Making his father very proud.

Graham is sick again. This time he’s got the gastroenteritis that’s going around… this is after two recent ear infections. The poor boy has been sick more than he’s been well lately.

I’d rather an ear infection to the stomach flu any day. At least with an ear infection you can give antibiotics and it gets better. There’s no real cure for the stomach bug… just "supportive care," i.e. keep them hydrated by mouth the best you can and if they are puking absolutely everything up and looking too dehydrated get them an IV. The worst thing about the stomach flu is the projectile, high-volume, exorcist-style puking.

Graham started this bout of gastroenteritis with a bang, by puking in Dan’s mouth… and the puking hasn’t stopped. It’s to the point where Cole has seen us spray the red can of Resolve and then blot the stain up with towel over and over and over.

Last night Cole was in his room reading books before bed and I was trying to deal with Graham in the nursery and I got a shower of formula puked all over me. I called to Cole, "Cole, mama’s gonna be another minute. Gi-gi puked and I need to clean it."

Cole came running in, all excited. He brought me the Resolve and said, "Mama do it." I dutifully removed the cap and sprayed down the puke stain on the carpet. He looked at the white foam all over the place and said, "I need paper towel." I handed him a dirty bath towel from the hamper and left him to have a field day while I ran to my room with Graham to change my puke soak sweats yet again.

Within 2 minutes I was changed and went back to the nursery, and Cole was standing at the door waiting for me with a big grin. "I cleaned Gi-gi’s puke!" I looked at the spot on the floor where the puke had been, and sure enough… the carpet was clean.

He is his father’s child.

Want to turn a nice guy into a prick? Send him to Police Academy.

This summary is not available. Please click here to view the post.

It Takes a Real Man.

It’s official – We’re moving Cole away from his little girlfriends across the street.

Here’s why:

Cole wants to do everything Abby does, and the other night, much to Dan’s chagrin, Abby was trying on her pretty new party dresses. Next thing we knew, Cole was demanding a dress for himself.

What you can’t see here is the twirling…. Abby start twirling in her dress, so what do you think Cole started doing?

In his defense, he is just beginning to learn about boys vs girls. He DOES know he’s a boy, believe it or not. That night we had the "boys don’t wear dresses" lesson. ("Except for fraternity rush week", commented Abby’s dad… Now there’s a thought I really needed. THANKS.)

All I can say is that it takes a real man to pull this look off… And no one is more secure in his studliness than our little man Cole.

I know Cole will miss his estrogen connection, but, alas… mama and dada found their dream home in another neighborhood across town.

Moving day is April 2nd!!

Sweet G

Sweet G is on the move more and more. This month he's hit a few milestones:

Several weeks ago I walked into his room in the morning and found him sitting straight up in his crib, just looking at me with a big shit-eatin' grin across his chubby cheeks, like "Hey Mama... look! I can sit up now." I'm sure it doesn't sound particularly overwhelming to read it, but to walk in and expect to see your little baby on his back the way you left him and then to see that, like a little magician, he's gotten himself upright... it really makes an impression.

And then from sitting up to pulling up... Little man will commando crawl to anything taller than him (bottom stair, Cole's chair, couch) and pull himself up to standing. He even does naked pull-ups in the bath on the side of the tub, quite a feat considering how slippery it must be for him. He's ready to move! Gi-gi will get himself wherever the hell he wants to be... I'll leave him with some toys on one side of the house and go to do something on the other side, and if I'm gone too long I'll hear grunting and look up to see my little determined man commando crawling to get me, sometimes from several rooms away. It is very endearing.

All of this motoring, sitting up and pulling up means he was dangerously close to flipping himself out of his crib. I had Dan drop his crib mattress to the lowest level this past weekend, so we don't have a repeat of what happened with Cole...

When Cole was beginning to do the same things Graham is, we were a little slower to lower his crib mattress and he DID flip himself out. Fortunately Dan was standing right there and caught him when it happened.

My boys are fearless!

Brotherly Love

Monday Cole gave me another early sign we're doing something right.

I was picking both boys up from daycare, and I carried Graham into Cole's classroom and sat him in the middle of the play area while I put Cole's coat on and collected his things. All the other little 2-year-olds were gathering around Graham touching him and asking me about him. I told them all, "This is Graham. He's Cole's baby brother."

Cole was standing about 5 feet away just watching, and I asked him, "Cole, are you proud of your little brother?"

Cole walked right over to the group of his little friends and looked at them all as he proclaimed, "I LOVE MY BROTHER."

These heart-melting moments are my favorite part of motherhood.

The Trouble With Surgeons - UPDATE

My write-up reporting the incident with the on-call surgeon who wouldn't come in for the emergency splenectomy made it's way to hospital administration and the shit hit the fan. Within 72 hours of the incident, the surgeon had "resigned."

Really he had been under scrutiny for some time for similar occurrences, and my incident with him was just the straw that broke the camel's back. But, nonetheless.... Don't mess with Doctor Mom!!

