Haven't you forgotten something pretty important?

This one is from my wife.  I can't go to bed without mentioning that both girls nursed today.  Removing the OG tubes and replacing them with NG ones seems to have made it possible for both girls to latch properly.  Anna had been able to do so even with the OG tube, but Evelyn hadn't.  Today, she did.  They said it couldn't be done, and that 33 weeks gestational age is too young to do so much.  I guess they didn't count on Ginger, Anna and Evelyn.

Evelyn Kitten.

Anna Mouse.

What was new today?

Slight change in feeding methodology.  Anna's had one or two episodes of emesis -- what is called "spitting up" outside the NICU.  So they want to slow down her feedings to see if she'll keep more down.  The gravity-feed method they were using previously will only go so slowly, and the nurse can't stand there forever with the syringe in hand.

Much better than gravity is the device pictured.  It's got a syringe with breastmilk laid horizontally, then a piston that extends out to the right and gradually plunges the syringe down the very narrow NG tube and into the stomach.  In this case, Anna and Evelyn each had 30 ml of milk administered at a rate of 60 ml/hr.  In other words, the machine pushed 30 ml of milk into each of their tummies over the span of half an hour.  A speed that slow would be impractical for a nurse to do manually, and it better simulates the rate of milk intake from nursing.

The amount of each feeding is now going to hold steady at 30 ml, but they're fortifying the breastmilk with more calories, gradually increasing the richness of the milk to speed weight gain.  A nurse said today that we're probably not too far off from weaning them from the feeding via the tubes (the technical term is "gavage"; I recommend against Googling this because it's also what they do to geese destined for pâté de foie gras).  They'll then be on a combination of nursing and bottle feeding for a while, then (it is sincerely to be hoped) breastfeeding exclusively.

Can we have more technical details, please?

Of course.

To the right is a snapshot of the monitor screen.  The green waveform and number is heart rate, measured via the adhesive pads affixed to their torsos.  (This particular screen shot is Anna's, but Evelyn's looks basically the same).  At this particular moment, it shows a heart rate of 149.  (Duh.)  The smaller green number further to the left says "PVC," which in this instance stands for "premature ventricular contraction," which for our purposes here is equivalent to a coronary hiccup.  The current count is zero, but I've seen some on Anna's monitor.  They're relatively benign, unless they're not.  We've not been told that the occasional PVC on Anna's monitor is any kind of indication of a problem, so we're not worried about it.  Note that there is a number for "Pulse" in blue.  That's because it's measured by another monitor entirely.  The green data comes from one probe, the blue from a second, and the white from a third.  So heart rate and PVCs are monitored by the green probe, but pulse (which a medically trained individual can tell you is merely a symptom of heart rate and is not the heart rate itself) is measured by the blue probe.

The blue pulse data, blue waveform and large blue number are the data from the oximeter.  The waveform shows the pulse as it goes through the right foot.  As you can see, the heart rate and pulse correspond in a general sense.  (The disparity between the measured heart rate of 149 and the pulse of 148 is probably a result of the fact that the heart rate is dynamic and at any given moment the number is changing, and then being multiplied to give a per minute figure.) The large blue number is the oxygen saturation.  At this particular moment, Anna is at 100% saturation, which is as good as it gets.  No one's worried if it occasionally drops below 90%.  If it's regularly low, or if it suddenly drops into the low 80s or 70s, there might be a problem to be solved.  At the moment this photo was taken, Anna was steady as a rock at 100%.  During the same timeframe, Evelyn was fluctuating around 97%.

The white waveform and number is the respiration rate, measured as respirations per minute.  I've happened to have caught Anna during a particularly steady period of breathing while she was asleep.  This waveform is the most variable of all; it could be all over the map if the baby is awake.  There are periods of a few seconds in which short, sharp, ineffective breaths are taken; the nurses call this "zipper breathing" (because of the shape of the waveform) and it's nothing to be particularly concerned about at this gestational age.  This is the waveform that would be flat during an apnea event.  An apnea of longer than 20 seconds is met with some kind of intervention, such as a pat on the back, a poke in the ribs, or tickling the feet.  Recurring apneas can be treated with medication -- in this case, caffeine.  I'm not kidding.  They administer caffeine because it is a benign central nervous system stimulant.  They haven't administered any caffeine to the girls yet, but it amuses me to think they would be hooked on a drug their father had to wait 'til college to discover.

Which one is your favorite?

This is not a frequently asked question.  Only one person has asked me this question, and I think it's important for me to rat her out.  It's Jen.  I do not think for a moment that she was serious in asking it, especially given that she was laughing when she said it, and I laughed when I heard it.  But now I'm going to answer it anyway, as if she were serious:  Neither.  Neither is my favorite, Jen.  They are both equally wonderful, Jen.  I love them both equally.

I am posting this because I want to participate in the long tradition of holding the clergy to a double standard of goodness, sweetness and light, and then directing reproach at them when they occasionally fail to meet the benchmarks for personal virtue that laypeople meanwhile rarely even attempt, much less meet.  And I'm doing this in full knowledge that the priest in question spent, by my count, and I'm not kidding here, over 21 hours with us in labor, taking fewer breaks than I did.  And then knitted hats for Anna and Evelyn.

