Marriage Vs the Kids

Happily my post about the benefits of co-sleeping generated a few spin-off posts in the blogosphere. First, reader Melissa reposted what I wrote to her blog, which generated some interesting questions beyond the mere safety or healthiness of it: for instance, about whether a marriage (and sexual intimacy) can survive having a baby in the bed. She responded with her own viewpoint here.

Then Dana Willms wrote the post "Children vs. the Marriage" in which she addresses some of the broader problems brought up by objections to co-sleeping: that parents need to position themselves as a unit apart from the children, or rather the family altogether. She quotes from yet another blogger about the necessity of having 'date nights' away from the kids. Now, I'm a fan of date night, and alone-time with my wife, but I loved this paragraph:

In the 6 years since I’ve been a mother I’ve probably gone on about a dozen “dates” with my husband....I can’t say that any of these dates—even the overnight trips—are particularly memorable to me as bonding events for my marriage. They are pleasant events that provide a chance to relax away from the kids, yes, but bonding? Not particularly.

What I do find to be a bonding experience in my marriage is sharing in the joys and struggles of raising a family together. Nothing has made me love my husband more than seeing him gently hold our newborn babies, examining the contrast between their tiny hands and feet and his larger ones. The memories that we hold dear and reminisce on together are of working around our house—with kids underfoot for the most part. Often having the kids underfoot is what helps to lead to the situations that are so memorable and bonding. One time when I asked my grandmother—who raised 5 children and had been married for about 55 years when I posed the question—about the necessity of date nights she assured me that she and my grandfather had rarely gone on dates until after the kids were out of the house, and that her belief was that mature adults would find everyday life more bonding than dates away from the kids.

Pretty much. Some of the best conversations I have with my wife are while we're driving the kids somewhere, or we have a wiggling baby in the bed who thinks it's party night (and who would be screaming if they were in a crib). We bond on our dates alone, certainly. But I would think, in general, the everyday life of any happy marriage should be a bonding experience.

Day in the Life of an ICU Nurse's Aide

helped change someone's skin tone from grayish-yellow to rosy pink!

It's amazing what 8 units of blood, 7 of platelets, 6 of plasma, 4 of cryoprecipitate, some vitamin K and desmopressin, and bags and bags of crystalloid solution.

In all seriousness, it was an extremely long and busy day for the nurse who had this patient, and I felt more than helpful in being able to coordinate all these transfusions and infusions with the blood bank and pharmacy (no easy task) and then physically run them to the room for the nurse who was basically attached by a chain to the bed of this patient who was basically bleeding out in front of us—i.e. an initial hemoglobin of 4 (!) after four units of packed red cells only went up to 5 (!!). The big problem? The patient was not only bleeding massively but also (due to some other complications) had an acutely failing liver, so there were no clotting factors. I've never considered the fact that you could be bleeding massively in a way that can't be fixed by a surgeon because you have no ability to clot—any surgical manipulation would just cause more bleeding. In this case, it's essentially the nurse who saves you—dumping fluids and blood and clotting factors into your body while everyone hopes your lab results show your clotting times have improved enough to go to the OR.

The unit I was on is not a trauma unit and does not often handle rapid bleeders. She (the nurse) really felt like she accomplished something, that she really saved this guy. At one point she yells to me "I've got pink nailbeds!! I've got a pressure! I've got capillary refill!!!" It was very, very cool to be a part of helping save someone.

(In case you're wondering, I did pass nursing school but haven't taken my boards, and you can't work as an RN until then!)

Co-Sleeping: Does It Really Need To Be Explained?

It is recommended that your baby shares a room with you for at least the first 6 months, as this helps with breastfeeding and protects babies against cot death.
(From the UNICEF UK Baby Friendly Initiative and the Foundation for the Study of Infant Deaths)

It amazes me that people have concerns about co-sleeping. People seem to really think that they'll roll over in their sleep and crush or smother their baby. Do you roll off the bed onto the floor at night? Do you roll onto your spouse (I mean, in your sleep, not in an effort to start something)? You have proprioception, or spatial awareness, even in your sleep. That's why you don't fall off the bed every night. I mean, if you fall off the bed every night, don't co-sleep. So it doesn't take long to become accustomed to a baby in your bed. My wife and I have co-slept with four kids (including two babies at once) and have never had the slightest problem.^*

I've read a few articles about 'co-sleeping deaths', but they all seem to revolve around a few themes: alcohol; parents who don't normally co-sleep falling asleep on the couch with a baby; infants being left alone in adult beds; and obesity. None of these apply to the average co-sleeper. The fact is that if a non-co-sleeping parent gets drunk and falls asleep on the couch with their baby and the baby dies, this is reported as a co-sleeping death. That's not co-sleeping! There are hundreds of not-newsworthy SIDS cases where a baby died the "safety" of an unwatched crib. I can't help feeling that some of those deaths could have been avoided by safer sleeping practices; practices which exist in most of the world outside the United States.

