Tiggers don't Jump

Open letter to the President of the United States

2012-01-30T18:23:00.000-05:00

Mr. President,
The recent decision by your administration to proceed with the violation of the First Amendment rights of millions of American citizens offends me. Your administration dares to ignore the very clear words and intent of our founders by demanding that faith-based employers ignore their conscience and the doctrines of their faith BECAUSE YOU SAY SO.

Mr. President, this will not happen. those of us who believe that we are not permitted by our God to participate in sterilization, abortion, and contraception by paying for it will simply not obey your orders. We choose to obey our God.

Furthermore, I believe that you will find that many who disagree with us as regards sterilization, abortion, and contraception will agree that the First Amendment prohibits the government of the United States from making such demands. They are wise enough to know that they cannot simply ignore this violation of the First Amendment then whine when their rights are trampled.

In case you have forgotten, the First Amendment states:

Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the Government for a redress of grievances.

You are doubtless aware of the hundreds of thousands of citizens who marched on Washington in support of Life last Monday. That was nothing compared to the numbers of people who are angry about this assault on our First Amendment rights. We vote. We campaign. We will not tolerate this.

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

2010-11-21T16:01:00.004-05:00

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.

Celebration of Life

2010-10-25T21:27:00.002-04:00

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.

Gianna Jessen Abortion Survivor in Australia Part 2

2010-10-05T16:43:00.000-04:00

Gianna Jessen Abortion Survivor in Australia Part 1

2010-10-05T16:32:00.000-04:00

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.

American Sign Language - free class on-line

2010-09-16T13:55:00.004-04:00

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.

Hold that position!

2010-08-25T14:37:00.004-04:00

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.

Assume the position!

2010-08-09T11:35:00.004-04:00

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.

I have an App for that...

2010-08-04T23:58:00.003-04:00

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.

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

2010-07-20T16:32:00.002-04:00

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.

Physics lessons

2010-07-18T21:04:00.002-04:00

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.

Summer Camp

2010-07-06T13:40:00.003-04:00

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.

Watch out for the quiet ones

2010-04-15T10:44:00.002-04:00

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."

Another quiet night in the NICU

2009-11-15T22:14:00.004-05:00

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.

English, please!

2009-08-13T23:48:00.002-04:00

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!

Day 14

2009-04-27T23:32:00.003-04:00

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.

Perspective

2009-04-21T01:21:00.002-04:00

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.

My mother doesn't curse

2009-02-17T01:09:00.002-05:00

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.

Spare me O Lord!

2009-01-31T23:54:00.005-05:00

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.

Survivor!

2009-01-28T02:35:00.003-05:00

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.

Don't use that word

2009-01-17T10:52:00.005-05:00

My sister talked me into going tubing.

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

Cold weather. Big hills. Falling. Fun.

Ok.

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.

Ditalini and Bean Soup

2009-01-12T11:31:00.003-05:00

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.

Serve.

Freeze leftovers if you like. It reheats quite well.

Patterns

2008-12-29T10:34:00.003-05:00

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."

"Thanks!"

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.

Perfect

2008-09-21T08:37:00.004-04:00

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.

Support our Troops, Packs, and Crews

2008-08-27T23:47:00.002-04:00

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.

Finished!

2008-08-20T13:12:00.004-04:00

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.

Cake Wrecks

2008-08-13T16:17:00.002-04:00

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.

Stripping

2008-08-12T13:28:00.002-04:00

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.

Countdown

2008-08-08T00:04:00.002-04:00

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.

Slow Learners

2008-07-24T19:07:00.005-04:00

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.."

BANG!

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.

Enter the Collective

2008-07-17T01:43:00.002-04:00

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?"

"No"

"Do you know what year it is?"

"No"

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.

Beats the heck out of me

2008-07-15T00:37:00.004-04:00

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.

APGAR 0, 0, 0, 2

2008-07-14T01:46:00.002-04:00

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

Infants without signs of life (no heart beat and no respiratoryeffort) after 10 minutes of resuscitation show either a highmortality or severe neurodevelopmental disability (LOE 5).^106,107After10 minutes of continuous and adequate resuscitative efforts,discontinuation of resuscitation may be justified if there areno 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.

I'm glad this evil person is my friend

2008-06-26T17:36:00.002-04:00

AmyKhar.com

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

2008-06-05T23:54:00.004-04:00

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.

A Scout is Reverent

2008-05-11T23:10:00.003-04:00

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.

Welcome to the NICU, let me show you around

2008-04-30T12:22:00.002-04:00

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

Captain Barbecue hangs a chicken

2008-04-25T14:03:00.003-04:00

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.

Crouching Tourist, Hidden

2008-04-23T14:25:00.001-04:00

Need help? Try this!

Star

2008-04-12T13:54:00.004-04:00

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

2008-04-12T12:42:00.003-04:00

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.

The Pope is Coming!

2008-04-09T23:38:00.003-04:00

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.

Consequences

2008-03-28T03:10:00.002-04:00

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!

2008-03-28T01:04:00.002-04:00

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

2008-03-19T23:30:00.003-04:00

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

2008-03-03T02:37:00.002-05:00

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.

How to get rid of your discipline problems

2008-02-28T22:46:00.002-05:00

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.

Happy Valentine's Day

2008-02-15T00:43:00.002-05:00

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.

08/08/08

2008-02-12T00:30:00.000-05:00

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.

Just Don't Ask!

2008-01-30T02:03:00.000-05:00

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?"

One.

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.

New Record

2008-01-28T23:38:00.001-05:00

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.

NICU Nightmare

2008-01-27T23:39:00.001-05:00

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.

Neonatal thrombocytopenia - a puzzle

2008-01-19T00:28:00.000-05:00

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.

Mother of the year. Again.

2008-01-18T00:18:00.001-05:00

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.

Children, (do not always) Obey Your Parents!

2008-01-14T00:47:00.000-05:00

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.

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

2008-01-08T02:56:00.000-05:00

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.

Indigestion

2008-01-07T01:46:00.000-05:00

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.

Legos! We got Legos!

2008-01-02T23:41:00.000-05:00

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.

Suck, Swallow, Breathe

2007-12-03T21:07:00.000-05:00

I spend a lot of time feeding preemies -- and teaching their parents to feed them. Often, the parents have the mistaken notion that practice makes perfect. For the adults involved, that may be true. For the babies, not so much.

There is a phenomenon among near-term preemies which demonstrates the issues pretty well for that group. The baby will poke along, choking and dribbling - sometimes failing to breathe as well. One day the baby just gets things together. It's almost magical - as if someone has flipped a switch. I've explained this to countless parents and recently a dad summed it up much better than I could. He said, "I see, it's like walking! He won't be able to do it until he can." The baby's mom was not exactly thrilled with any of us (dad, me, or baby), but she did seem to understand. Good thing. For that particular baby, it was weeks before he managed to pull his act together and nipple all his feedings.

Feeding preemies is much more complicated than feeding healthy term kids. With a term baby, you may have to help them figure out how to latch at the breast (or more rarely on an artificial nipple). Beyond that, the whole thing is pretty much reflex. Preemies have a pretty good suck reflex by 34-35 weeks gestation, but many don't get that swallow part. If they get the suck-swallow, they may not manage to coordinate breathing along with it. Eventually most of them will be able to manage, but it can be very frustrating for the parents while they're reaching that point.

