Everybody lies (if only by omission)

I could subtitle this "True Confessions of a NICU nurse" or "Things I Never Told my Children's Pediatrician"

Nurses worry about their kids, sometimes more than non-nurses, sometimes less. Some worries I've shared with the pediatrician, others not.

On the not shared list:

1. Pediatrician: "Does he spit up very much?"
Me: (thinking Not for a kid in my family) No, not really.
Truth: The child spewed after every feeding to the point that I carried towels for burp cloths.
Why not tell? He was my first. I didn't know the pediatrician well enough then to know that as long as the child was gaining weight, he wasn't likely to insist on any unnecessary tests.

2. Breastfeeding 2 day old choked and turned blue with letdown when my milk came in. I never bothered to share this with the pediatrician because the baby had stopped choking by our first office visit 5 days later. I had thoroughly assessed him to be sure he didn't have a murmur or any evidence of aspiration, pneumonia, or other respiratory issues. Also, we'd only had well-child issues with the first one at this point and I didn't fully appreciate the pediatrician's ability to diagnose based on a history and physical exam. IOW, I was still leery of unnecessary testing.

3. Calls to poison control. I can't remember, many years later, whether poison control asked for the pediatrician's name. I expect they did and that he got a report. All 3 times should have given him a good chuckle, they certainly amused the folks at poison control. More on those in a separate post.

4. Child with a history of swallowing objects swallows yet another one. Pediatrician hadn't been impressed by previous events and had simply instructed me on what to watch for. This was one time I should have called. When I eventually mentioned the event to him, he was more than a little unhappy with me. Seems wires from orthopedic equipment are in a different class than small buttons or springs from pocket knives, but he didn't see any point in ordering studies by the time I told him.

I'm sure there are more, but you'll have to wait until they pop into my head.

Stress Reduction?

Authorities called in the bomb squad early Tuesday and diverted a flight to Las Vegas after Los Angeles International Airport security screeners found hidden wires and other objects in a body cavity of a Philadelphia-bound passenger.


I bet you can guess which body cavity. The man said he did it to reduce stress. Somehow I don't think his technique worked very well - not for him and not for any of the folks involved in the investigation. Maybe he should consider medication next time.

Heart-healthy Mac & Cheese

OK, it's still high sodium, but you can't have everything.

8 oz Velveeta light
8 oz fat free shredded cheddar
1/4 cup low fat (or fat free if you can find it) parmesan cheese
3/4 cup skim milk
1 pound of your favorite pasta shape

Cook the pasta according to package directions. Drain. Add the milk and cheeses. You can melt everything on the stove or put it in a microwave safe dish and nuke it for about 5 minutes. Serves 8 (main dish size servings). My sister says the secret is the Velveeta. She calls it the universal solvent.

Nutrition information:

Using traditional pasta (healthier with whole wheat - and pretty tasty)
336 calories, 50 g carbohydrates, 5 g fat, 23 g protein. Sodium 750 mg - more if you add salt to the water while you're cooking the pasta.

Questions you might not want to ask

If the patient in the bed is wearing a wedding band and holding her husband's hand and her chief complaint is "threatened abortion" (miscarriage) AND the pregnancy test was positive, you might just want to skip the question on the history "Are you sexually active?"

Barring that, don't look so freaking puzzled when her response is more than a little sarcastic.




Yes, the patient in the bed was me, but it was a long time ago. Funny how things pop into your head, anger intact, many years later. I wouldn't recognize the resident if I met him on the street. That might be a consolation to anyone who's been on the receiving end of a sarcastic response to an ill-timed question. The OB resident in question graduated from medical school in the era prior to role-playing "patients". I realize that "Are you sexually active?" is a question that needs an answer in a typical office or clinic setting and in many ER situations as well. It shouldn't be one of the first questions asked, though, because you need to develop some sort of rapport with the patient. If the patient's private physician is on his way in, it might best be deferred.

The Blog that Ate Manhattan has a great post on the various permutations this can take even in a private practice setting - and the often unhelpful responses. #1 Dinosaur shares his experiences with this rather touchy question as well.

I hate to float

I'm a NICU nurse. I like my relatively controlled environment. Yes, I know many of you think I'm totally certifiable for that preference. I hate to float, as in to another unit. Something always happens to make me very sorry I've left the relative safety of the NICU.

