Uncompromised Airways

How Cardiac Conduction is Like a Toilet

2011-07-19T00:54:00.000-05:00

Frequently, we encounter babies in the NICU with sudden wonkiness on the cardiac monitor. At first glance, many of these "funny looking beats" appear to be PVC's, but much more commonly they represent artifact: hiccups, preemie myoclonic jerks, or other abnormal body movements. Since things like hiccups can be signs of overstimulation in the preemie, it's nice if we can differentiate a hiccup from a PVC without lifting an isolette cover to peek inside.

The good news is that often we can make this distinction by carefully examining the rhythm, if we have an understanding of the relative and absolute refractory periods. To best understand this stuff, first think about flushing a toilet. Right after the flush, what happens if you try to press the handle again? Nothing, right? The toilet is absolutely refractory to another flush since it has just been "depolarized." After a few seconds, though, if I depress the handle again, the toilet is only relatively refractory to another flush, and we get an abnormal, weak and funny-sounding "depolarization." Let's translate that to the heart.

The absolute refractory period stretches from the QRS complex to the first half of the T wave. No abnormal beats will be conducted during this interval. If I see a QRS and then another "beat" immediately after that QRS, I know that the second "beat" could not possibly be a cardiac depolarization. It's most likely a hiccup.

From the apex of the T wave to the end of the T wave, you have the relative refractory period. Remember our abnormal flush? Same thing in the heart, only with worse consequences. The abnormal depolarizations during this vulnerable period can lead to lethal arrhythmias. Look up the R-on-T phenomenon for an example of the badness that can ensue when an ectopic beat lands on the previous T wave.

Finally, following the T wave, there is a non-refractory period. This is where abnormal electrical foci most commonly cause PVC's. In this area, PVC's are usually not dangerous unless they are very frequent.

A Google Images search for "EKG refractory period" will turn up some neat diagrams that depict these periods and the corresponding parts of the EKG complex. And where did I get this crazy toilet analogy? I got it from an old medic, who had learned it from an even older medic. Based solely on its weirdness, I suspect that it did originate within EMS circles long ago.

What They Mean

2011-07-05T11:04:00.002-05:00

Good to be back after a long break! I rarely steal post ideas this blatantly, but this is a variation on the theme posted by At Your Cervix a couple of weeks ago. Here are some things that we say to our coworkers, followed by the thoughts in our heads that we know to be true.

Pediatric resident says: "Hmm - good question. Hey... Can I call you back in ten minutes?"
What They Mean (WTM): "I have no earthly idea, but I'm 'bout to get my Google on."

Pharmacist says: "You didn't get those fluids? Weird! I tubed them an hour ago!"
WTM: "Prepared the fluids an hour ago and just found them on the counter. Tubing them now."

NICU nurse says: "Yes, I repeated the patient's temp, but heck, wouldn't hurt to do it again."
WTM: "I totally %#$&#^ forgot about that temperature. I'm sure gonna look dumb if it's 94!"

NICU nurse #2 says: "Dude, you should have gone to medical school."
WTM: "How can you know pharmacology, yet your babies' diapers slide right off their butts?"

Neonatologist says: "Good job, nurse. Another life saved!"
WTM: "In spite of everything you've been doing, this kiddo has inexplicably survived."

Respiratory therapist says: *loud slurping, gurgling noises* Hey, check this out!"
WTM: "Do not look at the orange, chunky, potentially pulsatile blob in this sputum trap."

E.J. says: "I love everything about my coworkers, even the crazy things you say to me."
WIM: "Okay, except for pharmacy. The 'slow tube system' thing again? Really?"

NICU Handshakes: Gracious or Grubby?

2010-12-08T12:16:00.003-06:00

After a baby is admitted to our neonatal intensive care unit, nurses have several goals in our initial talks with the infant's visitors. Two big ones always come to mind for me right away: to instill a sense of confidence among family members and to help keep the baby free from infection. For a long time, I failed to connect the two issues, but I've learned that they do intersect at a curious place: the handshake.

I'm a handshaker. Chalk it up to a conservative, old school upbringing. I try to shake hands with every father I meet in our unit. I think that dads are frequently ignored in the NICU, and I think a handshake is a good start to making a professional impression and to making fathers feel valued. Every once in a while, however, my handshake does not have the intended effect. Recently I extended my hand to a father and he looked at me like I was an outright whackadoo, saying that he had just sanitized with Purell.

This set me out on a quest for more information about provider-patient interactions, infection and expectations. Here's what I found. Apparently, around 80% of patients like handshakes from their physicians. A handshake with a mom can even be a neonatal diagnostic tool. Just be careful not to get hurt! However, my PubMed search turned up no data on the infection control ramifications in any setting, nothing about handshakes by nurses and nothing on the social expectations of NICU families in particular.

What do you think? If I wash my hands at the beginning of the shift and I use hand sanitizer before every baby contact and after every baby contact, is it okay to continue with my handshakes? For my part, in the absence of some data, I'm forging ahead... even if it gets me the occasional odd look.

Gratitude

2010-11-08T13:49:00.003-06:00

I've been away for a couple of weeks on a trip where I met nurses from all corners of the globe. When I set off for another country a full day away from the US, I knew this would not be an ordinary NICU nursing conference. And as promised, I did learn a lot about modifications of neonatal care in low-resource areas. But more than that, my entire perspective on neo nursing has changed.

If you're a nurse in an area that has the computer access to read this blog, consider yourself fortunate. You're ahead of thousands of nurses, many of whom would really just be content with an uncontaminated water supply. Before you complain about your next assignment, think about the incredible people I met who decribed the following situations.

What if you worked in a hospital so overcrowded that you weaned preemies to open crib at a kilogram even? What if, at that same place, you were expected to utilize forced cup feeding to meet a goal of discharge between 1400 and 1500 grams?

What if your neonatologist was a "general physician and surgeon" who primarily treated and operated on adults? What if, on the same unit, 28 weeks was the limit of viability?

What if you went to work every day with the knowledge of a 46% mortality rate hanging over your head... and while that was hard, it was the infant abandonment issue that really killed the morale?

What if your unit director had never even heard of a cord blood gas?

What if you remember seeing an Ambu bag in nursing school, but you hadn't come across one in five years because your current facility didn't even have an oxygen source?

What if you worked in a huge ward of 60-70 babies, both sick and well, and you were the only nurse supported by a few unlicensed assistants?

What if you were a bedside nurse who was told that insertion of a peripheral IV was a physician function, because as a nurse you risk "damaging the patient's organs?"

In the global picture, we have it made here in the states. I don't know about you, but at least for this month of thanksgiving, I'm resolving not to complain.

Happy week, ER nurses!

2010-10-10T09:22:00.003-05:00

This is just a quick note to acknowledge one amazing group of people. This week is specially set aside to recognize the nurses of the emergency department - and deservedly so!

I'm always amazed when ER nurses tell me, "Oh, I could never take care of tiny preemies." The truth is, there isn't anything you guys can't do. Babies and mamas, the young and the old, the rich and the poor, the overly assertive and the completely helpless. No other specialty can claim the ability to care for such a variety of patients and problems. (If you want to see an example of chaos, let a 40 year old, 150 pound nurse have a simple syncopal episode in the NICU.)

I wish for each of you a week of appreciative patients and great assignments. Hopefully EMS will even bring you some tasty treats. But no matter how big or small your celebrations are, know that your buds in the NICU admire and adore you.

Cyanotic heart defects: cool mnemonic

2010-10-05T19:43:00.005-05:00

To remember the five common types of congenital heart disease that present with early cyanosis, simply count to five.

One: truncus arteriosus

There is no separation between the aorta and pulmonary artery, leaving one great artery instead of two. This one vessel sits over a large VSD and carries blood to both the body and the lungs, eventually causing pulmonary hypertension if unrepaired.

Two: transposition of the great arteries

In this condition, the two great arteries are transposed, with the left ventricle abnormally connected to the pulmonary artery and the right ventricle abnormally connected to the aorta. Pulmonary venous return, however, is normal. This results in parallel circulation - blood goes from right heart to body to right heart, and from left heart to lungs back to left heart.

Three: tricuspid atresia

The three-leaflet triscuspid valve normally allows deoxygenated blood to flow from the right atrium to the right ventricle. When this valve is atretic (absent or seriously malformed), blood cannot flow easily to the lungs.

Four: tetralogy of Fallot

This is a cluster of four interrelated cardiac defects - pulmonary stenosis, right ventricular hypertrophy, overriding aorta and a ventricular septal defect.

Five: total anomalous pulmonary venous return

TAPVR is when the pulmonary veins carry oxygenated blood back to the right heart instead of the left heart. There are five words in this condition.

I first saw this somewhere on the web a while back. If you know who deserves credit, please let me know.

Cold Feet

2010-09-17T00:50:00.002-05:00

Thoughts of a brand new ECMO specialist anticipating his first "buddy run" on the pump:

One month ago, having just completed the course: "Ooo, ooo! I hope we have some ECMO again soon before I forget everything!"