Several things can help. First, don't cold stress the baby. They need to be warm - this often means spending time in an incubator, or at the least being dressed warmly and double-wrapped. Sometimes parents need a lot of education to understand that their preemie simply won't tolerate being unwrapped and passed around the group, especially prior to feedings. If the baby is using excess calories to keep warm, he won't have the energy to nipple or breast feed.

Preemies may not feed well if they are handled a lot or bathed just prior to a feeding. Again, they only have so much energy and need to conserve.

Positioning is important. The impulse is to snuggle the baby in the crook of your arm to feed him. This is a bad idea with preemies for 2 reasons - the baby will probably sleep if you snuggle him, and if he chokes, it will take longer to reposition him to clear his airway.

Choice of nipple can be very important. We have 4 different types of conventional nipples ( and a couple of others for babies with clefts). First is the standard nipple used for healthy term babies. I use that for most preemies as well. Then there is the "orthodontic" nipple which allegedly is more like feeding at the breast. I've never been convinced, but the nipple is quite useful for a subset of babies who choke or dribble, since it places the breast milk or formula in a different spot in the mouth. Another is softer than the others and has a larger hole. It is useful for feeding babies who have the swallow and breathe portions down, but who have a weak suck. Sometimes I use this one to finish a feeding if the baby starts to tire. The last nipple is a "slow-flow" nipple. That one is useful for the babies who have a really strong suck, but are inexperienced with the swallow-breathe portion of feeding.

Breastfeeding has a separate set of challenges in near-term preemies. Most babies take some time to develop an effective latch and suck due to a disparity between baby's mouth size and mom's nipple characteristics. It's hard for the baby to get enough of the areola into the mouth. There are ways to deal with this if the disparity isn't too great.

Mom may need a second set of hands to get the baby positioned and the mouth opened wide enough in some cases. Once the baby latches, mom needs to pull the baby in closer while she (or someone else) presses down gently on the chin to get the mouth open wider. As with term babies, it is important to make sure the lips are turned out, not in. In extreme cases, it may be necessary to use a nipple shield (silicone is best according to our lactation consultants) until the baby grows a little. I encourage the mom to try without the nipple shield first - only for a few minutes if it isn't working.

Dribbling and choking aren't a problem for breastfeeding babies unless the mom has an especially vigorous let-down. That can be managed too. We sometimes have the mother pump her breasts for a few minutes before letting the baby nurse. Estimating intake can be an issue. In most cases, we just weigh the baby's diapers to make sure he isn't getting dehydrated. In special circumstances, the baby is weighed before and after feedings (dressed and diapered). That allows an estimate of intake if that is necessary.

$10.9 Million for the Good Guys

2007-10-31T22:57:00.000-04:00

I can't embed the video but it's worth watching.

A federal jury in Baltimore, MD awarded $10.9 million to the family of Lance Cpl. Matthew Snyder. They found that the "protest" by the Westboro Baptist Church wasn't protected speech.

The members of Westboro Baptist Church have the right to their beliefs. They have the right to meet and to discuss them. As Lance Corporal Snyder's father says, they even have the right to express them in public places - in front of courthouses, public parks or streets - yes, even outside the U.S. Naval Academy as they did this week. I really do not believe that funerals are the sort of public venues where they should be able to express their views. I'm glad the jury feels that way as well. This will be appealed, of course and I hope they lose on appeal.

I'm not going to post any links to WBC. They're easy enough to find. I am going to throw in a plug for the Patriot Guard who have been attempting to shield military families from the vitriol of WBC actions at funerals across the nation - with permission of the family. They do this through strictly legal and non-violent means. More recently, they have added Honor Missions to deceased veterans and law enforcement personnel.

Enter the Samurai

2007-10-29T19:07:00.000-04:00

This is what has kept me busy all week. The helmet (kabuto) took the bulk of the time with the body armor (Do) a strong second. Lots of duct tape and foam-core poster board went into the armor. It's still missing important pieces for authenticity -- waist, leg, and throat armor to start -- we'll be working on those later. He's really pleased with his wins for scariest and most original in his age group at 2 different contests.

Been a little busy

2007-10-26T15:55:00.001-04:00

Armor is as finished as it's going to get. Pictures will be ready by Sunday - 2 costume contests in the meantime and his dad will be there with the camera.

My son is very excited. I'm really pleased with the way it's turned out. We'll be adding to it on an ongoing basis until it's really completed, but it will do for now. Next project, find the local Society for Creative Anachronism because he wants to learn much more about the making of armor, SCA style. And I didn't even tell him that they get together on Sundays to practice archery.

We did learn some things. You can do pretty amazing things with tinfoil and duct tape.

We also learned that it's a really bad idea to put on your gauntlet (forearm armor), which is made in one piece(not at all like authentics Samurai forearm armor), and slide it up over your bicep. Since it was made of posterboard and duct tape, scissors solved that problem. THEN I realized it probably would have come off the way it went on - with his hand straight up over his head. Not planning to test the theory, though. It takes a good 20 minutes to make a new one and I'm running out of patience. Lots of duct tape left, though.

Pictures coming soon

2007-10-21T23:38:00.000-04:00

Samurai armor is definitely the most challenging project we've attempted in a while. The helmet is nearly finished and the armor is coming along nicely.

We followed the directions on the Clan Yama Kaminari "How to make armor" page using foam core poster board covered with Duct tape instead of the plastic barrel they recommend. It's easier to cut than the plastic and he'll outgrow it too soon to make it worth going through all that. Also, he doesn't plan to go out and pound on people with sticks while wearing this. They only wear headgear and hand and foot protection when they pound on each other with sticks in his karate class.

Unlike the barrels, foam core poster board isn't flexible, so I cut part way through at 1.5 inch intervals on the side panels before applying black duct tape. This allows the armor to bend in order to fit. Instead of taking the time to lace the panels together, we used red duct tape for the hinges. We will be lacing the upper pieces to the front and back as well as the shoulder straps. Torso armor (Do) should be completed by tomorrow evening. Helmet (Kabuto) shortly afterwards. If we have time, we'll add additional pieces as we have time. Armor should be completed in time for next year's Renaissance festival (or an SCA event if we can find one nearby sooner).

shirt.woot derby #13 - Halloween

2007-10-19T18:08:00.000-04:00

Shameless pimp here. My friend has a shirt in the derby and will probably enter more. If you've ever bought anything on Woot or shirt.woot or wine.woot you can vote.

Shirt has been axed twice for technical reasons. Rats. It had moved up to #33 before getting cut this time. They reject many outstanding designs because they'd be too hard to print. This is one of them.

There are lots more choices in the derby, though. You can see the rest of the entries in the derby and vote. There is some really clever stuff there.

Halloween is coming!

2007-10-15T13:53:00.001-04:00

My youngest son has designed his own costumes since he was 5 years old. My job is to help implement them. This gets more challenging every year. Considering that his first (prize-winning) costume was a hammerhead shark, that's saying a lot.

This year I may need to swap him off to someone from the Society for Creative Anachronism as he wants to be a Samurai Warrior. With armor. So far, we've figured out how to build the helmet - recycling the Clone Trooper helmet from a few years ago as a base. He's hoping it will look a little like this one:

which we found on the projects page of Clan Yama Kaminari. He wants the whole shebang, so this is going to turn into a long-term project.

