JMT-J

NurseBob_1
JMT-J??? I’ve decided to keep a journal of my John Muir Trail planning, training, prep, logistics, etc., and then the trek itself. Actually there will be a couple of journals – this one is text-based, the other one will be video-based and posted on my video blog). So, if you’ve any interest in the logistics, etc., as well as the trek itself, stay tuned-in. Otherwise… 🙂

For now my biggest challenge has been figuring out how to incorporate the time required for training hikes into my daily/weekly schedule. The time demands of teaching for a nursing program and tracking 150 students are challenging, and it’s very easy to put off the excercise and focus on trying to stay abreast of the work, the students’ needs and expectations, as well as managing my own expectations about the quality and quantity of my work.

Today’s goal: Start this blog journal, capture and edit related video to post on my vblog, and most importantly, do at least a 3.5 mile hike with pack and camera(s).
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Well, it’s post training hike. Shot some video; met a PUC Business Major student who expressed an interest in hiking the JMT and had two brief but enjoyable conversations. Video needs a little post-processing, so Friday??? 🙂

Want to know more about the JMT?
Very enjoyable video on Netflix: Mile, Mile and a Half

Stay Well!!!

Bob

Fifty, and counting…

 

Bob at 240#

Bob at 240#

Actually, this image is closer to where I am now…

NurseBob_1

While it is some 15 years older, it’s closer to my current look. The weight is right, but I am MUCH more grey… As Billy Pilgrim would say, “So it goes.”

For the first time in the better part of a couple of decades, when I walk towards the mirror in the bathroom, I don’t cringe; in fact, I’m pleased with what I see. While not at the goal I’d set, I’m on the right side of the curve, and feeling I just may make it back to what I weighed back when a college student. FWIW, that’s still heavier than what the BMI charts indicate are “correct” for my height. However, those charts have wide error ranges. If I get down to 170+, I will be ecstatic. As it is, I am able to see parts of my anatomy that have been hiding for quite some time. And, more importantly, my wife is very, very pleased with my new, reacquired physiogonmy.
In short: On Track.

Stay well,

NurseBob

Mom’s Stroke – My Dilemma

Bob

On Christmas Eve, about 0900 I took a call from a nurse at the Alzheimer’s/Dementia facility where my mother now resides. At her current age, 94, I was not surprised by the news: “Your mother’s in her bed, unresponsive; her left side is flacid, and she’s not following commands.”

Before diving into the emotional challenges this presented, I want to reassure you that as of now she’s exhibited a near miraculous recovery, with only a minimal residual left-sided weakness, which has left her a bit more at risk for falls.

So, back to the story… Ok, of course if she’s “unresponsive” she’s not following commands, but as a nurse, I saw no conflict in the report. It’s similar to what I’ve reported to physicians regarding patients in the ICU under my care. It’s the jargon…
My in-the-moment analysis – she’s had a stroke, and a significant one. What’s unknown – is it a clot blocking the blood flow to her brain, or is it a ruptured vessel bleeding into her brain.

My sister and I are both designated as decision-makers for her health care if she’s not able or competent to attend to her own needs. And, importantly, my sister and I are in agreement regarding our understanding of how Mom wants life-threatening events dealt with if she’s not able to answer for herself. She wants no heroics; no last-minute efforts to stave off the inevitable as long as possible; she’s DNR – that is, Do Not resuscitate. Further, no intubation (breathing tube driven by a machine to breathe for her), no artificial nutritional support – that is, no tube feedings.

As I dealt internally with the likely impending demise of my mother, I busied myself in gathering and confirming the documents regarding both her health care, and how she wanted to be buried – well, cremated – and her ultimate resting place next to my father. And, of course, I sent off an email to family regarding the turn of events.

For those of you who may not already know, my mother has suffered a profound loss of both long-term and short-term memory, and while not diagnosed with Alzheimer’s, she exhibits many aspects of that condition. For the last two years she’s not recognized me, nor does she remember her marriage to my father. When I last introduced myself as “Bob, your son.” She commented, “How can I have children? I’m not married.” She has, at times, identified me as her late brother, but there is no recognition beyond that.

So, I’m ok. No last-minute life-saving efforts; let nature take its course… Then comes the real-life turn of events. Late that afternoon I get a report: She’s up and walking with assistance; not following commands; and is exhibiting an expressive aphasia – that is, she speaks, but it’s a jumble of words in a non-sensical order – “word salad.”