Three weeks ago: "Come on, ECMO! Can't wait to get some pump time."

Two weeks ago: "Man! I can't believe I was off for three days and missed my chance at a short run in PICU!"

Two days ago: "Two patients went on the pump in less than twelve hours! I'm up to bat tomorrow!"

Yesterday afternoon, upon waking: "Oh my god. What have I done? I must vomit."

Driving in: "Maybe both of those patients will have inexplicably gotten better and they'll be off the pump when I get there."

Two hours into the shift: "Wow - my preceptor is so patient and this really isn't so bad. And I haven't thrown up yet. I can do this."

Ten hours into the shift: "Oh dear lord. Let me out!"

"Sign here. Oh... and this is my first time."

2010-08-25T02:55:00.005-05:00

Here's the question of the day. Do patients and their families have an explicit right to know about the experience levels of their providers as a part of every informed consent?

This is the report of an inquest conducted by the government of Manitoba following the deaths of twelve pediatric heart surgery patients in 1994. These cases involved a children's hospital with a newly reopened cardiac surgery program led by a young pediatric heart surgeon who had just completed his fellowship.

The above report details the problems faced by the program in its relatively brief run. There were pure technical errors and there were system issues such as poor planning and communication breakdown. But the report is also surprisingly adamant that the informed consent process was inadequate, stating that families should have been told of the inexperience of the surgeon and surgical team.

I've witnessed many surgical consents involving providers with the full spectrum of experience levels, albeit in a different country than these cases. Surprisingly, parents rarely ask about this sort of thing and I find that providers almost certainly will not volunteer the info. Should they?

And that question just leads to more questions. Who would consent to a major procedure at the hands of a known first-timer? What is the impact if patients refuse these things? Thinking broadly, would it produce physicians who completed training with less hands-on experience? And if we run with this thinking, should these disclosures apply to less invasive procedures? What about the impact on nursing? Should I be telling families that this is my first unsupervised ECMO run as the pump specialist?

What say you?

Beatdown

2010-06-24T11:01:00.004-05:00

It just never fails. On that rare shift when you just don't feel quite right, things will, like clockwork, go straight downhill. Rare combinations of events will create the perfect storm.

For inexplicable reasons, I had the attention span of a fruit fly. (Okay, so that isn't rare, but it was even more pronounced than usual.)

Early in the shift, I assumed care for a baby with a new onset of NEC. A 6 cm increase in abdominal girth within a few hours, frank blood in the diaper, that familiar and haunting look of generalized craptasticity. Multiple pH's less than 7. Portal venous gas.

Nasal cannula, nasal CPAP, conventional ventilator, oscillator. Blood, plasma, saline boluses, IV immune globulin, multiple antibiotics, starting and restarting peripheral IV's. The OR team came for an exploratory laparotomy and bowel resection.

This kid was acidotic as a can of Coke, had air in places that air was never intended to go, and had an abdomen so large that it impeded the movement of her chest. Those are big, big issues. But when things get bad, it's the little stuff that gets you. Apparently I got the defective box of fragile gloves. Mom wouldn't answer her phone. The leads would not stick. Once the patient was fully draped and anesthesia needed to access my IV, I couldn't remember right from left.

When I left in the morning, the patient remained quite critical, but she was alive with some chance of recovery. As for me, I am absolutely amazed at the beatdown I took -- all at the hands of a million tiny details.

Is it hard?

2010-05-29T06:20:00.003-05:00

I have a pretty disturbed work/play balance in my life. Even when I'm off, I read for work, I talk about work, and I blog about work. My layperson friends are actually enablers of my affliction, because they like (or pretend to like) hearing about my job as much as I like gabbing about it. At any rate, I get a lot of comments along the lines of "It must be very hard to see babies die." In reality, NICU work is hard, but not for the reasons that you might think.

For starters, death is not nearly the worst thing that happens to babies in the neonatal ICU. Make no mistake - sudden deaths are quite difficult. It can be devastating when a resilient preemie is bopping along for weeks and then falls victim to NEC, dying within the same shift that he became symptomatic. But difficult as they are, sudden deaths in the NICU are more rare than TV dramas might have you believe. Most of the time, a NICU death means a sense of peace following a long period of suffering. It means freedom from a protracted assault of painful interventions that were, sadly, probably futile all along. The death is not the hardest part... by any stretch.

What's hard about this job? I'll say it. Sometimes, it's the kids that don't die. It's taking care of the kiddo with a lethal bone disorder who fractures nearly every time we touch him. He doesn't breathe on his own and he never will, but we have technology to do that for him. Diaper changes are excruciatingly painful for him, so we give him pain medication prior to providing even this routine care. Those meds ceased to touch his pain weeks ago, but it's all we have at this point, so why not? I go along with this insanity under the guise of "respecting a family's wishes." I continue the torture for one more shift. But it's not one shift. It's 155 days. And counting.

That is hard.

What else is hard? The judgment calls. We're taking care of this beautiful, growing preemie. It's time for a tube feeding, but something is different this time. The baby's belly is just a little more rounded than I remember it being earlier. It doesn't feel quite as soft now either - or is that just the baby's muscle tension from me annoying her? It's the middle of the night and I'll likely be able to convince the impressionable young resident to do what I want. Do we stop the feeds, get X-rays and collect labs? In the quest not to overlook something ominous, will we delay a baby's feeding progress, unnecessarily alarm her parents, and expose the baby to unneeded tests?

That is hard.

Beyond that though, there's something that may be even harder. Nurses sometimes get trapped between policy and reality. I've got this kiddo with very complex heart defects. We're going to send him to the operating room this morning in an attempt to rearrange some of his anomalous circulatory structures. However, the risks are very high. The policy is that parents cannot hold babies who have this type of arterial line in place. The reality is that this could represent the only - yes, that kind of only - opportunity that Mom has to hold him. Do I feign ignorance of the policy and hope the wrong person doesn't walk in on us? Or do I just let her stand there at his bedside, tearful and clumsily stroking his head, because that is the only way she knows to comfort him?

And that right there... yeah, now that is hard.

Fear not...

2010-05-27T15:58:00.002-05:00

Every once in a while I throw in a pause for dramatic effect. Don't worry, though. I'm back to blogging and should be posting in the coming days. Enjoyed reading the comments and emails yesterday that I received while I was away.

ACLS, PALS and Beer

2010-02-19T16:29:00.004-06:00

I've just knocked out the didactic and written exam portions of both ACLS and PALS. After all these years, I've landed upon an amazing truth: Emergency cardiac care education is so much better if you have an ice cold Pearl in one hand. Impossible, you say?

Utilitizing the AHA's HeartCode courses, I was able to get through all but the final portions of both classes right in my humble abode. The PALS content is delivered by CD and the ACLS course is available via online download. After successfully getting through both, here's what I think about them.

The Good:

You can stay in your house. And fast forward through a few things. And drink beer. It's even relatively inexpensive. PALS ran me just over $100, not including the skills check that I'll arrange soon with a training center. The course is mostly scenario-based, with realistic scenarios and menus that allow (require) the learner to direct each assessment and intervention.

The Bad:

While HeartCode courses are not specifically recert courses, I wouldn't recommend them for the starter ACLS or PALS student. There is enough of a challenge inherent in the computer format of the scenarios. If you don't take enough time playing with the menus during the orientation period, you could easily find yourself screaming "Chest tube!" at your laptop, all the while having no idea where to go to actually insert one. You really need to know the algorithms going into the course to minimize further difficulties.

The Ugly:

The PALS Team Concept Video. What in the world? When they hired the cast of characters to simulate an actual pediatric resuscitation, someone forgot to tell these guys that, in general, emergency providers should be the ones to bring calm to a crisis situation. I can forgive the fact that each participant has perfect hair, presumably in the middle of a busy shift, but must our speech be clipped and hurried, a la ER?

Overall, these courses were winners for me. I was able to efficiently work through them, to avoid wasting as much time on areas where I felt very comfortable, and to learn new things. Thumbs up!

The First Call-In

2010-02-18T10:32:00.003-06:00

So I hate calling in sick to work. I also dislike people who insist on coming to work with frank toxic manifestations of infectious disease. I guess I've just been lucky in my nursing career so far and haven't had to call in often at all.

I was unlucky - oh so unlucky - earlier this week. I had a stressful weekend, complete with a funeral for friend's child, so if I felt a little off as I left work on Monday morning, I chalked it up to fatigue. Within a couple of hours of getting home, it became evident that this was a little more than just fatigue. It was poisoning. Or possibly Ebola.

At any rate, before long I knew that I would be in no shape to safely return to work that night. I wasn't looking forward to the phone call. After all, I'm still fairly new and it did seem shady. I had just left the place a short time ago appearing just fine.

"Charge nurse."

"Hi. This is EJ. I work nights and I'm going to have to call in sick for tonight."

"No problem, sir. I've got you down."

