Miki's Studio

New Blog

2010-10-14T12:46:00.000-07:00

Miki's Studio Blog is closed. But don't despair. Her new blog is up and running over at Fir Creek Pediatrics. Check it out here:

Http://www.fircreekpeds.com

~Miki

ANYONE Can Have a H1N1 Vaccine

2010-01-09T16:23:00.000-08:00

Updated info as of 1/9/10

Anyone can have their H1N1 vaccine at Fir Creek Pediatrics. Still no charge if you don't have insurance. Give us a call now!!

FREE H1N1 Shots at Fir Creek Pediatrics!

2009-12-08T14:04:00.000-08:00

As of 12/8/09 we have more than 600 doses of H1N1 (Swine Flu) Vaccine available at Fir Creek Pediatrics. We also have some preservative free for young children & pregnant women, and the nasal (flu-mist) form available.

If you are 6 months old to 24 years old, pregnant, living with a young infant, or in another high risk category and still need your shot please give us a call and we'll take care of you.

253-565-7686

9am to 5pm

9101 Bridgeport Way SW, Building A

Lakewood, WA 98499

We will bill your insurance if you have it, but if you don't have insurance we will not charge you.

Your health comes first here!

Saving Christmas, One Santa at a Time

2009-12-04T19:49:00.000-08:00

It's been a tumultuous year for us at Fir Creek Pediatrics but we have a lot to be thankful for. We have our beautiful new bigger clinic right on Bridgeport Way in Lakewood. We've said goodbye to a staff member, and added others to the team. We've gone from caring for a small population of patient families and an average of 10 patients a day, to serving a large group of families associated with the US military forces and 20-30 patients a day. We started with paper charts and transitioned to Epic Connect electronic medical record. We expanded our care of children with special health care needs including ADHD and autism spectrum disorder. And we jumped feet first into the deep end of a pandemic that is particularly hard on children and young people.

From the very beginning of the pandemic, I felt a strong responsibility to the health of my staff and patient families. In a sense, I've been preparing for this much of my professional life. I've always had a special interest in emerging infections. When the first reports of H1N1 influenza began hitting the news, I gathered my staff and we developed an action plan to keep ourselves and our patients' families as safe as possible. This meant some sacrifices, such as deciding not to restart our knitting social hour and a heightened vigilance for flu-like symptoms. And it meant considering possible worst case scenarios such as turning our break room into an ad hoc daycare if schools closed and our staff's children needed to be cared for while we cared for many very sick patients.

During the next months, the pandemic evolved and our national and world health organizations ramped up to face the challenge of learning as much as possible about the virus and its impact on populations. Vaccines were developed, priority groups were defined, and private and public health organizations prepared for the biggest infectious threat to health the modern world has seen since AIDS.

Once schools were in session after the summer ended, we began seeing lots of very sick children. At the same time, vaccine for H1N1 influenza became available in very limited quantities. The virus did not grow as well as hoped and so supplies of vaccine were significantly less than promised. Despite this, Fir Creek Pediatrics was fortunate enough to obtain a steady supply.

From the beginning, we knew we wanted to provide the vaccine to ANY person who needed it. Because the vaccine is supplied through US public health channels, we must give it first to the people who have been designated at highest risk of complications of flu. These priority people have been well publicized and include children 6 months to 24 years of age. People older than 24 years of age with chronic health problems. Pregnant women. And family members living with infants younger than 6 months.

The decision to offer the vaccine to any person in the high risk categories wasn't as simple as one might think. Systems had to be developed to capture demographics and billing information so that a complete and accurate accounting could be made of who got the vaccine. Existing patients have records in Epic, the electronic medical record we are using. They could be placed on the schedule without any fuss. Adult vaccine recipients, though, would have to be added to the schedule in such a way that they would not actually become our patients within Epic. Also, we'd need a way to add them into our schedules on the fly. This is because most of the adults we'd be immunizing would be parents or relatives of the children who are our patients.

Also, this would mean many more patients per day than we usually care for. We made the decision to work longer hours. We even brought our personal lives into it by bringing work home after hours and weekends to ensure that all the record keeping was up to date and we could accurately account for each vaccine in monthly reports to the health department. (we do this monthly for all state supplied vaccine, and the H1N1 vaccine would be no different) And with more patients, we'd need extra help at the clinic so that our pediatric patients could still get the care they need while we were also simultaneously administering H1N1 vaccine to ANY high risk person who needed it.

So it was no surprise that just about a week ago, we decided that we'd make sure Santa had the opportunity to get the 2009 pandemic H1N1 influenza vaccine at Fir Creek Pediatrics if he fit into the high risk groups designated by the CDC. The decision was based on information we'd gotten from King 5 Seattle News that Santa's serving local malls were concerned about their exposure to the virus. Santa worried that he would not be able to get the vaccine because he wasn't obviously high risk. And he worried that he'd not only be exposed to the virus, but that he could also expose children once he was exposed. It was a no-brainer.

Theresa made a quick call to the North Pole and it was a go. Fir Creek Pediatrics saved Christmas with the help of Theresa, Elisha, Debra, Craig, Miki, Teddy, and the CDC.

