Sometimes a 9 is really a 9

As nurses we’ve been taught to take a patient’s word for his level of pain. Most of us don’t. Especially those high numbers. We tend to shade the numbers with what we think the patient may be experiencing based on physical assessment.  If the patient can respond calmly, that 8 or 9 can’t really be what they’re experiencing. With all the drug-seeking patients out there, I can understand that. However, I had an experience recently that will stick with me for a very long time. 

My son came to me at 10 pm on a Saturday night complaining of “gas”. I recommended simethicone and, when that didn’t help, an antacid. Not only did he continue to complain of “gas” but he started to vomit. OK. His diagnosis was wrong. When things calmed down a bit I asked a few more questions. Pressure in the upper abdomen, pain on the right side which didn’t radiate anywhere. At this point, I thought biliary colic (gallbladder disease). I recommended a trip to the ER since our favorite doc-in-the box location would be closed before we could get there. He declined stating that he didn’t want to risk high medical bills (he has a large deductible on his insurance). He said he would try to “sleep it off.”  It was 11:30 when he went back to his room. I waited 30 minutes to see if he would change his mind.

By midnight, he came back requesting a ride to the ER. Registration, triage (where he claimed a pain score of 7), saline lock insertion, blood for the lab, abdominal ultrasound. Then he was sent back to the waiting room because all the ED rooms were full. Apparently they have almost no exceptions to the “order of arrival” at this ER. Kids who can play video games while waiting are an exception – but I would wager that they go to the ‘fast-track’ side. Been there with kids myself, but if possible, I’m waiting until morning and going to Patient First. 

When my son asked if I had a knife so he could relieve his own pain, I thought he was kidding. When he started to moan every time he moved and to get progressively paler, I realized he wasn’t and got the attention of the next nurse to walk through the doors. She assured me he would be taken “in order”. 

It took about 3.5 hours from registration to placement in a room, not actually long for an ER Saturday night, but when someone who won't take Tylenol for a headache starts asking for pain medication I worry.

 Since the lab work and sonogram had already been done, we didn’t think it would take too much longer to get some pain relief. The nurse who admitted him asked his pain score – a 9 by this time.  His oxygen saturation was 93-94%. I was concerned that she would not take that 9 seriously, but her next question was, “is he always this pale?” She looked appropriately concerned when I assured her that he had been pink when we arrived. Clearly his pain was interfering with breathing because his saturation increased to 98-100% after a combination of Reglan, morphine, and Toradol was administered. 

The ER doc checked his sonogram report and informed him that he had several large gallstones, but his gallbladder didn’t “look too bad”. He offered to let him go home and follow up with a surgeon for elective cholecystectomy. After a brief discussion of possible complications of waiting and a few sarcastic remarks from me suggesting that he might not want to follow my example and wait until said complications occurred, my son said he’d rather “just get it over with” and the surgeon was summoned. 

He was assured the laparoscopic procedure was “very safe” and that everything would be OK. 2 hours later, the surgeon appeared with some very ugly pictures of my son’s gangrenous gallbladder. He told us that things had gone well, that he was able to complete the procedure laparoscopically but that my son would have to spend the night for observation and more IV antibiotics. Nobody could believe that he hadn’t had symptoms prior to 10 the previous night.  I wonder if they’d have taken his initial pain score more seriously if I’d told them that he once drove himself to the ER with a fractured elbow.

I decided to consult Dr. Google to learn more about gangrenous cholecystitis(GC). It's pretty grim as the mortality rate can be up to 20%. It's more common in older men (he's 34) who have cardiovascular disease or diabetes (he doesn't) and sometimes follows a delay in treatment -- not a 3.5 hour delay, but weeks or months of ignoring symptoms or taking a "wait and see" approach.

There are some specific findings which can indicate gangrenous cholecystitis See this NIH article for details , but ultrasound is not particularly sensitive and the presence of large gallstones is not particularly common. Interestingly, a high pain score does not necessarily accompany this condition either as the dying gallbladder loses its nerve endings. Basically, an elevated white cell count (above 17,000) is one of the few consistent markers and, while I haven't seen my son's labs, I expect that he skipped that one, too.

Open cholecystectomy used to be the standard of care for GC but a surgeon with plenty of experience in laparoscopic surgery is often able to produce better outcomes if he or she attempts the laparoscopic approach and decides whether or not an open approach will be needed.