"Well, see, I--"

"No sweat, man. Feel better, okay?"

"I just hate to--"

"No biggie. Thanks for calling early. Just get to feeling better."

That was it. No questions asked. No inquisition about my symptoms. No mention of whether I had taken my temperature. No bartering about possibly coming in and just wearing a mask. Ahhh... this is the way it should be.

Over a month?

2010-02-01T04:02:00.006-06:00

I know I need to sit down and write. It's been too long. I finished orientation at the new place and it's absolutely great. I probably run into material just about every day that would make a great blog post, but for the moment I've run into a little bit of a blogging rut.

As I said, the job is fantastic. I feel like there's constantly something new and exciting to see. There are resources at this place like I've never known before. But despite all efforts to the contrary, I trudged through orientation in a frame of mind that was... um, less than ideal.

I'll spare you the depressing details, but let's just say that I've learned a lot about surviving shifts with critical patients when my mind was anywhere but at the hospital. I know I've written about working while fatigued, but working while pathetically consumed by relationship stress can be the most dangerous of all.

But fear not... I'm now looking forward and not backward. I have a new focus on faithful friends, supportive family and a great job. I no longer "do" hot-and-cold, off-and-on, or wishy-washy. And I'll be back to write some more, just as soon as I come up with a unique perspective on something that strikes me.

A thought for 2010

2009-12-29T10:49:00.002-06:00

I like this quote, although it is attributed to several sources, depending on your reference.

"Resolve to be tender with the young, compassionate with the aged, sympathetic with the striving and tolerant of the weak and the wrong. Sometime in life you will have been all of these."

Emergency!

2009-11-16T16:30:00.002-06:00

I got the H1N1 vaccine today. Read the consent, agreed, signed, took the shot. As I walked out into the very sunny day and drove away only minutes later, I was wracked with a sharp pain around my sinuses. As I gazed up into the sun, this was followed by four sharp sneezes. The thoughts that ran through my head in the next few moments:

- "Oh my god! I'm getting sick already!"

- "The consent said that this vaccine can't cause influenza! Those lying bastards!"

- "Is a headache associated with anaphylaxis? Am I itching?"

- "If I have to get back to the hospital quickly, where is the closest parking lot to the ER?"

Sometimes when we're the patients, even the most rational and evidence-driven among us can succumb to a little undue panic. I'm reminded of the saying of a favorite professor of mine:

"What exactly is an emergency? An emergency is something out of the ordinary that happens to YOU."

Holding Pattern

2009-11-08T20:46:00.003-06:00

Just a quick update since it's been a while. I'm currently jumping through the hoops of hospital orientation at the new place. I haven't been working any agency or PRN shifts while going through this change, so I haven't touched a neonate in weeks at this point. As a result, the primary source of my material has dried up, but only temporarily. I'll start direct care again with a preceptor in the next few days.

Meanwhile, a little food for thought. This old post from Street Watch (one of my favorite EMS blogs) is on precepting. It's a funny feeling to go from preceptor at one hospital to preceptee at another, so it's been on my mind a little. Wouldn't it be nice if all of us had preceptors like Peter? If a new nurse could go in and be assured that "I will never badmouth you" and nothing more than that, how different would our profession seem to newbies?

Ask me some questions

2009-10-26T01:02:00.003-05:00

I'm preparing for an EMS conference presentation and I need some help. I'm hoping to make my talk as relevant to prehospital personnel as I possibly can. That's where you guys come in.

If you're an EMT or paramedic and you were attending a talk on infant resuscitation, what questions do you have that you might want me to address? I'm also interested in questions from physicians, nurses, students and others - particularly those who do not regularly provide care to critical infants.

If you ask a great question, I might address it here on Uncompromised Airways in addition to covering it in my presentation. Just email me or leave a comment. Thanks everyone!

Little Voices

2009-10-22T22:34:00.002-05:00

I can still hear the tiny voice inside my head early this afternoon:

EJ, this is a public restroom in a gigantic, impersonal hospital. Do not set your briefcase down along the wall here by the paper towel dispenser. Your meds are in here, including one controlled ADHD drug that is going to be a pain in the neck to replace. Your orientation folder is also in here - and remember, they only gave that to you an hour ago. Do you really want to make the humiliating march back to HR for another one?

But there was also a second voice:

Nah! No worries. Set the bag down. You're going into a stall a mere fifteen feet away! And you'll only be a minute. And really, who would have the nerve to...?

I'll let you guess which voice was more persuasive.

NICU Survival for the Student

2009-09-19T04:16:00.003-05:00

Just a few tips for nursing students rotating through a level 3 neonatal intensive care unit. After precepting students for a few semesters, here are my suggestions.

Before the shift:

- Study necrotizing enterocolitis (NEC), respiratory distress syndrome (RDS) and intraventricular hemorrhage (IVH). What are the risk factors? How do we prevent, diagnose and treat these?

- Understand why infants of diabetic mothers, small for gestational age (SGA) infants and preterm babies are all at risk for hypoglycemia soon after birth.

- Read up on oxygen toxicity in preterm babies. What is retinopathy of prematurity (ROP)? Why are we conservative in cranking up the oxygen on preemies?

During the shift:

- Bring a comfy pair of shoes. Don't fall into the trap of sitting down too much. We're more likely to involve you in potential learning experiences if you look interested and active.

- Ask to read your baby's progress notes (the daily notes from the physician). In particular, computer-generated progress notes often go by systems and are particularly helpful in understanding your baby's treatment priorities.

- Wash or foam your hands frequently - before and after every baby, and any other time that you're thinking about it.

- Focus. Students generally aren't assigned to the sickest babies, and you may not even have the most interesting baby in the unit. Asking to look at the trisomy 18 kiddo in the next pod is okay, but make sure that you don't miss out on a learning experience with your own baby.

Questions? Comment or email me!

It might be a tough day in the NICU if...

2009-08-31T22:29:00.009-05:00

With our unit's booming census over the last few weeks, I've learned a good bit about how to recognize a crazy day. I'm pleased to share some of that here. Can't even make this stuff up.

It might be a tough day in the NICU if...

- Two fundamentalist Christian night shifters are trying to figure out where they can obtain large quantities of liquor at 0700 on a Sunday without being flagged as alcoholics or heathens in general.

- The report for the chromosome analysis on your infant includes the phrase "never before recorded in a living human being."

- The message "We're dying. Clock in and come help when you get here!" is written on the dry erase board in the lounge.

- The entire night shift is standing at a baby's bedside, arms folded uniformly and heads shaking in unison. And of course, it's your baby today.

- As you're checking the assignment board, the charge nurse's comments include the phrases "I apologize in advance" or "Get your roller skates on" or "I don't want to hear any bitching."

- Shift report takes 25 minutes on your first kiddo, then the offgoing nurse says, "Now for the hard baby."

Explained to me with a straight face...

2009-08-06T09:13:00.002-05:00

... by a nurse who was telling me about the high rate of "toasterheads" at her NICU, a level 2 center that almost never keeps babies at less than 32 weeks.

"Repositioning is not as much of an option for us. See, those reflective skin probe covers are expensive, so we try to save them. We use clear tape. And the tape sticks pretty well once we get it on there, so we can't go ripping it off the skin every 3 hours just to reposition the kid."

A Few Fun Facts About E.J.

2009-07-27T23:30:00.003-05:00

From the outset, it's been a goal of mine to avoid making this a personal blog. I've hoped to share with you what my work is like without revealing too many specifics of who I am. After some conversations with a great personal blogger, I've ~~realized that I'm flat out of material~~ reconsidered this stance. After all, how many NICU man-nurses named E.J. are there, really?

With some of my concerns over anonymity assuaged, I warn you that my personal life is not rife with exciting material. However, here is a list of random things you might not have known from reading my posts alone.

1. I have issues with handedness. I'm not ambidextrous, as I can't do anything with both hands. But I do some things right-handed and other things left-handed. Right? IV starts, arterial sticks, throw a ball, swing a bat, use scissors. Southpaw? Hold a pen, use a fork, impress my friends with chopsticks.

2. My modest living space is being overtaken. Not by (too many) rodents or termites, but by books. Currently I'm reading this one, which may not be surprising... and this one. In regard to the latter, I generally don't like fiction, but it's a baseball classic. I'm just trying to decide whether Malamud's sparse use of punctuation is intriguing or maddening.

3. My mom and dad met at my dad's first wedding. Despite that Springeresque beginning, they remain happily married after nearly 35 years.

4. I've grown an incredible amount as a nurse in 3 1/2 years, but I also notice that I complain a little more, roll my eyes a lot more, and have to work to see the good in people at times. It is no longer charming when mom is 28 years old and a G8L9. I'm working on it though.

5. Often I have trouble sleeping on the nights before I work a shift as an agency nurse. The people, policies and procedures are different on agency assignments and it adds some stress, but it helps broaden my perspective.