It isn't over yet although there has been a significant decrease in influenza illness in many states including ours. We have made it through the first wave of this season's pandemic. Meanwhile we've immunized approximately 1000 people- men, women, children, families, loved ones, Santa's. The work isn't done yet. I expect another wave of the flu, probably combined with seasonal influenza illness in the next couple of months. We just got approved to receive hundreds more doses of H1N1 vaccine and we will still give it to anyone in the high risk groups. And when the priority groups are protected, we'll move on to immunize anyone who wants the vaccine.

At the risk of sounding maudlin I'm going to let you in on my thought process. All this immunizing is a lot of work, but it's worth every long day and extra weekend. We're not just protecting our children. In our minds, we truly believe that we're doing much more. We're saving lives, one vaccine at a time. This pandemic won't become the disaster it could have become because we won't let it.

H1N1 SpokesDog for Fir Creek Pediatrics

2009-10-08T13:34:00.001-07:00

Tylenol Products from McNeil-Recall Lot #

2009-10-05T10:52:00.001-07:00

300450391049 3910400 SBM041, SBM067, SCM037,
SDM027, SEM109
Children's TYLENOL® Plus Cold MS
Suspension 4 oz. Grape
300450296047 2960400 SBM042, SCM015, SCM036,
SDM034
Children's TYLENOL® Suspension 4oz.
Grape
300450407047 4070400 SBM043, SBM044, SCM029 Children's TYLENOL® Suspension 4oz.
Bubble Gum
300450493040 4930400 SBM045, SCM011, SCM030,
SDM035
Children's TYLENOL® Suspension 4oz.
Strawberry
300450122407 1224000 SBM064, SCM033, SDM020 Infants' TYLENOL® Grape Suspension
Drops 1/4oz.
300450186157 1861500 SBM065, SCM005, SCM006,
SDM032
Infants' TYLENOL® Suspension 1/2oz.
Cherry
300450166043 1660400 SBM066, SCM068 Children's TYLENOL® Dye Free
Suspension 4oz. Cherry
300450123046 1230400 SBM068, SCM035, SCM070,
SCM080, SDM005
Children's TYLENOL® Suspension 4oz.
Cherry
300450249043 2490400 SBM069, SBM070, SCM081,
SDM006
Children's TYLENOL® Plus Cough &
Runny Nose 4oz. Cherry
300450122155 1221500 SCM012, SCM067,
SDM007, SDM068
Infants' TYLENOL® Suspension Drops
1/2oz. Grape
300450386045 3860400 SCM013, SCM014, SCM069 Children's TYLENOL® Plus Flu 4oz.
Bubble Gum
300450387042 3870400 SCM016, SFM024 Children's TYLENOL® Plus Cold
Suspension 4oz. Grape
300450247049 2470400 SCM017 Children's TYLENOL® Plus Cough/ST
Suspension 4oz. Cherry
300450122018 1220100 SCM082, SDM039, SDM040 Infants' TYLENOL® Suspension Drops
1oz. Grape
300450167019 1670100 SCM083, SCM084, SDM008 Infants' TYLENOL® Dye Free
Suspension 1oz. Cherry
300450123015 1230100 SDM064 Children's TYLENOL® Pediatric
Suspension 1oz. Cherry
300450186300 1863000 SDM038, SDM009 Infants' TYLENOL® Suspension Drops
1oz. Cherry
300450390042 3900400 SDM033 Children's TYLENOL® Plus Cold/Allergy
4oz. Bubble Gum
300450122100 1221000 SDM078 Infants' TYLENOL® Drops 1oz. Grape
350580144183 1221800 SCM034 Infants' TYLENOL® Grape Suspension
Drops H/G 1/2oz.
350580123034 1230300 SDM028 Children's TYLENOL® Suspension 4oz.
Cherry, Hospital Govt.

H1N1 Flu Update

2009-09-10T13:45:00.001-07:00

Fortunately data related to the H1N1 influenza is suggesting that this new flu is no more deadly than the regular seasonal flu. It is, though, very contagious as most of us don’t have any immunity to it at all. For some reason, it seems that the elderly are slightly less likely to have complications of this flu than younger people. The theory is that over the years they have been exposed to an influenza virus similar to the H1N1 and so have some immunity.

Beginning in October (most likely the end of October), local health departments plan to begin distributing H1N1 vaccine to health care clinics, pharmacies, and medical providers. Those clinics that already participate in the Vaccine for Children Program in Pierce County are already pre-enrolled in this program and will get vaccine. Fir Creek Pediatrics is already pre-enrolled and will carry the vaccine when it is available.

Because it’s unlikely that there will be enough vaccine to immunize everyone at once, there’s a priority list for who gets the vaccine first. These people should be immunized first. As more vaccine becomes available, other people will be able to also get immunized. People getting this vaccine will need two of them in a series to get the highest level of immunity to protect them from complications of H1N1 should they be exposed.

Here’s the priority list for 2009 H1N1 flu vaccine.

