Sunday, November 21, 2010

Give blood! Somebody else needs it more than you do.

We've been going through a lot of blood in the NICU lately. It's been crazy busy and the babies are smaller and sicker than usual. Packed cells, platelets, sometimes back-to-back transfusions. It's amazing how much blood a 500 gram (little over a pound) baby can use over the course of a week. They only need it by teaspoonfuls, but they need it frequently. Fortunately, the blood bank can split the units so we can get several transfusions from one unit of packed red blood cells.

Packed red blood cells are the oxygen-carrying component of blood. One donor gives about 500 ml of blood in a donation. Something less than half of that is red blood cells. Most of the plasma (liquid portion) of the blood is removed so we can give more red blood cells in a smaller volume. This is done for both adults and children, but our babies are very fluid-sensitive, so we especially need packed cells for them.

Platelets are important in clot formation. Not enough platelets and the baby is at higher risk of intraventricular hemorrhage (bleeding into the brain) as well as excessive blood loss from minor injuries (like heel sticks for blood draws). We only use single-donor platelet units collected by apheresis (collection by way of a machine which removes the platelets and returns the rest of the blood to the donor).

Our blood bank reserves a unit of packed cells for each baby who needs a transfusion. They do the same thing with platelet units. The baby may get one transfusion, or several, from that one unit. It helps to limit the number of donors to which each baby is exposed. Our micro-preemies (under 750 grams) are still exposed to several donors in their first weeks of life.

We are grateful to every one of those donors. Nearly all of the blood donors are type O, Rh negative donors. With platelets, matching isn't so sensitive, so nearly any blood type can be used. However, all of them must be negative for viruses which are harmless to most adults, but which most of us have experienced, making us good donors for other adults, but not OK for babies or those whose immune systems are failing. CMV (cytomegalovirus) in particular is potentially lethal to newborns - or others with weakened immune systems. When you need O negative, CMV negative, blood, you're talking about a pretty small donor pool. Those people may find that their local blood bank is calling them every 8 weeks to make another donation.

Blood donations are down in general, but historically, they drop even lower around holidays when the need can be great. If you can make a little free time this week - or next, make an appointment with your local Red Cross or hospital volunteer donor blood collection center.

Been told you can't donate blood? Ask again. Some reasons for declining your blood will never change, but some policies have -- fairly recently. For example, cancer survivors who are in good health - even those who had chemo - are often accepted as blood donors. Those who had lymphoma or leukemia still can't donate, but many of the rest of us are being welcomed back to the donor rolls.

Monday, October 25, 2010

Celebration of Life

In the last seven days, I have attended 3 funerals. The first was for a friend's mother. She wasn't a young woman and had been ill for some time. She nearly died several times last year and while her family felt blessed to have the additional time with her, she will be sorely missed. Her sons spoke of her love for her children and grandchildren. They wept freely as they celebrated her transition from this life to the next.

The second funeral was for a 93 year old friend whom I was privileged to know for nearly 33 years. She was an inspiration to us all. She was always charitable - even when offering needed corrections. She seemed tireless and when something was needed, she was there before anyone thought to ask. I will miss her, as will her family, but we all know she is enjoying a well-deserved reward.

Today's funeral was by far the most difficult. I didn't know the young man who died. I knew his aunt, my sign language teacher. Harry grew up between two cultures. The family of his birth is Deaf (though not all are deaf). He proudly brought legions of hearing friends home and shared his family with them. His death was unexpected and devastating to so many of his friends. Today his mother made us laugh and cry as she shared stories of his life. Her faith that he rests now in the arms of a loving God is her consolation in this time of great grief and an inspiration to all who attended the funeral.

Tuesday, October 05, 2010

Gianna Jessen Abortion Survivor in Australia Part 2

Gianna Jessen Abortion Survivor in Australia Part 1

Over the years, we've had a few abortion survivors pass through our NICU. A small number I remember.

All were born pre-term.

One young woman came to us in labor prior to 20 weeks. She had gone to another hospital for a prostaglandin abortion. She came to us hoping that her baby could be saved. Clearly she had not had appropriate counseling prior to her procedure. Sadly, there was nothing to be done but deliver her dying baby and console her.

The others were born early in their third trimesters after failed first trimester abortions. They were still very pre-term and only 2 survived their first few months of life. I don't know what happened to them. I hope their mothers were more accepting than Gianna's.

Thursday, September 16, 2010

American Sign Language - free class on-line

I've had an interest in American Sign Language (ASL) for a long time. The first time I did anything about it, I had a patient whose parents were deaf. That inspired me to take my first class in ASL.

My second inspiration to learn sign was my oldest child. When he was little he was quite hard of hearing as a result of frequent ear infections. This resulted in expressive language delays. He attended a special pre-school where they taught some basic signs which helped at school and home. Unfortunately, he doesn't remember much sign at all.

