Wednesday, December 22, 2010

The Case of Sister Margaret McBride

The Catholic Church is taking a big risk by excommunicating a nun, also a nurse, for doing her job. Sister Mary McBride, an RN administrator of a Catholic hospital in Phoenix Arizona, approved a life-saving abortion for a woman who was 11 weeks pregnant at her hospital. The woman suffers from pulmonary hypertension, a condition which would have a greater than 50% chance of killing both mom and baby if the pregnancy was allowed to go on. According to news reports, the Bishop who excommunicated her, later also stripping the hospital of it's affiliation with the Catholic church as well, claims to take issue with the fact that treatment of the mother was never attempted before the abortion was approved and carried out. Well, it basically shows that Catholic Priests have no business practicing medicine, because the TREATMENT for that disease IS termination of the pregnancy. All that delaying the abortion would have accomplished is forcing the mom to go through several more weeks or months of a doomed pregnancy (at the risk of losing her life at any time), only to be forced to perform a later term abortion on a more fully developed fetus.
It is interesting to note that the Catholic church does not feel that the crimes committed by pedophiliac priest/molesters are bad enough to warrant excommunication, yet they feel that a Registered Nurse who is carrying out her mission to heal others is worthy of this most awful punishment.
I am not a big fan of abortions. I would hazard a guess that, in this circumstance, nobody involved found an abortion to be the ideal solution to the problem. However, it was the only solution that could ensure the safety of the mother. An 11 week old fetus is not going to survive outside the womb, so if the mom died the baby would have died too. A double tragedy. As nurses, we are taught during our labor and delivery course that the mother's survival trumps survival of the baby. Sad and scary to think about having to make that decision, but...it makes sense.
I wish I had some way of reaching out to Sister Margaret. As a nurse, as a woman and as a mother. I wish I could tell her that I'm proud to know we have people like her in our profession. I wish I could tell her how much it means, as well, that there are administrators out there who truly put the patient first and then stand up to the world and defend their decision instead of letting someone on staff take the fall (of note, I read a report that indicated she had been "reassigned" to a different position as a result of this incident). Ultimately, I'd like to tell her I'm glad she broke the rules of her religion and answered a higher calling...her own personal conviction of what is right.

Monday, December 13, 2010

Me vs. Medical team

Me: hello dr. Smith. I'm calling you this evening because your patient is in compensated metabolic acidosis. Her ph is 7.34 but she is over breathing the vent and her base excess is -13. I'm concerned that if we don't give her some sodium bicarb, she will decompensate and become severely acidotic. Her calcium is also critically low.
Dr. Smith: why are you calling me?
Me: because you are listed as her primary MD.
Dr. Smith: yes, but she is intubated. Call pulmonary.
Me: but she is in metabolic acidosis. The pulmonologist doesn't want to fix non-respiratory problems. Can I give her some sodium bicarb and another dose of calcium gluconate.
Dr. Smith: the day shift nurse already gave three doses of calcium.
Me: but her calcium is still critically low.
Dr smith: no. It's 2300. Call in-house with any further problems.
One hour later
Me: good evening dr. Jones. Sorry to bother you. I have a patient of yours who has metabolic acidosis, is on several different pressers and an insulin drip and is intubated. She's in SVT with heart rate in the 150's. She's on an amiodarone drip but if I increase the rate her pressure will drop even more and I will have to go up on the pressors. I think she would respond well to some sodium bicarb. Right now her acidosis is preventing the pressors from working.
Dr. Jones: this isn't my patient, I'm just on call. Increase the amiodarone drip until 7 am
and then dr. Moore will take over.
One hour after that
Me: good morning dr. Brown. Sorry to bother you at 1 o'clock in the morning, but I just got a gas on my patient and she is now severely decompensated with a ph of 7.18. Her base excess is now -21. Her heart rate is in the 140's and her pressure is 84/46 on maximum drips. I feel she needs some bicarb.
Dr. Brown: that's not that bad.
Me: I just notified organ procurement due to the fact that she is non- responsive to painful stimuli with no gag reflex. I assure you, it IS that bad. Can I give her some bicarb?
Dr. Brown: she was admitted with DKA wasn't she?
Me: yes. She is on an insulin drip and her sugars are in the 400's despite hourly boluses of iv insulin.
dr. Smith: your doing everything you can. Insulin will fix her.
two hours later
Me: dr chance? Sorry to bother you. I know it's only 3 o'clock in the ,owning and this patient isn't actually in renal failure (in fact, her kidneysnare the only thing that are still miraculously functioning) but I've called every doctor on the case and I don't know what else to do.
Dr. Chance: what's the problem?
Me: my patient's last blood gas was 7.18 and that was two hours ago. I'm afraid to get another one.
Dr. Chance: well, she needs bicarb!
Me: thank you. I agree. Do you want me to give her a bicarb drip?
Dr. Chance: yes! How quick can pharmacy get that to you?
Me: I will call and offer them my first born child. She is two and very cute.
Dr. Chance: better grab a few amps from the accudose and give them as a push. Give 4. Start the sodium bicarb drip at 250 and call me back in 2 hours so we can see if that's doing the trick.
Me: I have a beautiful diamond that my husband gave me. It's yours if you want it.
Two hours later:
Me: dr. Chance? I gave 4 amps bicarb iv push. I started the bicarb drip. The patients blood pressure is 114/66. She is off all pressors. Her heart rate is 115 and her blood sugar is down to 196. Her blood gas is greatly improved and she appears to be waking up.
Dr. Chance: great job. Why didn't you give the bicarb sooner?

This was a fictional account. Nothing like that has ever actually happened to me, any doctors or any patients. I would never offer up my first born or my diamond ring to a colleague. I have never spent the entire night waking random doctors up until I finally find one who will give me the one little thing that I know will help the patient...

Sunday, December 5, 2010

Find Your New Favorite Blog

Ok, so maybe you think blogging is ridiculous and you wouldn't want to waste your time, but do you really understand what blogging really is? Do you have any interests, talents or hobbies, perhaps something you'd like to learn more about. I'll share with you some of mine.