1. Pregnant women

2. Household contacts of infants under 6 months of age (this is to protect babies too young to get the vaccine).

3. Healthcare workers (we need to be protected so we can continue to care for sick people; and because we are in such close contact with so many sick people, we need to be protected so we don’t SPREAD H1N1 by being sick ourselves).

4. Children and young people from 6 months old to 24 years old. There is supposed to be preservative free vaccine available for young children.

5.Anyone to age 64 with underlying health issues such as diabetes, lung disease, asthma, metabolic disorders, neurologic disorders, kidney or liver disease, and any condition that suppresses the immune system.

HOW TO PROTECT YOURSELF FROM INFLUENZA

Stay home if you are sick with a fever and cough symptoms. Wash hands frequently. Avoid close contact with people with fevers & coughs. Viruses and germs are carried on our hands…don’t put your hands in your mouth (without washing them first), avoid touching your face, don’t put objects that you handle or others might handle like your pen or pencil in your mouth. Use hand sanitizer if you think you’ve touched something that could have virus or bacteria on it and you can’t wash your hands right away. Sanitize toys and other potentially contaminated objects with an antiviral spray or by washing between use. Keep infants out of crowded places or places where they may be exposed to potentially sick people.

The bottom line is to USE COMMON SENSE. There’s no need to be frightened or to panic. Keep clean. Keep safe. And consider immunizing if you or a loved one fall into any of the priority groups.

**Updates about possible adverse effects from the H1N1 vaccine will be posted as soon as I am alerted to them. So far it seems that its side effect/adverse effect profile is similar to the regular seasonal flu vaccine.

To find out more on your own, check the Tacoma Pierce County Health Department Current Issues & Disease Alerts website and the CDC Website.

Health Care Reform

2009-06-25T20:01:00.001-07:00

If you’ve listened, read, or watched anything on the topic of Health Care Reform in America, you’ll notice that physicians and doctors are pretty much the only providers of health care getting the attention. They are taking the lead in formulating plans and working to advise the president that they, alone, are the stars in this important discussion.

People who value the care provided by Nurse Practitioners need to SPEAK UP. Let your legislators know that your NP must be a vital part of the future of health care. Here’s a sample letter (that I sent to Senator Cantwell). Feel free to copy it and personalize it to let your senators, state representatives, and EVERYONE ELSE know that NP’s provide quality, cost effective health care.

Dear Senator Cantwell, I am a pediatric nurse practitioner with a private practice in Lakewood, WA. In several states, including Washington state, nurse practitioners are qualified and allowed by law to provide primary care services for their patients independently. We do not require a medical doctor on staff to provide this care.

I am concerned that Mr.. Obama may not be aware of this fact. Repeatedly, he assures Americans that health care reform will allow people to choose their own "doctor." In order to ensure that Americans can also choose their own nurse practitioner, or keep the one they already have chosen, the language of health care reform needs to change.

Nurse practitioners have often been scorned by the powerful American Medical Association. Their ongoing agenda to limit the ability of NP's to continue to provide independent health care jeopardizes affordable and rational health care reform and limits the ability of many patients to access health care at all.

Please don't allow the language of health care reform to limit access to qualified health care providers by referencing doctors/physicians as the primary keepers of the "medical home."

You may contact me any time to discuss this. I also welcome you to my pediatric clinic, Fir Creek Pediatrics. You will find a great deal of support for broadening the language of health care reform to include all providers of primary care.

Sincerely,

Michelle Hayes, MN, ARNP

Update on Jefferson Park

2009-06-13T22:48:00.001-07:00

My last blog post was about ways to avoid diarrhea illness when enjoying splash parks. I noted that I did not know how our Tacoma splash parks sanitized the water. So, I emailed Metro Parks, and here’s their reply:

The water is sanitized through filtration and UV light at our three newest spraygrounds – Jefferson Park, South Park and McKinley Playfield.

At Wapato Hills the water is not recycled.

Sheree Trefry

Communications Coordinator

Metro Parks Tacoma

253-305-1059/253-305-1098

4702 S 19th St., Tacoma, WA 98405

CREATING HEALTHY OPPORTUNITIES TO PLAY, LEARN AND GROW

www.metroparkstacoma.org

Thanks, Ms. Trefry, for the very quick reply. So, you can see that Metro Parks uses methods to try to keep visitors safe. Cryptosporidium, the organism that can cause diarrhea illness at such parks is resistant to chlorine and chemical methods, filtration can remove up to 99%, and UV light will inactivate it entirely.

Splash Park Precautions

2009-06-12T12:46:00.001-07:00

With the wonderful warm weather we’ve had lately, no doubt the splash feature at Jefferson Park in Tacoma is getting lots of use. These kinds of parks are lots of fun for kids and help moms & dads keep cool too. But there is a potential problem, which was outlined in a recent MMWR article. Splash parks can be a great way to spread diarrhea illnesses.

Most diarrhea illnesses are spread through the dreaded “fecal-oral route.” We don’t like to think of this, but water or food can be contaminated by fecal matter by not washing hands well after using the toilet, changing baby diapers, or direct contamination of fecal matter into the water supply or onto a surface where food is prepared.