Ideas and helpful hints found here

We won't be using the face guard and our helmet started its life as a green military-style helmet which I spray-painted white for use as a clone trooper. It will change color again in this incarnation. He wants it black this time. My plan is to cover it with wedges of black Duct tape so it has a more authentic appearance than simply spray-painting would provide. Also, this makes it possible to construct the remaining part of the helmet in a manner which will match the top. Pictures to be posted as we make progress.

I ran into my oncologist today

2007-10-11T01:04:00.000-04:00

It's been nearly 2 years since I last saw him and 3 since he discharged me as a patient. I totally blanked on his name. I can't keep my kids straight, so that's nothing unusual. He, however, has a phenomenal memory - even asking if I still worked in the same place (not the hospital where I bumped into him). By name. Amazing.

I need to write a note thanking him for all that he did for me. I provided him with very little excitement in the way of complications of care, but - as with virtually all cancer patients -- more than a little complexity in my need for support.

He and his partners were always upbeat when it was appropriate. One of the partners would periodically pop into the waiting room with a brief comedy routine (always different). Another, who had never seen me, hunted down a test report that came in while he was on vacation.

What I remember above all else is that he wasn't afraid to use the "C" word.

No, not that one. At my first visit to his office, he told me that he thought it very likely that treatment would lead to a cure. Not a word I expected to hear from him for years, if at all.

Since you asked me to......

2007-10-10T00:42:00.000-04:00

Hat tip to Fat Doctor who asked (not just) me to pass this monitor cleaner along.

First, put down your cup and swallow.

Then click here.

That one seems to have exceeded their bandiwidth, so you might want to try this one.

"Uncle George is dead. Go see him!"

2007-10-05T00:14:00.000-04:00

Taking small children to funerals is always chancy. When the funeral is in another state, you don't always have options, though.

It was 22 years ago in the middle of winter when Uncle George went to meet his Maker. He'd always been a practical joker and insisted on being buried in his favorite red bow tie. His sons and son-in-law had all acquired red bow ties of their own for the occasion.

Having no nearby relatives with whom to leave them, we took our 2 and 4 year old sons with us to the funeral. We joined the family at the pre-service viewing and when the boys got fidgety, I left my husband with his cousins and took them outside. My oldest began greeting the guests with a cheery, "Uncle George is dead. Go see him!"

Uncle George's sons thought it was hysterical, but when one of the other attendees paled in response to the greeting, I thought it might be wiser to take the kids to the nearest McHappy place until closer to time for the service.

At the reception afterwards, they ran and played with Uncle George's grandchildren and visited with the rest of the relatives having a delightful time. When my oldest returned to preschool a few days later, I told his teacher that he'd been to a funeral, but he thought the whole thing had been a big party.

Today we attended the funeral of one of his sons. No red bow ties this time, and there were more than a few tears shed. Overall, though, the tone was one of joy for the deceased, much as Uncle George's funeral had been.

The pastor who preached the funeral sermon spoke of his sorrow for the widow who would be without her husband of 53 years and his sorrow for the friends and family who would also miss him - but of his overwhelming joy for his very dear friend. His joy is based in the promise of the Resurrection - in his belief, shared by most of those present, of a glorious eternity bought for us by the death and resurrection of our Savior.

We will miss our friend and cousin, but we live in the hope of seeing him again one day.

But it Itches!

2007-10-03T02:44:00.000-04:00

Poor kid. If he looked sick, I'd have taken him to the doctor. His only symptom was rash that, over the course of a week, spread from his chest to his back, shoulders, and then started to creep down his legs. Tiny bumps (papules) bright pink initially but fading so that you couldn't see them well at all any more. He knew they were there, though.

And they itched. Not that I wasn't sympathetic, but he only seemed to itch at bedtime. So we tried benadryl -- at least he could sleep. He probably itched the rest of the day, but he was too busy to complain. He's always doing something.

Besides, I figured self-limiting, probably viral. Not much point in going to the doctor for that. But it wasn't my rash and he insisted. So we went.

Funny thing is I was only wrong on one point. The pediatrician called it exanthem (aka exanthum) -- IOW, itchy rash, probably viral in origin. He did do a throat culture to rule out Strep, but he thought that was unlikely. Solution, atarax to help control the itching until it goes away in a few more days.

The culture was negative. He's still bumpy and itchy, but at least he believes someone cares. Maybe not his mother, but at least his pediatrician does.

AMATEUR TRANSPLANTS: Anaesthetists Hymn LIVE

2007-10-01T16:27:00.001-04:00

Just in case you were wondering

2007-09-30T21:21:00.000-04:00

No, we don't do stat paternity tests. It doesn't matter if you're from out of state. Would you like to see the baby? She looks just like you.

Actually, we don't do paternity tests at all. Here's the card. Contact them. They'll tell you how it's done. Yes, the doc will write a scrip if you need one. The company will tell you how much they charge.

No, medical assistance doesn't pay for paternity testing, but hey, the test is cheaper than child support unless the baby-momma has correctly ID'd you. In that case, you might as well skip the test and just pay up. Would you like to see the baby? She looks just like you.

If you really don't want to pay for the test, Maury Povich is recruiting maybe-daddies for his television show. Probably other shows are too. No, I won't be watching.

Memories

2007-09-16T23:53:00.000-04:00

Dr. Rob's 10 Reasons to NOT Like Pediatrics reminded me of a time when my older children were very small. It was item #10 if you're wondering.

My middle (then youngest) son was 15 months old at the time. He'd been up at about 2am looking for someone to play with. He didn't whine. He didn't cry. He was very cheerful. HOWEVER, this was a child who made a practice of sleeping through the night while cutting 4 teeth at a time. He NEVER complained about anything.

That and he'd been sleeping through the night since he was 2 days old. Really. Usually 12-14 hours.

So I did what any self-respecting mom would do.

I called the pediatrician and made an appointment to have him examined.

"Dr. Spock's office, how may I help you?"

"My 15 month old was awake last night. I think something is wrong with him."

"Was he crying?"

"No."

"Was he tugging on his ear?"

"No. In fact he was quite cheerful. But this isn't normal for him. Something is wrong."

"You want the doctor to examine your 15 month old because he was up once during the night last night?"

"That's right. Oh, and his brother (of the many ear infections) says his ears hurt, so I'd like to bring them both in."

(audible sigh) "Can you come at 11:30?"

"Sure. We'll be there."

For the record: his brother had bilateral otitis media - and so did he. According to the pediatrician, his ears looked much worse. He was the reason I bought an otoscope (ear-looker thingy) and why the pediatrician educated me in the proper use of it.

Prior to the otoscope, the first ear infection was the only one I caught before the poor kid had pus dripping from his ear canal. He NEVER complained. I got in the habit of checking his ears any time he had a sniffle. A year or so after I bought the "ear-looker thingy" he did ask me to "play check ears" - sure enough, the eardrum was ready to burst again. That was the closest the kid ever came to actually complaining about an ear infection.

That first incident was also the last time the office staff questioned my reasoning for wanting to bring a child in to be seen.