Prior to this report I was clear about my options, responsibilities and decisions. However, her condition at this point is something unanticipated and damn challenging. She is conscious but unable to understand incoming information and unable to communicate her needs and desires. My dilemma? She’s unable to express her desires; she can’t feed herself and likely won’t submit to any type of external feeding strategies (Intravenous, or, a tube in her nose, or directly into her stomach).

Now what? If I follow her expressed desires there is no feeding by staff, by tube, or intravenously. But… She’s going to potentially experience both thirst and hunger. Furthermore, she can’t say what she wants – remember the expressive aphasia (word salad), nor can she understand any explanation as to why she’d be denied water and food. And, she can’t understand an explanation – the evidence being her inability to follow simple commands.

Back to the present.  As I noted above, she’s back to her baseline.  She still doesn’t remember who I and my sister are, but she is able to feed herself, make her needs known, and move about without assistance.

I remain unsure about what how I might handle a repeat of her event.  What to do for someone who’s unable to understand incoming information, or express their desires, but with a previously laid-out plan for “no heroics” – no rescucitation; no life-extending measures.  We really never covered the scenario briefly experience over the Christmas holiday.

Stay Well

Stroke Resources:

F.A.S.T.
is an easy way to remember how to
recognize a stroke and what to do. Spot a stroke
FAST.
Face drooping.
Arm weakness.
Speech
Difficulty.
Time to call 9-1-1

Stroke – Stanford Health Care

 

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42… :)

Bob
42? Why does that get a smiley? Well, ask Douglas Adams, or read his book… According to his fictional characters, 42 is the answer to to life, the universe and everything. If only…

For me it’s a milestone in my quest to return to a smaller, former self. As a result of my medically managed diet, and my adherance to the diet (well, 98% of the time), I’ve now lost 42 pounds. More than halfway to my goal of 70 pounds. If/when I get there, I’ll be back to my high school weight, which is where I was supposed to stop, but didn’t/couldn’t.
Coupled with that happy achievement my wife and I took a Christmas/New Year’s vacation to Santa Fe, NM, whereupon I not only did not gain any weight, but managed to lose a couple more pounds. Not bad for both a vacation and the Holiday Season.
Other benefits: New/Old wardrobe: Clothes I’ve not fit into for years (maybe decades?) now fit. 🙂

Thus, while I did not strictly adhere to my meal replacement diet while out of state – my cousin’s wife’s New Year’s roast beef dinner with poached and caramelized pears for dessert was too inviting to ignore, it did not stop me from returning home lighter than when I left!!! 🙂

Stay Healthy

Medical Weight Management

NurseBob_1

My self-directed and self-managed attempt at a ketogenic diet this time last year was successful until… my wife and I traveled to Santa Fe, NM just after Christmas for just a week.  While on the road I went off my diet after having lost 20 pounds; upon our return home I was unable to resume the resume my plan, and, as happens to many, most? I had a “rebound” experience and gained back the 20, plus 5.  Argh!!!

I came to the conclusion that I could not do this on my own, and that my best bet was to enroll in a medical weight management program.  Last week I started in earnest with a Kaiser-based program. The program has demonstrated good results in the past, and I know from a personal contact who successfully did, and remains on, the program (officially 82 weeks, but apparently, a life membership for support meetings), that long term success is possible. Though a KP member, this program is outside of the KP benefits, so it’s out of pocket, about $800/month for the first four months, which includes weekly meal replacements.  After that initial period the cost drops significantly, but having not reached that point, I’ll hold off on any cost estimate for now.

My long term goal is to lose about 70 pounds. I have, in the first week, dropped 12 pounds.  Now, much of this is likely to be water, so I expect this weekly number to drop pretty rapidly to a more realistic 1-2 pounds per week.
Since weight loss tends to be physiologically sexist, I do expect to experience a more rapid rate of loss than most of the women in my cohort.  For now my diet is 960 calories daily, with a less than wonderful menu of two shakes, two soups and two nutrient bars per day.  To the credit of those at KP who designed the program I’ve not been starving, just had moments of elevated hunger.  I know that to get to sleep I need to have that last nutrient bar in the last hour before bed.

