The neuromuscular blockade: paralysis on purpose.

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When you're a new RN like me, you don't really know what crazy things you'll be expected to do during the day when you clock in to work. For me over during some recent shifts, it's been keeping a young patient chemically paralyzed.

Chemically-induced total paralysis, or neuromuscular blockade, is a treatment for severely critical pulmonary conditions like ARDS; in other words, anytime you need increased lung compliance or the patient's really fighting the ventilator. They also use it for oscillatory ventilation. These vents were formerly used only in the neonatal ICU, but they're being used for adult trauma and ARDS patients as well. When a patient's put on an oscillator (or jet-vent), their lungs are essentially kept permanently inflated with high pressure, and small, rapid waves or oscillations of oxygenated air are sent into the lungs. The patient's "breaths" are extremely rapid, and the machine is very noisy, grunting away at (if I remember right) something like 180 waves per minute.  Oscillators for adults are kind of a last-ditch effort but I've seen young trauma patients pull through them. It's a very unstable thing, usually requiring the RN to be in the room pretty much the whole time. Let me tell you, hearing the rhythm of an oscillator for 12 hours straight is something you don't easily forget.

Back to paralysis: the obvious first problem with it is that you paralyze the diaphragm, so they'd better be on a ventilator. The second, more clinically important problem is that paralytics don't sedate the patient at all, or treat pain. You can be chemically paralyzed and completely awake. So we always, always sedate first, paralyze second. However, as the nurse you have to be constantly watching for signs that the patient is too awake. Typically we go by heart rate or blood pressure. If you do something to them and their heart rate or BP spikes, you know they're more aware.  I was even in a room with a patient once (not my patient) when the residents were discussing a planned surgery and the patient's heart rate skyrocketed. I tend to err on the side of caution and titrate the sedatives on the high end.

The other problem is the neurological exam is really limited. All you really have to go by is pupillary response. The pupil's muscles are contained within the blood-brain barrier, so paralytic agents don't affect them, and pupils continue to react to light. This is the only really tangible sign that a person's still "in there" when they're paralyzed.

These are things I don't even remember discussing in nursing school. And when we were hired, the pharmacist who reviewed them with us (introduced them, you could say!) alerted us to two things: one, we're going to be better experts on using these drugs than even the physicians are, and two, these are the most dangerous drugs used in the entire hospital.

Pretty wild.

I can only HOPE to be eaten by hermit crabs.

We just bought hermit crabs for the kids. We purchased four because apparently they're not really hermits at all; they travel in large groups, even hundreds, on the beaches of Central America. They climb on each other, wiggle their antennae in each other's faces, steal things and hide them, pry other crabs out of their shells and force a swap, and engage in all sorts of other wacky hijinks social hierarchical behavior. Also they chirp. And a couple of them will very nearly launch themselves out of their shells when you pick them up.

We've been reading The Hobbit to the kids, so the kids named them, in order of size: Bombur (pictured above), Fili, Kili, and Bilbo.

There's endless information about them online: what shells they prefer (murex or apple snails apparently), what they'll eat (apparently anything), etc. Reading about hermit crabs led to reading about the biggest hermit crab of all, Birgus latro, the coconut crab or robber crab, which is HUGE - the largest arthropod on land.

Photo by fearlessRich

It doesn't even bother with a shell (only their young do), can break open coconuts, likes to steal and hide shiny things like pots and pans from people's houses in the tropics, and ate Amelia Earhart.

DID I MENTION AMELIA EARHART WAS EATEN BY CRABS.

Or rather her remains or bones may have been eaten or hidden after she succumbed and died while marooned on the island of Pacific island of Nikumaroro. Some Caucasian female bones were found among the giant coconut crabs in the 1940's, and in 2009 an expedition found a US-made zipper pull, a heel of a size 9 1930's-era Cat's Paw women's boot (check those out, they're pretty sweet), a navigational sextet, and some Plexiglas and other possible plane parts.

Nikumaroro

That's the interwebz for ya. You just want to find out how to set up a hermit crab terrarium, and you somehow spend hours reading about 1930s aviators, their footwear, and the crustaceans that ate them.

"Sugar Does Not Relieve Newborn Pain"

In nursing school we were told that infants didn't really need pain relief for needlesticks, IV starts, circumcisions, and other painful procedures; they just needed a pacifier dipped in a heavy sucrose solution. The sucrose solution elicited a sort of euphoria which blocked the pain, and possibly amnesia about the event so they didn't grow to feel rejected and abandoned in a hostile environment.

What a load of crap, we all thought. None of us believed it. I don't think the nursing instructors even believed it. There's not even a good physiological explanation for it. Yet it's a thoroughly established practice.

An interesting article from Peaceful Parenting highlighted a Lancet published study which showed that oral sucrose doesn't block pain in infants. Rather, it occasionally changes their facial expressions, which alters the caregiver's impression of their pain. Spinal cord pathways and brain activity related to pain reception did not change whether infants were given sterile water or sucrose solution prior to a painful procedure. Other infantile reflexes related to discomfort were not significantly different, either.

It's nice to see non-evidence-based practices being knocked down. However, I think it might be a long time before busy obstetrical and neonatal clinicians take this study (or, in general, the effects of pain on infant bonding, feeding, and neurological development) very seriously.

Blocking Formula Advertisements

Last year's semi-humorous, hopefully informative post on why Dads Prefer Breastfeeding received a surge in pageviews, Facebook links, and comments just recently. Which is awesome. What isn't awesome is that multiple commenters complained that my page was covered in formula company advertisements - namely, the ads served by Google Adsense. Now, I'm not completely against formula in all instances (for example, we had to use it once for our 8 month old baby when a subsequent pregnancy dried up my wife's breastmilk supply) but I'm not inclined to advertise for formula in an article that's all about why breastfeeding is the physiologically better thing to do.

It's kinda strange that a keyword-driven ad server like Adsense would deliver formula ads on a breastfeeding article, but it seems that formula companies target keywords related to breastfeeding. If that's true (as it seemed to be in my case), that's pretty nefarious.

Adsense only provides a way to block broad categories, i.e. cosmetics. However, a quick Google search revealed an excellent guide written by Lauren Wayne on how to block formula ads with Adsense using Adsense's competitive ad filter.  She even went through the "tedious and herculean" task (I can imagine) of compiling a list for you to copy and paste into the ad filter. While some of the listings seem innocuous (i.e. Target), apparently formula companies use sister sites to advertise their products.

The list is very exhaustive. It took all of three seconds to Select All, Copy, and Paste it into my filter.  Since I never saw the formula ads myself, I'm asking you readers to tell me how well it's working!

The effort to do this was apparently inspired by blogger PhD in Parenting's successful efforts to get a formula advertisement opt-out on the BlogHer blogging platform. And it's all based on the "WHO Code", the World Health Organization's code of the marketing of "breastmilk substitutes" - an interesting document in itself, worthy of another post!