The third impetus was my dyslexic middle child. He needed a second language for high school. Being unable to spell in one language is frustrating enough and the spelling used in ASL is English. Off we went in search of sign language classes which would accept a 14 year old. A local Deaf church provided those - along with some wonderfully accepting Deaf friends. We took classes there for several years and became proficient enough to carry on a conversation with any reasonably patient Deaf person. Unfortunately, I lost touch with that group and as a result, lost much of my signing ability.

My youngest son is now high school age and needs a second language. He remembers coming with me to ASL classes and Deaf parties, so he naturally wants to learn ASL. It just makes sense to him. It is also one of the more commonly used languages in this area and not at all uncommon to see people signing in public places here.

In my search for ASL classes that would accept someone his age, I found ASL University. It's a high school/college intro level ASL class in a very structured on-line format with accompanying resources.

I am amazed at how fast the ASL I'd forgotten is coming back through the use of this site -- and how quickly my son is learning expressive and receptive skills. We still want to find a live class, but we won't feel totally lost when we get there.

Wednesday, August 25, 2010

Hold that position!

Lumbar puncture (LP, spinal tap) is a relatively common procedure in neonatal ICU's. It can be done as part of a sepsis workup - looking for infection. Less commonly it may be done as a way of treating hydrocephalus (excess fluid in the ventricles of the brain) until a shunt can be placed or until a temporary condition causing hydrocephalus resolves. The most common temporary cause of hydrocephalus is interventricular hemorrhage (IVH, Bleeding in the brain). It's been years since we've had a baby with a bleed that severe, though.

More than one physician or nurse practitioner has commented that successful lumbar punctures depend more on the skill of the person positioning the baby than on the skill of the person wielding the needle.

There's more than a little truth in that, but the person doing the tap needs to be able to tell the holder how to adjust the position for best access. The more accurate their directions, the better the position.

There are two basic positions for LP. Sitting and lying on the side. Most of the time, we position the baby on his side with the lower part of the spine curved as much as is practical given the baby's condition and equipment being used. I generally place one hand on the baby's upper back and the other on the back of the upper thighs extending onto the diaper area.

The diaper is pulled down to expose the lower spine, but not so far as to risk fecal contamination. The nurse practitioner or physician cleans the site and places a sterile drape over the lower back. The lumbar area of the spine needs to be curled in order to open the spaces between the vertebrae. This is accomplished by curling the baby's spine from the bottom, keeping the upper part of the spine as straight as possible so as not to interfere with breathing. When I position a baby this way, it is very rare for a nurse practitioner or physician to fail to get a successful tap.

The seated position can be used for less fragile babies and the principle is the same, but hand position is different. The baby needs to be leaning forward with the head supported and lower spine flexed. One hand is placed on each side. I generally have 2 fingers of each hand on the upper back, thumbs under the chin, and pinkies under the knees. My hand size limits the size of babies I can position this way. It's trickier for the holder to learn this position and to keep the baby immobilized while the LP is done.

Monday, August 09, 2010

Assume the position!

I was chatting with a nurse from another unit recently and she commented on something she'd witnessed in my NICU. She saw one of our travelers feeding a baby - baby seated on her knee and held a distance from the body. She thought this very odd in spite of the travel nurse's explanation: "This baby's a puker and I don't want to wear her formula."

Sounds very reasonable to me - and I often feed babies in a similar position, not always to avoid baby vomit.

Newborns, especially preemies, will generally go to sleep when held close to an adult's body. This is counterproductive when you need the baby to consume a minimum amount of expressed breast milk or formula. The solution is to hold the baby a little distance from your body so your shared warmth doesn't make him drowsy.

It takes a little time to feel comfortable holding babies this way, but it actually gives you better control over the baby's airway than traditional positioning. It also makes it easier to react to choking episodes -- or the aforementioned "puking".

The baby is seated on one of your thigh (varies with handedness of the adult, and baby's propensity to vomit) in a fairly upright position. I generally place the baby on my left thigh with my left hand behind the baby's neck. my thumb and forefinger (middle finger for big kids) are supporting the ears. Heel of hand ring and pinky fingers under the shoulders, Baby's not going anywhere, no matter how much he wiggles and my right hand is free to hold the bottle for feedings and to grab anything else I might need - burp cloth, bulb syringe, suction, etc.

Keeping the baby upright helps facilitate swallowing in sleepy babies and those who haven't entirely managed the suck-swallow-breathe maneuver. If the baby chokes or spits, it takes fractions of a second to put the bottle down and reposition the baby with his head forward and facing down over the right hand. This generally clears the airway, but if it doesn't, I can easily free a hand to grab the nearby bulb syringe or suction as needed.

When I'm burping a particularly spitty baby, I will move him to my right thigh facing away from me and leaning forward onto my right hand. This directs any vomit onto the floor instead of my clothing, making for much easier clean-up.

Wednesday, August 04, 2010

I have an App for that...