I will see if I can manage a weekly update on both the experiences and, I hope, successes of the experience.

The numbers:
Height: 5-10 – Hoping/expecting this won’t change over time… 🙂
Starting weight: 241 lbs
This week: 229 lbs
Goal: 170

Stay Well!

Bob

20 down, 40 to go

It’s been about six weeks since I decided a major lifestyle change was in order.  I mentioned that over the years my weight had increased by some 60 pounds over what matches my height and frame.

SOAPBOX ON
I’m not a fan of “fad” diets.  I’m careful to explore the basis for lifestyle changes, and especially in regard to diet.  There is such an overwhelming abundance of dietary advice and products, which in my view are mostly focused on generating profits for companies preying on the ill-informed, desperate, and unhappy segments of our population, which is a very, very sizable percentage.  Sadly, sound evidence-based, scientifically valid information is pretty much overwhelmed by the noise created by these unscrupulous purveyors of pseudo-scientific or mystical solutions to the real problems affecting many of us.  Further, on a similarly sad note, the level of education in this country leaves much of the population unable to see through these scams.
SOAPBOX OFF

However, someone I know and trust had recently experienced great success with a medically supervised Very Low Carbohydrate Ketogenic Diet (VLCKD).  Not only in successfully losing some 80 pounds, but also managing to make a lifestyle change in terms of diet for the long term which should aid in keeping those excess pounds off.

Given that, I decided to explore a similar diet.  Mine was started after an email consultation with my MD, and some six weeks ago I cut out all refined sugar, processed foods, and starches.  My goal:  under 20 grams of carbohydrates per day, and a target of 1000 – 1100 calories.  I’m basically on a moderate protein, higher fat and near zero carbohydrate diet.

The results so far: I’ve been steadily losing weight; I’m now 20 pounds lighter than when I began.  While I’m only about 1/3 of the way to my target of 160 – 170, I’m feeling pretty successful.

The experience:  To my surprise, and in truth, wonder.  I’ve rarely felt excessively hungry.  I do try to have a bite of something satisfying every 4 – 5 hours to forestall any sense of extreme appetite, but interestingly I’ve not had cravings for what I have cut out of my diet. And, believe me, I did like a lot of sugar in my coffee and cream, loved breads, chips, tortillas, pasta, etc.
Further, I’ve been sleeping better, have generally been in a better mood, and seem to be more stable in regards to mood swings (not that I experienced extremes)

Finally, I have a reasonable wardrobe which I’ve not been able to wear for the last several years.  I’m looking forward to having a “what’s old is new again” moment as I am once again able to pull some of those items from the closet, and hang them on me instead.

So, the experiment continues. As of this morning I’m on the cusp of transitioning from “Obese” to “Overweight” in the BMI table.  More in the future as I have more experience, and as I delve further into the physiology of this all.

Stay Well.

Bob

Other interesting resources:

Low Carb Dietitian:
Lipid Changes on a Very-Low-Carb Ketogenic Diet: My Own Experience

My Thoughts on Low-Carbohydrate Ketogenic Diets

My Thoughts on Low-Carbohydrate Ketogenic Diets, Part 2

The Search For Long Term Care – Mom, Dementia, & Me

Previously posted on openplacement’s blog

Mom-3-17-2013The Beginning

Six years ago my mother was the primary caregiver for her elder sister. At the time she was eighty-six, and her sister was eighty-eight. Her sister’s health had been slowly declining, with increasing difficulty in her ability to manage not only her activities of daily living – mobility, hygiene, dressing, but also other tasks such as grocery shopping and meal preparation. Their time together up until then had been both pleasant and successful. However, as my aunt’s short term memory began failing with the onset of dementia showing, their relationship suffered. My mother could not understand why Lil couldn’t remember what they had just agreed upon, and Lil, when challenged about her failing memory, would become angry and verbally abusive.

The situation hit the breaking point when my mother feared for her safety and dialed 911. When my sister and I found out about the state of our mother’s relationship with her sister, we were compelled to step-in. My sister took on the challenge of finding an appropriate longer term care facility for our aunt. Happily, she’d worked for the same employer virtually all her adult life, and had a reasonable retirement income, and perhaps more importantly, excellent long term care insurance. Finding an appropriate long term care facility was not too difficult given her financial situation.