So, here's me, doing my part for the long tradition:  Shame, Jen.  Shame.

If I want to visit, how should I get there?

North on 280 to 19th Avenue, then to Park Presidio.  Right on Geary (after Golden Gate Park, before the Presidio).  Left on Commonwealth (after Arguello, before Masonic).  Left on California, then an immediate right on Cherry.  Turn left into the garage, and pray there is a space, or an attendant allowing double-parking inside the garage.  Most direct; best for non-commute hours.

OR:

North on 280 to Junipero Serra.  Veer right onto Portola.  Left on Claremont.  Veer right onto Dewey at the roundabout.  Left on Laguna Honda.  Right on Lincoln, then left on Kezar.  Veer right at the onramp just past Stanyan to enter the turn lane onto Stanyan northbound.  Right on Geary, then an immediate left onto Commonwealth, then as above.  Slightly more scenic; possibly better for commute hours, if you're a pessimist about 19th.

OR:

North on 280 to Brotherhood Way westbound.  Right on Lake Merced.  Right on Sunset.  Right on Lincoln.  Veer left onto Kezar, then as above.  Less stop-and-go than 19th; possibly better for commute hours.  Certainly better for the soul.

OR:

North on 101; follow the signs to Golden Gate Bridge/Van Ness. Left on Geary.  Right on Commonwealth (after Masonic; before Arguello), then as at top.  Most utilitarian; best for non-commute hours.

OR:

North on 280 to John Daly Blvd.  Right on Skyline.  Left onto Great Highway.  Follow Great Highway past Golden Gate Park until it turns into Geary, as it turns just past the Cliff House.  Left on Commonwealth, then as at top.  Most scenic; best for time only if you have no faith in the other routes above.  Good for the return route if you have the time for a scenic drive.  Reminds you why people live in San Francisco.

Return route tips:

Geary does not have a left turn onto 19th southbound, but California does.  When leaving via 19th Ave., take California westbound to 19th and turn left as though you have not a care in the world.  Leave Geary for the suckers.  However, California on the inbound route is a frustrated mess, so take Geary to Commonwealth for this purpose, as recommended.

If going home by 101, take Geary to Gough and then (and this is very important) ignore your GPS telling you to go to Market.  Instead, turn right onto Fell, and then left onto Octavia.  You'll want to be in the center of the roadway, between the two center medians.  (Media?)  This is only way to ensure you'll get on the fancy-schmancy Octavia onramp that replaced the old Central Freeway on- and off-ramps that your GPS probably still thinks are the bee's knees.

Evelyn, milk-drunk.

How's the commute?

Let me put it this way: A colleague who used to do a lot of med mal defense work asked me where the girls were in care. I said "CPMC, on California." He grimaced and said "You can't get there from here."

Yeah.

Nurses who live on the Peninsula have offered various alternate routes, but they've said they don't make the trip any shorter, just less unpleasant. We have found that to be true in both respects.

What's new this afternoon?

It's all about the As, Bs, and Ds.

A is for "apnea." Apnea is when the respiration rate drops out of normal limits. The monitor alarms are set to go off when the RR drops below 10 per minute. I haven't seen that happen to anyone in the NICU yet, but it's happened to both girls at night when we've been home.  The solution, as I've said, is frequently to administer a poke to the ribs to start the breathing again.

B is for bradycardia, or "Brady" in the med biz. It's a temporary anomaly in heart rate. It happens quite a lot, even to full term babies -- you just can't see it because there's no monitor at home. It tends to coincide with some sort of distraction for the baby, like a hiccup or a gas bubble, or even just a particularly difficult poop. So if you've ever taken a full term newborn home, you might have seen a couple of these a day and never have known it. Anna had one today while nursing. The monitor read "Severe Brady." She got over it.  Apparently the suck-swallow-breathe combo was a bit too much to ask at that particular moment.

D is for "desaturation," or just "desat." The monitors begin to alarm when Anna or Evelyn drop below 88%. I've already talked about what this is and why it's the end-all be-all of life in the NICU, at least for our run-of-the-mill 32 weekers. We've seen it happen now and again. It usually corrects itself without anyone doing anything, or you just calm the baby so it breathes more efficiently.

The NICU veterans hope for days with "no As, Bs or Ds." We're not there yet.

Anna, taking a break from nursing.

Did you finish your bed/bath remodel in time?

Yes!  The work was finished two weeks ago, in what we thought was plenty of time.  We're thankful we went with More-Expensive-Contractor-Who-Keeps-His-Promises rather than Less-Expensive-Contractor-Who-Seemed-Like-A-Nice-Guy-Maybe-Too-Nice.

It's beautiful.  Not as beautiful as our twin daughters, perhaps, but possibly more beautiful than other people's twin daughters.  We're thrilled with it all, because it took our Master Bath (which was our house's secret shame) and turned it into a showpiece.

If you're in the neighborhood, feel free to stop by to see it.  Wear short sleeves, and be prepared to remove any jewelry worn below the elbow, because you'll be required to scrub up.