The Circle Game

Earworms - those songs or fragments that just get caught in your head and stick until you can play them all the way through or replace them.

I couldn't remember the name and couldn't seem to get the lyrics straight. No time to google. I was too busy. Sometimes being on admissions means a dull night. Sometimes it means admitting a preemie to the NICU and following through. Sometimes you just feel like you're running around in circles -- hence the earworm.

"Can you get this kid over to newborn? He's 4 hours old - slow transition. They said he could come over after they get report."

"No problem. I'll call and see when it's convenient.... 20 minutes? I'll just make sure his documentation is together and grab a set of vitals."

The folks in the newborn nursery were glad to see he'd already been bathed and most of his admission paperwork completed. Back to the NICU, I started feeding one of my patients and the phone rang.

"It's the Birthing Center - high risk delivery in 4. Oh, you're busy. I'm free, I can cover this for you."

15 minutes later: "Sharon wants you to know she's bringing the baby back. Just for observation."

"OK. This one is finished eating. I'll be right over."

Sometimes even term babies are sick at birth. Rarely they're born with an infection or congenital heart disease Much more commonly they are simply slow transitioning to extrauterine life. Usually they just need a little time to clear the amniotic fluid, but it's not always easy to tell the difference in the first moments of life.

If a baby doesn't appear to be adjusting well, we do what we can to help them transition in the birthing room. Most of the time, all that is needed is to dry the baby and perhaps stimulate him. If necessary, we provide oxygen and suction secretions.

A very small fraction will actually require resuscitation - those babies usually are admitted to the NICU, but some will recover in time to stay with mom in the birthing center.

If a baby is breathing, but obviously working hard at it, or continues to require oxygen beyond the first minutes of life, he'll get to come back with us to the NICU for continued observation. If he doesn't transition very quickly there, we will almost certainly do some lab tests(blood count, arterial blood gas), get a chest x-ray, and possibly start more aggressive treatment if that's indicated. Many of these babies will complete the transition within an hour or two and we'll be able to return them to their moms either in the birthing center or by way of the well-baby nursery.

That's how my shift went. Over and over. As I was cleaning the bed for the third time in less than 4 hours, one of my co-workers remarked, "I think I'd pick another bed. That one's unlucky."

"Unlucky?" I responded, "Nope. Just busy. I think I'll stick with this one."

Running in circles isn't always a bad thing.


And the seasons they go round and round
And the painted ponies go up and down
Were captive on the carousel of time
We can't return we can only look behind
From where we came
And go round and round and round
In the circle game

Joni Mitchell -- The Circle Game

Photographs and Memories

The last couple of months have been pretty rough. The census has been at least 50% above our usual and people are tired of the overtime. Even with nurses floating in from other units and external agency, it's been pretty rough some days. I go home aching and wonder if it's all worth it.

It is, of course, and we keep a reminder very near the nurses station. The bulletin board with the photos and letters is supposed to be there to inspire the parents of our current patients - to let them know that there is hope. It helps the staff too. One picture in particular has been my inspiration lately. She was only 23 weeks, barely a pound.

Her course was rocky, as might be expected, but she eventually went home. That was 18 years ago. Her smiling face is posted on the board - her senior picture. She'll graduate from high school this year and go to college in the fall - athlete and honor student. Her parents are rightfully proud of her. So are her nurses -- and my step is just a little lighter this morning.

News from the Starving Artist Front

I'm visiting relatives in NC this week and found, to my delight, that one of my favorite artists has decided to increase his production. I've admired his work for a long time and he's finally going more public with it -- as in his own web site which is FoggArt.com He also makes trips to art fairs in Central NC (dates listed on the web site) and sells on Ebay. He makes fantasy creatures and alien life forms . He also paints and makes poured cement and hypertufa sculptures. All of his work is unique. The artist is a friend so I know he's honest. His photos don't really do justice to the artwork, but you'll get the idea. If you don't see what you want on the web site, contact him and ask. He can probably make what you want.

Futility

Born too early and nothing is going right. Systolic pressure hasn't been above 20 in 8 hours despite dopamine and dobutamine. Hematocrit and platelet count are still dropping in spite of multiple transfusions. There was a brief resus earlier in the day - only one round of epinephrine needed to bring back the heart rate, but it really isn't looking good.