There are a lot of interesting articles available, but most require institutional access or a subscription to the journal. From the abstracts I gather that elevated white cell count, age over 60, and co-morbidities of diabetes or coronary artery disease should have you thinking of urgent surgery. My son's experience is an example of why you can't trust statistics in making clinical decisions -- and it doesn't hurt to have a mom who doesn't trust you to come back later. 

Breast is best, but it may not be easy.

Strike 1 - born too soon. It's tough for the mother of a preemie to get started with breastfeeding. Depending on just how early the baby is, it may be impossible to put him/her to breast for many weeks. The only stimulation she gets, unless she's tandem nursing a sibling, is from the pump. I've pumped for my full-term babies. It's not fun. It's frustrating. Sometimes it hurts. In the beginning you get little or no rewards for your efforts -- rewards being the liquid gold of breastmilk.

Strike 2 - Mom is sick. Often babies are delivered prematurely because there is a maternal problem - an infection, elevated blood pressure, placental abruption or placenta previa. Some of these complications require major surgery for delivery. The surgery and any blood loss can delay lactation. A mom who is being treated for pre-eclampsia may be unable to pump at all, much less regularly.

Strike 3 - Unrealistic expectations can lead to ineffective or infrequent pumping. Most new moms seem to think that they will have milk from the first time they pump. This just isn't realistic. Colostrum is present in small quantities from before the baby is born, but extracting it with a pump instead of a healthy newborn is sometimes an exercise in futility for the first day or 3. Our lactation consultants and the NICU staff know this and make sure that our moms know it as well. Getting them to actually hear what we're saying is a major challenge, though.

Frequent pumping, adequate hydration, and a good pump (preferably hospital grade) can all make a difference. One intervention that can help both mom and baby is skin-to-skin contact. Mom comes dressed in clothing that is easily rearranged to allow the diaper clad baby to snuggle against the skin of her chest. Even very small babies tolerate this well if their condition is otherwise moderately stable. I've seen very rapid increases in milk volume with a good pump and skin-to-skin time. Babies clearly enjoy this as well. They usually snuggle in and often go to sleep. If they don't sleep while being held, they will frequently go into a deep sleep when they are returned to their bed.

Skin-to-skin isn't just for preemies. It's one of the most effective interventions for getting term babies to focus and nurse as well.

Irony

     There is a very strong tendency to form opinions about people based on very little information. I've been on the receiving end and I've done it myself. I'm pretty sure we've all been guilty from time to time.
      Some people are on the receiving end more often than others. People who dress differently from the people around them, people with facial piercings, and people with more than a couple of tattoos -- all tend to be judged based on appearance. I don't think they appreciate it. You might think they'd be a little more careful about judging others - but you might just be wrong about that.
     My daughter-in-law is tandem nursing her 2 young children. She wanted to celebrate her breastfeeding success with a tattoo of the international breastfeeding logo. Hers is a little different from the one in the link - red, heart-shaped background and her babies' initials on either side. As the image was being completed, one of the other artists in the shop came over to have a look. He asked her the significance of the image and when she finished explaining, he said, "You're not one of those fanatics who breastfeeds their kids for 10 years, are you?"
      I'm obstinate enough that I'd have said yes without thinking about it. She opted for a more moderate answer and told him she plans to breastfeed for 2 years.  She'll really breastfeed for as long as the kids need it. She said she didn't feel like being judged by someone who'd chosen have most of his visible skin covered in tattoos.

Dear ER Doc

Thank you for the opportunity to hone my skills by inviting me to start  IVs on your most challenging patients. I just have a few comments:

1. Please limit the number of sticks before calling the NICU for help. 2 attempts is probably not enough. 10 is definitely too many. If the patient is a baby who was discharged from any area NICU within the last week and is significantly dehydrated 3 or 4 attempts is plenty. YMMV with the other NICU nurses on that last.

2. When I arrive in your ER to start the IV, please do not decide that it's a good time to have me help hold the patient while you draw blood.

3. If the patient is going to be admitted to the NICU, you can forget about drawing the blood. We'll do that upstairs. We'd prefer that. I know the other units in the hospital have a different attitude. It's just that we're used to having total control over our patients from the moment they enter the hospital.

4. When I tell you the catheter is in a vein, do not argue with me because, yes, I would know.

5. I had no idea that your new onset DKA patients could be alert and converse with me when the pH on the blood gas is 6.9. Our babies don't look so good when they're that acidotic. OK, your patient didn't look so good either, but he was talking to me the whole time I was looking for a vein. Amazing!