6. I'm a foodie. I love obscure restaurants and ethnic cuisine of nearly any type. My sister-in-law is fond of saying that I'll eat anything that doesn't eat me first.

That's enough self-disclosure for now. Maybe more later.

Confucius Reads This Blog

2009-07-23T19:49:00.003-05:00

My venture to the local Chinese restaurant tonight yielded a fortune cookie with a great message:

You have a charming way with words.

I'm not sure if that's in reference to my writing on Uncompromised Airways, but I do know that it's better than the last fortune I received.

An admirer is concealing his affection for you.

Toastmasters

2009-07-22T16:26:00.003-05:00

I thought I would take this opportunity to post about an organization that has helped me tremendously as I prepared for and assumed a role as a nurse. Since 2003, I've belonged to Toastmasters, an international organization that helps people become better communicators and stronger leaders. I joined Toastmasters when I realized that I enjoyed teaching and I felt it would strengthen my presentation skills. In reality, it has done much more than that.

Most people familiar with Toastmasters will associate it with practicing prepared speeches. That's certainly part of it. But I honestly think that the real benefit for me has come in my day-to-day communication, rather than in the more rare instances when I teach or present.

Table Topics, which seemed like cruel and unusual punishment when I joined, is the portion of every Toastmasters meeting where members are able to practice speaking off the cuff in response to questions on a given theme. Now when I am able to comfortably answer unexpected questions from an administrator, a new parent or a nursing student, I know that I owe much of that ability to Toastmasters.

Evaluations are my favorite part of every Toastmasters meeting. That's the time when a member highlights a speaker's strengths and suggests opportunities for growth in the next speech. I won't suggest that I've been successful in confronting a physician's inappropriate orders every time, but Toastmasters evaluation techniques certainly make that confrontation much less difficult.

The good news is that, whereever you live, there's likely a Toastmasters club very near to you. Check one out! I hope you'll experience the kind of personal and professional growth that I have.

A Point Where It Hits You

2009-07-21T05:11:00.003-05:00

Up to a point, it's really neat work. Admitting a baby at the extreme edge of viability, working your hardest to correct a myriad of issues, responding to sudden condition changes, updating the family in a way that conveys the seriousness without eliminating the hope you can feel them wrapped in.

Ventilator changes, blood transfusions for anemia, antibiotics, phototherapy, surfactant. Lots of blood draws, but not too many or he'll just become more anemic. Fluid boluses and dopamine for low blood pressure, sodium bicarbonate for acidosis. Balancing the need for monitoring equipment with the need to preserve extremely delicate, gelatinous skin.

"So, in other words, we should take this one day at a time?"

"We often say that we take things one hour at a time in here, maam."

Man, this kid is busy. What's wrong with my art line? Is that really his blood pressure? He's one tough little $&*! - that's for sure.

For a good while, it's fun and a great challenge. And then there's the point, often for me on the third day, where reality sinks in like a ton of bricks. (Enter 23 weeks, 500, male, yes and yes.)

It can leave you trying to reach back in your mind for those success stories... or maybe it just leaves you longing for a cold shower, a colder drink and a couple of days of doing absolutely nothing at all.

A Getting Along Problem: Food for Thought

2009-07-14T12:33:00.005-05:00

Here is an interesting take on difficult people from Alfred Adler, an early 20th century Austrian psychiatrist.

"A simple rule in dealing with those who are hard to get along with is to remember that this person is striving to assert his superiority, and you must deal with him from that point of view."

That's refreshing, as it provides another option for me when I'm tempted to kick 'em upside the head.

What Makes Me Happy

2009-07-05T04:02:00.003-05:00

On the heels of the post about the happiness study, I thought I'd comment on a few things that make me happy, specifically in relation to the work I do in the neonatal intensive care unit.

- Babies who monkey around. There's something so hilariously sweet about a baby who can reach up and white knuckle the edge of the isolette as you're trying to pull him out for a weight or a bath.

- Extubations. Is there any better feeling than when a baby no longer needs the assistance of a ventilator to breathe? Even better: extubations where you get to skip the nursing torture device known as nasal CPAP and go straight to a nasal cannula.

- Discharge day. Even if it's a really chronic, sick kid and even if you're a little uncertain (okay, scared out of your mind) about the family situation, on some level it feels like a huge victory to get the child beyond the walls of the NICU. That's especially true for the kiddos whose "day of life" has gotten into the triple digits.

- Beer burps. So amazing the force that can be generated by a little three or four pound preemie after chugging 10 mL of milk.

Time for work. More later!

What Makes Us Happy?

2009-06-28T02:54:00.005-05:00

Enjoy this article from the June 2009 edition of The Atlantic. It details the Harvard Study of Adult Development, which has probed the mental and physical development of 268 men (former Harvard University students) since the 1930's.

I love a good solid psychological study - and this one just makes me downright giddy. There is amazingly tenacious longitudinal research here. The study director is an enigmatic sort. The subjects are such an interesting, thriving group. Although in their late eighties, close to half of them are alive.

Who doesn't want to uncover the secrets to health, longevity and happiness? To understand what advantage No. 218 possesses over No. 47? Although I suspect that the study may pose more questions than answers in the short term, it's an intriguing look into an arena with vast uncharted territory.

Peewee Potions: Sildenafil (Viagra)

2009-06-23T15:47:00.006-05:00

Yes, Uncompromised Airways is a blog centered around the care provided to newborns in the neonatal ICU. Yes, Peewee Potions is the section that deals with interesting medications that we give to those newborns. And yes, believe it or not, sildenafil (most widely marketed under the trade name of Viagra) does have a place in the treatment of our NICU babies.

In 1998, sildenafil made headlines when Pfizer introduced it as the first FDA-approved oral treatment for erectile dysfunction. The drug had not always been envisioned as a prescription aphrodisiac, however. Initially, work at one of Pfizer's labs in England focused on its potential as an antihypertensive (blood pressure drug) and a treatment for angina pectoris.

Although sildenafil was found to be pretty ineffective for those two original purposes, the Sandwich, UK researchers did discover the drug's ability to render a man... tumescent. And apparently, someone kept thinking about the drug's cardiovascular properties. Now sildenafil is used in both adults and children for the treatment of pulmonary hypertension.

Persistent pulmonary hypertension of the newborn (PPHN) results from complications before, during or after delivery. Instead of the lung blood vessels relaxing in the moments to hours following delivery, they remain constricted as they were during pregnancy. This restricts the normal flow of blood to the lungs for oxygenation. Depending on the degree of constriction and the tension produced, the severity of PPHN varies greatly. Some patients have no symptoms, while others may die within days or survive with chronic oxygenation issues.

In babies, sildenafil was initially only employed at large academic medical centers in research protocols, often after the mainstay treatment (inhaled nitric oxide) had failed. Now it is making its way into non-academic NICU's. One advantage of the drug is that it can be given in both IV form (for very sick babies that aren't orally fed) and oral form (allowing the drug to be given even after the baby is discharged to home).

I don't think we've even seen the end of sildenafil's potential. There is talk of its usefulness in preventing plant wilting (absurdly phallic but true), treating altitude sickness and even enhancing sports performance. We should all stay tuned for the next chapter in the exciting life of a versatile drug.

NICU 101: What's an assignment?

2009-06-04T10:49:00.004-05:00

A little something today for the nonmedical readers. I often get email, IM or personal comments from you (although you slackers never leave comments on the actual blog) that some of my terminology sounds a little funny. The term assignment is one that has raised people's ears a little.

You guys are familiar with the word itself. But I'm not referring to homework, to a military operation, or to something out of Mission: Impossible. An assignment is simply the load of patients that a nurse is tasked with taking care of in a given shift.

One of the important components of an assignment is the ratio of babies to the nurse. On the level 3 side of the unit (the sicker kids on ventilators), I generally get two patients. With level 2 babies (kids who are more stable, often former level 3 babies), I'll have three or four. Because of the juggling involved in multitasking for four newborns, a level 2 shift can easily turn busier than a level 3 shift.

You may hear me, on this blog or in real life, use the word assignment with any number of modifiers (some more colorful than others, at times). Examples:

a tight assignment - I don't mean tight as a hip, modern synonym for really great. This means that I was so busy I could barely provide the minimum acceptable level of care to each baby.

an easy assignment - Sometimes you get multiple kids that arent yet feeding or who are feeding by tube. Those save you a lot of time versus caring for their pokey eater counterparts. Why didn't I bring a book? Oh yeah... because all hell breaks loose any time I think to bring a book.

an admission assignment - This is the nurse who probably has the easiest assignment (like three level 2 babies) and will accept the first (second, third, etc) new baby admitted to our unit.

There you have it. Questions?

In my fourth year...

2009-06-03T03:37:00.003-05:00

So things have been a little crazy of late. It's mostly good stuff, but a couple of weeks ago the blue screen of death popped up on my laptop. Pardon the interruption. I'm back in service now. I don't want to publish a heavy post tonight, so I was looking for something simple. Here goes.