Water parks like Wild Waves and pools are regulated and use various techniques to sanitize the water. Examples are chemicals (such as chlorine) and UV light. Remember, there are some organisms that cause diarrhea illness that are actually resistant to chemical decontaminants and filtration (example is Cryptosporidium). Contamination can occur despite the most rigorous efforts to control the water safety. The good thing is that it doesn’t happen often, and so we don’t usually worry too much about it.

Splash parks may also use methods to decontaminate or sanitize the water. Usually, though, they are not regulated in the same way as pools. I honestly do not know how Jefferson Park’s splash feature is maintained, although I do have an email out to Metro Parks Tacoma asking for details. My grandson, Hunter, loves visiting that park as you can see in the picture above.

HERE ARE WAYS TO PREVENT CONTAMINATION OF SPLASH PARKS: as recommended by the editors of the MMWR:

1. Use soap & water to bathe children before playing in the water—be sure to wash their bottoms also.

2. Change diapers in designated areas such as the bathroom and use soap & water to wash the child if there is stool in the diaper. Wash your hands after with soap & water.

3. NEVER play at such a park if you or your child have a diarrhea illness.

4. Don’t drink the water or swallow splashes from the water in the water feature.

5. Don’t allow children or adults to sit on the water spraying part of the water feature.

6. Find out how your park maintains the water safety, and don’t utilize the park if it isn’t maintained and monitored properly to prevent spread of diarrhea illnesses.

7. Check with the local Health Department to find out if they regularly monitor the safety of your favorite park.

Sofie’s Oncology Appointment

2009-05-16T22:13:00.000-07:00

This week, on Wednesday, Sofie went to her first appointment with the oncology vet. A week out from her surgery to remove the melanoma from her lip, we trekked all the way to Seattle to Animal Cancer Specialists. We met with Dr. Gillings who is a vet of 6 years who returned to school to specialize in oncology. She is a tiny matter-of-fact woman who was very easy to talk with. She’d already reviewed Sofie’s pathology report on the oral melanoma tumor, and spoke with me as if I were her peer as we discussed the likely prognosis and treatment options. I’d read about the melanoma immunization (see the melanoma link above) and had just about decided that Sofie would get it.

But earlier in the week I’d noticed a weird lump on Sofie’s hip and so Dr. Gillings did a needle biopsy of that along with her neck lymph nodes. Just to be on the safe side (needle biopsies aren’t the most fun thing to have done), Sofie got to wear a lovely basket muzzle. She was thrilled, as you can see by her face in this picture. She was tense, but cooperative. After two needle biopsies of each lymph node and the bump on her hip, she was taken back for chest x-rays. These were all done to look for metastases.

After the x-rays and biopsies, Dr. Gillings returned to the exam room and told me her findings with the caveat that a radiologist would review the films, and a pathologist would review the biopsies. Her impression of the bump was that it likely was a mast cell tumor. Just the act of examining the bump and poking it with the needle for biopsy caused it to release histamine and swell. That made it seem more likely her impression was correct. This is what makes these tumors so dangerous. Sofie got an injection of Benadryl for the trip home. In the picture, she looks a little stoned from her Benadryl shot.

It took until Friday to hear the pathology & radiology results. Dr. Gillings called me just as I was leaving work. The bump is a mast cell tumor. The x-ray shows a shadow in the lung. The melanoma tumor in the mouth is Grade 1 probably as it was small and the nodes were ok.

Meanwhile, I set Sofie up with Dr. Patti Schaefer of Canisport. Dr. Patti is a holistic vet that does acupuncture, advises on diet and supplements, and does chiropractic work with animals. Here’s Sofie enjoying her acupuncture treatment.

So, what now? Today, we took Sofie to our vet, Dr. Mark Peterson at Animal Hospital of Parkland. I needed to talk to him as I was starting to feel a bit overwhelmed by the choices that needed to be made. Dr. Mark helped us (Dale and me) sort out what the heck to do next.

Obviously the mast cell tumor must be removed. In fact, it has to be removed with huge margins to be sure that it is completely gone. That’s happening next Tuesday. That tumor and surrounding tissue will be sent to pathology for confirmation of cell type and identification of it’s stage (how fast it is reproducing and likelihood it has spread.) Dr. Mark will also do some more x-rays to see if that shadow in the lungs is just a shadow, or if it’s another tumor of some sort. Based on that information, we can decide how to proceed. If the shadow is a tumor, it’s potentially melanoma. It’s unlikely to be mast cell (they rarely go to the lungs). We could monitor it, and if it begins to grow, and if we don’t have to worry about spreading mast cell cancer, then the melanoma immunization would be the way to go.

But if the mast cell cancer is widespread, it would not make sense to do the melanoma immunization. In that situation, keeping Sofie feeling happy and pain-free would be the game plan.