I glance up at the monitor above me and see one QRS complex on the left side of the screen. Our monitors are all interlinked and when an alarm goes off, everyone can see where the problem is. I hear, "Can someone get me an epi?" Calm voices, no anxious shouts, just a request for assistance. Most of us have been doing this a long time and we work well as a team. She has the epinephrine in her hand by the time I reach the bed seconds later.

The heart rate is still in the 30's so I start chest compressions and she draws up the epinephrine. Someone else picks up a clipboard and starts recording. The nurse practitioner asks for bicarb and another nurse has it in her hand, drawing up the dose.

6 rounds of epinephrine, at least 2 rounds of bicarb, 20 ml of saline for volume expanders. Hemoglobin is in single digits now. The blood pressure is better, but only with chest compressions. There has been no response at all to the resus drugs. I feel like I'm making a depression in the chest and realize that the baby is rapidly becoming edematous -- leaking all the volume expanders into the subcutaneous tissue. The blood pressure monitor on the arterial line shows a decline in the blood pressure although I have been very consistent with the chest compressions. 10 minutes into the resus, someone calls the neonatologist at home. He's on his way.

A blood gas to see how things are progressing - base excess of -20, pH so low there's clearly no point in continuing, but we can't stop until the neonatologist arrives to call the code. There's an occasional complex on the screen now, but when I stop compressions, there is no pulse. No audible heartbeat. It's pulseless electrical activity. I resume compressions and we wait. When the neonatologist arrives I stop for the last time.

Too little. Too immature. He never had a chance.

The Cable Box

Every time I drive past that cable box, I think about Michael. I wonder how he's doing. If he's in college or working (or both).

I met Michael near that cable box one late fall day. I was driving home from somewhere - no idea any more. The first thing I noticed was the small group of cars on the opposite side of the road. Then I saw the skid marks heading into the woods - and the car. It was upside down, windshield out. I pulled over, grabbed my cell phone and hopped out of the car.

As I stepped out, Michael stepped out from his side of the road. "Do you have a bandaid?" he asked. "I need a bandaid."

I glanced at the trickle of blood on his arm, then tried very hard to control my facial expressions as I spotted the bone protruding a few inches below the elbow. Deep breath.

"Sorry, I don't have a bandaid." He started to walk back across the road.

I spotted a friend, Linda - another nurse - who had also stopped. "Anybody call 911 yet?" I asked.

"My husband drove up to the fire station." she responded. It's only a few blocks away and cell service is spotty out here, so that made sense. I tucked my phone in my pocket and turned toward Michael.

Another vehicle approached and Michael started out in the road again. My friend and I reached for him simultaneously. "I need a bandaid." he said again.

Trying to keep my eyes on his face, I repeated that I didn't have one. He whipped off his t-shirt and wrapped it around the arm. Good. He doesn't seem to notice the bone.

We steered him to the side of the road and helped him to sit on the cable box. Fingers lingering on his wrist, I wished I had my watch with me, but his pulse was strong and slower than mine. No obvious trauma to his chest or abdomen.

"Was anyone else in the car with you?" I asked.

"No. I was going to see my girlfriend. My parents are going to kill me when they see the car."

My friend Linda diverted his attention and assured him that they would not. She tried to calm him with stories of her own experiences. He suddenly remembered that his homecoming dance pictures were in the car and tried to get up to retrieve them. Linda distracted him again and I went to see if I could locate the pictures.

I approached the car cautiously, remembering the warnings I'd gotten from my EMT son about the risks in any serious crash. No signs of smoke. No gasoline odor. I glanced in the windows and spotted a backpack in the pile resting on the interior roof of the car. I wondered again how he managed to escape more serious injury. He insisted he hadn't been speeding, but the skid marks told a different story. Thank goodness he'd been wearing his seatbelt. Air bags had deployed too.

I lifted the backpack, hoping the pictures were inside. They were under the backpack. I showed them to him and asked, "Is this your girlfriend, she's very pretty?"

"That's my girlfriend, but those aren't the homecoming pictures."

They were clearly from a dance - and from the decorations seemed to be the homecoming dance. I began to wonder about head trauma and decided that it might be a good idea to get some information from him in case he started to deteriorate. Name, phone, parents' names and contact information.

Sirens, finally!