It's mine and you can't have any

2007-09-09T22:44:00.000-04:00

By way of Navelgazing Midwife. It's one of the funniest breastmilk stories I've read in a long time.

Warning. If you're the least bit squeamish about breastfeeding, just don't go there.

Driver's Ed

2007-09-09T19:19:00.000-04:00

It was many years ago, but some things you don't forget.

My driver's ed instructor was full of useful bits of information:

Buckle your seat belt

He was right, of course. I've only crash-tested one seat belt, but the only damage to me was a bruise where my medic-alert tag got caught under the seat belt. Now the first thing I do after buckling up is find the damn thing and make sure it's ON TOP of the seat belt. Makes one hell of a bruise if you don't.

When parallel parking, back up until the back of your rear passenger door (or equivalent spot in a 2-door) just passes the rear bumper of the car in front of your space before cutting your rear wheels toward the curb (front wheels away). Start turning your steering wheel back the other way shortly before BEFORE your front bumper passes the rear bumper of the other car.

Works. I back in, pull up a little and am perfectly parked every time.

Don't run over ANYTHING, not even a paper bag. There could be a human head in it.

Colorful way of making sure I don't run over paper bags. Can't do it - not even 30+ years later.

If you're on a 2-lane road and someone is coming at you head-on, brake and stay in your own lane. Don't pull to the left or to the right, because the driver who is in the wrong lane will choose one of those most of the time.

I don't know where he got his statistics, but the only opportunity I had to test his theory, the other driver passed me at very high speed on my right - yes, going the opposite direction. I don't want another opportunity. NEVER.

Uber Cool Nerd Queen - that's me

2007-09-06T13:09:00.000-04:00

What are you?

I knew I should have kept that Amiga.

Visitor

2007-09-03T04:48:00.001-04:00

I don't know whether this bird belongs to a neighbor, escaped from an area wildlife preserve, or has been surviving on his own with the one leg. We've seen lots of raptors around here, but this is the first time I've seen one in the bird bath.

Yes, those are thistle feeders in the background for the many finches who visit our yard. You can't see the "squirrel proof" sunflower seed feeder nearby. We haven't seen any evidence, but I wonder if this one-legged visitor has been snacking at our bird feeders - and not the seeds.

He wouldn't have to. There is certainly enough road kill around here - mostly squirrels, with the occasional raccoon or 'possum, to keep him well fed.

Pediatric Grand Rounds

2007-09-02T23:21:00.001-04:00

The Labor Day Weekend edition is up at Unintelligent Design. Thanks to Dr. Clark Bartram for keeping this going!

Byler Babies arrive

2007-09-02T16:05:00.000-04:00

Karoline Byler, of Wesley Chapel, Florida, can finally take a deep breath. Her babies were delivered Saturday, September 1, between 9:00 and 9:03 pm at Bayfront Medical Center in St. Petersburg, Florida. They were taken through the connecting tunnel to adjacent All Children's Hospital. The 2 hospitals have been planning for months and there's a video linked from the All Children's web site that describes the plans. The hospitals have managed many sets of multiples - including quintuplets, so they are understandably confident of their ability to manage the Byler babies.

From the All Children's Web site:

Names and birth weights for the five boys and one girl are as follows:

Brady Christopher - 2 lbs., 8 oz.
Eli Benjamin - 3 lbs
Ryan Patrick - 3 lbs
Jackson Robert - 2 lbs., 10 oz.
Charlie Craig - 2 lbs., 5 oz.
Mackenzie Margaret - 2 lbs., 9 oz.

They describe the babies condition as stable, except for Ryan Patrick who is "receiving airway support" and in serious condition. To me, that means something short of a ventilator because that would generally be described as critical condition. The babies were born at 29 weeks, 4 days gestation. There are certainly risks for these babies, but at 29+ weeks and having come through delivery with apparently no major complications, statistics are in their favor.

The family, with an eye to supporting these 6 additions to their family, has signed an exclusivity contract with Inside Edition reportedly worth $12,000, so you'll have to watch their broadcast if you want to see pictures of the babies today. As the reporters in the video I linked above said, that will buy a lot of diapers.

Update:

I should have anticipated this. 2 of the Byler babies are now in critical condition and 2 others in serious condition. It's quite common for 29 week preemies to have some respiratory issues and I hope that's all that's going on here.

We call that initial period when the baby does so well the "honeymoon" and it last about 24 hours. The babies start running into problems with inadequate surfactant production after that.

If that's the issue, the 2 who are in critical condition probably had to have a breathing tube placed so they could receive surfactants. They'd be kept on the ventilator for a period afterwards. The time frame would depend on how quickly they recover. The 2 in serious condition may need respiratory support short of a ventilator. They may recover without needing a ventilator, or they may need some surfactant replacement within the next day or so themselves.

Breastfeeding - a personal choice

2007-09-01T10:28:00.000-04:00

It is well documented that breastfeeding provides many health advantages for moms and babies. The incidence of upper respiratory infections is lower. The incidence of severe allergies, asthma, and type 1 (insulin dependent) diabetes is lower. The incidence of sudden infant death syndrome is lower. Moms who breastfeed even have a lower incidence of breast cancer. There's a myth that the baby weight comes off faster. Many women find that it helps. I didn't find that to be true - and many women don't.

In the US, where we have access to clean water, refrigeration, and infant formula that is virtually always safe if stored properly (there have been a few alarming -- even lethal, but rare -- exceptions), women can choose to feed formula without fear of the risks found in third world countries. They should be informed of the benefits they are giving up. They should be supported with good breastfeeding education and workplace accommodations, but I don't believe in badgering women who choose not to breastfeed.

Some moms have medical reasons for choosing formula. Those vary from a need to take medication not compatible with breastfeeding to breast surgery which interferes with milk production and let-down. In rare circumstances, the baby may have a genetic disorder which makes breastfeeding impossible, due to special dietary requirements.

Some women have psychological reasons. For example, women who were molested as children may find it difficult to even consider breastfeeding. Some women have work schedules which will not accommodate breastfeeding or even pumping. Some have tried with a previous infant and for one reason or another found it too discouraging to even try again. Some women wish to share the closeness of feeding times with the baby's father or other relatives.

Whether or not I agree with their reasons, I don't badger. I educate about options - like partial breastfeeding. I help them research medications to be certain that they have the latest information. If they wish, I can refer them to our social worker for help with other issues. I make sure that they know WIC provides food for breastfeeding moms in addition to formula for babies. Under the right circumstances, I'll even offer them a pump to help deal with engorgement.

In the end, I support their choice. Moms have a hard enough time without people trying to make them feel guilty about one more thing.

Yes, I wish everyone could breastfeed, but that isn't ever going to happen. Moms need to educate themselves and make the best choices for themselves and their babies - and nobody should jump to conclusions or behave in a hostile manner regardless of the way a particular baby is being fed.

Breastfeeding in Public

2007-08-30T15:06:00.000-04:00

I did it. I didn't whip it out and show everyone the facilities, but I didn't hide under a blanket, either. I learned to arrange my clothes and the baby so that I hardly ever flashed anyone. My oldest is in his mid-20's so it was a little less common then than it is now.

OK, it was a lot less common and people occasionally made suggestions that the bathroom was the most appropriate place for that sort of activity, because -- it's a body function.