So, that’s where we are in the dog pack scheme of things. Sofie’s eating a cancer-dog diet with low grains. She gets pre & probiotics, vitamins, and other supplements to help her fight the cancer and maintain her health as much as possible. She’s not getting any more immunizations (except maybe the melanoma one). She gets quercetin, organic apples, blueberries, and wild salmon oil. And she’s getting 50 mg Benadryl three times a day. She gets to play, swim, go on walks and chew on bones and every other dog joy that is available. And we’re going to love her as long as we have her to love.

Swine Flu Update

2009-05-05T12:46:00.001-07:00

Now that we’re a couple weeks into the Swine Flu Outbreak it appears that swine flu is the same as the regular seasonal flu in its virulence and its transmission rate. It may even be LESS deadly than the regular flu. Symptoms are about the same as the regular flu too, with high fever, cough, and sniffles. Death from the flu generally happens when complications of the flu occur. These complications include pneumonia, meningitis, or sepsis. And the complications are more likely in people with immune compromise, asthma and respiratory chronic illness, and other chronic illnesses.

So, it’s still a good idea to use the typical infection control measures that are common sense. Wash hands before eating and after touching potentially infectious items. And stay home if you are sick with a fever & cough.

Swine Flu Epidemic?

2009-04-25T21:55:00.001-07:00

The current swine flu outbreak represents infection by a novel strain of influenza. It is composed of subtype H1N1 influenza A that typically affects humans and several subtypes of influenza that generally affect pigs and North American birds. Mexico health officials report that over 1000 people have been infected. 80 deaths have been reported, but only 20 of them had laboratory confirmation of the novel swine flu.

Cases reported in the US have been less serious. There have been no US deaths at this time. There have been only 19 confirmed cases, but about 202 suspected cases across five different states. Some of the infected people had visited Mexico. None had contact with pigs; therefore the infection can pass from person to person. Undoubtedly we will hear of more cases over the next months but hopefully very few deaths.

Several key points have raised international concern.

1. Just as in the 1918 influenza epidemic, mortality seems greater among young adults. The usual influenza that hits us each year is hardest on young children, the elderly, and people who have an immune compromised state.

2. Cases are being confirmed across a wide geographical span—Central Mexico to Mexico’s border with the US to Texas, California, Minnesota, New York, and Kansas.

3. A strain of animal influenza not seen before is causing illness in people and is transmitted person to person via respiratory route. This is actually an unusual situation—animal viruses tend to spread through contact with the animal and then stop there.

4. This influenza virus is resistant to a couple of the usual antiviral medications typically used for influenza.

Because of these facts, international health officials are gathering and doing some serious investigations. US scientists are working with the virus to develop a “seed strain” that can be used to make vaccine in case that is needed. And investigators are scrambling to determine if we’re facing a serious pandemic.

Here’s what we don’t know yet but are trying to find out: How infectious is this strain of swine flu? How easy is it for someone to catch from an infected person? How virulent is the strain? If you catch it, what’s the likelihood of serious complications or death for the average healthy adult? Who is most vulnerable? And what’s the best way to protect those most vulnerable people?

WHAT CAN WE DO WITH THIS INFORMATION?

Everything comes back to protecting your own health and that of your family. Things we do every day to prevent illness can help protect you from Swine Flu. Eat a balanced diet and get the rest you need. Wash your hands before eating and after touching things that could potentially have germs on them (ok, you don’t have to get OCD about it but use common sense when visiting, shopping, hanging out in groups of people). Don’t go among groups of people when you have an illness with a fever. Avoid hanging around people with fevers & coughs. COVER YOUR COUGH and WASH YOUR HANDS.

For more information & tips, check out the CDC website: http://www.cdc.gov/swineflu/

Good Dog Ted

2009-04-21T15:26:00.001-07:00

It’s a beautiful day at work and so at lunch Teddy and the gang enjoyed a game of chase the ball in our little grassy area behind the clinic. Hunter watched from his stroller. Ted ran and ran until he couldn’t run any more. Here he is resting between chasing episodes.

Happy Birthday Teddy

2009-03-29T22:03:00.001-07:00

After a year and half long search for our special puppy, Dale and I found Sharon Marples of Von Marc’s Kennels in Hayden Lake, ID. We had grieved our great big Merlin boy, fostered a wonderful rottie we called Prince (later in his forever home renamed Walter), and nurtured our rescue pack during this time. And I’d interviewed (and been interviewed by) some local and distant breeders. I’d done a lot of research into Rottweiler health issues and genetics issues. We’d also gotten Sofie through two CCL surgeries (knee ligament), and Lady through stomach surgery (gorilla glue).

Sharon’s dogs impressed us with their charming personalities and intelligence. Sharon impressed us with her knowledge of the breed and her genuine and gracious efforts to educate the people attracted to the breed. When we met her at a local dog show, and her dog, Anya rolled into my lap and let my toddler granddaughter pet her, we were in love.

We told Sharon that if she had the right puppy for us in a future litter, we wanted him. We were looking for a pet quality dog that would have a stable temperament, willingness to work as therapy dog, intelligence to learn and work as service dog if needed, and courage to face any situation we would find ourselves in as a team. Sharon told us, no guarantees, but she’d be in touch.