First, the elephant in the room. If you've read any of my previous blog entries, you know that my favorite blog is The Pioneer Woman. But why? I first discovered the blog when my sister revealed several toothsome recipes (including, and this is the actual name)"the best chocolate sheet cake...ever" which had come from her site. I decided to check it out. At the time, I was a new mom, at home for long long hours wih a baby who mostly slept. All my friends were back at work, disimpacting people to their hearts content, and I was ready to go crazy from boredom and my own need to provide colon-emptying support to a mostly elderly population of sick people. I'm sure you've been in the same situation. I had never been much of a cook and definitely had never been a baker at all (due to a habit of frequently forgetting to add key ingredients to recipes such as flour, eggs, baking powder, etc...). The Pioneer Woman has people like me's back, because she takes pictures of the entire process from start to finish. You simply scroll down the page, follow the steps which are described using detailed pictures and instructions, and before you know it, you have a delicious confection sitting in front of you on the counter with no real recollection of exactly how you accomplished the task. I started with the chocolate cake, moved on to the Sleepin' In Omelet ( oh it's too delicious for words) and before I knew it I was a cook and a baker! I was making bread, cakes, cookies, dinner casseroles that didn't have a single can of Campbell's in them, and many other things that I had never even heard of. Clafouti, pots de creme, French silk pie. Domestic goddess I ain't, but The Pioneer Woman at least made me into a functional housewife. The butter and eggs budget went up but the dining out and ordering out budgets went WAY WAY down. Thank you Pioneer Woman. That's from my husband.

The next thing on my list was my unmet healthcare-providing needs. How could I, in the middle of a 4 month long maternity leave, get those needs satisfied, in some small way? Enter Code Blog. This is a blog written by a fellow ICU nurse, with gross stories, drama and ICU nurse tips and thoughts on life. Perfect! I became a follower of that blog. Recently, I even had a story posted in that blog, as a guest blogger, about the time one of my coworkers found a dead cat under her patient. Fun stuff. For anyone interested in any specific niche of the healthcare spectrum, she also has a list of quite a few other medical blogs with links to them. Although I've always been fascinated by the "At Your Cervix" blog, written by a labor and delivery nurse, Thats really more of my sister Val's interest area.

For my newly piqued interest in writing and the idea of breaking into the world of fiction, I found a blog written by a published author and mentor to new and unpublished writers, Randy Ingmerson. He has a monthly newsletter and a blog with tons of helpful advice and encouragement for aspiring writers. He recently co-wrote the "Fiction Writing for Dummies" book, released in print and electronic formats and because I was a follower of his blog, I got a free copy downloaded to my IPad! Being a bloggee pays off in interesting ways sometimes...

I was recently in search of a recipe for a food that Hugo was waxing poetic about from his halcyon childhood days in Colombia. My sister in law Maria directed me to "My Colombian Recipes" a blog written in English by a Colombian lady who married an American and now lives in New England. I surprised Hugo by going to the Latin foods market, buying the stuff, and making him a delicious Colombian meal. All the Colombian recipes I have found online are in Spanish. Not only is this a language that I'm not particularly fluent in, they use metric measurements, which is really, ummm, interesting. You want to make a recipe that calls for 100 gramos of mantequilla? Me neither. I don't even know how you would measure 100 gramos of mantequilla. Do you use a scale? So this lady, Erica, has taken all those recipes and translated them for morons like me. Wasn't that nice of her?

Now that I have shared my favorite blogs with you, won't you tell me what YOUR favorite blogs are? You never know, I might be a devoted follower of that one...


Www.codeblog.com
www.thepioneerwoman.com
www.advancedfictionwriting.com/blog
www.mycolombianrecipes.com

Thursday, December 2, 2010

My Hobby

Yes, I am a blogger. I consider myself to be a very lite blogger, with emphasis on the lite (spelled the way it is, to signify a lack of depth rather than a lack of color). I basically spew out various things onto this format, much as a normal person would write in a diary and then hide it away from the rest of the world. My brand of journaling for anyone who wants to see ( though admittedly few) is a sort of lazy person's way of channeling mild creativity into a media which requires very little effort, no cost, and as little or as much time as the blogger wants to put into it. There are blogs out there on every subject known to man...people passionate enough about food, photography, dieting, exercise, writing, and any other topic you could think of to write consistently on those subjects on a very regular basis. This brings me to my growing affection for and interest in such blogs. Therefore, I'm not just a blogger, but a devoted bloggee.

I'm not the only one you know. Just check out The Pioneer Woman's blog. Her blog, which has won numerous national awards and has caused her to become somewhat of a cooking, photography and homeschooling ( amongst other things) celebrity, is kind of a blog of all blogs. Many of the other blogs that I follow were found through The Pioneer Woman's blog. Recently, just as an example, Ree (The Pioneer Woman's real name) had a contest on her cooking page wherein she gave away 4 expenses paid trips to her guest lodge on her ranch for a cooking weekend. She was going to do it, like, a month later, so she indicated that she thought, due to the short notice of the contest that she wouldn't get a huge number of entrants, which would give those who actually could conceivably do it a better chance of winning than some of her other contests which are extremely popular. My fingers tingling at the thought of meeting Ree, hanging out on her ranch in Oklahoma, cooking with her and becoming best friends (it's absolutely bound to happen if we ever actually meet), I entered. Quit my job if necessary I would, but if I won that contest, I was going. There were 64,000 entrants, or something like that. This was in the space of about 4 hours after she posted the announcement. That's how many people visit her blog on a regular basis and think highly enough of her to want to spend a weekend in her guest bedroom, so to speak.

I like to visit The Pioneer Woman's blog, amongst others, and read her recipes, look at the pictures of her daily life on the ranch, hear about her homeschooling exploits and get the latest on her cookbook, her true life romance novel, due out the beginning of next year, her recent Throwdown with Bobby Flay and all kinds of other related things. It's amazing to think that one woman, a woman with a strong voice and personality who was sitting there on a ranch out in the middle of nowhere with dial up Internet service (at the time, if my thinking is correct) managed to plug into the very new idea of blogging and turn it into a huge big deal. Her fans connect, not only with her but with each other. It's a network of people with similar interests.

