Sumdood makes an appearance

Warning to anyone who might be standing on the corner minding their own business. Sumdood is tough.

Actually, I've only watched him spar, I've never seen him in serious action. I expect that's the story those 2 guys told when they got to the ER. Just standing on the corner, minding my own business, when Sumdood smacked me around.

His side of the story was a little different. According to HIM, he was just walking down the street minding his own business when 2 mouth-breathers about his size (not small) approached him and demanded his wallet. He said he only had a couple of dollars in it and was afraid they'd just be pissed if he gave it to them. So he said, "No." and kept walking. He was in a public place with people nearby, and it was daylight, so he figured they'd just move on.

Nope. Mouth-breathing type #1 shoved him up against the wall of the adjacent building and again demanded the (nearly empty) wallet. He backhanded MB#1 and kept walking. I'd have thought the man could feel the muscle behind the backhand, but I suppose he was adequately self-medicated and didn't notice.

MB#1 took offense at being denied twice and swung. Block, crunch & MB#1 was sitting on the sidewalk whimpering.

Next, MB#2 decided to swing. Rinse and repeat. Definitely felt crunch of ribs fracturing that time. Result: 2 mouthbreathers sitting on the sidewalk whimpering. He's pretty sure their story when they got to the ER was that they'd only had a couple of beers and they were standing on the corner, minding their own business..........

No. He didn't call 911 for them. Not his town and he didn't feel like explaining. They were breathing - rather loudly - when he left them. It was daylight, and there were people around.

Conjoined twins

The Dogaru twins have been in the news a lot lately. The most recent news was that yesterday's surgery was stopped due to swelling in Anastasia's brain. They had planned a staged procedure and this means they'll have to reassess and make new plans. I'm fascinated by the whole process. Conjoined twins aren't something you typically see in a community hospital NICU.

We did get one set. It was back in my early days as a NICU nurse. Before prenatal ultrasounds were so common. Before the equipment gave the sort of clear images widely available now.

Preterm twins. I don't remember how premature, but something between 30 and 35 weeks. It was a maternal transport from a small hospital in a distant part of the state. The only thing we knew initially was that they were twins and preterm. When the mom was re-scanned, the verdict was "hugging twins" and almost certainly conjoined. The state of the art in prenatal ultrasound was nowhere near what it is now.

Ideally, the way to move these babies would be in utero, but by the time she reached us, the mom was very actively laboring and moving her again wasn't an option. The regional neonatal transport team was notified to be on standby and we got ready to admit the babies to our NICU for stabilization.

Unlike the Dogaru twins who are joined at the head (cephalopagus), these twins were joined from the top of the sternum to just above the umbilicus (thoracopagus). This is the most common form of conjoined twins, and the heart is always involved. It was obvious that this was the case for these twins once they were admitted - they always had the same heart rate.

There were a number of interesting challenges.

First, positioning the babies to intubate them so they could be placed on ventilators was a challenge. It had to be done very quickly so that they could both be ventilated. One baby had to be held up out of the way so that the other could be intubated, then the babies had to be flipped without dislodging the tube so that the second twin could be intubated.

Once that was accomplished, placing lines for access to do blood gases and provide fluids was the next challenge. At least the babies could be kept in a side-lying position so no acrobatics were required, just the usual challenges of placing umbilical lines. We had to settle for lateral (side) views on the xrays since positioning the babies for any other view would have been more of a challenge than we wanted.

Each baby had his own nurse and they had to coordinate their care so as not to be in each others way. Medication dosages had to be calculated, and since the circulation was connected, what one got, the other did as well.

We were glad to see the transport team when they arrived. It was a fascinating experience, but the babies could only receive definitive treatment at a center with more advanced capabilities.

Extra shift tonight - really lazy food

2 lbs chicken tenderloins. Cut into bite sized pieces and browned if you're feeling ambitious. Otherwise, just toss into the crock pot.

1 large vidalia onion, sliced. Also in the crock pot.

Add 1 large or 2 small chicken bouillon cubes

one 6 oz can of orange concentrate (thawed)

and anything else that looks good -- sliced carrots, maybe.

If you want to add tomatoes, do that at the end, just before serving.

Cook on low for 5-6 hours. Serve over rice or noodles. I'm partial to rice, myself. I start it in the steamer when I start the chicken and it's all ready at the same time. Steam some broccoli while setting the table and Voila! Dinner.

Recital

My youngest has been taking lessons for nearly 5 years. He still gets nervous on recital nights, but his playing has definitely improved. The students were all quiet and respectfully attentive for each other - as were most of the parents.

Coolest event of the night: one of the other moms came up to my son after the recital and told him how much she looks forward to hearing him play. It really made his night!

Save a Life, Give Blood!

"Blood Bank."

"I need platelets for baby Anemic. Do you have any for her?"

"No. Sorry. I'll have to get those for you from the Red Cross."

"How long will that take?"

"At least 4 hours."

"Oh. Let them know the platelet count is 35,000"

"Didn't come up much after the last transfusion, did it?"

"No. Looks like it's going to be a long night. Can you send me some packed red cells while we're waiting for the platelets?"

"Sure thing. I'll have those ready in 15 minutes and I'll call when the platelets come in."

"Thanks. I'll send someone down for the blood in a few minutes."

The conversation could happen pretty much any day in any busy Neonatal ICU -- or adult ICU, for that matter. Platelets are one of the blood components responsible for clotting. There are many illnesses and traumas that can make the platelet count drop precipitously. Packed red cells (PRBC) are the cells in blood that carry oxygen. Babies, and to a lesser extent, adult ICU patients, often need transfusions simply because we have to take so much blood out for lab testing. We try to limit the draws, and we only take tiny amounts, but in a critically ill patient it adds up.

Babies can lose blood as a result of surgery, hemorrhaging into the brain or the intestine (usually a result of necrotizing enterocolitis). Blood cells can be destroyed by infection, and rarely as a result of Rh incompatibility. It's rare, but it still happens. Transfusions can be our only option.

When transfusing a newborn, we can't just use any blood. The blood has to pass all the screening tests used to test blood for adults -- and one more. The blood has to test negative for Cytomegalovirus (CMV). 50-85% of adults in the US test positive for CMV, so we are seldom able to use directed donor blood. The families who request directed donation are upset at first, but once we explain the potential devastating effects of CMV infection in newborns, they realize that we are only trying to protect their baby. CMV can cause profound neurological damage in people whose immune system isn't working properly -- and especially in premature infants because their immune systems are immature.

With 50-85% of adults testing positive for CMV, we sometimes have to wait for safe blood for our babies. In the summer, when donations drop off, that is much more likely. While you're planning your summer, please give some thought to scheduling time to donate blood whether you're CMV negative or not -- someone is waiting for it.



Images shamelessly stolen from the World Blood Donor Day web site.

Update: Since posting, I've discovered that there is a whole list of people who need CMV negative blood. The list includes prenatal transfusions (slaps head), transfusions for CMV negative pregnant women, organ and bone marrow recipients (unless they or the organ are CMV positive). There's a longer list below that one on the same page of people who might benefit.

Pediatric Grand Rounds

Awesome Mom has done a great job with this week's edition of Pediatric Grand Rounds.

Lots of good reading from old favorites and new (to me) bloggers.

2 Beers

On the ER blogs, I keep reading that the intoxicated patients (and family members) have only had 2 beers.

Mystery solved (5L mini-keg). 2 of these should explain most elevated blood alcohol levels.