The sad thing to see is the stress some parents go through when they insist on crib-sleeping their infant. I've seen parents intensely frustrated (at their baby!!) because their infant won't sleep unless, say, they have a hand on its back, and they have to sit up half the night next to the crib. If the baby obviously wants is proximity to the parent, and the parent wants sleep, these can both be accomplished IN A NORMAL BED! Co-sleeping is so easy compared to crib-sleeping. I don't understand the rationale of locating your child away from you, so that they're fully conscious and screaming before you get to them. A fussy co-sleeping child can be nursed or held or rocked back to sleep while they're still half-asleep.

What I really don't understand about co-sleeping is the fact that we talk about it at all. Why is there even a term for it? Doesn't it just...happen? You lay down to nurse your infant and they go to sleep. Going through the ordeal of buying a crib and organizing an entire separate room of the house around it and then trying to wean your child into sleeping alone after they've been living inside you for nine months...that's an epic process that deserves a term.

* Except being nudged, pushed, or kicked by a little six month old who somehow manages to own half of a queen sized bed to itself...

Open ICUs Are Good for Patients

I already spoke in support of open ICUs.Here's some stuff more or less in the way of evidence.

Way back in 2004 a commentary was published in JAMA proposing open ICU visitation. It addressed three main objections staff raise: that family members stress the patient, that family gets in the way of the staff, and that families can't handle the stressful and gruesome sights of the ICU. I think families getting in the way and being grossed out can be handled judiciously by the wise nurse. A nurse who can't use confidence and discretion to skillfully manage visitors is not a good nurse for the bedside experience.
But as for patient stress, I thought this was interesting:

The concern that the patient should be left alone to rest incorrectly assumes that family presence at the bedside causes stress. The empirical literature suggests that the presence of family and friends tends to reassure and soothe the patient, providing sensory organization in an overstimulated environment and familiarity in unfamiliar surroundings. Visits of family and friends do not usually increase patients' stress levels, as measured by blood pressure, heart rate, and intracranial pressure, but may in fact lower them. Nursing visits, on the other hand, often increase stress. (emphasis mine)

In January of last year, Paul Levy analyzed this from an administration point of view, and describes eliminating ICU visiting hour restrictions. He received many professional comments, not all of them pleased. These he addressed further in a guest post here.

There's also plenty of 'open ICUs are coming! it's the end of the world!!' discussion on allnurses. The nurses there bring up one point not addressed in that JAMA article: HIPAA violations. Letting visitors in for more than 15 minutes every four hours is somehow going to violate privacy regulations left and right. And yet, somehow they accomplish this on the regular medical floors, and in psych units where HIPAA probably applies more than anywhere. One ICU I worked at utilized passwords—you know, the patient or next of kin makes a password, and no info is given over the phone or in person without it. And for large families, they had no qualms asking for one person (preferably the DPOA or closest kin) to be the point of contact between the family and the physicians and nurses. So it's not the end of the world.

The revulsion some nurses have for open ICUs kind of gets to the crux of the matter: these rules are there for us, not them. I understand that you don't want families in the way, but this patient is not yours. They belong to themselves and their families much more than they belong to you. It drives us nuts when a physician is there for five minutes making decisions without your input for a patient you have for twelve hours. How do you think an informed, prudent family member or visitor feels when you, who they've never met, treat them like an intruder?

Last month Levy described the nuts and bolts of opening ICU to visitors, and how they made innovative changes to reform the ICU experience for patients and families, such as (something I've thought of!) pagers for families so we can reach them. How often does the physician arrive for his momentary daily visit just after the family, after a 16 hour bedside vigil, went to find a much-needed cup of coffee?

All in all, I think the open ICU, with reasonable restrictions and useful innovations, is just how it's gonna be. So it irritates me now when hospitals fail to implement it.

Do Not Resuscitate Orders - and Spouses

I hope I don't get in trouble for this, but somewhat recently in a hospital somewhere (I'm shying away from patient details!) we had a more-or-less terminal patient in the ICU—you know, end-stage heart failure and renal failure and so on. I can't remember the initial insult, unless it was just old age.

At any rate, this patient wanted to be made a DNR. They were fully awake and aware and had already been subject to resuscitative efforts in the past. But the spouse said no. A few nurses spoke with the spouse and said that we weren't talking hospice or withdrawing treatment; the patient wasn't actively dying; just that if the patient began to die, we wouldn't do CPR or push drugs or defibrillate or put them on a mechanical ventilator. The patient agreed with all of this, but the spouse still said no.

Spouse said they'd never heard of someone's heart stopping unless they were "really dead". We said we do that all the time. Hearts stop (or go into a downward spiral) and we very aggressively make them start again. Breathing stops (or begins to fail) and we intubate and ventilate. These measures are good, but they're rough on patients, and if you're very elderly and frail and in pain, they're the farthest thing possible from a peaceful death. Very often we go through these measures and THEN the family decides to make them a DNR, which is, objectively speaking, silly and useless.

All this was reported to the physician, who essentially said that the surviving spouse, and not the patient, is the one who will sue us, so we can't obey her wishes. This is not at all legal, but it's a fact of life.

I can't say there's an easy solution to this, though. I can just imagine a court trying to decide that this patient, frail, diseased, old, on strong medications, irritable, sometimes yelling at people, was mentally capable to make themselves a DNR. But as I've said before, psychiatric patients who hear voices telling them to kill people have more rights to make decisions for themselves than medical patients do.