Monday, March 29, 2010


I taught my nursery class our Easter lesson on Sunday. All seven 2-3 year olds were so excited to learn about Easter, and they asked me to tell the story over and over. I told it at least 4 times. We talked about how Jesus died, was put in a tomb (Me: say Tomb. Them: "Tooooom!"), then was resurrected three days later. They especially loved the part about how the stone was rolled in front of and then away from the tomb. They are cute kids, and it was a fun lesson to teach.

Then during coloring time, I remembered that one of the kids had just had a birthday. So in order to highlight the birthday girl, I asked her, "What did you do on your birthday?"

She replied, "Well, I was resurrected on my birthday."

I obviously got the meaning across very well. Happy Easter!

Wednesday, March 17, 2010

Close Call

This is my dad's plane...
And he loves flying it. Flying makes him so happy that his wife and four children don't really mind his risky hobby. In fact, my mother has worked through her fears and has embraced his hobby. Because Dad is a good, safe pilot, Mom often goes flying with them, and they take small trips together in their little plane.

It was on one of these small trips, just last night, that my dad was forced to make an emergency landing. They lost power, landed on a snow machine road (thankfully not too far from home), and Search & Rescue went to pick them up. The landing was perfect, so my parents and the plane were uninjured. Search & Rescue responded quickly, and their big concern was that Mom & Dad were without heat on a cold evening on a snow-machine-accessible road. They think the plane lost power because the carburetor iced up. This has happened before, and they have taken preventative measures to keep it from happening again.

I spoke with my mother late last night, and she seemed chipper, energetic, and unconcerned. This reassured me enough to be able to fall asleep.

I was at a party when I found out. It was late, and I checked my phone only to find that I had missed two calls from my siblings, who never call that late. I knew something was wrong. The first message I received from my sister informed me that my parents' plane had "gone down", but that they were fine. The second message was from my brother who said, "Why aren't you answering your phone? Pick up your phone! We have news."

These messages left images in my head of balls of flaming metal careening to the ground from the sky, and images of my parents barely escaping the burning wreckage. Of course I was grateful to my siblings for letting me know what happened, and I am so very grateful that Mom & Dad are okay. It doesn't do much to slow my imagination, though.

Ever since our family has embraced my father's passion, we joke that my parents will die together in a plane crash. And quite honestly, for them, I don't think it would be a bad way to go. My dad would probably be smiling all the way to the ground, and my mom would be happy to be holding his hand. And neither of them would be left behind to live life alone.

On the other side of things, anyone who is familiar with Stephanie Nielson's story knows that dying in a plane crash maybe isn't the worst thing that can happen. I have bigger fears than that now.

And last night, when I received those messages, my thought was, "I'm not ready." I quickly found out that everything was fine, but I was still shaken. I'm not ready to live without my parents. I'm not ready for them not to be in Gunner's life. I'm not ready for them to not be a phone call away. It sounds petty, but I'm not ready to go without my mom's cooking advice and Dad's computer, car and building knowledge. I'm not ready to deal with the loss of my parents in any way, and I feel for those people who are dealing with that.

Today I'm grateful for the safety of my parents and that my dad is a good pilot.

Next project: Figuring out how to get their plane off of that snowy road and back to the airport.

Sunday, March 14, 2010


Gunner is a Long Hugger. He is one of those people who goes in for a hug and just doesn't know when to quit. I have had him in nursery a few times and watched him chase down some of the younger kids (older than him), tackle them to the ground with a hug, and continue to hug them while they are begging anyone to help get this kid off them! He hugs babies, and he's mostly soft with them. He hugs older kids, and mostly they just want him to leave them alone. I can tell that he has good intentions, but he just doesn't know when to quit.

Besides that, he is very enthusiastic when he is around other kids. He wants to be involved with them, but they generally don't want to have anything to do with him. This means that when we are together with other kids, I spend my time running interference. I try my best to teach him how to behave around other kids, and to keep him from hurting them (feelings or otherwise). This means that I spend this time keeping him from pushing, taking toys, pulling hair, knocking down towers, and especially tackling with love.

It is exhausting.

I babysat a good friend's 2 1/2 year old for most of the day a month or two ago, and she and Gunner spent the entire day fighting.

I get together for play dates with friends, and I spend the entire time chasing him around, trying to keep him from doing any of the above things. By the end of the play date, I am so tired, frustrated, and stressed that I have wondered if it is worth it for us to get together with other people at all.

But not yesterday. Yesterday I babysat two children. The older one is 3 1/2. I'm not sure whether it's an age thing, or a combination of age and the fact that she is a big sister, but she was amazing! He did his regular tricks, including tackling her with long hugs.

And she just laughed. She hugged and wrestled him back. She played soccer with him. She encouraged him to play with her. She and Gunner actually played together all day long. It was actually easier for me to be at home yesterday while babysitting all day than it normally is because Gunner was being entertained, and I didn't have to constantly referee.

Really what it comes down to is the fact that Gunner should have been a second child. He needs an older sibling. I don't know how we're going to accomplish that, but in the mean time, I'm going to insist that he play with this little girl. A lot. Which is extra good for me since I love spending time with her mother.