We wanted a puppy from Anya’s litter, but Dale had back surgery so we had to wait. When Hooker had a litter, we contacted Sharon again to let her know we were interested still.

March 31, 2008, Teddy was whelped. His mom, Von Marc’s Happi Hooker; and his dad, Clearwater’s Black Tie Affair. Both dogs with more titles than I have room to type out here…international champions in conformation as well as holding working titles. Both dogs have illustrious pedigrees.

Just before Memorial Day, we got the news that we would be traveling to Idaho to pick up our 8 week old special pup. We were told that our puppy, Von Marc’s Essential Cat Scratch Fever, was pet quality because of an overbite. In all other things, he was just like his littermates. We fell in love with him right away.

Teddy is going to be one year old this week. He’s exceeded our every expectation. Ted has faced every challenge with enthusiasm and joy. He loves his work as therapy dog in our clinic. He adores his Great Dane big brother and respects his older sisters, Lady & Sofie. He’s gentle with children, loves meeting new people, loves performing tricks (for a cookie) and is eager to work at dog school. If I hadn’t broken my arm in October, he’d have his CGC by now. (the test was the week I had surgery) When I was incapacitated, he stepped in to help me. He learned to pick up and give me things I’d drop. He learned to put the laundry from the washer into the dryer, and to carry clothes out to the living room for folding (or tossing in the air for a game). He even learned to help me put on my socks—pulling them up for me.

He’s so smart he figured out how to open the front door and let out all the other dogs without anyone teaching him. He’s so steady that even the construction outside of our clinic doesn’t concern him. Soon he’ll be competing in Rally. I’m certain he’ll take to competing just as willingly as he’s taken to anything else I’ve asked of him. At the age of 1 year, this dog amazes me every single day. I don’t want to imagine life without Teddy in it. He’s become my heart and my constant companion.

Happy Birthday, Ted. Here’s to our next year together, and many amazing years beyond…..

Security and Health Information

2009-03-22T21:56:00.001-07:00

Yesterday I received some email from a patient’s mom with a question about her son’s health. Now, I do accept email from patients’ families, but it must be understood that this kind of communication is not private or secure at all. Public email can be intercepted on a number of levels and so should not be considered private at all. My answers attempt to be general and encourage families to keep it general and avoid communicating private information this way. If there is a sensitive topic, then it is best discussed in person actually.

Anyway, she had a question about her son and she included a picture taken with her cell phone to help describe the concern better. After the exchange, I copied the emails and a picture and created a “telephone encounter” note for her son’s chart. Prior to Epic, this would have been printed out and then filed in his paper chart. Now, however, the information goes into an electronic chart.

When I commented that I had made a note that was in his electronic chart and could be available for review by others who may provide health care for this child in the Epic system, she was alarmed. She wanted the note removed immediately. She was concerned for the privacy of her son’s health information. I had to reassure her that although the chart could be accessed by others in the Epic system, it was protected and secure and not available to be used inappropriately by anyone in the system. Did she believe this? I hope so. Yet, her concerns dredge up an important issue that is at the foundation of our nation’s movement to implement information technology.

Fir Creek Pediatrics is eliminating our paper charts. Right now they are in the chart rack behind the front desk. Soon they’ll be stored in the clinic basement stored in a big wall cabinet behind doors and secured by our office security system. What happens to information in an electronic chart? How safe is it? Who can access it? Where does it go? These important questions are on my mind as we move toward a mostly paperless medical record. Obviously they are also on the minds of our patient families.

All the FCP staff has a login and password to get into the server that houses our patient charts at MultiCare. When we are at the office, we are connected through a virtual private network that is protected by firewalls and encryption. Our own network also has a special password that each computer needs to know in order to connect. Each tablet PC that is used by direct care staff is also secured by the user’s fingerprint.

Patient care information is not stored on individual computers at all. All this information is encrypted, stored and backed up on multiple servers within MultiCare. Once we log onto the server, we have another login which is a five digit number and a password that includes letters & numbers. It is illegal (yes, illegal) and punishable by at a minimum firing, to share any of these passwords or logins. It must not be written down anywhere that it can be found and used by an unauthorized user.

Computers left unattended must be locked by securing the workspace or logged out of, and then unlocked with the pass-codes when needed again. Remote access is granted with another layer of security by the use of a RSA token that has a 6 digit number that changes every few minutes and is tied to the user login number.

Any time the chart is accessed, the server tags it with the user that is logged in, the date, time and what the user did with it. any note put in the chart stays there forever. It can be addended, but not deleted. This creates a digital trail that can be used to track and make sure that the chart’s protected health information and any other information held there is used appropriately.

So, the bottom line is that we have an ongoing duty to keep our patients’ health information secure and private. And it is my sincere mission and goal to ensure that transitioning to the electronic medical record not only increases this safety and security, but also enhances it.