I faced a more challenging situation. My mother had also worked her entire adult life, but had moved from one temporary job to another. Those positions had not included any long term benefits. Furthermore, her one long term employer, a small art college, had offered very little in the way of retirement or long term health care benefits. In short, all my mother had to work with was her social security benefit, and later, state benefits for her health and housing (Medicaid). It was our good fortune that while in training as an RN, I’d had the opportunity to visit a number of assisted living facilities within a short drive from my home, and not too far for my sister to drive when she wanted to visit. After a review of the available long term care facilities within reach of my mother’s budget, we settled on the one that offered the best combination of services and social programs for our mother.

The Move to Long Term Care

The physical move, about 50 miles from her old apartment to the new long term care facility, wasn’t too challenging, except for my mother’s upright piano. Having played all her life, that was the one item that she felt she needed to keep her feeling good about herself. Since neither my brother-in-law nor I were interested in adding piano moving to our resumes, we found a firm to accomplish that move (if I remember correctly, about $200), the rest of her possessions my sister and I moved into her new apartment.

After relocating to long term care, the first challenge for my mother was getting to know her new neighbors. This went fairly smoothly, or so my sister and I thought. One aspect of my mother’s personality is her profound desire to avoid any confrontation. She’d told me in past conversations that her approach potentially confrontational situations was to “smile, nod my head, and then do as I wanted.”

Transition to Long Term Care and Discoveries

I ran across this behavior on numerous occasions as my mother would agree with plans, and then ignore them, or actively, but surreptitiously, subvert plans. Since our contact was mostly by phone it was easy for her to do as she pleased in most situations. I would only find out after the fact that she’d made contrary decisions and had acted on her whims, which were not necessarily in her own best interest. This tendency put her in the hospital twice after falls that were initiated by her failing to use her walker or cane as her gait became increasingly unsteady. I know in my experience as a nurse that this is not an unusual behavior. I’ve had numerous patients over the years who would say, “I hate using that thing. I’m OK without it.” Of course with my Mom, if I wasn’t in the room to remind her, she’d choose to believe she was OK too, until she fell. Her first fall led to a week in the hospital with a hairline fracture of her hip. Painful, but luckily, not requiring more than rest and rehab. She then spent a month in a skilled nursing facility for the follow-up rehab.

It was during this stay in long term care that we got the first strong hints about changes in her mental status and memory that had not been particularly apparent before. I got several panicky phone calls in the middle of the night with all sorts of seemingly wild claims. I realized that my mother was “Sundowning,” a phenomenon commonly seen in hospitals, where patients who are relatively lucid during the day, become increasingly disoriented as the night progresses. There were not only calls to me, but 911 calls as well. When her rehab was completed and she went back to her apartment, I’m not sure who was more relieved, my mother, the facility, or myself…

Progressive Changes – Onset of Dementia

After that initial fall, my mother began a slow decline and showing signs of dementia. On about a weekly basis I would get angry phone calls accusing me, or my sister, of not caring about her, followed by tearful, embarrassed apologies, sometimes within minutes, or perhaps the next day. She repeatedly insisted on moving back to her old apartment and resuming the care for her elder sister. When we talked about the situation that triggered the move, it was met with a range of responses from acknowledgement, to enraged denial. Her mood swings were becoming more labile and profound.

After a visit to her doctor, which included a brief mental status exam (MMSE), her daily regimen included both Donepezil and an anti-depressant. Her behavior improved and mood swings were less extreme, but the phone calls and outbursts still continued, just at a reduced frequency. And, her apparent feelings of guilt about having “abandoned” her sister continued, with an increasing level of denial that there had ever been a problem. However, during this period, she had a second fall while hurrying to dress for breakfast, falling backwards into a filing cabinet and fracturing three ribs. The hospital and nursing home stays were repeated, with similar experiences. I did feel a need to intervene when I discovered that the nursing facility was allowing outside lab personnel to come in at 3 a.m. to perform lab draws. This was extremely disorienting and frightening for my mother, and I had to insist that her labs be drawn after she’d awakened for the day.

While there was a grumbling acceptance by the long term care facility management, I felt it was a necessary step for my mother’s well-being. Furthermore, I’m sure the night staff and the local police where happier as their nights were not interrupted by unnecessary disruptions and phone calls. During this time my mother decided that in addition to being her designated power of attorney for her health care, that I should also be designated her financial power of attorney as well. This was a fortunate choice. For the first 4+ years, my mother had been successfully managing her own funds. While I had joint access to her account, I had no authority over her spending, but not long after my change in status, I found she was writing checks she couldn’t cover, and which she didn’t remember.