Tonight I chuckled as I read my last post. I noticed that I referred to myself as being "in my fourth year" as a NICU nurse. Now that I think about it, I've even caught myself saying that a couple of times in real life. You know you're still a pretty green nurse when it sounds significantly better to say "in my ____ year" rather than "____ years of experience."

I think I'm at a point in my career where I have the experience and knowledge to comfortably manage most of the babies that I encounter. At times I can even give some useful input to other nurses. On a unit where there is a nice balance of highly experienced nurses and newbies, it feels great when I'm respected as a colleague.

With that said, the "come to Jesus" moments are still there with alarming frequency. One minute I'm teaching lectures in our nurse internship program and considering a career as a nurse educator. The next minute I'm barely treading water with a busy assignment and questioning whether I'm competent. I've had some successes, but should my head ever get too big, there's a baby with an obscure condition just waiting to bring me back down a notch.

I guess I've discovered how important it is to take those learning experiences and allow them to make me a better nurse. On the other hand, I've learned that controlled confidence is a powerful thing. So on I go, learning while appearing confident... even if I must use tricky phrasing to pad my experience level along the way.

Why NICU? Part II

2009-05-21T04:08:00.007-05:00

So there were some advantages to the NICU that I anticipated prior to taking the job. However, the best parts of neo nursing are things that I couldn't have imagined beforehand. Here are the things that still amaze me and keep me content in my fourth year as a neonatal intensive care nurse.

- The variety involved in this job keeps it interesting. One day I'm taking care of two critical patients on ventilators and an assortment of medication drips. The next day I'm checking off nurses at an NRP renewal course for the nurses in our building. The day after that, I'm feeding three stable babies and helping their families master the basics of baby care.

- I love the fact that I don't have to keep track of six to eight patients like I might on some adult med-surg units. The ideal assignment for my ADHD mind: providing intensive and focused care for two critical patients and learning every detail about them. I often get just that in the NICU.

- While some are intimidated by the size of our NICU patients, I see it as an advantage. I never have to worry about a back injury from heavy lifting. Any mess can only get so big. And even if you could swaddle up a 150 kg patient and rock him, "cute" would not be the sentiment that generally came to mind.

- NICU experience opens up opportunities everywhere. It inspires confidence that you can handle any job assignment in any setting. Careful with this one, though. "You work with tiny preemies? Floating to psych will be a piece of cake then!" I'm not sure it works that way.

- Finally, babies are just amazing. There is just no other way to put it. If you insert a nasogastric tube in a baby and then drop one in an adult, you'll know what I mean. There's an adage that babies "crash so fast." I see just the opposite. I see extreme resilience, strength and survival... sometimes in spite of what we do for them.

Stay tuned...

2009-05-18T12:59:00.003-05:00

So I was set on sitting down this afternoon to hammer out "Why NICU? Part II." I'm passionate about what I do. It wasn't going to be a matter of coming up with reasons, but I wanted it to be written well.

I sat down with a pen, paper and my laptop. Then my phone rang. On two hours notice, I'm about to head out for a 3-11 agency shift at a large hospital down the road. In previous jobs, I might have screened my calls from employers, but no longer.

Though they can easily become a curse if they get out of hand, last-minute opportunities and schedule changes are a blessing to a guy who is saving for a down payment on a house. Most staff nurse positions come with some level of unpredictability in scheduling, but I don't think I'd have it any other way.

Why NICU? Part I

2009-05-14T00:26:00.005-05:00

Maybe it's because I don't exactly look the part. Maybe everyone gets asked these questions. I'm really not sure. But frequently, I find myself answering, "Why NICU?" I'll answer in two parts. It's a long answer, and - well, honestly I've been slacking lately and it won't hurt to pad my post count just a little until I come up with another good topic.

The first part of the answer involves why I thought I would like the NICU - why I chose it. Part II has to do with the great things I've since learned about the NICU and about babies - why I've stayed for nearly 3 1/2 years.

So here goes Part I. Why would a brand new grad, a single guy with no kids, choose neonatal intensive care nursing among all of the possibilities?

- I wanted a career that would be similar to my prior involvement in EMS, but distinct from it at the same time. I liked emergency intervention and resuscitation, but I'd seen all the chest pain and stroke I could stand.

- I liked the way that the NICU integrated problems involving numerous body systems. I didn't want to be a cardiac nurse, or a renal nurse, or a PACU nurse. Now I have some knowledge of each of those areas, but none of them dominate my practice.

- I liked the fact that a critical neonate stays on the same unit from birth until discharge. You don't get that long-term relationship as much on adult units, or even at large regional referral center NICU's.

- I felt personally connected to the NICU because of my early experiences as a spina bifida and hydrocephalus patient.

I got exceptionally lucky. My perceptions closely matched what the NICU has to offer. The initial months were rough - the hardest time I've had with any job. It's tough to acquire time management and delegation skills while working on the tiniest babies. But in the end, it feels like the NICU is exactly where I'm supposed to be. The reasons above are certainly a part of it... but there's so much more. Stay tuned for Part II.

Did you know...

2009-04-28T09:50:00.003-05:00

... that for many years, there was an age restriction (17-30 years old) for applicants to Texas nursing schools? In 1942, the Board of Nurse Examiners made a wartime allowance for applicants up to the age of 35.

... that 88% of all newborns with hypertension have had an umbilical artery catheter? However, only about 3% of newborns with a UAC will develop significant hypertension.

... that National Student Nurses Day is celebrated each year on May 8? Is it me, or is it just wrong that we finally let students have their day... after most of them have finished finals? What's up with that? How about a nice October recognition to break things up better?

... that infants of diabetic mothers have significantly increased rates of congenital heart disease? Some degree of cardiomyopathy (a thickening, enlargement or weakening of the heart muscle) occurs in as many as 30% of babies born to diabetic moms.

... that Finland, in stats collected in 2000 and published in 2003, led the world in nurses per capita? They had 14.7 nurses for every 100,000 people. The US had only 8.1 per 100,000. I wonder how the statistics have changed since then.

That's it for today... just a smattering of random trivia.

More FAQ's

2009-04-24T16:09:00.005-05:00

Some frequently asked questions (or, at least, once asked questions) from the last few days:

Are you male or female?
I'm male.

Is that your arm?
No. Sorry to disappoint.

Can you make the header image fit inside the white frame?
No, I can't. Enlarging the width of the pic makes it so tall as to take up a whole page.

I see that you list spina bifida and hydrocephalus as profile interests? Why?
I was born with myelomeningocele and developed hydrocephalus within a few days. My early medical care and frequent surgeries are part of the reason that I feel personally connected to my NICU job.

NICU 101: Neonatal Nemeses

2009-04-21T16:37:00.003-05:00

So I've realized that this blog gets peppered with a lot of befuddling acronyms. I envision that this site could appeal to people with varied backgrounds - NICU personnel, nurses outside of the NICU, family members of NICU babies, and others who just love me and really have little interest in ill infants. With that in mind, some clarification is in order.

I thought I might explain a few of the things that might have previously confused you in perusing this blog. We'll start with some of the acronyms related to NICU disease processes, particularly the ones that affect premature babies.

IVH - IVH stands for intraventricular hemorrhage. This is bleeding that can occur in the brains of preemies. It usually occurs in the first 48 hours of life, although it may not be detected until a bit later. IVH's are divided into four grades of severity. Grades I and II do not significantly increase a baby's chances for developmental delays, while grades III and IV are more severe.

NEC - Pronounced 'neck' or, less commonly, N-E-C. Acronym for necrotizing enterocolitis, an inflammation of the stomach and intestines that occurs almost exclusively in preterm babies. The causes are still not firmly understood. Some NEC is mild and resolves with only observation. Other cases are sudden and life-threatening, often requiring surgery to remove damaged bowel segments and place a colostomy.

RDS - respiratory distress syndrome. Surfactant is a substance that makes normal lungs very elastic, but it is produced late in pregnancy. With RDS, premature babies lack surfactant, so they have varying degrees of breathing problems requiring observation, supplemental oxygen (through oxygen nose prongs or a mechanical ventilator) and sometimes synthetic surfactant.

BPD - bronchopulmonary dysplasia. Precise definitions vary, but this is chronic lung disease resulting from significant prematurity and RDS. Many BPD kids are discharged with home oxygen tanks and require close follow-up to avoid respiratory infections and even cardiac complications.

I'll try to add in some links with more info. Send me comments with questions about these terms or others!

Koyie Hill

2009-04-07T21:15:00.017-05:00

I'm sitting here at home watching my Astros battle the Cubs in a real pitchers' duel at Minute Maid Park. It's 2-2 in the bottom of the ninth and likely headed to extra innings. Talk all you want about baseball being a slow, tedious game. For me, it's all about the small details. And the stories.

The 2008 season saw the Cubs win an impressive 97 games, clinching a second consecutive National League Central title. Fans and writers alike predicted that this year might hold all that they had been waiting for: a return to the World Series after 100 years. After it was all said and done, they came up well short. No storied run to the Series. But for anyone who was really paying attention, Chicago was where you found the story of 2008.