Latest CDC Recommendations for Hib Vaccination

2009-03-18T19:37:00.001-07:00

Recommendations

The following non-high risk children should be scheduled to receive the primary series of Hib vaccine as outlined below:

If the child is at least 6 weeks but less than 12 months of age and has received zero, one, or two doses of Hib vaccine, schedule him/her for the first or next dose(s) immediately with a minimum of four weeks between the doses. These children will need one booster dose when the Hib vaccine shortage is over.
If the child is between 12 and 14 months of age and has not had any doses of Hib vaccine, schedule appointments for two doses, eight weeks apart.
If the child is between 12 and 14 months of age and has received Hib vaccine but did not complete the primary series before they turned 1 year old (i.e., had 1 dose of the Merck product OR 1-2 doses of the sanofi product), schedule an appointment for 1 additional dose, a minimum of eight weeks from the last dose.
If the child is at least 15 months of age but less than 5 years of age and has not received any doses of Hib vaccine OR has not completed the primary series (i.e., had 1 dose of the Merck product OR 1-2 doses of the sanofi product), schedule an appointment for one dose.
If the child is 5 years old or older and hasn’t received any Hib vaccine, Hib vaccine is not necessary.

Certain children are at increased risk for Hib disease, including children with asplenia, sickle cell disease, human immunodeficiency virus infection and certain other immunodeficiency syndromes, and malignant neoplasms. CDC recommends that providers continue to vaccinate these children with available Hib conjugate vaccines according to the routinely recommended schedules, including the 12 through 15 month booster dose. Providers who serve predominantly American Indian/Alaska Native (AI/AN) children living in AI/AN communities should continue to stock and use PRP-OMP– containing Hib vaccines (Merck product) and vaccinate according to the routinely recommended schedule, which includes the 2-dose primary series (ages 2 and 4 months) and a 12 through 15 month booster dose. This product is available from the VFC Pediatric Vaccine Stockpile, through their state immunization programs.

For more information about Hib disease and vaccination contact your state or local public health official or CDC at 1-800-232-4636/1-800-CDC-INFO or by email at www.cdc.gov/vaccines/about/contact/nipinfo_contact_form.htm. Information about current vaccine shortages and delays can be found at http://www.cdc.gov/vaccines/vac-gen/shortages/default.htm

Survival of Go-Live Week

2009-03-07T17:51:00.001-08:00

On Wednesday, Fir Creek Pediatrics went "go-live" with Epic Ambulatory. Epic is the electronic medical record (EMR) & system that is used by MultiCare clinics and hospitals in our area. Kids that are seen at Mary Bridge ER or hospital or specialist clinics, Good Samaritan Hospital, and MultiCare urgent care clinics all have a secure electronic chart that can be accessed by anyone in that system that provides care to them. Now we can also access that chart and utilize to document care given in our clinic.

This is the culmination of months of preparation. Last summer we applied for a grant to upgrade our health information technology in the clinic. The grant was offered by First Choice Health Insurance and a consortium of other parties interested in improving health care in Washington State. This was all prior to our new president's initiative to stimulate the use of electronic medical systems. We won the grant and got a check for $20,000.00 in October. The money was to buy new hardware, software, and whatever else would be needed to put in place an electronic medical record in our clinic.

Meanwhile, we'd done some checking around. We looked at various types of electronic medical record systems and evaluated their potential usefulness in the clinic, as well as cost effectiveness and tech support. We also consulted with a good friend, Stacy Basse, who we knew worked at MultiCare in the IT department. Stacy looked over our grant application and gave it to Rick Sheppard, who presented it to his department and suggested that Epic might be just what we were looking for. He managed to talk the department into working with us as a "demonstration project." (a mini-research study to test a project out) Because of his influence, we were able to get an incredible amount of help and resources at a special reduced price in order to implement Epic Ambulatory in our clinic.

When the grant money arrived, we got to work purchasing new, more powerful computers for the billing and reception staff (ok, Theresa & Elisha). And we bought tablet PC's for the back office (ok, Miki & Peach...and a spare for student or for just in case a computer needs repairs or something). Also a big monster network color laser printer.

Another meanwhile....we moved to clinic to Lakewood. The move delayed out progress with the project, and also increased its cost. With a bigger clinic, more exam rooms, a basement.....etc....we had to expand our network. We hired another good friend from the Geek Squad (Charles Paul, tech wizard extrordinaire and a really wonderful guy as well) to reorganize our network and get it up to speed for the big Epic switcheroo. We wired the new clinic so that computers could be hardwired into the network. And we also set up a wireless access point so that we could use the tablet pc's without wires. We put in TWO internet connections. One is dedicated to linking us directly to MultiCare's servers for the EMR through a virtual private network (VPN-an internet tunnel essentially). The other is for our routine internet work like email, a Microsoft live office space for the clinic, and internet searches, etc.

We spent a few weeks learning how to use Epic, and also troubleshooting all kinds of issues that cropped up. For example, making the printer work with all the computers; making the VPN work correctly so we could actually log-in. We discovered that some of our hardware didn't work with the system. Other hardware we ordered has to be sent back because it turned out we didn't need it after all or we ordered the wrong thing.