6. Seriously, I appreciate the opportunity to start IVs on your most challenging patients. Thanks for calling. If I'm not too busy, I will always come. Again, YMMV with the rest of the NICU staff -- especially on anyone over a year old.

Road to Eagle, Part II: the early ranks

      The newest member of our troop, a young man with no previous Cub Scouting experience, just earned his Scout badge. It's technically not a rank and has only a few requirements. If he'd spent much time in a Cub Pack, he'd probably have earned that patch on his first day in the troop. There's a reason the requirements for the Scout badge are called Joining Requirements. The only one of them that can't be completed at the first meeting is the pamphlet exercises about preventing child abuse which MUST be completed with the new Scout's parent or guardian. Once that is done, the rest can be completed at a Scoutmaster's conference.

     In our troop, as in all truly boy-led troops, most of the requirements for the  early ranks can be signed off by higher-ranking Scouts and the rest by adult leaders. We try to encourage our younger Scouts to work with the older ones and we strongly discourage parents - even leaders - from signing off requirements for their own Scout. It isn't that we don't trust them, we just prefer that the boys reach out of their comfort level a little when seeking advancements.Your Scout will need to find out who can sign off each requirement and take responsibility for presenting his Boy Scout Handbook to them once he has mastered or completed each one. It is best not to wait too long after completing a requirement to have it signed off.

     In our troop, the boys are also responsible for showing their Handbook to the advancement coordinator (me) periodically for recording in the Troopmaster software I use to track progress. Some troops keep a wall chart or paper log book. Whatever the means, that secondary record can be a lifesaver if a boy loses his book.

     The early ranks are Tenderfoot, Second Class, and First Class. There isn't a specific time frame for earning each rank and boys should be working on requirements for them simultaneously rather than sequentially, even though the ranks have to be earned in order. It is easier, for example, to complete the First Class requirement to identify 10 native plants when the ground is not covered with snow -- even if the scout hasn't completed the Tenderfoot physical fitness requirement. Summer camp is a good time to complete the Second Class and First Class swimming requirements regardless of the Scout's current rank.

     If a Scout has a permanent or long-term condition which would prevent him from completing one or more of the requirements before his 18th birthday, it is possible to request alternate requirements  It's a fairly complex process which starts after a boy has completed all the requirements he is able to complete to the best of his ability.

Road to Eagle - Part I - Finding a Troop or Pack

My youngest son recently earned his Eagle rank. Anyone involved in Scouting knows just how proud I am of him for this. I am proud of all my sons, but this puts him in a very small percentage of Boy Scouts who have achieved this highest rank.

His comment shortly after his Eagle Court of Honor was, "Mom, you should write about this in your blog." He wasn't asking for kudos - that's just not him. He realizes that he had an advantage that many Scouts don't have. Both his parents are Scout leaders. We've been doing it since long before he was born, so we had an advantage in helping him find his path to Eagle. He wants me to share what I've learned in the 33+ years I've been involved with BSA and the even longer time his father has been a Scouter.

The first step is to find a good Troop or Pack -- depends on your son's age. If you have significant experience in Scouting, the quality of the program is less critical because you'll be able to help make it a good unit. The first stop may be Be a Scout . org  This is the BSA troop/pack/crew locator site. You can use it to find the units located closest to your home. You'll probably want the unit to be close, because meetings are generally held weekly and other activities may be closer to you as well. Unless you have friends in one of the units, it is best to visit at least the 3 closest to you.  It isn't necessary to be a Cub Scout before being a Boy Scout, but it doesn't hurt either.

 Look for the following:

Are they organized? I don't mean are the kids sitting down doing activities - that's not always a good thing. I mean does the chaos look like it is focused in some direction?

Are the boys having fun? Pretty self-explanatory, but are nearly all of them engaged in the activity most of the time. With older Scouts, the activity may be instructional more than exciting at times, but it shouldn't look boring for more than a couple of minutes at a time.

Are the leaders yelling at the boys?  This is NOT a good thing. The leaders should be able to maintain control without raising their voices more than occasionally. I never had to yell at a den -- NEVER. Not even with 12+ boys in it. I was a den leader twice, for a total of  6 years and an assistant Webelos leader for 2.  I've never had to raise my voice to a Boy Scout either and I've spent a lot more years working with them. It doesn't hurt that I am, by nature, somewhat loud and can put on a happy face no matter how much my feet hurt. Quiet people can be very effective - perhaps more effective.