I didn't get nasty with anyone. I just did the same thing I did with other unwanted parenting advice. I ignored them. After all, I didn't see THEM taking their plate into the bathroom to perform that bodily function in private.

We have a serious problem in this country, folks. There are still people who can say with a straight face, "It's a body function and should be private." They think their sensibilities are more important than the health and safety of someone's child.

I simply do NOT understand their problem. I know it's a cultural issue. They were raised to believe that breasts are for sex and that suckling = sex. For babies it equals food. The best possible food for babies - who can't wait until nobody with breast issues is looking.

"Nurse-ins" can be used to demonstrate that it is possible to breastfeed in public without unnecessary exposure - or they can be used as an in-your-face political statement that doesn't do much to further the cause of breastfeeding.

The breastfeeding statistics in this country are abysmal. The good news is that we're getting more than 70% of moms to at least try breastfeeding. The bad news is that most of them don't keep it up. Partly that's lack of support at the outset. Much of it, though, is lack of support - and sometimes outright hostility - when they get home.

FDA Warning for Breastfeeding Moms

2007-08-23T12:25:00.000-04:00

Last Friday, the US Food and Drug Administration released a warning for breastfeeding moms and their healthcare providers. A rare genetic tendency to metabolize codeine more rapidly than usual may put infants at risk. One infant death has been reported.

That mom was reportedly taking a relatively low dose of codeine when her 13 day old baby died of a morphine overdose. The mother was not taking morphine. She was taking codeine. It is normal for the body to change some of the codeine into morphine, but this should happen relatively slowly so that there is little risk to nursing infants.

Nursing moms need to pay attention to their babies whenever they are taking any medication or herbal supplement. A change in behavior, especially excessive sleepiness, lethargy, poor muscle tone, or difficulty getting baby to feed can indicate that the baby is getting an unhealthy amount of whatever you are taking. The same is true if the baby becomes very fussy, vomits, or has very tight muscle tone, color change, or increase in respiratory rate. Complicating matters, any of these can also indicate illness in a newborn.

Bottom line, if you are taking a medication, make sure it's approved for use with nursing babies (codeine is, in moderation). If your baby's behavior changes markedly - even if the medication is approved - check with the baby's doctor.

It is always possible to reach someone outside of office hours. If your baby's pediatrician hasn't given you other instructions, call the office phone number and leave a message with the answering service or follow the instructions on the office voicemail about reaching the pediatrician. If for some reason you cannot reach the pediatrician and/or you believe it is an emergency, the ER is open all the time.

Avoiding the problem? Take the codeine if you need it, but if over the counter pain medications like Tylenol or ibuprofen will do, that might be a better choice. Read labels. Some cough medications can contribute to the increasing morphine levels. If you're getting really sleepy after taking codeine, watch the baby extra-carefully.

Don't mix prescription pain medications unless your doctor tells you to. Many contain codeine and you could get a double dose. If you aren't sure what's in the medication, ask your doctor or pharmacist.

Your best source for information about medications and breastfeeding should be your doctor, the pediatrician, a lactation consultant, or a pharmacist, but here is a link with more information on breastfeeding and medications:

Dr. Thomas Hale - wrote the bible on the subject, called Medications and Mother's Milk. Make sure you're looking at the latest edition (12th). It's updated regularly and you shouldn't use a copy more than a year or 2 old. The differences can be huge. Absolutely do not waste your money buying an older edition.

TC has shared an excellent web resource it's called Kellymom.com: Breastfeeding and Parenting a site run by Kelly Bonyata, BS, IBCLC. She sources her information and tells you how current the information is.

The dates on many of the other links I found were nearly 10 years old. NOT ACCEPTABLE, in my opinion. The science on this changes. Yes, some medications are quite well studied, but you may drop a perfectly safe medication or "pump and dump" unnecessarily - or even put your baby at risk - if you don't have the most current information. Feel free to share any good CURRENT information in the comments.

Search terms - sometimes they make me laugh. Sometimes not so much.

2007-08-22T21:45:00.000-04:00

"premature babies with blood on their brains, what do they do"

This one made me sad. They probably mean intraventricular hemorrhage (AKA interventricular hemorrhage). Bleeding into the ventricles can be relatively insignificant if there is only a little blood - but that depends on the location of the bleeding. Many babies with grade I or grade II IVH are completely healthy with no significant developmental delay - but not all.

Larger amounts of bleeding (grade III and grade IV) are more commonly, but not always, associated with developmental delays and cerebral palsy.

Sometimes there is so much blood in the ventricles that not enough fluid flows out of them. This causes increased pressure within the brain (hydrocephalus), which can also increase the risk of developmental delays. If the fluid persists, the baby may need a ventriculoperitoneal shunt placed. With the smaller babies, serial lumbar punctures (spinal taps) may be used to postpone shunt placement until the baby is large enough.

Sextuplet update

2007-08-22T21:10:00.000-04:00

Actually, no news is good news at this point - and there isn't much. You won't be seeing the irate bloggers talking about litters for at least a few more days. Hopefully closer to 2-3 weeks.

Karoline Byler (more here) was admitted to the hospital over 2 weeks ago and is 28+ weeks now. The docs hope to get a few more weeks with medical management and bed rest, but the survival rate at 28 weeks is pretty good.

The Sodani family has been quiet, too. They should be about 27 weeks by now. The last update on Brian and Gracie's web site says that she's in the hospital - no date, but it's been there for a month or so.

The Masche's are all home and doubtless too busy to do much in the way of updates. I don't even see any new pictures in their photo gallery.

There hasn't been an update on the remaining Morrison baby. He was still in critical condition at the last update, nearly a month ago. He may well be in critical condition for another month. Possibly even longer. He was tiny and it takes a long time for those tiniest babies to outgrow their respiratory and feeding issues.

The families all still have their "how to help" links on their web sites. I hope they're getting what they need. I won't be contributing to any of the sextuplet families. There are plenty of families in need in my own community.

I also found a web site called MOST - Mothers of Super Twins.

This is how they describe themselves:

MOST is a network of families with triplets, quadruplets and more that provides information, resources, empathy and good humor during pregnancy, infancy, toddlerhood and school age

If I had the resources to donate outside my own community, I'd support their adopt-a-family program. With the upsurge in higher order multiples, people with 3-5 babies at a time just don't get the publicity (and the assistance) that they did a few years ago.

Is it possible to disagree about religion without calling names?

2007-08-17T16:14:00.000-04:00

From a comment on a previous post:

your own child you would be willing to sacrifice to make a religious point.

To me, that is religious fanaticism.

Throughout the ages, people have been willing to die for their beliefs -- and yes, to allow their children to die also. I wouldn't call someone a religious fanatic simply because I disagree with them. To me a fanatic is willing to have someone over whom they should have NO control or responsibility die for their beliefs. Religious wars through the ages, some of the current terrorist acts, and many of the deaths during the Inquisition fall under that heading.

I am responsible to my God for my children. They are gifts from Him and I must answer to him for choices I make in raising them.

I realize that other people do not consider embryonic stem cell research to be evil. I believe that it requires destroying a living human. I would no more accept for myself or my child the results of that research than I would accept a donor heart from a living, breathing fully functioning human being (we're not talking brain death, here).