Pictured above is Koyie (pronounced 'coy') Hill. By most accounts, he's a regular, boring ballplayer. In fact, he's not even a starter. But when catcher Koyie Hill was called up to the Cubs for the September 2008 roster expansion, that was special. You see, less than a year earlier, Hill had reattachment surgery on a thumb and three fingers following a gnarly table saw accident... involving his throwing hand.

You may not see Hill light up the highlight reels on ESPN this season. The box scores likely won't adequately reflect what a competitor he is. But in baseball, just as in healthcare, the best parts of the story aren't ever found on the surface.

Living for the ER

2009-04-01T21:55:00.005-05:00

Wow... check this out.

http://news.yahoo.com/s/ap/20090401/ap_on_re_us/frequent_er_patients

So... nine patients, nearly 2700 visits over six years. Each patient would have visited the ER, on the average, once every 7-8 days... over the entire six-year period. Amazing!

The article does hit on some contributing issues that aren't surprising: homelessness, drug abuse and mental illness. But if I've jokingly said it before, I guess some people really do live to clog up the ER's. No foolin'.

Things that make my day

2009-03-30T12:46:00.002-05:00

What makes a NICU nurse tick? Here's a short list of things that have made me smile this week.

- Precepting: I love it. I have a senior BSN student doing a high acuity practicum with me this semester. A way better feeling than success with an IV on a newborn? Coaching someone else to do it herself.

- NICU graduate visits: Is there anything better than having a family call or come back to see us a few months after discharge?

- Along the same lines, my buddy Eddie started taking steps this week at 19 months of age. He's not one of our grads, but a friend's baby who was born just past 23 weeks gestation. He's survived a Grade IV IVH, NEC with a perforation, a pneumothorax, craniosynostosis, a PDA ligation, and retinopathy/glasses.

- Tiny, structurally unstable restaurants: I love adventures in eating at new places. If the building could blow down mid-meal, I swear it makes the food taste better.

Air Exchange: Barber College Deferred

2009-03-25T10:51:00.006-05:00

In this job, it's the ups and downs that will get you. When it's good, it tends to be really good. When it's not... well, you know where I'm going. The good news is that, for most experienced NICU nurses, the ups far outnumber the downs. The trick is figuring out how to gain that experience while fighting the daily urge to hang up the stethoscope for the first several months.

New graduates of nursing school often feel a great sense of excitement upon accepting that first job in the NICU. After all, they've spent several semesters working on nursing school prerequisites, followed by two or more years in a demanding nursing program. The hard part is supposed to be over. All that should be left is a life of saving babies and making good money.

There can be a great deal of disillusionment as reality sets in. New NICU nurses find that the hard work is just beginning. It's a whole new world that was hardly touched upon in school. There isn't enough time to get everything done. The nurse is often sandwiched between the competing demands of families, physicians and other providers. The kids either seem too stable or too complex - and sometimes those occur in the same patient in rapid succession.

To make matters more difficult, no one seems to understand. Family members and friends have the best intentions, but they just can't relate. Management is often too quick to reassure rather than actually listening. Even fellow staff nurses can forget what it was like after some time goes by.

I'm here to tell you what it's like on the other side. Just over three years in, I've gained knowledge, efficiency, and perspective - but I still remember what the beginning was like. I'm so glad that I stuck things out - and if this post speaks to you, I hope you do the same. Now I can't imagine a life doing anything else.

How Doctors Think

2009-03-19T23:50:00.006-05:00

I recently finished up How Doctors Think by Dr Jerome Groopman. My ADHD has been particularly problematic with regard to reading lately, but I blazed through this one. I didn't know what to expect at the outset, but I quickly took a liking to it. (Yes - in Texas, we take a liking to things, usually right before we get a hankerin' fer 'em.)

How Doctors Think tells the stories of complicated and not-so-complicated patients on the inpatient wards, in the ER, and in outpatient clinics, describing the decision-making processes that are involved in the diagnosis and treatment of each. Along the way, Groopman highlights both great triumphs and dismal failures, explaining the cognitive details that led to the given outcomes.

Understand that I didn't read this book because I'm some jaded nurse who hates physicians. What I realize is that, for all of its successes, healthcare is far from perfect. Given the right circumstances, it can be downright dangerous. I'm very interested in how doctors, nurses, and patients can work together to make it safer. How Doctors Think doesn't disappoint as it acknowledges the startling realities and lays out plans to deal with them.

Groopman goes to great lengths to point out that most medical error doesn't consist of a nurse injecting the wrong dose of a drug or of a doctor snipping the wrong structure in surgery. Rather, it's about how we think through dilemmas and respond to the unexpected. Those thought processes are the things that have lasting impacts, for better or for worse. The good news is that patients have some level of control in this process. In explaining that power, Groopman makes the epilogue (A Patient's Questions) worth the buy in itself... for patients and for medical personnel.

My "to be read" stack is a little unwieldy these days, but I think I may have to include some more Groopman soon.

The Dr. Nurse Debate

2009-03-09T02:09:00.005-05:00

A recommendation from the American Association of Colleges of Nursing (AACN) says that entry into advanced practice nursing after 2015 should require a doctoral degree. There is currently a firestorm of debate and uncertainty surrounding the emergence of the Doctor of Nursing Practice (DNP) degree. I'd like to tackle just one specific issue: Should John Smith, DNP, NP-C be introduced as Dr. Smith in patient care settings? As hard as it is on my pro-nursing sensibilities, I have to think that he should not.

The days are over when a patient's entire plan of care is addressed solely by a physician and a nurse. Now we have an increasingly complex cast of allied health providers, each of whom has completed distinct educational preparation. (In fact, one of the goals of the DNP degree is to teach APN's (!) to better navigate the current system.) But throughout the years, there has been one constant: If you go to a clinic for the sniffles and the provider introduces herself as Dr. Jones, she is almost certainly a physician - an MD or DO. Now we're trying to introduce a wrinkle to even that most basic idea?

Competition is stiff among the healthcare disciplines when it comes to autonomy and scope of practice issues. Advanced practice nursing isn't the first healthcare profession to look toward the doctorate. Disciplines like pharmacy and physical therapy beat us to it by quite some time. The levels of compensation and specialization within pharmacy have certainly benefited from the shift to the PharmD. However, you still pick your scripts up from Dave, not from Doctor Williams. Should APN's really lead the way in asserting their non-physician doctoral titles?

It's important to consider the perceptions of patients who see nurse practitioners and other APN's. Several studies have uncovered unique personality traits of NP's that keep their patients returning to them rather than marching right back to a physician. Accessibility, clear communication, and a down-to-earth approach are traits often cited as favorable by patients. I have to think that being on a first name basis with a provider cannot hurt those perceptions.

With so much for APN's to be proud of, why should they cloud matters by introducing themselves as "doctor" just in the name of seeking some parity?

Update: I am acutely aware of how much this post sucks. I just can't seem to frame it in a way that makes sense just yet.

Perspective

2009-03-04T15:25:00.002-06:00

I have to admit that I was mildly annoyed at myself yesterday before I even got to work. It was supposed to be the first of three days off for me. No work, no errands and no plans... until I caved in. The phone rang early yesterday morning. "Joint Commission is in the house! Can you come in for a while and help us get some things straightened up?"

When I arrived, the charge nurse told me that a baby needed her eyes dilated for an eye exam. This is a simple procedure that involves instilling drops into the eyes of a preemie after gently retracting the eyelids. A pediatric ophthalmologist then comes along and looks at the baby for any signs of retinal damage resulting from the high oxygen concentrations given to these babies. Piece of cake, right? Well, typically it's simple.

This baby made it known that she wasn't going to allow anything to be straightforward. Over and over she arched, she turned her head, and she squinted her eyes together as tightly as I had ever seen. As ashamed as I am to admit it, I got so frustrated that I actually had to step away from the bedside to calm down. That's when everything was put into perspective for me.

My eyes zeroed in on the nametag attached to the baby's crib... and it clicked. The last time I had taken care of her, this kiddo was critical. A bloodstream infection had rendered her unable to even move. A ventilator had been shouldering her entire work of breathing. Now she was in an open crib, not requiring any supplemental oxygen, and she was feisty enough to frustrate a 200 pound nurse trying to open her eyes. In a flash, this little ball of fire had gone from ruining my day to making my day.

It was a nice reminder. Sometimes when you're so frustrated that you could scream, the best thing to do is take a few steps back, breathe and look around for a little bit of perspective.

Satisfaction

2009-03-02T21:48:00.003-06:00

I know that it has only been a couple of days since the darkest, most pathetic post in this blog's short history. Those moments are rare at work and now I'm all better. At the risk of sounding like I have multiple personalities, today's theme is satisfaction.