I've had a computer much longer than most people. Blame that on a sister who programs microcomputers (now known as desktops and laptops). I've had one that long. Actually, I'm on computer #6, so I'm hardly a luddite.

I did resist one particular tech item for reasons I no longer remember. I have an Ipod touch. It plays music. And videos. And games. It goes everywhere with me.

It has replaced the PDA I used to carry. It has books in it - audio and text. I found a list application (Listomni) that tracks whatever I want to buy as well as books I want to read and movies I want to watch. My calendar is in there, along with my note pad. It has news from the NY times and NPR, among others. Alarm clock, calculator. On and on as I discover previously unnecessary applications that fit in my pocket.

One of the most recent is called SparkPeople. It's an application for tracking food intake and exercise - and weight loss.

I watched a friend drop more than 20 pounds by logging every bite and exercise. It wasn't easy, but she met her goal. She was doing it on paper, though. Not something I'd be able to maintain. I'd spend too much time looking for the notebook - and the calorie counter.

SparkPeople is easy. It's educational - did you know that McD's 12 ounce Mocha Frappe has 450 calories? So does the Caramel Frappe. They don't taste nearly as good once you know, do they?

It has exercise demos, along with estimates of how many calories you burn for cardio. No credit for strength-building exercises, but I can live with that. 30 minutes of mild exercise 3 times/week meets my goal - for now.

I've been using it for a month - not even all the features, just a few basic ones - and am down 6 pounds. SparkPeople is listed on the US News web site in the article "5 weight loss web sites that work"

One of the things I found most attractive was the price. Free.

Tuesday, July 20, 2010

If you weigh more than 10 pounds......

I usually finish that with "I can't do anything for you". The weight limit is actually somewhat higher, but not much more than double unless you need an IV. I do know CPR, and I hope I'd remember how to do chest compressions with more than my thumbs should the need arise.

Years ago, when I was a fairly new nurse, I took a friend to the airport on a very hot summer day. We went to an extended parking lot and walked toward the bus which we planned to ride to the airport. As we rounded the back of the bus, we spotted the bus driver with her head on the concrete and her feet on the bottom step of the bus. I stood there with my mouth open until my friend slugged my shoulder and said, "You're a nurse, do something."

I sprung into action and determined that the bus driver was breathing and pink and, since we couldn't tell whether there were serious injuries, we shouldn't move her. Then I turned to my friend and said, "There's a radio on that bus. You're an engineer - your turn." Fortunately, the bus driver regained consciousness at that point and was able to call for assistance herself.

As I was telling this story to a friend recently, she glanced out the window of the restaurant where we were dining and noted the presence of an ambulance, commenting that she'd seen several others that day. Moments later, a contingent from the local EMS entered the restaurant and approached a nearby table where a patron was slumped over.

Yep. If you weigh more than 10 pounds, you might want to find a nurse with some actual adult experience if you're not feeling well. I can call 911 as fast as anyone, but I don't promise to notice that you're not actually napping when your eyes are closed.

Sunday, July 18, 2010

Physics lessons

One of the skills taught at the Mountain Man camp my son attended last week was the art of knife throwing. In addition to learning the proper way to throw a knife, he learned that if you don't do it quite right, the principle of equal and opposite reaction applies. Fortunately they were required to wear boots and he moves fast when faced with a rapidly returning knife. Didn't keep him from trying again until he got it right.

Tuesday, July 06, 2010

Summer Camp

My youngest son, a Life Scout, is heading off to BSA summer camp shortly. He's a little sad because he will again be at camp for his birthday. Only a little, because we celebrate the week before and the week after and again in August when his cousin comes to stay with us. That and he's looking forward to this particular high adventure camp. He's already completed all but one of the Eagle-required merit badges, so instead of working on traditional merit badges, he'll be living as the Mountain Men did in the 18th century. He'll learn blacksmithing, muzzle-loading riflery, wilderness survival and other useful skills. I'd predict that his favorite will the tomahawk and knife-throwing sessions, although shooting pretty much any firearm comes in a close second for him.

Thursday, April 15, 2010

Watch out for the quiet ones

My mom taught 9th grade general math for many years. As a math teacher, she had her choice of positions - and schools. She chose this particular school because she felt that she could make a difference there. Her justifiably high opinion of her teaching skills was part of that equation. The support of the no-nonsense administrators was the balance. She knew that any discipline problems would be dealt with promptly and effectively -- and with as much concern for the offender as possible.

She loved the school and the kids. They were nearly all from poverty-level homes and many of them lacked basic arithmetic skills. She chose to teach each one at his or her level - everything from first grade math facts to pre-algebra. She could control a class of 30-35 kids without ever raising her voice. Her students knew that she would not hesitate to send them to the office if they defied her - but that seldom happened.

One of her more trying students pushed the limits too far, using language completely unacceptable for the classroom.

When she ordered him to the office, he looked her in the eye and cheerfully announced, "You won't say that word out loud."

He paled as she lowered her voice and responded, "That's true, but I can write anything on paper."