As I stated in a comment to that prior post. To me, the difference between the Jehovah's Witness believe about the proven benefits of transfusion and my belief about any theoretical benefit of embryonic stem cell research is that nobody dies when they donate blood. The rest is very much about our responsibility to God as we understand Him. I respectfully disagree with their position on blood transfusion, but I would not call them fanatics.

I also believe that our focus should be on the already successful cord blood stem cells and adult stem cells. That research has been beneficial already and should be expanded.

Religion and Healthcare - how much freedom should we allow?

2007-08-15T18:22:00.000-04:00

I have given transfusions to children of Jehovah's Witness children. Virtually all of the parents consented tacitly by not opposing the court orders we obtained in order to give the transfusions. I never felt bad about that until I visited a web site which refers to JW teaching on the subject as "moronic"

That made me more uncomfortable than you might think, given that I believe they are misinterpreting the scripture.

Why?

Because I can see a battle coming. If ever there is any successful treatment from embryonic stem cell research, I would refuse that treatment. I would refuse to allow my child to have that treatment - even if it meant that my child would almost certainly die. I believe very strongly that life begins at conception and that destroying embryos for research purposes is a great moral evil.

I still think that the Jehovah's Witnesses are misinterpreting the scripture. If a child's life is in danger, and if we can get a court order for a transfusion, I'll still give it. I will have a great deal more sympathy for those parents, though.

Religious beliefs in the NICU - Jehovah's Witnesses

2007-08-11T21:13:00.000-04:00

My first experience as a NICU nurse with a Jehovah's Witness family was in the 1970's. The baby had severe hydrops fetalis because his mother was Rh negative and had developed antibodies to the baby's Rh positive blood. This sensitization very likely occurred prior to the introduction of Rhogam.

The baby was so critically ill and so unlikely to survive that our neonatologist opted not to request a court order to permit him to transfuse the baby. He felt that it would cause unnecessary pain for the family without any benefit to the baby.

Since then, I've had the opportunity to discuss blood transfusion with several families who are Jehovah's Witnesses. Their responses vary.

The very young moms who have been raised in the faith tend to say, "I can't give consent, but you can get a court order, can't you?" Not always the case, but they often have to balance their concern for the baby with their relationship with relatives.

The physician's answer is always the same. "We'll try to avoid transfusing your baby, but we can get a court order if needed." Care for those babies isn't significantly different than for our other preemies. We try to avoid transfusions in all of them if we can. The one difference is that the babies for whom we need a court order get an appointed guardian who has to approve any transfusions. It's not simply left up to the physician once the court order is in place. The guardian, who is generally a hospital administrator, has to be convinced of the need. I've only seen one transfusion refused, but the guardians take their responsibility very seriously.

Older Jehovah's Witness families don't always have the hard-line belief that all transfusions are prohibited for all members of the faith. Some believe very strongly that transfusion is always wrong. Others believe that it would be wrong for them to have a transfusion, but that their baby is not yet in a position to make that choice. They, like our appointed guardians, want to be convinced that each transfusion is actually needed, but they will sign the consent form themselves. Retaining control is probably an important part of choosing that path.

While doing some background reading for this post, I discovered a web site titled Associated Jehovah's Witnesses for Reform on Blood. The site says that they have members who are or have been elders or members of Hospital Liaison Committees. They disagree with stated positions of the Watchtower on the use of blood and blood products and say that they hope to educate Jehovah's Witnesses on what they call inconsistencies in doctrine.

I don't share the Jehovah's Witness belief that it is a sin to use blood or blood products, but I do appreciate the technological advances that have resulted from medical and surgical attempts to minimize or avoid transfusions. Transfusions save lives, but they're not free of risk.

And one more thing

2007-08-09T00:38:00.000-04:00

I know the nurses who took care of my husband must have been glad to see us go home. He's a notoriously poor historian with a couple of significant allergies. He remembers the one about the shellfish, usually, and nearly always forgets to tell them about the peanuts. At least the peanut allergy isn't an issue until they start feeding him. Then he remembers and they ALWAYS want to know what else he's forgotten. Can't blame them.

He can't remember the name of the drug that made his platelet count drop to 30,000.

And neither of us thought it would be a problem to simply give them a list of his medications without a list of "not allergic, but do not give" meds. We were trying to figure out which medications he'd been given prior to discharge and which he might need to take when he got home. Plavix, check. Toprol, check. Aspirin, check. Zocor. Yes, he got Zetia and Lipitor.

"Wait. He got Lipitor? You can't give him Lipitor...."

and then I remembered we hadn't told them about the whacko liver function studies when he was taking Lipitor. And he'd referred every single one of them to me to review his medications and history -- well, everyone except the house doc who wrote the orders and the nurse who'd given him the Lipitor without telling him the name of the damn pill. He'd have remembered if he'd been told the name of the pill.

One isn't going to kill him, of course, but it is aggravating - both that we forgot and that he had a nurse who couldn't be bothered to tell my husband the names of the pills he was handing out.

I need to do a little training: "Yes, honey, you need to ask the name of EVERY SINGLE PILL. I don't care who is giving it to you. Don't put anything in your mouth until you know its name."

Vaccine, Autism, and Statistical Nonsense

2007-08-08T20:41:00.000-04:00

Since Med Journal Watch has comments turned off, I'm going to comment here.

He's right on nearly all his points, but he missed a BIG one.

The discussion of Autism related to the alleged prenatal exposure to Thimerosal from Rhogam requires a visit to the Rhogam web site

Since at least 2001, THERE IS NO THIMEROSAL IN RHOGAM. Scroll down. You'll find it.

Once again, statistical nonsense which totally ignores reality. Thimerosal must cause Autism, according to the anti-vaxers, so there must be thimerosal in Rhogam.

Even when there isn't.

Update: See Christian's comment. The only thing he missed was the date when the Rhogam (or similar product) was given. The study subjects were prior to the exclusion of Thimerosal.

I haven't been able to access the full text of the study yet. I'll keep trying, but I did a little investigation of the researchers. Christian, of Med Journal Watch, is quite right to be suspicious. The researchers definitely have a dog in this fight. Dr. Mark Geier is a paid professional witness in anti-vaccine trials. He has had his testimony stricken on at least one occasion because he did not have the necessary credentials to be an expert witness in that case.

Additionally, Dr. Mark Geier has been cited for attempting to breach confidentiality and had a different study suspended for that reason.

For some very interesting information on the Geiers, see this post on the Neurodiversity Weblog.

As an Rh negative mother of a young adult with ADHD (too old to have gotten prenatal thimerosal), I'd be interested in research that truly shows a higher incidence of any type of developmental issue in children of Rh negative women. The study population was only 53 and it truly was not a prospective study in the way I understand prospective studies. Further research would be interesting, but I'd want it done by someone who doesn't have anything to gain other than knowledge.

Making a difference

2007-08-08T18:44:00.000-04:00

Abbie Armstrong comes from a family with a tradition of changing lives. She's carrying on the tradition - even before she graduates from nursing school.

While still in high school, she was invited to fill an empty seat at a fundraising dinner. The dinner was to benefit the people of the island of Sumba, a small island in Indonesia. No, I never heard of it before I read the story either.

The pictures Abbie saw at that dinner weren't the pretty tourist pictures on the first link. They were the pictures of the indigenous people of the island. The people who have very little in the way of health care - and often not much in the way of clean water or protection from malaria.