America lost a legend this week. Paul Harvey died on Saturday, just a few months after the death of his wife of 68 years, Lynne. Say what you will about Harvey, but I think that when it came to satisfaction, he had it all figured out. Here was a man who was getting up to go to work at 3:30 am at the age of 90.

In explaining his success, Harvey's simple and straightforward attitude came through. "Like what you do," he said. "If you don't like it, do something else." How many of us have spent years in need of such common sense advice? Maybe we really are stuck for a variety of reasons. Maybe we just don't realize that the best opportunities begin at 3:30 in the morning.

Paul Harvey wasn't without his contradictions. Sometimes that was a source of criticism. I think it made him more endearing. "I've never seen a momument erected for a pessismist," he would say. He also said, "If there is a 50-50 chance that something can go wrong, then nine times out of ten it will."

Paul left us some great advice for the current economic worries. "In times like these, it helps to remember that there have always been times like these." And a less famous quote, but one that I like the best: "Tomorrow has always been better than today, and it always will be."

Are you happy with your station in life? I am... and I can't wait for tomorrow.

Barber College

2009-02-28T01:41:00.004-06:00

This blogger is getting the occasional comment or email from nursing students, non-NICU nurses, or others with some curiosity about the workings of the NICU. While I try to paint a positive picture of the work I do, be warned that it isn't always pretty. "This ain't always happy flower kitty land," a fellow neo nurse says.

I've run up against a few really rough shifts. Unexpected death, sudden deterioration, frustratingly unpredictable baby outcomes - you name it. When this happens, I have a recurring dream: I'm going to barber college.

Think about it. It's still precise work with immediately visible results. I'd still deal with and gab with the public. Probably much better hours. No death or disfigurement, unless you do a really bad job.

I think my subconscious is on to something.

Trust me... I might kill you

2009-02-19T22:58:00.005-06:00

There are two excellent posts over at Doctor in Training about the frustrations of being witness to, but not in control of, the medical care of a loved one. They really got me to thinking about an issue that has become inescapable in my life as of late.

Without going into each gory detail, suffice it to say that I've had more than my share of experience as a healthcare bystander in the last few months. Now, I've long had experience as the patient (owing to myelomeningocele) and I'm somewhat experienced as the provider. But being the family member or friend is something largely new to me. This job is hard.

I like to think of myself as a great patient. I write down my questions prior to appointments. I arrive early and never complain about wait times. I smile as much as I can. I chat with and compliment my care providers on their work. I'm loyal, as evidenced by the fact that I've seen one of my doctors continuously since I was a baby... even though I have to visit a children's hospital to do so.

On my more egotistical days, I tend to think of myself as a pretty good provider as well. A lot of the principles are the same as above: I try to smile, to communicate and to plan for each contingency. Granted, if you're an 85 year old in V-tach and I'm your last hope... you could be in big trouble. But within my tiny sphere of oscillating ventilators and kids with no skin, I think I'm becoming a decently competent nurse.

So I guess I'm surprised that this new role, the healthcare bystander, is so challenging. At times its complexities are as nebulous to me as astrophysics or Hmong grammar. I thought I would be good at it. I am not. I'm lousy. Loathsome, you might say. But I really, really have to believe that it's not just me here. I think that the system could help me out just a tad.

A few scattered thoughts:

- I wish that our medical care in this country weren't set up with such a power differential between the omniscient provider and the deferential, unquestioning patient.

- "It's the doctor's job to please the patient, not the patient's job to please the doctor," a brilliant and renowned surgeon once told me. If only more providers and patients had such insight.

- Doctors and nurses are wrong when we feign perfection and become annoyed at the patient who has questions. And patients are wrong when they perpetuate that behavior by putting up with it.

- Patients, almost across the board, do not ask nearly enough questions of the providers who can kill or permanently injure them with one false stroke of the pen or the scalpel. Somehow they've been programmed to trust us - or at least not to pester us with their questions.

- In lieu of pestering us, they nod politely and later run the medication by Aunt Jane who used to be a medical secretary. Ask any high school junior in a health occupations class about this phenomenon. It is not rare.

- If I'm your healthcare bystander, please try to remember that I have the patience of Job. If something about your care causes me enough consternation to stand up for you, know that I'm not trying to cause a confrontation. I'm not trying to stress you out. I'm not trying to be the savior who swoops down with all of the answers (as cool as that would be). I'm trying to make sure that you don't die.

I feel better now.

That is all.

Peewee Potions: Caffeine

2009-02-11T17:29:00.007-06:00

As I've been back on days in the NICU for a few shifts, I find myself noticing and pondering a few things that I hadn't considered in a good while. One of these recent rediscoveries concerns the magical properties of a little substance known as caffeine.

No, it's not that I'm left in complete wonderment at the workings of my 5 am cup of joe. Well, maybe that is pretty amazing, come to think of it. But if you're a NICU nurse, you know that caffeine is, in all seriousness, a wonder drug.

We administer caffeine citrate (in IV or oral form) to tiny preemies for a condition known as apnea of prematurity. Without the drug, they can stop breathing repeatedly if they aren't on a mechanical ventilator. Essentially, caffeine stimulates the central nervous system in these kiddos so that they remember to breathe. If all of that isn't neat enough, when one of these babies suffers an unexpected increase in apneic episodes, we can actually send blood to the lab for a caffeine level.

Just how much caffeine does it take to do the job? Last week I was taking care of an 880 gram baby (about 1 pound and 15 ounces). I administered 4.4 mg of Cafcit, which actually only contains 2.2 mg of the good stuff. (The loading dose, or first dose that we give to the baby, would be several times larger.) By way of contrast, a 12 oz can of Coke contains 34.5 mg of caffeine.

As you might imagine, this great potion is not without its side effects. We give it in the mornings around 8 or 9 so as to minimize sleep pattern alterations. And we have to consider the baby's vital signs before administration since caffeine could worsen an elevated pulse rate. But overall, it's a lot safer than its predecessor (a drug called theophylline, which still has some uses in non-NICU settings).

The take-home message: I'm here to tell you that caffeine has gotten a bad rap. The next time that you need that a little shot of it to get going in the morning, I hope you won't feel guilty or unhealthy. I hope you'll think of this post and say, "Premature babies need this stuff to live. How bad could it be?"

Noodad.com

2009-02-03T23:22:00.006-06:00

In response to finding out what I do for a living, people often comment that I must really relate well to fathers in the NICU. As time goes by, I realize that I actually struggle with that. I have no kids of my own. My girlfriend B has a 3 1/2 year old son who makes me very happy, but I've only been around Z for a few hours a week max - and for less than six months, skipping all of the baby stuff. Truth be told, I have no idea what it would be like to have a baby - much less one in the NICU. I really have no golden advice or magic words simply because of a shared gender.

Imagine how tickled I was to find noodad.com while fighting off some insomnia with aimless web surfing. The concept is golden. It's fathers helping other fathers to navigate the unpredictable terrain of parenthood. Finally, I might have found an information source that is unknown to other nurses. I might at last have a unique contribution to make to dads.

Posts to noodad.com are organized into categories. The Manual is where you'll find the majority of the parenting information (a how-to on diaper changes or an article on BPA vs. non-BPA baby bottles, for example). But alone, The Manual would get boring. To make sure that attention doesn't waver, the site is injected with a healthy dose of testosterone. Sections entitled Mantivities, Libations and Hot Celebrity Moms all house entertaining (but unquestionably important) information for dads both new and experienced.

It's pretty immediately obvious that Noodad.com is not really for every dad. The language on the header for each page could turn some off. And examining side-by-side photo comparisons of a pregnant vs. pre-pregnant Jaime Pressley in between articles on basic baby care? I guess some dads wouldn't find that enjoyable.

Really though, I think we're talking small numbers.

NICU 101: FAQ's

2009-01-23T10:16:00.003-06:00

Maybe this is a few posts late, but I thought I'd introduce myself by way of a series of Frequently Asked Questions (FAQ's). Actually the title is a little bit of a fudge, as my nine posts have generated only a few comments and virtually no questions. Although no one has really asked me anything, this is what I'm thinking they would want to know if they did.

Do you like your job?

I love it. I've been a neonatal intensive care nurse for 3 years. I work full-time in a combined Level II/Level III NICU at an urban hospital. That means that I take care of newborns with a wide range of health problems, from the stable full-term kid with mild breathing difficulties all the way to the severely premature baby who requires a ventilator to breathe and IV medications to maintain adequate blood pressure.

Isn't it hard?

When it sucks, it tends to suck pretty badly. Sometimes it sucks for two or three shifts in a row. But most of the time, it's great. Babies are amazingly tough. Sometimes I feel like we're just there to take the credit.

I could never do that.

There are lots of jobs that I couldn't do. I'm glad that we have great long-term care nurses, for example. I could never take care of patients at the other end of the age spectrum.

Is it weird being a guy working in a female-dominated nursing specialty?

I don't think it is, but I'm sure there are people who do think so. I have to admit that I don't dislike working with dozens of women at a time.

What did you do prior to becoming a NICU RN three years ago?

