did you know that the vast majority of folks on welfare are white?" Or other similarly pointless remarks, because those folks just know that they are right.

I won't try to pretend that I don't have any personal biases, but these myths that any particular minority group shares the same character flaws just bug the hell out of me.

It is particularly unwise to follow up your ignorant statement with "I'm not a racist. I'm just stating a fact."

And when I've been awake for more than 36 hours, you are truly playing with fire if you try to go there. I did warn him.

I'm pretty sure he thinks I'm the ignorant one, because after all, he stood up for a minority co-worker when the chips were down and he even called the co-worker "Mr." when he talked to him. He couldn't possibly be racist, could he?

I probably should have just walked away when he started. I doubt I accomplished anything.

Wednesday, January 28, 2009


As it turns out, there is no cliff at the tubing park. It bears no resemblance to a cliff at all.

Also, one cannot flop on their belly there as to do so would risk serious facial injury from the hard-packed snow walls of the tubing slides.

There was virtually no risk involved in sliding down the hill -- at least not unless another patron managed to follow too closely behind and hit you. I didn't see that happen even once, so I doubt it's a common source of injury. Common enough to be included on their posted list of risks, though.

There were 2 fairly risky spots though. One was the gentle downward slope from the end of the tubing run to the people mover. That would have been safe, except for the children who insisted on coasting toward the conveyor on their tubes without regard to the safety of other patrons and apparently with the blessing of their parents - or at least with their tacit consent.

I did find a very quick way to put an end to that. Threat of physical injury, even by small children, does not bring out the best in me.

"If you knock me over, I'm going to make a point of landing on you. I don't believe you'll enjoy that very much."

Either the kid would wise up or the parents would snatch them away before they managed to topple me.

The second danger spot was the conveyor-belt style people mover. Again, unsupervised, or marginally supervised children insisted on engaging in risky behavior immediately in front of or behind me. After asking politely for them to desist -- to no effect, I employed the tone of voice I generally save for first year residents who say things like "In my experience....." Works just as well on kids.

Saturday, January 17, 2009

Don't use that word

My sister talked me into going tubing.

We'll take the kids, she said. It will be fun.

Cold weather. Big hills. Falling. Fun.


So I bought the tickets and reserved the hotel room.

I told the kid. He was definitely excited. He tried to explain just how much fun it would be.

"Look mom, you hold your tube like this. You run and flop down on your belly just before you get to the cliff.......

Too bad the tickets are non-refundable.

Monday, January 12, 2009

Ditalini and Bean Soup

I love to make soup in the winter. It's easy to make good soup and I'm often asked for my recipe. The response is always the same.

Recipe? It's soup. You don't need a recipe!

I do steal concepts, though. This one is based loosely on a recipe I found on the box of San Giorgio Ditalini pasta. Instead of a 5 quart saucepan, though, I use my 12 quart stock pot. You'll see why.

Their instructions don't call for cooking beans. They recommend 2 cans of pre-cooked beans, but paying more for less when beans are easy to cook doesn't work for me so I started fairly early this morning simmering the beans - a pound of them. It takes about 2 hours to cook Great Northern beans to the proper texture, but as long as you don't forget them, you can do lots of other things while you're waiting.

Their recipe calls for chopped onion. Today I'm all out, so dried minced is the order of the day -- be careful to read the package and note that 1 tablespoon of minced onion is equivalent to a whole lot more fresh chopped. I try to keep that in mind as I sprinkle generously over the cooked beans. No fresh garlic today, so powder will have to do. If you have fresh, chop it and cook until tender, but not brown, in a little olive oil.

I have leftover ham from yesterday's dinner, so that gets chopped while I cook the beans. About 3 cups. 4 would be better, but 3 will do.

Tomato sauce - the recipe calls for a 28 ounce can for half as much soup as I'm making. I add two 26 ounce bottles of pasta sauce and 2 cans of diced tomatoes.

Salt, pepper, a little oregano to taste.

Once the beans are done, add everything but the pasta and simmer for 30-40 minuted to blend the flavors. Add water and adjust the seasonings if needed. I decided it was a little bland, so I chopped about 3 ounces of turkey pepperoni and tossed it in.

Bring the pot to a boil and add the pasta. Cook for about 10 minutes until the pasta is tender. You'll need to stir occasionally so the pasta doesn't clump at the bottom of the pan.


Freeze leftovers if you like. It reheats quite well.