It's not always sweetness and light either. Maybe I'm a freak for admitting this, but I read a large number of her posts from beginning to end, including the comments. The comments often number in the hundreds, sometimes the thousands. But it can be a lot of fun. For instance, there's one lady named Suzanne, who has her own blog, who shamelessly promotes her own blog by attempting to be the first to comment on just about every single one of Ree's posts, along with a link to her own blog. Ree doesn't seem to mind people doing this; in fact, as I've said, one can find a plethora of like-minded people out there simply by starting with one good blog and clicking on links in the comments section to travel to other peoples' blogs. Suzanne doesn't really play fair though. I mean, every single post, there she is, with her link and some inane, often generic sounding comment. Not only that but she's found a way of cheating to get herself up at the top even when she wasn't the first person to comment. She simply "replies" to the first person who did comment, sticking her link in there and then up it pops just under that person's comment instead of at the bottom of all the other replies. She's not the only one who does this either, but she is pretty blatant and very persistent and one has to wonder if she spends any time at all working on her own blog, what with all the blog hitching she does over at Ree's site. The hilarious thing though, the thing that has me checking furiously for her ubiquitous comment under every post of Ree's is that someone else, a woman who goes by the name of Gin, no blog link, has appointed herself the police-woman of The Pioneer Woman site. Suzanne and her irritating comments are pretty much ignored completely by Ree, but Gin feels strongly enough about the integrity of Ree's posts to reply to many of Suzanne's more annoying comments and replies with scathing rebuttals. I often wonder if Ree is even aware of the underbelly of her blog, the quiet scandals taking place in the forgotten annals of the comments section. Lord knows, she can't possibly go back and read all, or even most of the comments left on her blog. She posts 4 or 5 new things in the various sections of her blog every day and typically gets at least a hundred replies to each, sometimes many many more. It's a world she created and yet, it has taken on a life of its own. Kind of like the Trekkies or the Harry Potter fans; they overwhelm even the ability of the initial draw to continuously entertain and so they end up having to propagate the fun themselves, in ways the original creators of the phenomenon could never have envisioned. And by my own fascination with that underbelly...POP! I've become a member of the club. What would The Pioneer Woman's rabid fan base be called, I wonder? The Pineys? the Piners. The PinWo's. I'm gonna have to work on that. In a little while though. First, I need to check back at the site. She may have posted something new in the time it took me to write this...

Monday, November 22, 2010

I like medical terminology

Yup. I really do. I use it every day at work and I've found that the longer I do it what I do, the more it bleeds over into my personal life. I tell Hugo he can repeat the dose of Tylenol Q1 hour, prn. Every time I see that ridiculous infomercial for the fitness made simple DVDs it makes me laugh hysterically, because the big logo, FMS means something very different than fitness made simple to any healthcare worker. You see, we have this thing called a fecal management system that we use on people having profuse watery diarrhea (you'd be surprised by how many of our patients do). It's a plastic hose with a big bubble that gets inserted into a patients, well, rear end. The bubble gets inflated with a fairly large amount of water to hold it in there and Presto! You have cut your bed bath count down significantly, as the liquid stuff drains into a bag rather than into the bed and all over the patient. It's revolutionized the care of the cdiff patient (more medical jargon).

The FMS inservice lady came recently to update us on a few advances in the use of the device (that would be such a rewarding job, wouldn't it?) and she was trying to quiz me on the thing. It turns out, I'm kind of an expert. I took all the wind out of her sails. She was like, "And does anyone know how many cc's exactly your supposed to instill in the balloon?". "45" I answered immediately. She smiled at me, graciously. "Very good. And do you know what this port is for here on the side.". "Irrigation" I shot back. Her smile was wearing thin. This was what she got paid for darn it! She came back at me with everything she had. "How long is the FMS device approved for continuous use in a patient?". I shot it out of the park. "29 days!" We haven't seen her back since then.

One other fun story about the FMS. I was eating my lunch in the break room one day at the little table we have back there, back in the days before I transferred to night shifts. Dr Rodriguez, one of the hospitalists, came back to ask me about a patient. I happily updated him as I chewed away on my sandwich. Suddenly I realized he wasn't paying attention to me. "What is that?" he asked in disgust, pointing to the bulletin board, which is located right over the table, so you are kind of staring at whatever happens to be posted up there at the time. "That"
was a fairly graphic diagram of how to insert the FMS into a patient. I realized in amusement that I had been unconsciously looking at it every day while eating my lunch without ever realizing just how disturbing of a thing that is.

Anyway, today I was laying there in the dentist chair getting my mouth worked on. The tables were neatly turned on me. I had my mouth open as wide as I possibly could (with frequent semi-annoyed requests from the dentist to open back up nice and wide. He was working on one of my very back teeth for a good hour and a half. I had just come off a 12 hour night shift. I was freezing cold and shivering from all the cold water that the drill sprays out all over. My jaw was trembling uncontrollably from all the strain of trying to hold it open that wide for all that time. I began mentally reviewing all the mean things I had done the night before to my patients. This was obviously my karmic payback. There was the little confused guy who pulled his ng tube out (a plastic tube that gets shoved into someone's nostril and down the back of their throat, into their stomach, used for various reasons on a variety of patients). I had to replace it...twice. There was blood involved. He didn't enjoy it. There was another confused patient of Molly's, who had to be forcibly restrained from pulling her endotracheal tube out (yet another of the wonderful tubes that we, as nurses, are charged with keeping in patients who very frequently try to pull them out). There was an ugly code I was involved in that did not end well. All in all, I pretty much deserved whatever the dentist could dole out to me. Plus, I was laying there with no idea what was actually going on in there, which may have been the hardest thing of all for me to deal with. Finally, the assistant murmured something like, "are you ready for the temporary?". "No, not yet" Dr Dell replied in his deep baritone voice. "I still have to reduce the lingual.". I felt myself relaxing immediately. I had only the faintest of ideas as to what exactly reducing the lingual meant, but for some reason it helped me out a lot. Medical jargon, you know?

Tuesday, November 16, 2010

I'm switching doctors

I decided today that I want to get a new doctor. I already picked her out. It's Dr. Mas, my kids' pediatrician. I know, I know, I'm too old. Last time I called my own doctor, about an annoying little issue I was having, I mentioned to the nurse on the phone that maybe I should make an appointment to come in, since I was due for a check-up anyway. She laughed. "Oh, I don't think well be able to fit you in until after the first of the year, Lauren" she said. Ok, but why was it funny? Why is it so amusing that I might actually think I could have a legitimate medical concern and come in and be seen to have it taken care of?
Let me explain why I want to go to Dr. Mas from now on. I called there this morning, because Fiona has a little bug and is running a temp of 102-103, which is just a tad higher than what I think is acceptable in my one year olds. The nurse responded to my call within a half hour, though I emphasized to the secretary when I called that it wasn't urgent. I explained my concern when she called me back and said, "I was just wondering if I should bring her in so someone could take a peek at her?". "Yes, I think you should." she responded immediately. "Is 12:15 ok for you?".
Last time I called there, to find out if I could give Fiona the higher dose of Tylenol yet, the nurse urged me, "Don't hesitate to call us tomorrow if the temperature isn't better, or if you just want Dr. Mas to have a look" (tomorrow was Saturday). "Dr. Mas will be here till noon tomorrow." My kids have a doctor who works on Saturdays. No fair. I want her for myself. The well-child waiting room has a flat screen television with Shrek playing most days. They give you a sticker even if you're not totally brave when you get your shots. They treat the customer like, well, a customer. My doctor's office, bless them, treats me like a complete nuisance.
The interesting thing, as a nurse myself, that I notice about this situation, is that the doctor herself (or himself) doesn't set the tone for this sort of thing. The average time spent dealing with the actual doctor (even Dr. Mas) is negligible when compared with the time spent talking and interacting with the office staff. The nurse who calls me back. The secretary who takes my call in the first place. The person at the desk who talks to me about billing and setting up new appointments. These are the people who make or break your day. As one of those people myself, its a constant reminder that, even though I rarely get credit for either making or breaking someone's day, the power to do either is in my hands. Nobody wants to be sick. Its a real pain in the neck, and often happens at the worst possible time. In the end, though I don't in fact have the option of switching my care to the pediatrician, I do have the option to take my business elsewhere. Someday, maybe I'll find an adult practitioner whose office treats the little kid inside.

