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