I was involved in EMS for several years as a volunteer, worked in outpatient pediatric and family practice clinics at various points, and was a phlebotomist/apheresis technician for a large cancer center for five years.

What kind of education do you have?

I have an Associate of Science in Nursing and an RN license. School gives you a broad preparation as a nursing generalist. Specializing is something that you do once you graduate and obtain your first job. I have a non-nursing degree as well - a BA in Psychology from Texas A&M University. I'm now looking at graduate nursing programs for RN's with a non-nursing BA/BS.

What else would you like to know?

Black Cats and White Coats

2009-01-20T01:34:00.004-06:00

Healthcare providers are just a strange lot. Whether you're a patient or a provider, I suspect that you know it's true. We could go many different directions with this one, but to expose the depths of our weirdness, we need only look at how medicine deals with the concept of the evidence-based versus the unproven.

Mention the words chiropractic or aromatherapy to many mainstream providers and you're likely to get an eyeroll and a low grumble about "alternative medicine." Of course, if you have enough RCT results in hand, that's different. Then it's no longer alternative medicine, but instead "complementary care" that must be offered to patients even at large academic medical centers.

In healthcare, we make our decisions based on cold, hard data. Right?

Don't we?

If so, then why...

... are there scrubs in my closet that I won't wear for fear of another horrid night like the one I had back in July?

... is it sometimes a bigger deal on the unit to say "Sure is quiet" than it is to make a medication error?

... am I convinced that naming a preemie Heaven or Miracle is the easiest way to ensure either tragic, painful death or lifelong disability?

These things fail the test of the scientific method, but they're very pervasive beliefs in hospitals all over the nation. Why are we sometimes slow to grasp new research findings, yet so willing to embrace the unproven?

I've written before about life in the NICU not being a predictable, exact science. With vulnerable patients who can't speak, a provider's intuition can be the difference between a near miss and a patient's death. Intuition and judgment don't seem scientific at all, but they become essential skills for anyone who works in critical care. Maybe that enters into the equation here.

Maybe that's why this hardcore science guy was horrified the other night at the Vietnamese restaurant after receiving the dreaded... empty fortune cookie.

Facebook isn't starving babies

2009-01-13T10:45:00.005-06:00

In recent weeks, the 2007 Facebook.com/breastfeeding debate has reignited. The central issue: whether or not Facebook is justified in deleting some pictures of moms breastfeeding their infants. Many say that Facebook administrators are being unreasonable. I'm not so sure.

Some thoughts on the subject:

- I see the benefits of breastfeeding every single day in the NICU. It's a shame that more people, especially women of childbearing age, do not. That has nothing to do with pedantic attempts to taunt Facebook staffers or with flaunting photos that increasingly flirt with Terms of Use violations. If I'm a young expectant mother and I look at the group linked above, do I see educational information about the benefits of breastfeeding? Do I see genuine efforts to get more babies fed in the ideal manner? Or do I see mostly melodrama and games?

- Facebook is an incredibly large and popular site. With millions of users, it must be a strenuous task to make repeated decisions about appropriate vs. inappropriate content. At some point, a gigantic website would have to set down some rules that staff members can apply uniformly.

- "Breastfeeding is natural" is a tired line that keeps coming up in this debate. Lots of things are natural. Although I'm not ashamed of my bathroom behavior, you sure won't catch me urinating and posting a picture of it on the site. And if I did that, I wouldn't expect an army of supporters crying foul on my behalf when Facebook deleted it. Sexual intercourse is also very natural and it's even more crucial to the survival of our species. But there's a time and a place.

- In looking through pictures on the Facebook group set up in protest of this policy, it looks like Facebook still does allow pictures that depict breastfeeding discreetly.

If this whole thing is really about getting babies fed, how hard would it be for these committed activists to work within the site's rules and try a different camera angle? They would still be able to spread the word - and the message would be clearer without all the catfighting.

Gupta for Surgeon General

2009-01-06T23:54:00.011-06:00

Word is making its way across news media that Sanjay Gupta is under serious consideration for nomination as U.S. Surgeon General. While I'm still holding out hope that I'll eventually see Dr. Red Duke serve as top doc, I think that Gupta is a solid choice in the meantime.

Gupta is a neurosurgeon, but he is familiar to many as chief medical correspondent for CNN. As a well-known reporter and bestselling author, Gupta should bring a unique skill to the table: an ability to connect with the public. As one of People's Magazine's Sexiest Men of 2003, that shouldn't hurt his public approval ratings either.

Gupta has already gained significant experience in dealing with controversy. In the aftermath of Hurricane Katrina, he was the first to break the news that, contrary to official reports, 200 patients were unable to be evacuated from Charity Hospital. More recently, he took on Michael Moore after the release of Sicko, although that exchange still confuses me.

Another point in his favor: This isn't his first time dealing with high-level government officials. In 1997, Gupta was selected for the White House Fellows program, where he served as an advisor to First Lady Hillary Clinton.

This should be interesting as it unfolds. Many Americans have no idea what the Surgeon General does outside of stamping cigarette packs. With a little name recognition and a young, friendly face, Sanjay Gupta may be just the guy to change that.

The Three Questions

2009-01-02T10:42:00.004-06:00

I've gotten my hands on an intriguing read recently. It's called Not Quite What I Was Planning: Six-Word Memoirs by Writers Famous and Obscure. The premise is that a person describes his or her life using a six-word phrase. (Stephen Colbert, for example, says, "Well, I thought it was funny.")

I felt like this was a pretty novel concept, so I set out to come up with my own six-word memoir. The best I could do: "I can't think of my own." This does reveal more about my life and my personality than I would like to admit, but I had to keep thinking. Hours later, nothing. What does keep dancing in my head: The Three Questions.

There are Three Questions that define my on-the-job interactions with families of critically ill newborns almost every day. Every neonatal intensive care nurse knows them, whether or not they've framed them in these terms before.

#1: When can my baby eat?

#2: How long is my baby going to be here?

#3: Is my baby going to be okay?

While these seem like natural questions for family members to ask at some point, I'm simply amazed at the consistency and at the contexts in which they come up. And deep down, I'm always a little perturbed at the ambiguity - at what we can offer in response. At times, healthcare communication seems to be all about delivering the most confident answer that you can while sprinkling in hefty doses of "the majority of the time" and "fairly certain" as often as possible.

The Three Questions highlight the uncertainty that surrounds the NICU on a daily basis. For as much as we like to think it's an exact science, much of the work on our unit involves nothing more than educated guesses. No two children will respond in the same way. Our stable Level II kids may eat on the day of admission, while the six month old former 24 weeker may go to a pediatric LTAC having never fed from a bottle. And that's just feeding. Predicting length of admission and divining long-term outcomes are even more vexing issues.

Actually, there's a Fourth Question, but it's reserved for families of male infants, and even then only the tiniest, earliest, and most critical kids on high-frequency ventilators and multiple IV medication drips.

"When can we have him circumcised?"

Shhh... hear that? It's the sound of me walking away, taking deep, calming breaths as I go.

What defines your interactions at work and at home? Can you think of your own Three Questions?

43things.com

2008-12-31T12:59:00.005-06:00

It's that time of year again. Are you thinking about your New Year's resolutions yet? Do you vow to lose weight? Stop smoking? Finally clean out the attic? If you're like I was at one time, resolutions can be elusive things. You may start out with impassioned self-promises for change, only to see your enthusiasm die out before the middle of January.

Jogging two miles every morning? Turns out that that's really hard work. Becoming a Weight Watchers Core Plan superstar? Not so convenient if you eat out 364 nights a year. For all of the distractions, detours and excuses that stand between us and our dreams, we need something to help us maintain a focus. I found just that in 43things.com.

Owned and operated by a Seattle startup called Robot Co-op, this website allows you to make your own personal bucket list. But it's a bucket list on steroids - complete with options to set deadlines for your goals, to see what others are accomplishing, and to gain cheers and advice from others along the way.

What do you hope to accomplish this year? There is no time like the present to get started on your dreams. Decide what's important and go for it -- and let 43 Things help you get there!

(And if you're in need of a little inspiration to get started, check out the story of one tough old lady here.)

Racer: US health care better than we think

2008-12-18T12:54:00.005-06:00

Dave Racer of the Star Tribune writes a great article on the state of American medicine. Feeling pessimistic about our nation's health care system? There is some great food for thought here.

I spent five years working for a large cancer center. Patients from all over the world would travel to the United States expressly for the treatment of cancers with grave prognoses. Maybe this foundation is part of what makes me unable to relate to cries of inadequacy about health care here.

Currently, I'm a neonatal intensive care nurse at a hospital that serves a primarily urban population. Even in our setting, where families almost uniformly have few financial and educational resources, we are pushing the limits of survivability down under one pound for some babies. Could American health care really be that inferior?

Thanks, Dave Racer. You remind us that, while the system has some very real challenges to tackle, things aren't as bad as some would have us believe.