Thursday, September 16, 2010

Love your Liva...

The liver is not an organ we hear much about. There is no American Liver Association (OK, maybe there is...but you don't hear much about them in the news), no Annual Liver Walk for raising awareness and funds, no special liver healthy diet. The reason for all of this is that your liver, a powerhouse organ that is just as important to your daily life as your heart, lungs, brain or kidneys, is a silent hero. It works nonstop to purify toxins in your blood and it doesn't require the kind of upkeep that your other organs do. You have to exercise to keep your heart and lungs healthy, drink plenty of water and eat a balanced, electrolyte rich diet to keep your kidneys happy, get plenty of fresh oxygen to keep your brain cells truckin' along. Meanwhile your liver, as long as you do those things to keep your other organs happy, is perfectly content and will most likely work tirelessly for you without a single glitch until the day you die.

Your liver, in fact, will outlive you if you have made the decision to donate your organs when you die. A lot of times nurses don't call the organ center when they have an extremely old person who is considered terminal, thinking that their organs are too old for the organ procurement people to possibly be interested in them. However, the organ people will gladly take any liver from an otherwise healthy individual of virtually any age. I had an 82 year old whose liver was hotly pursued by the agency because he was a vegetarian nondrinker who didn't take any medications and they knew that such a well cared for liver would be very useful for someone else who hadn't taken such care of their own.

So, if the liver is so resiliant and selfless, than why should I be so concerned about it? Shouldn't we just let well enough alone and let it keep on keepin' on? Well, yes. And no. Because in fact, I HAVE seen people die of liver failure. Young people. Rich people, poor people, educated and uneducated. In just about every case, the people I saw die of liver failure had one thing in common. They drank alcohol. You're probably thinking that what I meant to say was that they were alcoholics who abused alcohol, but I didn't say that on purpose. In truth, some of the people I have seen die of liver failure WERE nasty old drunks. However, a good number of them were moderate to moderately heavy drinkers. As in, a couple glasses of wine every night. A twelve pack of beer most weekends. A weekly knock down drag out party where everyone got trashed but were all back to their normal, everyday selves by Monday morning. Those are always the people who are so shocked to hear that they are in liver failure. "Liver failure?" they say, bewilderedly. "But I'm not an alcoholic."

Let me lead you through a possible scenario that could culminate in liver failure. We have a person who enjoys a cocktail hour with her friends every Thursday after work. She has two or three and goes home. Friday nights, she likes to get together with family and usually has a few glasses of wine. On other nights of the week, she usually has a single glass of wine with dinner because its good for you now, didn'tcha hear? Only, what she secretly knows and doesn't admit to anyone is that her wine glass holds about a third of a bottle of wine (lots of the wine glasses out there do nowadays) and thats a good three times what "they" are now saying has heart healthy benefits. The serving size that is extolled by the heart people is a teensy weensy 4 ounce glass for women. For men its a tiny bit bigger, like, 5 or 6 ounces.

Now, there's a good chance that this woman will live her life out normally and die contendedly of something completely unrelated to her moderate drinking habit. There's also a chance that she will get morbidly ill at some point in her life. Most of us do have at least one major illness during our lifetimes. This is when the moderate drinker will live to rue the day he or she ever picked up a wineglass. Because during a serious illness is when our body's liver power suddenly gets heavily taxed.

When you're fighting a really bad infection, for instance, the doctors have to throw all kinds of really strong antibiotics at you that are really hard on your liver. A normal liver does just fine. It has lots of reserves. And, once the illness is over, the liver will be able to rest and recuperate and come back to its normal function. A liver that has been steadily detoxifying small amounts of alcohol away all these years, like our example's liver for instance, is a little bit tuckered out to begin with. Its almost like that liver has been getting pinched every day for a long long time. When someone comes along and throws a sucker punch, the healthy liver can take the punch and come back swinging. The pinched liver is already hunched over and in pain. The sucker punch knocks it out and its down.

This is an example of how the way you treat your liver can decide whether you survive a lengthy or catastrophic illness. You can either live to complain about the bad hospital food you endured or leave your family shaking their heads going, "I never even knew she was an alcoholic. How did she die of liver failure?"

This is one scenario that can play out to result in liver failure. Its not the only one. Pill poppers, the ones who never go to the doctor and don't drink at all but who take a few tylenol and ibuprofen every single day because its over the counter so it must be perfectly healthy are also at risk. If you take tylenol on a regular basis, you are pinching your liver. Just like an alcoholic beverage! Drink some water and lay down on the couch for a few minutes if you have a headache! And don't even get me started on people who give their kids children's tylenol for every single sniffle and whine. They are setting their children up for a lifetime of medication-reliance and starting the liver pinching way too early.

On the alcohol front, though, I have another scenario to describe to you. It is a scenario that is all too familiar to any hospital nurse out there. People who drink a few beers religiously every single night or a few servings of wine are not only pinching their livers, they are putting themselves on a medication schedule and setting themselves up for DT's when they alter that schedule at all. What are the odds that you are going to be hospitalized for some length of time in your lifetime? Pretty good, right? You might need some small trifling surgery, you might get an infection, you might have a mild heart attack. It happens all the time. With all those aforementioned examples, we can usually get you fixed up and send you on your way in a few days.