Abbie's life was changed forever that night. She decided that she must visit Sumba - and it was arranged. She decided that she could not go empty-handed, so she invited friends and family to donate money, not knowing how it would be spent before she left home. The rest of her story is truly inspirational. Abbie's life has been changed, but not only her life. Read the article to see how one person can make a difference - if they are willing to make the effort.

Surviving childhood -- your children's

2007-08-07T22:35:00.001-04:00

My friend Pippa, of Pippa Said is having a little trouble with her youngest child. Said child likes to play in the street. And is being encouraged by the older siblings. Pippa could use some advice. Mine would be along the lines of "Have a glass of wine."

Drinking won't help, of course, but when your kids act like that, the neighbors already believe that you do. I should know. I have boys. 3 of them.

My oldest was fond of playing in the street. I didn't exactly encourage it, but blink and he was out there. It was the one infraction for which I routinely spanked - accompanied by the admonition, "If a car doesn't hit you, I will. Every time."

To which my son would respond, "That doesn't hurt!"

Kid never knew how close that put him to death. He did survive - his excursions into the street and his mother's wrath.

He's the only one of my kids I never put the "Mother's Curse" on -- you know, "I hope you have a kid just like you!" I was too afraid he'd ask me to babysit.

Want to know what life was like when he was little? I once told a co-worker that nobody who'd read Ransom of Red Chief, by O. Henry, would ever consider kidnapping him.

Part of his problem was that he had a significant speech delay. At age 3.5, I could only understand about half of what he was saying. This was quite frustrating for both of us. Only after his speech improved did I realize that it was actually a mixed blessing.

I also learned of the hazards of teaching small children the correct names for their body parts.

By age 3 3/4, after only a couple of months of speech therapy, he could very clearly (and very loudly) ask, "Mom! Mom, does that man have a penis?"

Loud. Every time he saw a man standing still in a public place.

I knew it was really about the attention, so I'd try to ignore him, because shushing just didn't work. So of course he'd ask again -- louder.

Eventually, I took a chance.

"I don't know, honey, why don't you ask him?"

To my everlasting relief, he did not.

Tiny Turtle update

2007-08-01T11:50:00.001-04:00

Most of tiny turtle's meals consist of Romaine lettuce. He gets a little tomato, little bits of fruit, and as a special treat a tiny cricket to hunt or a bit of shrimp. We're still having a drought here, and worms are mighty hard to come by.

The turtle prefers his lettuce leaves large. He crawls underneath and nibbles from below. We're all entertained by the moving lettuce leaves. With most other foods, he hides until he thinks we're gone before he will come out to eat. With the shrimp, he just doesn't care. He'll eat in front of whoever happens to be around. He looks damp in the picture because I had just misted his terrarium to keep him from having a drought in there too.

He's grown a little. His shell is now 38 mm wide and 41 mm long. He seems to be healthy. He's quite active in the early mornings when there aren't many people around. His skin looks clean and his eyes are shiny. He's quit hissing at us, so I think he's getting used to us. He still likes to hang out in his little pool, but never when I'm looking. I can tell by the little turtle footprints he tracks into the water.

Vacation Bible School

2007-07-27T14:08:00.000-04:00

This week, in addition to my other entertainment, I assisted at my parish Vacation Bible School -- with a western theme - Wah-Hoo!

My part, fortunately, was very scripted. I don't think I could have managed otherwise.

Day 1. The story of Rahab, who hid the spies sent by Joshua from the King's army. Joshua, chapter 2

We had the "spies" hidden under a sheet and when the soldiers came, I tossed more sheets over the kids to hide them too. The soldiers were actually voices on a CD and I only had to read my part and poke the kids with "swords" and "spears" through the sheets. Before I uncovered the kids, the "spies" (also on the CD) gave me a red cord to hang from my window so I wouldn't be killed when Jericho was destroyed.

Day 2. Joshua's Army crosses the Jordan river. Joshua, chapters 3-4. The river is flooded, but when the priests step into the river carrying the Ark of the Covenant, the waters are parted and the army crosses on dry land.

We put several thick towels on a tarp and soaked them. Then we had the kids take off their shoes and cross the "marshy ground" to approach the river (blue sheets held up to look like a flooded river. When the kids approached the river they could feel the spray from the flooded river (my partner had a spray bottle) and when the "priests" touched the river, it dropped away revealing rocks on the "river bed".

Day 3. The walls fall down. Joshua, Chapter 6

I was at the hospital with my husband, but my co-teacher had this under control. He had the children marching around the "walls" he'd set up and when they stopped and sounded their "horns", he had a pull-down video screen that rolled up like a window shade - causing some of the kids to bolt out of the room. I'm sorry I missed that one.

Day 4. The resurrection. Mark 15-16 I missed that one too, but my co-teacher had about 30 balloons blown up and hidden. When it was time to announce the resurrection, he pulled them out of hiding and tossed them around the room. The kids won't forget that any time soon.

Day 5. Naaman is cured of leprosy. 2 Kings 5: 1-14

We set up by the "Jordan River" again - this time with pots of water. We rubbed onion on the kids to give them an idea what it would be like to have leprosy. Some were upset. Some said they thought it smelled good - at first. By the time we cleaned the smell off, they were all glad to be rid of it.

Believe it or not, you can take the smell of onion off fairly quickly by rubbing the skin, under water, with the back of a stainless steel spoon. I have no idea how that works, but it does.

Afterwards, I dabbed vanilla extract on the back of each hand and invited them to "let God be in control" of their lives. That was a big hit after the onions.

Finally, it was back to the parish hall for the closing and traditional pizza party. I asked some of the kids if they plan to come back next year -- and got a resounding YES! from each one.

The program we used is Avalanche Ranch by Harcourt and each part of the program is scripted so that the teacher can just follow the program. You can choose your own crafts, but theirs come in kits and fit into the program themes. Our director of religious education opted to purchase a CD with all the music for each of the kids. It's well worth it. The kids who attended last year's camp still have their CD's and still sing the songs - whenever their parents can stand it. The music is peppy and upbeat. Some of it they already know, the rest written for VBS by PROFESSIONAL musicians.

I can't wait to see what they'll have for us next year.

Men

2007-07-26T14:44:00.001-04:00

Could someone please explain to me what part of "Take it easy for a few days" would lead a man to believe that his doctor had given him the OK to go out and clean the swimming pool the day after a cardiac cath with stent placement.

I'm not sure I'm going to survive this. I really need a nap, but I do not dare go to sleep before he does.

Adoptaplatoon.org

2007-07-26T06:13:00.000-04:00

One of my co-workers told me about an organization called Adopt a Platoon which matches deployed troops with individuals, families, and organizations in the US who send letters and care packages. She's been doing it for a while.

They're very careful to protect the identities and addresses of our troops, so it can take a while to get cleared by the organization. I got home from the hospital last night to find my acceptance notice from them. The first letter will go out in the mail today. The first care package will go early next week. After that, letters at least weekly and care packages at least monthly.

They have lists of suggested (and prohibited) items so I'll have a clue where to start - and in case our troop isn't able to let us know what he or she really needs. I plan to send a check list in each package with a self-addressed envelope that simply lists the contents with a spot to check "send more soon, send more later, and send something else instead." I hope he or she will not worry that our feelings will be hurt by checking that last one, because I'd much rather send things that are wanted or needed. I want to keep it really simple, because his/her free time can be better spent writing home than writing me.

