Back Home/Apple falls not far....

Got back after a bit of an issue with the truck near Spokane, but home. It's Seattle redux, 40's and raining, the snow is gone, hear me?, gone from my yard. In April. Unheard of....

Anyway, the time with the Adorable Grandchild was so good........she's a fabulous child

No idea why she's sideways in the pic, anybody?

While there, one evening my oldest brought out a pic of her sister, in 1999 I believe....I remembered it, it was on the front page of the Seattle Times......I was in Chicago as I remember, for those days, at the ATA conference. I got a call saying my youngest had made it 'above the fold' as the newspaper saying goes. She was maybe 16, skipped school and demonstrated with the other anti-WTA people. I should say at this point she came home afterward, did not, repeat, did not take part in the anarchist stuff....

But.....I remembered a time, years ago...

A pic I've posted before, 1970, after the Kent state incident. I'm in the middle, white shirt.

Anyway, nowadays, protesters often wear masks over their faces, scarves, etc. Not my kid. Nope, nope, nope...

The one in the middle, no mask, whistling, two fingers method I taught her?  Yeah, my kid.

What can I say.....

I'm proud of her, then and now. She's managing a buisness now, and doing it well.

The road home

The drive back starts at 5am, hope to get home by mid-afternoon. The only hitch will be whether or not the Montana border guards will search the truck. One holds up his paw to stop the vehicle, the others come around and sniff for things like sandwiches and snacks.

I'll pick up a burger in Spokane and hope that get's me across.

A little background......

The granddaughter Fiona is off to bed, and I have some quiet time, so here's a little of her history.

She's nearing four, and at the risk of sounding like any grandparent, she's bright, insatiably curious, mischevious and full of fun. Active enough to exhaust a NFL linebacker, on the go from the moment she wakes at 6am onward. It's something of a miracle, and I don't use that term ever.

When the first ultrasound was done in my daughter K.'s first trimester, she called me very distraught. Very. It was determined that the forming baby had an giant omphalocele. In brief, that's the condition where some of the organs are outside the body, usually in the abdomen. It can include liver, stomach, bowels. It also means that the organs like the lungs and heart do not develop normally, they are not being held in place by an intact abdomen. They cannot survive a natural birth, a C-section is done. They have a high mortality rate after birth, and over 50% have other issues like cardiac and pulmonary defects. They also have a high chance of genetic defects.

In the next months, my daughter became an expert on the subject, using the research skills that made her a math whiz in school. Fiona was born with a portion of her liver extruding from her abdomen. Seattle Children's Hospital took over her care after birth at UW Medical Center. There are about 5 children's hospitals in the US that use a particular protocol called 'paint and wait', vs. a fairly quick closure of the opening. They put a dressing on it and let the body slowly draw the organ(s)back in, this method has a much higher success rate in many instances.

Omphalocele children often have an extended stay, weeks or even months in a NICU, Fiona was there a matter of a few days, and she was home in less than a month. The next year plus were a busy time for Kate and her husband Drew; caring for the opening while it healed and the liver slowly retracted.  By month three or so she was entirely tube-fed, first through a naso-gastric tube, later they put in a port in her abdomen to her stomach. A result of this, common among this group, is oral aversion. Sometime the child has to be tube fed for more than a couple years.

Fiona hasn't had a tube feeding now in 8 months. Today she gobbled cereal, snacks, a cheeseburger, ribs, mac and cheese, corn on the cob and ice cream. Grandpa is piling on the calories.

I'm glossing over a fair amount here; but on the scatter graph of how well these kids do over time, how many or few complications they have (small bowel obstruction is a common one, cardiac problems another), Fiona is an outlier.....the SCMC docs say they have no experience with one like her. Observing her in her daily life, you'd never know what her prognosis was before she was born.

She is a little miracle.

Watch with me....addendum

Come. They won't know we're here. We'll be quiet.

The picture swims into view, fuzzy at first, then sharpens

The man, his beard once streaked with grey, now completely white, sits slumped in a chair. We can see most of the room around him, toys scattered on the floor, legos waiting for unsuspecting feet. A random piece of a small child's clothing is hanging off the coffee table.

We hear noise, faint at first, then much louder. We instinctively reach for the volume control and find it gone. 

A child rushes into view, blonde hair bouncing. We see the old man's eyes blearily trying to focus on the girl. "Juice!" she screams, causing the man to wince. "I want cheese!!" As we rub our ears, she zips across the room to a large toy box, bending over and flinging toys back over her shoulder. We see the man struggle to his feet and walk unsteadily out of view, as he passes we hear the plaintive word 'sleep' come from his parched lips.

Let us leave them now, we've seen enough. With pity in our hearts we wish him well.

 

Actually, as some of you have guessed, we're having a great time. The tone of the post was just something that occurred to me. 

Missing a step/The mattress suture

I wrote some time ago about this netflix series I've been watching, 'Grey's Anatomy'. I rarely watch network tv, but some how got sucked into this one. There are 9 seasons on netflix, and I'm nearing the end, but it's been at times a slog, with watching 2 or 4 episodes in an evening.

Recently I watched one where one of the residents missed a step in a procedure due to confusion and chaos around them. I suddenly remember once when I did the same thing.