Anyone who has an alcohol consumption history better hope, though, that they do not require more than a single night in the hospital. Because round about the middle of that second night, we nurses have become accustomed to seeing those special signs that someone is experiencing delerium tremens, or alcohol withdrawal. We know it as soon as we see it. And to know it is to love it. Get out the wrist restraints, order up an ativan drip, and notify the family that their loved one will be busy for the next three days. The families often act completely mystified when we tell them that their loved one is in DT's. They have a picture in their head of the typical DT experiencing person and it is NOT their loved one. Sometimes they flat out deny that their loved one drinks regularly at all. Those patients often get sent for CT scans of the head to rule out stroke, they have neuro consults to rule out seizure disorder and neuro disease, and in the end we almost always conclude that it was, after all, alcohol. The family isn't lying. They are in complete denial or are totally unaware of the actual extent of their loved one's alcohol consumption, even though it has been going on under their very noses for years. A six pack at a time is NOT normal. It is NOT minimal. A three rum and coke drinker who doesn't even act drunk IS at high risk for going into DT's. Even if you think they don't do it every single night.

I have seen ministers and PhD's go through DT's. It has been my humble privilege to wipe their asses because they're so gorked out on DT's that they can't even control their own bodily functions. I have lovingly jumped on top of a 240 pound man with an 18 guage needle, as he was being held down by two security guards and a nurse to reinsert the iv that he has forced out of his arm with the violent tremors associated with this condition. I have dried rivers of sweat from the clammy, diaphoretic bodies of perfectly young, fairly healthy people as their family members and friends watched from safely outside the room, shaking their heads in wonder and disbelief. Finally, I have seen a young person have to be completely paralyzed with medicine and put on a ventilator (which eventually caused him to get pneumonia and experience a life-threatening infection) because he was in such a bad state. His wife did not know that he was a drinker. It added about 9 days to his hospital stay. I can imagine what it did to his hospital bill.

So, if you do have a planned hospitalization coming up and you are tempted to gloss over your actual use of alcohol to the doctor or your admitting nurse, you might want to think twice. If we KNOW your drinking history, there are steps we can take to prevent this terrible cascade of events from transpiring. If we don't know, we will know soon enough. And so will every member of your family (even your annoying Aunt Bea who feels the need to spread the news about everything to everyone) as well as your work associates and social circle.

If you think you might be one of these low level alcohol users, one of these social drinkers who socialize a lot, one of these mild headache pill poppers that I'm talking about, you should at least be aware that you are pinching your liver. You are pinching it and if you aren't careful, it might pinch ya back one of these days.

Tuesday, September 7, 2010

Soapbox Post: Dietary Sugar Reduction

We have all heard that excessive fat consumption is related to poor heart health and excessive weight. But did you know that research now proves that excessive sugar intake is just as bad or worse? Increased sugar intake by Americans over the past 40 years is being pointed to by the American Heart Association as a primary reason for increased weight, proliferation of cadiovascular disease and reduced intake of nutrients in our diets. As a result of this compelling research, the American Heart Association recommends that we all minimize the intake of beverages and foods with added sugars, like soft drinks (also known as "liquid candy"). If you have been telling yourself that it is natural to gain weight as you age and blaming it on your metabolism...think again. Maybe it is simply because, on average, Americans are taking in 19% more calories than they were 40 years ago. Where do those excess calories go? Straight to your waistline. To read the entire article, search Dietary Sugar Intake and Cardiovascular Health.

Source: http://circ.ahajournals.org/cgi/content/full/120/11/1011

Goal: Eliminate soda from your diet for one whole week. Don't replace it with diet soda or other unhealthy beverages like sweet tea, milkshakes or energy drinks. Simply drink plenty of cold refreshing water. Do you think you can do it? I did it. This is despite the easy availability of soda in my workplace. While everyone else is sipping down the calories (or the unhealthy chemical sugar substitutes that some experts say are even worse), I treat myself to one cup of coffee per shift and about a liter of water. I rarely crave soda anymore like I used to and every once in a while, when I allow myself to have a single serving...I often wonder why I ever thought it was so great. Where else can you eliminate added sugars in your diet? Can you learn to drink your coffee without sugar? Can you experiment with reducing the added sugar in dessert recipes? What about breakfast? Breakfast cereals are a landmine of hidden sugar. Find a tasty one with plenty of fiber and no high fructose corn syrup. I bet you will be surprised at how difficult that is. An easy solution is plain instant oatmeal (plain is the only one with no added sugar) with fresh fruit, nuts, and cinnamon sprinkled in. Delicious! I also like raisins, pure vanilla extract and hazelnut in my oatmeal. I've even added unsweetened cocoa to make it a real indulgance! And for a cold indulgance, try my sister's recipe for homemade granola. Store bought granola has an unearned repuation as a health food. Most have outlandish amounts of sugar and high fructose corn syrup. My sister relies on a small amount of honey and dried fruits to sweeten hers.



Val's Homemade Granola:
3 cups old fashioned rolled oats
3/4 cup slivered almonds
1/2 cup sunflower seeds
1/2 cup unsweetened coconut
1/2 cup wheat bran
1 teaspoon ground cinnamon
1/4 teaspoon salt
1 teaspoon vanilla extract
2 tablespoons butter
1/2 cup honey
1 cup dried fruits (raisins, dried cherries, dried cranberries, etc...)

Melt butter in small saucepan. Add cinnamon, salt, vanilla extract and honey and stir to combine. Combine remaining dry ingredients (except dried fruit). Pour honey/butter mixture over and mix well. Spread on two baking sheets in thin layer and bake 20-25 minutes at 325 degrees F. As soon as it comes out of the oven, break it up and mix in dried fruit. Store in airtight container. Enjoy dry or with milk or soy milk.