The paramedic approached and I quietly informed her of the compound fracture he'd hidden under the T-shirt. She asked him again, "Who was in the car with you?"

Same response, nobody.

I watched as they assessed him and packaged him for delivery to the local hospital - collar, full backboard. Unwrapped his arm and re-dressed it. Started an IV. The whole thing couldn't have taken more than 5 minutes. Teamwork - quiet, calm.

Michael kept insisting that none of this was necessary. He'd be fine. Yes, the paramedic responded. You'll be fine. We'll just call your parents to meet us at the hospital. You won't be able to drive your car anyway.

I handed over the contact information and asked what I should do with his backpack.

Last thing the paramedic said to me before getting in the back of the ambulance with Michael. "I'll take that. This isn't going to get him out of doing his homework."

Lies, Damn Lies, and Statistics

Screen after screen of tables flashed across the screen. Here and there an asterisk appeared beside a bar graph or table. "You know what that means," exulted the speaker. "That means this difference is statistically significant. It means that every time you repeat this study, you'll get the same results."

Umm. Not exactly. At least not when I studied statistics. I know it's been a long time and what the hell, I took statistics for Psych majors, not statistics for nurses, but it can't be that different, can it? They accepted the credit when I transferred.

Oh, and the Chi Square was 0.1, so it really means there's only a 10% probability that the results were due to chance. Given the nature of the study, I'd say there's a hell of a lot more probability than that. They didn't appear to control for much more than the one element they were trying to prove was significant.

I very nearly raised my hand again to correct the speaker, but I'd already done that twice, so I settled for rolling my eyes and figuring she's either not as smart as she looks, or she's bought into the whole big pharma promotion of this particular product.

At least I got a good dinner out of the deal.

Fear in the NICU

Image from Feebleminds

The day shift nurse is new. She doesn't know me and apparently doesn't listen much to gossip, so she was puzzled when I laughed at her question: "Do you mind helping breastfeeding moms?"

While I was trying to come up with an answer that wasn't sarcastic, she went on, "I can get L to help you if you're not comfortable with it." By this time, L was trying not to snicker too. She knows my reputation. She's watched me work. We both assured the day shift nurse that I could handle it.

They give me the hard cases - the ones where you simply cannot laugh while there are visitors in the NICU; the moms who need 3 people to get one baby latched and who bring ALL their visitors over to watch while they do it. I love taking care of the tiniest, most critical babies, but I enjoy the challenge of helping new moms learn to breastfeed too.

A NICU admission, even of a term baby, can create truly challenging circumstances for learning to breastfeed. That's especially true if mom lacks experience, has flat or inverted nipples, damage to one or both nipples prior to the NICU admission due to the baby's nursing style which in this case was Great White Shark.

Some babies have difficulty latching because the suck isn't strong enough. Others have such a strong suck that if they aren't latched perfectly, they can damage a new mom's nipples in a relatively short time. The hungrier and more frantic the baby, and the more inexperienced the mom, the greater the potential for damage. Issue mom a breast pump with inadequate instruction and you have a setup to absolutely sabotage breastfeeding.

Round 1:

Enter the Nipple Nazi: I'm usually not, but this case required extreme measures. The day shift nurse had phoned the mom while I was getting report on my other patient. She asked her to PUMP before coming to the NICU. Mom arrived with nipples tender from pumping, about 6 ml of colostrum in a bottle, and an entourage. I like to have mom's support person around when I'm helping a new mom learn to breastfeed, because I've found that the support person (often the baby's father) is able to quickly learn how to assist in positioning and evaluating the latch. Adding an audience tends to distract the mom and her partner and to add confusion. Especially when the audience wants to help. Double that when they have very little idea what they're talking about. At least this entourage was very pro-breastfeeding.

Step 1: Make the mom as comfortable as possible. Comfortable chair, check; footstool, check; screens, "No thank you, it's too hot in here." Mom strips to the waist. Uh-oh. Potential problem. Not for me, I've certainly seen enough breasts not to develop twitch when I see one, but there was another dad in the room and many of our ancillary personnel (housekeeping, laundry, etc) come through in the evening and they're not all comfortable with that much exposure. Fortunately, L heard the exchange and set up screens to give the other dad some privacy so he could pay attention to his own child instead of the performance across the room. Unfortunately, the screens weren't placed to do much for the gentleman from the laundry who entered the room eyes averted and one hand blocking out the view.