Failing Short-term Memory

At this point in time her failing memory was becoming increasingly apparent. With her inability to safely manage her accounts, I stepped-in and removed checkbooks and debit cards from her possession (with her cooperation), and also directed that the bank was not to advance funds to her without my approval. Her having granted me legal authority over her finances was a critical piece in my ability to protect her from herself. Without those documents in place, I could not have limited her access to her accounts. Once again, enraged phone calls, but now accusing me of having taken her account without her consent, and obviously not caring about or loving her. These were terrifically hard calls to receive.

I won’t claim that over the years we haven’t had our “issues,” but there had never been any question about care or love. What was particularly frustrating from my perspective was that my training and experience as a nurse seemed to vaporize in those moments. It didn’t matter that I was in my 60′s and she in her 90′s; once again I was her little boy, and I was deeply challenged to respond and act as an intelligent, trained, health professional. This situation lasted for close to a year. I not only had numerous painful conversations with my mother, I also had encounters with the local police (she called them claiming I’d abandoned her and stolen her money), emergency responders (calls triggered by her anxiety, leading to hyperventilation syndrome and related symptoms), and both calls and visits to the local emergency room.

Current Situation & Long Term Care for Mom

Currently, we have a caregiver who follows checks-in with my mother several times per day, making sure she takes her medications appropriately, attends meals and facility activities, and most importantly, that she’s safely in her room at the end of the day. My mother’s short term memory is non-existent. It’s not uncommon for her to forget in mid-sentence that she initiated a phone call, and instead thank me for contacting her. When she leaves her room for a meal, upon her return to her room she’ll call me to let me know she’s “moved back in” to her old place. Sadly, her long term memory is beginning to show signs of significant deterioration as well. She calls me upwards of a dozen times a day, often asking how to contact her parents, and it’s been clear on more than one occasion that she’s confused me with her late brother, or even my late father, both on the phone and in person.

At this point, the saddest aspect of her deterioration is that she is unable to recognize her grandchildren, and has no recollection that she also has great grandchildren. I’ve supplied our caregiver with an abridged version of her life and family, so that she can reminisce with my mother about experiences she’s had. According to the caregiver, she enjoys hearing these stories, and to either relive, or better, remember.

My wife, sister, and I feel fortunate that my mother is in a safe environment, and one that we could not as safely provide if my mother were to live with us. Our home would be unsafe for her due to bedrooms located up a flight of stairs, access to the stove, and our location in a semi-rural situation where she could easily wander while my wife and I are off to work. In her current living situation her housing and meals are provided, and her caregiver is able to see and assess her situation several times per day, as well as arrange for appointments with her healthcare providers.

NurseBobStay Well

Disclaimer: This information is not intended to diagnose or treat any condition, or to replace the advice of a doctor. NurseBob disclaims any liability for the decisions you make based on this information.

Let Them Eat Dirt?

In the U.S. we are increasingly obsessive when it comes to cleanliness.  Just take a moment to analyze the T.V. ads, if the subject isn’t cars, food, or booze, it seems they’re focused on  killing those damn germs; OMG, they’re everywhere!  Ahhhg!!!  I swear, many of the ads remind me of my college roommate’s mantra:  When in danger, when in doubt, run in circles, scream and shout.
I know the marketeers are shouting to push danger and doubt regarding those ever-present microbes to increase sales, but I believe the true danger lurking in the shadows resides in not allowing our immune systems, and more importantly, our childrens’ immune systems to develop as nature intended – learning which microbes are benign, which are our allies, and fighting the good fight against pathogens.
Not all germs are BAD; in fact, many are beneficial and most are neutral. We each have more microbes in our gut than there are stars in the Milky Way. Increasingly, current research points to a possible link between the health of our internal microbiome and our physical and mental health.  There is also a growing body of evidence that the increase in allergic conditions and autoimmune diseases may be connected to our near-obsessive efforts to kill-off all the invisible organisms in and around us.