Thursday, August 26, 2010

Lauren's Straight Talk about Health, part two

The second high risk behavior I want to share with you is being overweight. Being overweight sucks. I'm not sure which sucks more. Being overweight or smoking. They might suck equally. If you are overweight AND you smoke, well, you've got issues. I'll be seeing you one day. The thing is, weight is a continuum. Smoking is an all or nothing thing. If you quit, you have to quit completely and never do it again. Eating, now that's another story. You can't give up food. Its the worst addiction to have if you think about it, because its the only thing that you can't go cold turkey on. You have to eat. You have to learn how to do it in moderation. No addiction expert would ever advise you to try just smoking in moderation. You have to go cold turkey or you won't succeed.
And if you're one of those people who thinks that their weight is not related to a food addiction...please. Tell someone else about your bad genes, thyroid issues and glandular things. Every reputable source I have ever found is pretty clear cut on this. Being overweight is about one thing and one thing only. Calories consumed exceed calories expended. Plain and simple. There is one and only one weight loss approach that is effective. I'll even tell you it for free. This is not a difficult concept. Close mouth, move ass. There is no colon cleanse, detox regiman, secret herb from the jungles of the African Sahara (hehe) special combination of foods or mantra that will alter this cold hard fact.
I am not trying to say that overweight people are just fatasses with no self control. There ARE a plethora of different situations that CAUSE people to consume more calories than they expend. Psychological issues, mobility issues that limit ones ability to expend calories and yes, even glandular issues. Those issues are only exacerbated by excess weight though, so if you don't deal with the underlying problem and get on your way to a healthier weight than you will only make those problems worse. Using it as an excuse to justify excess weight is a really bad idea.
I have seen people die for no other reason than an inability to control their weight. Diabetes, high blood pressure, high cholesterol, poor circulation, chronic pain, degenerative joint disease, anxiety, all manner of psychological disorders (if you can't get a handle on your issues with eating, then why would you think you could manage any of the other stressors in your life very well?) nonhealing wounds and skin breakdown, oh my! Granted, I know that not everyone who struggles with their weight is morbidly obese, but if you aren't headed the correct way, towards a more healthy weight, then you're most likely headed in the other direction which is morbid obesity; few people just get somewhat overweight and then stay there.
Here's the thing. I love fat people! I am not a fat phobe. I have had excellent relationships with some of my fattest patients. Also, I have some food issues myself. I have found myself elbows deep in a carton of Chubby Hubby ice cream at 2 oclock in the morning and wondered whether it would be totally insane of me to go to the store for some more because one pint was surely not going to be enough. I comfort myself with food. If I had anything to be depressed about (which I don't) I would probably weigh a metric ton. I'm writing this blog as much for myself as anyone out there. I would never ridicule overweight people gratuitously. I would never ridicule them at all.
The problem is that a lot of people who ARE overweight have not been counseled by anyone to lose weight BECAUSE it is such a sensitive issue. Your average doctor will sit there all say talking about your high blood pressure reading and the cold hard facts of what that means medically, but shys completely away from dealing with the numbers on the scale because its uncomfortable and embarassing to talk about weight. Plus, you can't look your doctor up and down and throw his own blood pressure numbers back at him, but he's secretly afraid that you WILL say something about his weight if he starts talking to you about yours.
As a society, we feel completely comfortable with criticizing and chiding those who choose to smoke. However, if we mention someone's weight, as in, "You really should think about losing some weight Deloris. Its gonna kill you someday you know," that's totally unacceptable social behavior. Why? Why is one ok and not the other? I'm not advocating that we start or continue giving anyone a hard time, whether smokers or overweight people. I'm just pointing out an interesting disparity. I happen to have one of the good doctors. One who isn't afraid to throw it out there. At 30 my cholesterol is a smidge above normal, my resting blood sugar is a trifle troubling and my abdominal circumerference is one eensy weensy inch beyond the cutoff for being high risk for heart disease. She flat out told me; "Lauren, you either lose 5 pounds and stay at that weight or don't and you'll be a diabetic in 10 or 15 years." I wouldn't appreciate hearing that information from, say, my hairdresser, but I kind of appreciated her candor since she is the person I pay to give me unpleasant facts such as that. I lost the 5 pounds and I'm doing everything I can to keep it off. I do NOT want to be a diabetic. If you can't count on your doctor to drop little bombs on you like that, then fire your doctor and find one who will.
So. in closing, don't get fat. If You ARE fat already, lose weight. If you are impossibly skinny and you can eat whatever you want to and not gain weight, you suck. Go back to your home planet.