In a Boy Scout troop, are there boy leaders running much of the show? You want a troop that is boy-led to the extent possible. Some things need adult leadership, but much of the program should be in the hands of the older scouts. We have our older scouts teach the younger ones fire safety, knife and ax handling, outdoor cooking, first aid, etc. We haven't had any serious injuries and the younger kids particularly enjoy the "don't do it this way" demos which make their points with humor.

Is your son welcomed when he arrives? Do the other boys seem happy to have another potential Scout in their unit? Do the leaders? 

Do you see any warning signs that the BSA Youth Protection Guidelines are being ignored? This is a HUGE red flag. Stay away from any unit that  isn't following BSA's Youth Protection guidelines . They are all important, but the rules about 2-deep leadership and use of the buddy system are among the most important. If you see violations of those rules, don't just leave - call your local Scout Executive.

Additional suggestions on finding a unit are welcome!

Light a candle with me

     October 15 is the date chosen to celebrate the lives of babies who never celebrate a birthday with their families -- Babies whose moms and dads mourn their loss prior to birth or within the first days afterwards. 

     I know women who name their babies and celebrate their lives on birthdays or other days. I know women who only reluctantly share their pain and then usually only with other women experiencing the same agony. There are other responses as well. I believe that all are legitimate. We all mourn differently.

     Whatever your mourning style, today is the day set aside to remember that loss. At 7 pm tonight in your time zone, light a candle and keep it burning for at least an hour. Together we can create a wave of light around the world.







Image courtesy
of Darren Roberts
on Free Digital Photos

Baby on Board!

I was running some errands this morning and had an interesting road rage experience.

I put on my turn signal, braked and pulled off the road. The massive SUV behind me honked and flew past only to swerve off the road into the same parking lot. The driver came to a stop just in front of my car, leaped out and came screaming toward me.

Screaming.

"Don't tell me you slammed on your brakes and pulled over without signalling when I had my two babies in the car!"

"Well, no, I didn't slam on my brakes and yes, I did signal. Maybe you need to allow a little more following distance"

More screaming from her, more calm (I think) suggestions that not tailgating might make her safer on the road. 

I backed up and headed out onto the road as she climbed back into her car. One errand postponed. I didn't plan on speaking to the woman without the metal shelter of my car.

When I took Drivers' Ed so very many years ago, I was taught that when the person in front of you brakes, you'd better not hit them. No matter how suddenly they brake and that if you do, it's your responsibility. Apparently she missed that lesson.

I was also taught that you need 1 car length for every 10 miles per hour of driving speed. I realize that's not always going to happen, but it should be a goal. The  SmartMotorist.com   web site uses a 3 second rule instead. Spot a fixed object as the car ahead of you passes it. Count to three slowly (one one thousand, two one thousand, three one thousand). If you pass the object before you get to three, you're too close. That's in good weather. In bad weather, you need to allow more distance. Check out the distance tables on that Smart Motorist page. They're very interesting.

There are some interesting statistics on the Smart Motorist page, too. People driving family or economy cars are less likely to tailgate. Men in sports cars are more likely to tailgate than women. Women are more likely to tailgate than men if they're driving SUVs. In fact, women in SUVs are the most likely to tailgate and twice as likely as men or women in family cars.

I leave more than the recommended following distance as often as I can and I no longer have small children in the car to distract me. I've never rear ended anyone and I've only been rear ended once - slow speed, distracted driver, no damage to either car. 

So what happened back there? I drive a small sporty vehicle that is very responsive and decelerates quickly with light pressure on the brake. She was driving a large SUV and claimed to have 2 babies in the car. I'll give her the benefit of the doubt and presume that the kids distracted her rather than her cell phone.   I wouldn't have braked if I thought it would be dangerous. Getting run over by an SUV does not have a place on my bucket list. Chiefly because it could potentially be the very last thing to get checked off.

Another thing not on my bucket list -- jumping out of my car to confront strangers about their driving. I sure wouldn't every have put my babies at risk by doing that with them in the car. I hope she gets some help for her anger management issues before the kids get old enough to make her mad.

Open letter to the President of the United States

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.

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

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

Gianna Jessen Abortion Survivor in Australia Part 1

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

All were born pre-term.

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

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

American Sign Language - free class on-line

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

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

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

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

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

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

Hold that position!

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

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

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

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

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

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

Assume the position!

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

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

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

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

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

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

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

I have an App for that...

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Physics lessons

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

Summer Camp

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