It was several decades ago, in an improvised ER, actually a bunker made of sandbags. I had a young man with a deep laceration on his arm, perhaps 4 inches long and over an inch deep, in one place the bone was visible. I put out the tray and gloved up, in front of me I had all the necessary implements, syringe with lidocaine, scissors, kelly clamps, sutures with a couple kinds of thread.

I decided to use a mattress suture, one where an anastomosis of both the sub-cutaneous and the derma can be closed with the same stitch.

I frankly don't remember whether or not the young Marine had been given any pain meds, I doubt that he had. As I was getting ready to start all hell broke loose. Helicopters came in carrying several wounded soldiers. I was busy for several minutes doing triage, trying to give order to something very disorderly.

I got back to the Marine with the laceration, sat down and started suturing. With all the noise and activity around, I dimly noticed the Marine was visibly wincing and jerking with each suture. I kept on, I'd guess it took several minutes to finish and put on a dressing. Then I cleared off the tray, and saw it....the unused syringe with 10ml of 1% lidocaine under a dressing. I'd just done a fairly major repair of a laceration without even giving the poor kid a bullet to bite.

I promise this'll be the last medical post for a while, spring is trying to get here, and there are fish in the river.

CPR...Better than Nothing, But.....

Rather than get depressed about the sight of snow flurries outside my window, I'll see if I can't make your day a bit more sobering.

CardioPulmonary Resuscitation is historically fairly new; Safar et al showed in the 50's it could be effective as a method, and it became more widely used during and after Viet Nam. (About the only good thing that wars do is further medical science) It has evolved and changed over the years, the most recent update in technique was from the American Heart Association a couple years ago.

Put simply, it's a way of maintaining some circulation to critical areas (heart muscle, brain) until either the heart re-starts, or more definitive medical measures can occur.

It is done by compressing the sternum enough (generally, 2 inches in adults) to squeeze the left ventricle of the heart, pushing blood out the aorta and hopefully to needed areas. Ventilation of the lungs occurs either by mouth-to-mouth, or preferably with a mask/bag, like an Ambu bag. The ventilation part of CPR has been somewhat 'downgraded' in importance, at least in CPR lasting less than 5 minutes.

Now the sobering part: just how effective is CPR? The quick answer is 'better than nothing'. If the heart stops pumping, fewer than 1% will spontaneously re-start. So statistics have been compiled over the past years, and it divides the event into ones that occur out in the general community, and those occurring in a hospital.

As you can imagine, the ones that occur in a hospital have a higher recovery rate. Here's the statistics compiled by the AHA:

Statistical Update	Out-of-Hospital Cardiac Arrest			In-Hospital Cardiac Arrest
	Incidence	Bystander CPR (overall)	Survivor rate* (overall)	Incidence	Survival rate*
					Adults	Children
2013	359,400	40.1%	9.5%	209,000	23.9%	40.2%
2012	382,800	41.0%	11.4%	209,000	23.1%	35.0%

    *Survival rates represent survival to hospital discharge

A couple things stand out: Only 40 percent of cardiac arrest occurring out of hospitals have CPR performed. This is somewhat skewed, many are not witnessed, the person is alone, driving, or something else where no one is around. Of those where CPR does occur, the survival rate is roughly 10%.

You notice also the survival rate in children is much higher. Likely because fewer of them have an underlying heart condition, the heart stoppage is more likely from an accident, or electrical shock, hence the heart is more likely to re-start.

This pretty much correlates with my personal experience. I've probably done more than 200 CPR procedures, only two were not in a medical center. Neither of those two survived.

Now, what is a lot more successful is defibrillation.  Once only available in hospitals, now many areas have portable defibrillators in public places. The principal is that a electrical shock sent through the heart muscle can cause the heart's own electrical system to start working. Statistics are not available yet, but it appears to be much better than only CPR.

I once did a series of measurements of cardiac output (how much blood is being pumped by the heart) during CPR. We used the thermodilution method, and found the average cardiac output was 0.4 liters per minute during CPR. Normal output is around 4-6 liters per minute.

What that tells me is that extended CPR, lasting longer than 15 minutes without the heart re-starting, will rarely be successful. Also, the brain will be without oxygen for that period, and will be damaged. I'm certainly not suggesting that you not do CPR, it should be done until medical personnel arrive. Every once in awhile it'll work and a life is saved.



So CPR has a low success rate, but it's a lot better than nothing.

If you're interested, the current guidelines can be found here:

http://www.cprcertificationonlinehq.com/aha-cpr-guidelines-latest-jan-2014/
 

Fading Reminders

Most days I drive to the grocery store, a habit I got into in Europe where the fridge and storage area was minimal. Each day I pass reminders of what this now-quiet mining town was once. The population has remained stagnant for the last 20 years after a sharp decline when mining stopped. Depending on the source, the population in 1900 was around 70,000, now it's about 25,000. I've been looking at these for years, and like anything you see everyday, often you don't see it; it doesn't register. Signs on buildings were common back then, painted on by hand.

Of course it does, probably arthritis too.

Did you know sheep shearers had their own union?

There were at least two different signs on this building, on the right is Highlander Beer

For those with a sweet tooth all over the world









The last one is not a sign, but a reminder of the town's labor past, and the fact that today it's a blue town in a red state.

April 2nd...it's springtime. Light snow falls outside, the tulips and daffodils are under a foot of packed snow, the lilac hasn't even thought about putting out buds yet.