Step 2: Evaluate mom's technique: She requested (and was given) a syringe to feed the colostrum. She was concerned about nipple confusion, but apparently missed the point that ANYTHING which encourages the baby to suckle incorrectly will contribute. Give me a bottle any day over an incorrectly used syringe, finger, spoon, cup, etc.

Step 3: Try to get the baby to latch. 6ml of colostrum just wasn't taking the edge off the baby's hunger and every time the baby got close to the breast she lunged. And mom cringed and pulled away - making her nipples even more tender. The lactation consultant had been in earlier and left 2 different styles of nipple shields, so we tried those. And I spent a LOT of time repeating "Don't pull the nipple out, put your finger in the corner of the baby's mouth to break the suction."

Nipple shields can be helpful, but when the challenges include a tendency not to open the mouth wide enough, an incorrectly used nipple shield can make this much worse. We were eventually able to get the baby to latch and nurse on one side with the nipple shield. There was a lot of off and on behavior, though. Between the nipple shield, the fight to get a good latch, and the slow flow from the recent pumping, baby was getting more and more frustrated.

So we switched and the baby had a total meltdown. It was Shark Attack in the NICU on side 2. The baby lunged, missed the nipple and latched above it. This is quite painful and mom was becoming more anxious by the minute. Baby lunged, hitting closer to the target this time, but with her mouth not wide enough, so that she only got the tip of the nipple. Mom shrieked and pulled away, causing even more pain.

I showed her how to soothe the baby with a finger, making baby open WIDE before allowing her to suckle. By this time, mom was so gun-shy, she seriously asked if the baby wouldn't be satisfied with what she'd gotten so far and the finger.

Grandpa chimed in at this point, "She wants steak"

I had to laugh and responded, "Yes, and she's trying to get it from mom."

Mom looked at me and asked, "Don't you have some kind of nippley thing you can use to give her some formula?"

I said, "Yes, it's called a bottle."

Mom: "We didn't want to use bottles."

Me: "I don't want to give her a whole feeding, just give her enough to take the edge off so she stops acting like a shark."

Mom: Laughing (finally), "OK. Let's try that."

Out comes the orthodontic nipple and the formula. I take the baby and let her suck about 4 times, making sure that her mouth opens wide before I pop it in and making sure that her lips are turned out, not in. The baby relaxes and we're finally able to get her latched comfortably on side 2.

Baby sleeps for 4 hours. Hopefully so does mom.


Round 2

Baby is alert and rooting, but not crying. This is the point at which the NICU admission becomes a real problem. I call mom and 35 minutes later she makes her way to the NICU. By this time, baby is SCREAMING and frantic. Mom didn't pump before she came this time, but she had pumped after leaving the last time and her sore nipple is now cracked and bruised.

I ask mom's permission and we start with colostrum and 5 ml of formula by NUK again. Baby immediately latches strongly but not painfully on mom's less sore breast. We have a very long chat about breast pump use and how this is only about nipple stimulation and NOT a contest to see how much colostrum she can extract. I explain that "It didn't hurt that much" is NOT the goal and "It didn't hurt at all" is the only acceptable goal, so don't turn the vacuum up so high this time. Mom isn't able to offer the sore side at all at this feeding and baby isn't satisfied after nursing 20+ minutes on the available side, so we give 10 ml more of formula and tuck baby in. She sleeps for 3 hours. Mom pumps the sore side and sends 5 ml colostrum back with dad for later use.

Round 3

NICU interference again: Morning blood work gets baby totally frazzled so we need to use the bottle trick to soothe her, but this time she doesn't take more than 2-3 ml before she's calm enough to latch. 20 minutes on the not sore side and mom is off to pump the damaged side. Baby is satisfied with the 5 ml colostrum from the last pumping and the 20 minutes of nursing. She's still sleeping 1 1/2 hours later when I go home.


I have no idea why, but I also have a reputation of being "nice". Totally undeserved, really. Before the day shift arrives, I slip out to the nurses' station to talk to the day charge nurse. I make sure that our orientee has my assignment. I leave to the preceptor's sincere "Gee thanks!"

It's not so bad as all that, really. The lactation consultant will be available and mom should have all her visitors around to help too.