There are tips on the web site I'd never have considered - like newspaper not only makes good cushioning material for care packages, but may serve double duty as reading material when it gets there. That means my local newspaper would probably be a better choice than the larger city paper to which I also subscribe, except perhaps for the city paper's comics.

It was a long day, but not a bad one

2007-07-25T22:44:00.000-04:00

They took my husband to the cardiac catheterization lab at about 12:30 and told me the procedure would take 45 minutes to an hour. 3 hours later, he finally made it to the recovery area. At least he's consistent. He never makes any procedure easy for the physician who has to perform it. Thanks to the nurse who came out every 45 minutes or so, I was kept up to date on the progress and knew he was doing as well as could be expected.

I have only good things to say about this visit so far - from the valet service to the medical and nursing staff. Everyone has been wonderful. I'd love to know how they jam cell phones, but there was always a telephone around I could use when I needed to contact family to let them know how things were going.

I was concerned about leaving him for the night -- until I met his night nurse. The nurse is a former Scout leader, so they hit it off right away. After watching him work for a little while, I had no worries about the quality of care he'd get either.

Yes, I took names, and yes, they'll be going in a complementary letter - along with a thank-you to all the cheerful, but nameless faces who made the day more pleasant.

Vaccines lead to age-related diseases

2007-07-25T00:03:00.000-04:00

I had an interesting conversation recently with a friend who made the above allegation. I promptly went into defense mode and gave my rant about people misunderstanding vaccines.

Turns out my friend had no such misunderstanding. She simply meant that, prior to immunizations, most people died before they had the opportunity to experience such ills as arthritis, heart disease, cancer, type 2 diabetes, and all those other diseases we may experience on the far side of 40.

Informed consent?

2007-07-23T12:20:00.000-04:00

My husband has a cardiac cath scheduled for Wednesday to check a couple of relatively small areas with decreased perfusion after exercise. 9 minutes on the treadmill and he was having no chest pain or shortness of breath when they did the scan. If he was less active, he'd never have known he needed to get this checked out. His only symptoms were some dizziness and shortness of breath when he spent 20 minutes on a stair climber at the gym last month. That and if he mows the lawn when the temperature in the 90's he gets a little winded. I'm glad he's paying attention. Lots of people would think that was normal.

It sounds like he may need a couple of stents, but that there hasn't been any damage done - yet. I listened as the cardiologist explained the procedure - in very simple language. I watched as he explained the risks and asked if we had any questions. I was the only one asking questions and those were mostly "When and where?" As soon as the cardiologist left the room, my husband looked at me and said, "So is there any danger that the procedure could trigger something?"

Well, yes, but not much and it's safer than not doing it.

The interventional cardiologist will review all this with him again on Wednesday, but I expect that the conversation will be the same. He will have no questions for the doctor and lots for me as soon as the cardiologist walks out of the room. Good thing these cardiologists explain things so clearly. I know the vocabulary, but this sure isn't my area of expertise.

Preceptor -- learning to teach heel stick blood draws

2007-07-22T19:10:00.000-04:00

I occasionally help orient a new staff member or precept a student. I really enjoy this, because it makes me think. They always have questions. The one that makes me really think about how I'm performing a technical skill is "Why does this work for you and it doesn't for me?" -- could be blood draws, could be getting a preemie to eat. Could be something more technical.

When I get asked that question, I realize that I failed to properly explain the skill. I have to think through every single step of an action which has become so ingrained that I barely know how I'm doing it any more. Only by watching someone do what they think I've told them and what they think I've demonstrated do I learn the subtleties of finger placement so I can explain a little better the next time.

One thing that is exceptionally easy to do, but hard to teach is heel stick blood draws. Everyone does this a little differently, so in addition to demonstrating my technique, I encourage the student or orientee to observe other nurses and adapt the various differences in technique until something clicks.

There are some basics, though.

Prepping the skin is simple - clean with antiseptic (alcohol for most heel sticks), allow to air dry. I watched a new resident prep skin for a blood culture once. He went through the routine and then BLEW on the site. No. I didn't let him draw the blood until he'd re-cleaned the area.

We use an automatic safety lancet designed for heel sticks. Placement is important -- on the side of the heel, not in the center. Choice of inner or outer side depends on the baby's position and whether the nurse is right or left handed. It also may depend on just how badly damaged the skin already is.

Those things are easy to teach. Much harder is teaching just how hard to squeeze a given baby to get the blood you need without damaging the baby's skin or leaving a bruise. Most people are too gentle at first and have to be encouraged to squeeze just a little harder. With the smaller preemies, it's important to keep your fingers from slipping so that you don't tear the skin. With all of them, technique has to be adjusted to the gestational age and the baby's general condition.

It's important to get a free-flowing specimen for CBC's (blood counts) and electrolytes. If the blood isn't flowing freely, the CBC might clot and give false readings (or be rejected by the lab) and with electrolytes, the serum potassium can be falsely elevated if the blood cells are hemolyzed. Warming the heel prior to sticking helps. So does wiping off a drop of blood after every 2-3 that you collect. It's also important that the blood flows into the microtainer instead of being scooped off the skin. Scooping picks up micro clots which lead to bigger clots or which contain hemolyzed cells.

The objection I hear most often to wiping those drops is that the new nurse or student doesn't want to "waste" blood. It wastes more blood if the specimen is rejected due to a clot or gross hemolysis.

The microtainers we use have lines to let you know when you've collected enough blood. Some tests require that the container be filled to the top line, some just to the bottom one. For CBC's, it's important to fill to a level between the 2 lines so that there is enough blood for the test, but not too much for the EDTA that keeps the blood from clotting before it gets to the lab. Inverting the tube a few times (after capping it) helps to mix the blood with the EDTA so it doesn't clot. It also gives you the opportunity to examine the specimen for clots before sending it to the lab. If you can see a clot, toss the specimen and try again. There's no sense wasting the lab's time by sending an obviously clotted CBC.

Once you've collected the specimen you have to get the baby to stop bleeding. That can be as simple as placing a bandaid or gauze and tape on the area - or applying pressure for a couple of minutes. If the baby has a low platelet count or other bleeding issues, it can be much more difficult. Since a preemie has about 100 ml/kg total circulating volume, you want to avoid any unnecessary blood loss. The tiniest preemies have skin that is too fragile for bandaids or tape, so I generally apply pressure until the bleeding has stopped.

Breathe

2007-07-22T01:38:00.000-04:00

The cardiologist called while I was napping Friday in preparation for work. He talked to my husband, so I STILL don't have the whole story. Apparently, the Thallium stress test was normal, but there was something on one of the other tests he didn't like. Something about a couple of those things they fixed when they did the bypass (I'm quoting here). I gather the blood flow through 2 of his 5 grafts isn't as good as it was on the last echocardiogram. Good thing he had some urgent errands to run after he told me that, because I hyperventilated for about 30 minutes. I don't think it would have helped him much to watch me panic.

The good news is that I don't have to wait until the bills come to find out what tests were done. We have an appointment at 11 on Monday. This time I'm not sitting in the waiting room.