I know you wouldn’t wish these maladies on yourself, and  most certainly not on your children.  I’m even willing to guess you wouldn’t wish them on your enemies.  So, what to do?  I’m not actually encouraging you or your children to eat dirt; I don’t really believe that  pica, which has a somewhat negative reputation, is the solution.
What we need to accomplish is to let go of our compulsion for attempting to sterilize our environment; it’s neither a healthy nor healthful practice.  Of course, in the kitchen, if you’ve been preparing any meats or eggs, a cleaning of the work surfaces and hands is in order.  For the hands, just a thorough wash with plain soap and water.  By thorough, I mean a vigorous effort for a minimum of 15 seconds and a rinse under running water.  As to the work surfaces, following a wipe-down, use of a spray bottle filled with a dilute solution of bleach is an excellent choice, it’s effective, inexpensive, and doesn’t lead to the creation of superbugs.  And, a weak bleach solution can be used in the bathrooms as well for the final pass.

My point is to use common sense.  While it’s not true that if it looks clean, it’s clean. It is true that the effort used to clean the kitchen, dining areas, and bathrooms doesn’t need to be excessive.  Furthermore, I believe the use of anti-bacterial hand soaps and cleansers is detrimental to both the environment and public health.  These products put sub-therapeutic levels of antibiotics into the environment, and can contribute to the creation of antibiotic resistant bacteria.  So, stay well, stay clean (reasonably so), and enjoy.

NurseBob – Stay Well

Disclaimer: This information is not intended to diagnose or treat any condition, or to replace the advice of a doctor. NurseBob  disclaims any liability for the decisions you make based on this information.

Fever! Starve it? Feed it? Treat it? What to do?

Ok, what is a fever and why do we get them?  More importantly, what to do?  As with many health issues, the answer to the second question revolves around, “It depends.” Of course, there’s the old saw: Feed a cold, starve a fever.  Is that advice we can trust?

Let’s start with the “executive summary:”

  • Fever is NOT an indicator of illness severity
  • Treating with aspirin, or other salicylates, may be life-threatening  for children and teens
  • High fevers, between 103 F (39.4 C) and 106 F (41.1 C), can be life-threatening and require immediate treatment

What is a fever?

One section of the brain, specifically, the hypothalamus, is the body’s thermostat.  It manages its task via a complex mix of neurotransmitters which control metabolic rate, as well as, blood flow to muscles, skin and mucous membranes.  Infections cause the release of chemicals which the hypothalamus detects and responds to.  Interestingly, the response is not limited to raising temperature; in fact, one indicator for sepsis (a potentially life-threatening condition) is a sub-normal temperature.

Why do we get fevers?

What is the purpose of a fever?   Good question, and the answer is not completely understood.  Current thinking leans towards fever as a positive evolutionary response, and includes the thought that we might be better off letting a fever run its course.  The rationale is that the immune system is kicking-in to “high gear’ and is more effective at higher body temperature.  (Any competent chemist will tell you that reactions are often driven, and more efficient at higher temperatures, and virtually all of the body’s system are chemical in nature.)  There is also the thought that many pathogens are adapted to fairly narrow temperature ranges, and raising the temperature inhibits their growth and spread.  On balance, there are some pathogens that prefer higher temperatures, and themselves release the same temperature regulating chemicals in an attempt to drive the body to supply the conditions more favorable to them…

What should we do for a fever?

Well, if you’ve gotten this far, you’ve probably already come to your own version of “it depends.”  Definately, high fevers require treatment, and possible medical intervention.  But what about those garden variety fevers? My personal opinion is to let them run their course.  I come down on the side of the last million years of physiological evolution, and believing that Mother Nature often knows best.  Of course, if you’ve got a cranky, whining child, due in part to some of the other associated symptoms, such as aches and pains, then for the comfort of all involved, consulting with your medical provider and treating may be a rational and appropriate choice.

Feed or Starve?

According to an entry on the Duke Medicine site, John Withals wrote back in 1574, “Fasting is a great remedie of feuer.”  I’d suggest letting your own judgement take precedence: If you’re hungry (or your child is hungry), eat!  If not, don’t eat.  Basically, I believe our body sends appropriate signals in most cases.

NurseBobStay Well

References:

Disclaimer: This information is not intended to replace the advice of a doctor. NurseBob  disclaims any liability for the decisions you make based on this information.
Previously posted on www.crassparenting.com