Monday, March 08, 2010


I had an intersesting patient this week. JM (we'll call him) is a 43 yo male truck driver with history of asthma, depression, and alcohol abuse who was admitted from clinic after a pulse oximeter (hand held device that measures O2 in the blood) read his oxygen saturation as 78% (normal is 98-100%). At home he has been prescribed multiple inhaled bronchodilators, inhaled steroids, theophylline, and 5 L of 02 via nasal cannula. He was taken from an oustide clinic to the ED, treated with albuterol inhalers, his pulse ox checked again, and it was decided that he should be admitted. His past medical history is significant for numerous admissions for asthma exacerbations, but under names with different demographic information (eg birthday).

The story gets interesting when the pt is admitted to the unit, a blood gas is done which showed a respiratory alkalosis. This means his blood was basic (high pH) with respect to the physiologic norm. Asthmatic patients in crisis are generally unable to sufficiently expel all of the accumulating CO2 due to their constricted airways, and treatment is aimed at opening those airways so that efficient ventilation and thus gas exchange can take place. In the absence of good ventilation, CO2 builds up in the lungs and makes the blood acidic. This patient had the opposite problem, however, which called into question the diagnosis of acute exacerbation of the asthma, which would typically present with an acidosis, rather than an alkalosis.

A respiratory alkalosis can be seen in the case of hyperventilation. When the respiratory rate increases, more CO2 is blown off, decreasing the amount of CO2 in the blood, thus increasing the pH (rendering the blood alkalotic or basic). Why would the respiratory rate increase? In the case of an acute, pure respiratory alkalosis, panic attack is high on the list of possible causes.

The patient was dishcarged to be cared for by us on the floor team after a brief stay in the unit. We checked his blood levels for some of his home medications which showed that he had not been taking them at all. While staying on the floor, the patient rested comfortably, but when visited would complain of chest tightness and would have very poor respiratory effort, shallow breaths, and appear to be in moderate distress. At night and during the day, the patient could be seen to be napping or sleeping comfortably without any evidence of shortness of breath, difficulty breathing, or increased respiratory effort.

The clinical picture I have painted you led us to suspect that his current condition was not an acute exacerbation of asthma. The tricky thing about taking care of patients such as this is parsing out how much of their illness is organic (i.e. deriving from diseased lungs), and how much is psychogenic, i.e. what components of his symptoms were derived from his mind. Despite being psychogenic, the symptoms the patient complained of and the signs he demonstrated on exam are nevertheless real, just not fully explainable by an organic process localized solely to the respiratory tract and consistent with a diagnosis of asthma.

The real challenge is also trying to differentiate whether the pt is conciously faking, i.e. malingering, in order to get some secondary gain i.e. time off work, disability, drugs, or something else, or whether the psychic gain is unconcious. In patients with conversion disorders, a psychic stressor manifests itself through physical symptoms. It is possible, then, that our patient has some stressor in his life that is so profound that his body manifests physically what the mind is feeling psychically. Alternatively, our patient is faking his symptoms or exaggerating them in order to recieve care and to be placed in the dependant role of "patient". What makes this kind of patient especially trying is that it is very tempting to disregard all of their complaints as being psychogenic, when of course they may actually be genuinely sick. It's the old problem of crying wolf. In Aesop's fable, the villager's eventually turned their back on the boy who was eaten by the wolf in the end. The same thing can happen to patients with factitious disorders who every now and again will be genuinely sick, but have cried wolf so frequently that they are disregarded. Trying to sincerely engage a patient in whom you are questioning the legitimacy of their symptoms is very challenging. Those who have cared for a factitious patient will know what I mean, those who haven't may think I am callous for even entertaining the possibility of considering that a patient may be feigning illness. What do you do when this patient comes back to the ER short of breath?

*Editor's note: the patient presented is a composite and the information presented does not reflect the clinical course of any one person for whom I have cared. JM is a pseudonym.

Sunday, March 07, 2010

It's all in the details

I played for the high school solo/ensemble festival yesterday. I am very happy that it's over, and the kids did very well. I even managed to talk people into switching their schedules around so that I was done before noon. It was a pain for a lot of people to switch around the solos, and I feel bad for being demanding, but I couldn't justify being gone from Gunner all day long. It worked out in the end, and even the parents ended up being happy about things.

I have grumbled a lot throughout this experience about learning the music and about scheduling issues. And they really are issues for me. But after rehearsing with the kids and their awesome teacher, I remembered how much I enjoy it. Not all of the music is horrible, and even the horrible stuff is sort of exciting when it's played well. These particular students are fantastic. They're smart, they work hard, and they're talented, and I love being their coach/accompanist. I thought at one time of pursuing a career in coach/accompanying. I don't think I could ever do it for professional musicians, but I do love doing it in the student to teacher/coach situation.

One of the things I love about it is the attention to detail. I remember a piano lesson in college when my professor pointed out to me that I wasn't holding a note long enough. I was completely shocked that I hadn't noticed the full note value. Or that it even mattered that I notice that particular note value. And then I went to grad school and realized that everything about music is about the nuances. Every little note has to be held for a precise length of time, every rest released at an exact moment. There must be attention paid to every accent, staccato or slur. Not to mention the numerous musical directions slathered around the pages.

These are things I didn't pay attention to as a high school student, and like I said, I was shocked to find out that they were important. I enjoy teaching students about these things and watching them figure it out. I enjoy coaching them on ensemble issues, including cues, transitions, tempos, rhythms, especially since most of the kids haven't played with an accompanist much, or at all.

Anyway, this is a long way of me saying that I'll probably do it again next year. I will most likely go to the state festival later this Spring to play for the five kids who scored high enough. And I have told their teacher that I will accompany for his middle school students in their solo festival coming up in April.