Within a week of hearing about the surgeon getting the ax, I had another coup in the continual struggle against grumpy specialists: This past Friday in the middle of the night an ambulance brought in a little 7 months old girl who had stopped breathing in her sleep. She had no spontaneous respirations and no pulse and, to make a long story short, I got her back in a resuscitation effort that I'm pretty proud of. We have no pediatric ICU (PICU) in my little hospital, so it was a no-brainer that she needed transfer to a facility with a PICU since she was on the ventilator. I called the helicopter to come get her and simultaneously began calling around for an accepting facility. Any facility with a PICU bed is legally obligated to accept her since they offer a higher level of care. The first place I called had no available PICU bed. The second place I called had a bed, so that should have been the end of it -- accept the patient and let me send her. But they gave me the royal run-around. The pediatric ER doctor wouldn't accept and referred me to the pediatric ICU doc. She accepted the patient but only after asking me 101 ridiculous questions about what the patient ate for breakfast, what her favorite color is, etc., etc. (Okay, maybe not that painful... but nothing I said was going to change her management at that instant and the fact that she was keeping me on the phone playing 20 questions when all the patient needed was to get flown out was ridiculous) and THEN... Then she reamed me out on the phone for launching the helicopter BEFORE I had an accepting physician. Hello! If I waited to jump through all the hoops these docs were giving me before calling the helicopter, the baby's transport would have been delayed an hour or more. Besides, it is totally the standard of care to call the helicopter first and figure out were you're sending them second if the patient is unstable. So she REALLY pissed me off by fussing at me, especially because everything I was doing was in the patient's best interest.

Well, lo and behold, the following night toward the beginning of my shift this doctor called me back and said "I owe you an apology"!!!!! She ate a big piece of humble pie and told me I was right and she was sorry.

What a rare pleasure for an ER doc to have this kind of validation... two times in one month!! Next time I'm getting an earful from a grumpy specialist, I'll think about these two coups and keep my chin up!

Feast your eyes --

Here's the latest professional photo shoot of my handsome boys. We went to Portrait Innovations again. I still highly recommend it. Here's the 11 best shots.

(You'll notice there are more of Graham. This is partly because Graham was a lot more cooperative than Cole, who wanted to run around the studio like a wild man. But mostly it's because I put Graham in the blue overalls and had several pictures just of him, since Cole got a whole session by himself in the same outfit when he was that age.)

Feast your eyes and eat your heart out!

**Notice Graham's two little teeth!

And early sign we're doing something right

Dan’s in Atlanta this week (or "Lanta," as Cole says), and Cole’s been a little more difficult with his Dada gone. Last night it was all I could do to get him across the street to have dinner with my friend and her 2 little girls. He showed up with no shoes on, only one sock, and tears all over his face after a temper tantrum in the car. I was worried about what the rest of the week has in store until Dada comes home.

Fortunately, Cole perked right up when he got around his little girlfriends.

I don’t know if he knew I was nervous and wanted to reassure me, or if he just wanted a free pass for more difficult behavior later, but my little man really poured on the charm as I was sitting at the table with all the kids and Michelle was passing out strawberries for dessert:

First Cole got his plate full of berries and requested a fork, which Michelle dutifully gave him. Then I got my plate full of berries and began eating them with my fingers.

"Mama need fork."

"Thank you, sweetie, but I’m okay using my fingers."

Cole put down his own fork, got up from the table and walked all the way over to the drawer where Michelle keeps her utensils. He looked up at Michelle who handed him a grown-up sized fork. Then my considerate little chivalrous man brought the fork right over to me at the table, just like a short little waiter and proudly said, "Mama fork," with the sweetest smile.

I don’t know if it was the relief at that moment that the tantrums were apparently over for the night, or the sheer sweetness of the gesture, or the realization that my little man was worrying about his mama, but my eyes welled up with tears. Those were the sweetest strawberries I’ve ever eaten. Moments like that are what it’s all about.

As Mastercard would say:

Strawberries: $4.00

Fork: $4.00

Realizing your little man is looking out for his Mama: PRICELESS

The Trouble With Surgeons

This post is actually something I wrote for my own purposes, documenting an incident that occurred during my overnight shift on Saturday. Even with my matter-of-fact reporting and medical jargon, the drama of the moment is more than apparent, so I decided it would make an interesting blog entry. I've gone through and made annotations in green for all my nonmedical friends.

Saturday night a 23-year-old male presented to the ER with progressively worsening shortness of breath and low-grade fever following several days of febrile illness and flu-like symptoms. On arrival to the ER he was supremely tachycardic (fast heart rate) (150’s/160’s - normal is less than 100), tachypneic (fast respiratory rate), unable to urinate (from decreased kidney perfusion, I thought at this point from dehydration), and intermittently hypoxic (inadequate oxygenation). I treated him for dehydration with IV fluids, ruled out pneumonia and then, when he remained tachycardic and dyspneic (short of breath), ordered a PE (pulmonary embolus, i.e., blood clot in the lung) CT. I had initially noted diaphragmatic tenderness, possibly secondary to coughing. Around 2am while waiting for the PE CT results his mother came out and said he was having left shoulder pain (Many things can cause this, but it is significant here because in retrospect this guy had referred pain from his diaphragm and spleen, which often goes to the shoulder). It was around 2:30am when the radiologist called with the results of the PE CT: Lungs were clear but there was fluid around the spleen and under the left diaphragm, from a ruptured or lacerated spleen.