Lauren's Straight Talk about Health, part one

OK, I'm not a public health expert. Nor do I work for the CDC. I am just a wee humble ICU nurse who has spent the past 7 years (amongst other things) taking care of the sick and dying amongst our society. And in that time, I have noticed a few things. For lack of any better inspiration on what to write about on my blog I'm going to do a straight talk on health series. If you have delicate feelings, please avert your eyes and back away from the computer screen. If you appreciate getting your health information in CNN formatted, Dr. Sanjay Gupta type sound bite form, this won't be for you. I tend to ramble, expelling lots of unnecessary information along the way. Self editing is not my strong suit.
Let's assume that you, like most people out there, want to live a long and healthy life. Let's assume that you have at least a smidgen of interest in that. From the front lines, I can tell you what is making people sick these days. I can tell you what causes people to die in their 60's. Now, I know that there are a lot of people who will scoff and say, "What do I want to live to be OLD for? I'd rather live my life and enjoy it! Who wants to live to be a hundred anyway?"
First of all, I do. And I can tell you that I have seen a lot of really old people who are in their 80's and 90's who come in to my ICU and say, "I don't want to be rescusitated. I've had a good life. I'm at peace no matter what happens." I have seen a lot of people in their 50's and 60's who come in and are really sick and I haven't met a single one yet who says, "Well, I didn't really want to be old anyway. I'm ready to go." Funny thing about that. Old people = at peace and ready to die. Middle aged people = bitter, sad and not ready to say goodbye to their loved ones yet. I love taking care of the really old ones. Sometimes we even send them home for another 5 or 10 years. The 50 and 60 year old sad and bitter ones? Not so much fun.
So if you don't want to be 50 or 60 and sitting in an ICU bed waiting for death to take you, you might want to pay attention to what I have to say. Because I have just about narrowed it down to a few risky behaviors that put you at extremely high risk for being one of my patients. I haven't ever actually crunched the numbers but I'm pretty sure about 90% of the people I take care of fall into one of three categories. They smoke. They are overweight. They drink more alcohol than what would be considered moderate. These three things just about sum up the modifiable risk factors (read: you can control and change them) that cause a vast majority of the many acute illnesses that bring people into the ICU and often kill them.
I'm going to address the first of these today. In my opinion, one of the top things you can do to ensure that you will not live long enough to collect social security...
Smoking. Duh! Are you an idiot? Remember when we were kids and they used to tell us that if we smoke we might die of (gasp!) lung cancer? Well, "they" didn't know what they were talking about. If you smoke and you get lung cancer, that sucks. Yeah. Its a pretty sure likelihood that you will die. They might try to save you by cutting out part or all of your lung, putting toxic chemicals into your body to try and kill the cancer (without killing you...a tricky task), and then see how your other lung, the one you've also been inhaling poisenous gas through for years, handles it. However, its highly likely that you will just die. Case closed. End of story.
The real horror story, though, is not what MIGHT happen to you in the form of cancer. The really tough stuff is the chronic obstructive pulmonary disease that you are virtually guaranteed to develop in your middle years as a result of smoking. If you smoke, you WILL have COPD. Count on it. What is COPD, you ask? Its what causes smokers to slowly lose any and all tolerance for physical activity as they get older, until they end up living on the couch, hooked up to oxygen, still smoking (thereby putting everyone in their near vacinity at risk for dying of an explosion when their tank catches fire)and waiting to go into respiratory failure. This is no sudden death. COPD kills you slowly, over 10 or 20 years, in a gradually increasing web of personal misery culminating in a horrifying death of, basically, strangulation. I have seen people in their 50's and 60's who live on the couch. They come in to the hospital in respiratory failure, still reeking of cigerette smoke and we try to stabilize them. Sometimes we succeed with breathing treatments and such. Other times we have to intubate them and put them on a breathing machine. We keep them intubated for several days, do the best we can to fix whatever underlying thing caused them to go over the edge (whether it be pneumonia or just an exacerbation of their COPD)and if they are lucky, we extubate them a few days later. The first thing a lot of them ask for is a cigerette. Sometimes we aren't able to stabilize them for a long time and then we have to send them off for a tracheostomy. That's when they cut a hole in your neck for you to breathe through. That we we can easily put you back on the breathing machine if it becomes necessary. There is one certain thing: And remember, I have seen this happen many times and followed the same people who come in again and again with the same issue. Eventually, these people die. There is a downwardly spiraling continuum of what happens in every single case. At first, its just coming in to the ER with CBS (can't breathe syndrome) and getting tanked up with some breathing treatments and nebulizers. This tends to become normal to them after awhile, to the point that they know the EMS guys who come to their houses to get them when they dial 911 and can just about tell them exactly what to do to fix them. Then, they might get admitted to the floor with mild pneumonia or emphysema a few times. Eventually they will be in total respiratory failure and have to be intubated. If they survive that a time or two, they end up trached. The family will eventually have to make the decision whether they want to intubate AGAIN. If they make that decision, then awhile later they will have to make the decision to pull the plug. Because it doesn't get better at that point. It is a chronically degenerative disease, meaning it gets worse over time, not better. And if you don't smoke, it is virtually guaranteed not to happen to you. If you do smoke, it is virtually guaranteed to happen to you.
That's if your heart doesn't give out first. Because did I mention that smoking also causes hardening of all your blood vessels, putting you at very high risk of heart attacks, pulmonary embolisms and strokes? I frequently see people in their
30's and 40's who come in with their very first heart attack (aww, isn't that cute?) and the only risk factor they have is smoking. They look at me like I'm nuts when I tell them that it was smoking that caused their heart attack. How come their high school health teacher didn't mention that? They thought they only had to worry about lung cancer!
So if you don't want to die young or spend your final ten years or so in and out of the hospital, QUIT SMOKING knucklehead! It doesn't get any easier the longer you wait. And even if you do smoke and you've begun to experience the downward spiral that is COPD, quitting smoking will vastly improve your quality of life. Even though you may not be able to totally reverse the disease, quitting will most likely buy you some more time here on this Earth. I have heard every excuse known to man for why people smoke. You can blame it on whomever you want, but in the end, its you who will die because of it. In my opinion, the medical community doesn't do enough to stress the importance of quitting smoking. The pharmaceutical industry has some really cool medications they want to put you on to help you "manage" your COPD. Your primary doctor will eventually refer you to a pulmonologist to help you "manage" your disease. At the hospital we have a really helpful handout that we give to you to advise you of the benefits of quitting. The long and the short of it is that the only reasonable treatment is to stop immediately and hope to God that you haven't done any irreversible damage.
Those of you who don't smoke are probably nodding your heads smugly, saying, that's right! Dumbass smokers! Your all gonna die! Well, we're not through yet. We have a few steps to go before you can decide if you're likely to live a long and healthy life. And remember, I'm only talking about modifiable risk factors here. You can't change your genes. If you have bad genes, then you REALLY better listen, because you need to do everything you can to not make matters worse. Be sure to stop back in a few days to read my scintillating thoughts on being overweight and what that means for your health.

Wednesday, July 14, 2010

Duppy

The other day Sofia started using the word "duppy" quite frequently. It's not the first word she's invented. Anyone who has hung out with us knows about her "deedly deedly doodly doodly" sing song voice that she speaks in. It's a largely self-invented language in which she makes up a rather convincing sounding sentence, finishing with a single comprehensible word which may lead the listener to assume that he or she simply didn't understand the first part, but that it was indeed a complete thought. This is ever so slowly morphing into scarily complete sounding sentences as she has begun to fill in the doodly doodly parts of the phrases with actual, discernible, honest to goodness words. Duppy, though. Duppy is her own word. She invented it to describe the action of bending the knees, then extending them in a sudden motion that results in a short separation from firm ground into the air. Jump?, you say? Yeah, sort of. Duppy. She hops around in the house saying duppy duppy. She holds my hand when we are crossing the parking lot and spontaneously duppies every few steps. I was able to successfully teach her not to duppy her way down the stairs. However, she now walks solemnly down the stairs, one step at a time, and when she reaches the last step, she yells "duppy!!!" and rockets off the last step onto the floor. So stinking cute.

Tuesday, May 11, 2010

This One's for You, Flo






For Nurses Week the night shift ICU nurses had a retro nurses night. We all showed up to work in our whites with nursing caps and everything. It was GREAT! The day babes looked at us like we were nuts (we are) and the other nurses from around the hospital thought that the ICU had been overtaken by nursing students. One of our more alert patients saw us all parading in at the beginning of the shift and asked, "Are those new graduates?" My patient, on the other hand, was more concerned with the coldness of our ice water (it wasn't...cold enough I mean) than what her nutjob nurse looked like.

Monday, April 26, 2010

The Bill of Night Shift Nurses' Rights

1. All evening and early morning appointments should be offered to night shifters first. Nobody asks you to get up at 3 AM to go to the doctor.
2. It shall be prohibited for your place of employment to call at noon to see if you want to work that night. Nobody calls day shift workers at midnight "just to see".
3. If the sign says "Night Shift Worker Asleep Inside" DO NOT KNOCK OR RING THE BELL!
4. It is entirely appropriate for night shift workers to have a beer at 7:30 in the morning. For us, its early evening. We just finished a long hard shift and we need to unwind. Quit staring. What are we supposed to do, have a beer with dinner before we go to work? That wouldn't go over well with the patients...
5. Shananigans that go on at 2:30 in the morning (such as attacking co-workers with pre-filled syringes of normal saline) are an extremely necessary means of staying awake when the rest of the world is resting peacefully in their beds.
6. Any empty beds in the hospital are up for grabs.
7. Starbucks should make 3 am rounds. They'd make a fortune.
8. Any tricks played on the Day shift are simply a coping mechanism.
9. Anything that happens after 5 AM becomes a DSP (Day Shift Problem) by virtue of the fact that there's a lot more people around during the day to handle such things.
10. Staff Meetings at 9AM? Yeah, as if. See you tonight.