Most recently, it was the pediatric unit and the 6 week old with an admission diagnosis of ALTE - apparent life threatening event. According to the mom, baby simply turned blue for no obvious reason. Only as Dr. House says, everyone lies.

The mom insisted that the baby was not feeding when the episode occurred, so the baby got the inevitable big deal workup for ALTE - cultures, LP, various scans and studies.

We all had our doubts about the mom's story, but they grew as the shift progressed.

8 pm: Charge nurse walked into the room and found mom feeding the baby -- baby was lying in the crib, mom was standing beside the crib holding the bottle. Charge nurse instructed mom to sit in a chair, handed her the baby and explained WHY feeding a 6 week old infant who is lying in his crib puts him at risk for choking episodes - which tend to make the baby turn blue and experience the above mentioned ALTE. Mom appeared to listen and finished feeding the baby while holding him.

Midnight: I walked into the room and again found mom feeding the baby in the crib - standing beside the bed, only this time she'd propped the bottle and was standing beside the crib watching the baby. I removed the bottle from the baby's mouth and went over the whole explanation about choking and ALTE's (mom still denied that baby was eating when said event occurred). Mom picked up baby, sat in chair, finished feeding without incident.

12:30 am: The pediatric resident stopped in to see how things were going. I updated her on the situation and documented VERY carefully while the resident went in to have another chat with mom. Social service consult was ordered.

2am: Mother of another patient stopped by the nurses station. She had seen the baby's mom and dad. She said they were relatives and there were some things we really needed to know. Charge nurse and pediatric resident escorted her to a private place for further discussion. Social service consult was ordered.

5am: I opened the door of the patient/parent bathroom on the floor (no locks, no response to knocking). Baby's father was pink, breathing, and sound asleep seated on the toilet. I closed the door and left.

5:30: I entered the baby's room again. Mom was snoring gently in the bed on one side of the room. Baby was lying in the crib, sucking on a bottle of formula. I removed the bottle from the baby's mouth, quickly assessed him to make sure he was OK, and took a deep breath to compose myself. Then I moved over to the mother's side and said:

WAKE UP!

Mom regained consciousness with a start. I explained, none too gently, that her baby could easily have died if she was in the habit of feeding him this way at home. She insisted that the baby's father must have propped the bottle. From the bathroom. Right.

If the mom had admitted to her unsafe feeding practices, the baby could have been observed and much of the uncomfortable and expensive workup would have been unnecessary. What was she thinking!

Good Reading

Change of Shift celebrates Valentines Day at Nurse Ratched's Place.

You'll find Grand Rounds at Tales from the Emergency Room

And in the better late than never category, Pediatric Grand Rounds was posted at Unintelligent Design last week.

IV Therapy Escapades - Part III

Valentine's weekend, as the song says, Ninteen-ninety-something. The patient had just been moved to the floor from the ICU. The admission was for pulmonary embolus and his heparin drip had infiltrated. Two IV therapy nurses had already been tossed out of the room and the general consensus was rapidly coming around to "Let his doctor start it." Not one to pass up a challenge, I volunteered to give it a try.

I looked at the rather grumpy patient in the bed, shot him my best Sally Sunshine smile, and quipped, "This is one hell of a place to spend Valentine's Day."

To my surprise, he actually smiled. Then he said, "You don't know the half of it, honey."

Normally, I don't respond well to "honey," but I was in the room unpacking my IV gear and he'd shown no signs of tossing me, so I encouraged him to continue. He certainly hadn't planned on being in the hospital for Valentine's Day. He hadn't even planned on being in town. What he had planned was a wedding - and a honeymoon in the Carribean. The ICU nurses had helped arrange for the wedding in their unit, but there was really nothing we could do about that honeymoon. Unfortunately, when he was transferred to the floor, his newlywed status hadn't been passed along, so his nurse had no idea why he was so unhappy.

As he continued to vent, I applied the tourniquet, cleaned the chosen site, inserted a 22 gauge catheter, secured it, and got his heparin drip running again. On my way out, I updated his nurse on his situation - and as I left, she was taking steps to ensure that the empty bed in his double room would stay that way as long as possible.

This is part 3 of a very occasional series. You'll find part 1 and part 2 in the archives.