I immediately went back to the patient's room to repeat his abdominal exam, and he had increased peritoneal signs (usually indicating a surgical emergency in the belly) compared to his exam on arrival hours earlier, with pain in all 4 quadrants, guarding and rebound (these would be the peritoneal signs). He also was still tachycardic in the 130’s despite aggressive fluid hydration (over 3 liters by that point). I immediately called the surgeon on call (Dr. X), and I ordered O neg blood ("universal donor" blood -- can be given to anyone regardless of their blood type in an emergency), a type and screen (to determine his blood type for type-specific blood transfusion), a monospot (the test for mono infection, which causes enlargement of the spleen and makes it more prone to rupture), and a repeat hemoglobin (blood count).

Dr. X didn’t call back. We wondered if there was a mistake on the call schedule, as is often the case, and paged Dr. Y. Dr. Y immediately called back and listened to my brief case history. He explained that he wasn’t on the call schedule, but agreed to come in given the patient’s emergent medical condition and our inability to contact Dr. X. I continued to page Dr. X. It was just before 3am when Dr. X called back, and I gave him the same case history I had given Dr. Y. Specifically, I explained to him that I had a patient with a ruptured or lacerated spleen, diagnosed by PE CT, and that the patient needed a surgical evaluation as soon as possible because of his worsening peritoneal signs and hemodynamic (related to blood circulation, as determined by pulse and blood pressure, among other things) instability. Dr. X was incredulous that I had called him regarding a splenic rupture diagnosed on PE CT and told me neither he nor any other surgeon would operate on a spleen without an abdomen pelvic CT. I assured him that I was not asking him to operate without an abdominal CT, and re-iterated how the atypical presentation had led me to make the diagnosis via a PE study rather than an abdominal scan. Dr. X asked more questions and focused on the fact that there was no history of trauma and that the patient’s hemoglobin on arrival was 18 (Way above the normal value of 12, though this guy's hemoglobin was probably concentrated from his severe dehydration). I kindly reminded him that I was the one at the bedside with more intimate knowledge of the patient’s condition, and he therefore should defer to my clinical judgment. I urged him to come as soon as possible, offering to get the CT while he was in route or to re-discuss the existing CT images with the radiologist. He stated that it would be unacceptable for him to wait in the ER if the CT wasn’t already done by the time he got there. He was so irate that I had called him without an abdominal CT that he requested the name of my medical director. I gave him his name, and he hung up on me. (Later I found out that instead of coming to the ER like he should have, he proceeded to call and wake up my medical director at 3am to scream at him like a prima donna. My medical director totally had my back, though.)

Just after he hung up on me, the nurse informed me that the while I had been on the phone the patient’s blood pressure had dropped to 80’s systolic (too low... you want that number to be 100 or more) and the repeat hemoglobin had come back at 12 (down from 18 hours earlier). I rushed back to the bedside and found the patient with a systolic blood pressure of 60. I had considered transferring the patient to a more accommodating surgeon, but did not feel he was stable for transport at this point. While we were securing more IV access for even more aggressive fluid resuscitation and blood, Dr. Y, thankfully, walked into the ER and assumed care of the patient. His blood pressure began to respond to fluids. He remained tachycardic, though, and his abdominal exam continued to progress.

Dr. X called back closer to 3:30am, and I updated him on the patient’s status and told him Dr. Y had assumed care. At this point Dr. X said that if it were up to him, he would have advised me to do a DPL on the patient and call him back. (Diagnostic peritoneal lavage: an obsolete procedure in which you cut a small hole in the belly wall, squirt saline into the abdominal cavity and then suck it back out to see if there is blood in it. If there is enough blood, the surgeon needs to take the patient to the OR. They don't even really teach this procedure in residency any more... that's how obsolete it is. It would have been an unnecessary and unsafe delay to definitive treatment for this patient.) The recommendation for DPL was despite my explanation that the patient was unstable and that there was an obvious bleed both by CT and by my clinical assessment. I chose not to dispute this point with Dr. X, but if there had been any doubt in my mind that this patient had intra-abdominal bleeding, the FAST bedside ultrasound exam (a quick and easy 4-view ultrasound of the belly looking for free fluid) would have been the preferred screening modality, not the DPL. He said it was a mute point by then and I agreed. The patient went to the OR for an emergent splenectomy with Dr. Y not long after. (I was 100% right... He HAD needed a surgeon stat.)

If Dr. Y had not come in, this incident could have been detrimental to the patient. Other patients could have been adversely affected as well, because at the same time this incident was occurring, another patient with chest pain was ruling in (having a heart attack) by Troponin (the enzyme that is elevated in your blood when there has been cardiac tissue damage, usually associated with a heart attack) and needed my critical attention as well. (So take all this drama and double it.)

I hope in the future the surgeons on call to the ER will be more willing to render their services emergently and without delay when the ER physician expresses an acute need, regardless of what imaging has or has not been done at the time that they are called. (Translation: Quit whining, get off your ass, and come in already!)