Saturday, April 24, 2010

The Drama Queen

Sofia is a major drama queen. I woke up from a sound sleep yesterday (it was 11:30 AM and I worked the night before, so I was sleeping) to the sound of Sofia screaming. Hugo was down there with her and I figured he probably had it under control, so I tried to go back to sleep. She continued to cry in various degrees of distress for about 45 minutes, so finally I went downstairs to investigate. Hugo informed me that she had scraped her knee on the sidewalk outside and was having a hard time moving on. He had kissed it, applied antibiotic ointment, given her tylenol and a sippy cup with milk all to no avail. He had her favorite program on the television, one she usually only gets to watch at bedtime. She was still freaking out.

My appearance on the scene did not help matters, I'm sorry to say. Her wails began again with new urgency. I cuddled her and fussed over her for a good hour to give Hugo a break, and then retired back to my room. After all, I had to go back to work that night. Later on that afternoon, I woke up to the sounds of her crying again. She had finally passed out from shear exhaustion, and upon waking from her nap the drama began once again. Good Lord! If you've ever seen a 2 year old limping you might know what I mean. It was adorable and pathetic.

She has used the experience to add a very important word to her vocabulary...booboo. For those who have heard her speaking in her own little language, I will try to approximate what she sounded like. "Diddly diddly BOO BOO, Mama. Deedly Deedly BOO BOO." Hopefully by the time I get home from work this morning she will be sufficiently recovered from her trauma. I love her in the morning. She almost always wakes up in a good mood. I certainly hope she retains that quality as she grows.

Thursday, January 14, 2010

Lesson on Parenting No. 999

...The vessel in which the food or drink is served is of greater importance than the food or drink itself.
Example 1: The subject (one 19 month old female heretofore known as "Sofia") is offered a sippy cup with water in it. Though she frequently accepts said sippy cup with milk in it, she flatly refuses to take more than the one sip of water from it, leading this researcher to believe that the child does not, in fact, like water. However, Sofia is then offered a second drink of water, this time from her mother's gigantic purple water thermos that she uses to down unnatural amounts of water while at work for the purpose of staving off the dreaded UTI. This time, the subject happily downs several ounces of the stuff, while simultaneously getting several more ounces of it all over herself and the carpet.
Example 2: Sofia is offered a bite of delicious macaroni and cheese florentine that her mother spent hours (or at least a half hour) slaving over the oven to prepare. She sees green and immediately turns her head, with a look upon her face that clearly indicates she will not be trying any of it, even though this researcher knows she will love it if she can just get one bite of the stuff in her mouth. Thinking, the researcher gets up and rummages through the cupboard until she finds a baby food jar. She smashes the macaroni and cheese florentine into the jar and then offers it to the child. The child sees it coming from the baby food jar and is tricked into trying it. The researcher is correct. She loves the macaroni and cheese florentine.
Fascinating stuff, this parenting.

Tuesday, January 12, 2010

On Second Thought...Maybe I'll Just Stay In

Yesterday I received further education in my voyage to becoming a succesful mom of two. STAY HOME! For some reason I have this foolish idea that I should try to "get out" during the week when Hugo's at work. I spent 30 minutes packing the babies up so I could go to the store yesterday. Did I need to go to the store? No. Hugo had very thoughtfully taken me to the grocery store the evening before so we could get all the food we needed for the week.

I decided to take a trip to a cute little consignment shop down the street that has clothing and furniture for sale so I could "get out" of the house. Hello people. Its not prison. There's no metal toilet bowl. You aren't limited to one phone call. Its home. Its cozy and warm. There's a huge television on the wall, lots of yummy food in the refrigerator and if your 18 month-old decides to yank your shirt down and effect a thorough inspection of your boobs, nobody will see.

So anyway, I bundled the kids up (its COLD in Gainesville right now...like, 30 degrees). I checked both their diapers. I made sure Fiona was fed. I put Sofia's shoes on. I loaded Fiona into her Snugride carseat, put Sofia's shoes on, carried the diaper bag and my purse out to the car, put Sofia's shoes on, loaded Fiona's carseat (with her in it) into the car, put Sofia's shoes on and put her in the car as well, locked the house, went back in for my cell phone, locked the house again and finally pulled out the driveway, while listening to the unmistakeable sound of velcro as Sofia took her shoes off....again. At this point I have realized that having infant shoes be easy to put on is not nearly so important as it is to have infant shoes that are difficult to get off. Though I haven't yet found any she can't get out of yet.

Once we got to the store, I unloaded the gigantic double stroller. I put Fiona into the back slot and, after putting Sofia's shoes back on her...AGAIN...I put her into the front slot. I did not, I am ashamed to report, strap her in. This would be a fact that I would end up regretting. The store, which was delightful aisles of clothing interspersed with antique and gently used furniture when I used to shop there childless was now a maze of crowded stuff with tantalizing bits and pieces hanging out for Sofia to grab onto and pull off the hangers, plus lots of annoying metal feet for my to run into with the too-wide stroller. I was navigating through valiantly though, when Sofia, unbeknownst to me, managed to stand up in the stroller and toppled over to the horror of the people around us.

Let me give you a little description of what it looked like though. She was wearing this very warm and adorable coat that my in-laws gave her for Christmas, which is puffy and well-insulated and has a huge hood on it, making her resemble a cross between the little brother in A Christmas Story, when his mom dresses him in his snowsuit, and a South Park character. She can't quite hold her arms down and she has very limited peripheral vision. So, when she toppled over, she was well insulated for the fall and I knew she wasn't actually injured, so the event had a certain hilarious quality to it, with her laying there on the floor with her arms akimbo, screaming offendedly and unable to actually roll over and get back on her feet. All the concerned passersby were mildly horrified by my irresponsibility and my insensitive nature. Sofia needed to be fluffed back into my good graces and at that point, I came to the realization that "getting out" is highly overrated.

So I tossed them both back into the car, loaded the behemoth into the back and went straight there. Where I still am now, in my pajamas at 2:30 in the afternoon. Sipping on my second cup of home brewed coffee today, while Sofia takes her afternoon siesta and Fiona lies contentedly in her Boppy, gumming her fist. No judgemental passersby invited. If you need me anytime in the next 4 years or so, feel free to stop by.