And then we dove in and Wednesday was no-paper-charts, throw caution to the wind, we're electronic now! OH MY GOSH, What a day! Each of us had a trainer assigned to work alongside us and help out. We scheduled very few patients. And yet, we all were confused and lost at least some of the time. Thursday was a little better, but the front office was really having some frustration and confusion. They need a card scanner after all (we thought the all-in-one printer and scanner would do the trick but it doesn't work with the Epic Citrix server apparently.) Some of the things that needed printing weren't printing right or at all. Everyone was exhausted at the end of it all. We tried to schedule an office meeting so we could gather and talk about how things were going...but we just couldn't make the time in between learning and doing everything in a whole new way.

Friday was a little better again, but BUSIER. We nearly had our usual amount of patients. It took me about two hours after work to finish my charting for some reason. Gak! At least everyone else got home on time!

So, is it worth it? Absolutely. While I'm at home, if a patient calls, I can look their chart up and document the call. If a prescription is needed, it only takes a couple of minutes to set it up and it's automatically faxed away electronically. If a patient is in the ER, I can monitor their progress and even set up a reminder to call and check up on them in the morning. I still don't know how to make an appointment. But I can look at the schedule from anywhere I am. I did a baby house call this afternoon, and was able to enter my entire charting document immediately and show the parents a growth chart....ok, I did enter the wrong birth date initially and got rude ugly beeps when I tried to put the first hepatitis B shot on a date before the birth date.....but I was able to correct that and everything fell together nicely. Soon we'll be able to pack up the paper charts and store them in the new clinic's basement. Life will be good. But right now, my head is about to pop from learning so many new ways to keep track of my patient care.

Ted being Ted

2009-02-13T12:51:00.001-08:00

Hi All, Teddy’s 11 months old and has turned into a great big goofball! Here he is playing “salamander dog.”

Von Marc’s Essential Cat Scratch Fever

“Teddy” born 3/31/08

On his more serious side, he’s becoming a wonderful therapy dog in my clinic. When he first came to me at 8 weeks, he met a 13 year old who had just disclosed that she’d been sexually assaulted by her stepfather. This young lady had shut down and was not communicating well with anyone. When she held Teddy, she began to sob and tell her mother and me about her feelings. Over the next few months she came to the office for various complaints (sore throat, cough, etc.) and spent as much time with Ted as possible. That was last spring & summer. At Christmas time, my clinic holds a charity photo shoot to raise money for one of our needy families, and this year we raised $300.00 for this family to help the gal and her 3 sisters and mom as they were on their own and living with grandma. Because of the weather, we mailed the check inside a Christmas card signed by the office staff. And Teddy put a paw-print in the card too.

I hadn’t seen the family in a few months, but they came to the office yesterday. Ted immediately ran to the girl and she sat on the ground so he could sit in her lap (his other thing he loves to do). During the entire visit, he remained in her lap, periodically turning his head to give Ted kisses. She was so delighted and said, “he remembers me!” And her mother said “he knows how much you needed him!” She’s doing much better in school now, and her mom reports that her demeanor has changed from sullen and angry to that of a normal adolescent girl. She’s in counseling (as is her mom) and the family is still living with grandma, but will soon be in a home of their own again. There is a court battle going on about the step-dad, of course, but they say it doesn’t interfere with their daily lives and the recovery process.

Teddy starts an introduction to rally class next week. And as soon as I can hunt down a therapy dog test & CGC test for him, I believe he’s ready. He’s got a dentist appointment next week to see if he really has to have the lower canines eventually capped or removed. My hope is that the dentist will have ideas that will help him keep his teeth, since he does have the cutest doggy smile despite the overbite. His health is great and I am so in love with him that it’s nearly embarrassing! Thanks to Sharon, his breeder, again and again for allowing this amazing dog into my life!

Peanut Recalls--No End In Sight

2009-02-05T15:52:00.001-08:00

More products are being recalled daily and the best advice for consumers is avoidance. Do not eat any peanut product unless you are sure it is safe. How can you tell? 1. Check the manufacturer's website or call the phone number on the package and ask. 2. Check the FDA website for lists of recalled peanut products daily. If neither of these methods give you the information you need, just avoid those peanut products in general until this all sorts itself out.

Here's a CDC YouTube Channel with a video about the Peanut Recall:

http://www.youtube.com/cdcstreaminghealth

It's alarming how our food supply is intertwined and so vulnerable to problems.

Five Children in Minnesota Reported With Invasive HIB Disease 2008--pneumonia, meningitis, & epoglotitis (bacterial croup)

2009-01-24T20:58:00.001-08:00

(picture of HIB bacteria cultured on a blood agar plate)

I just read this story in the MMWR (Morbidity and Mortality Weekly Report) which discusses infectious disease as it relates to events in the US. This report is put out by the Centers for Disease Control and is free to anyone interested. Click the link above to check it out.

This time the report describes something that causes me to worry. A group of underimmunized children who contracted invasive HIB disease. This disease affects children the most, and has been nearly a non-issue since the HIB vaccine became available in the US. The bacteria, Haemophilus influenza type B (which is actually misnamed since it doesn't cause the flu at all), causes respiratory infections including ear infections. It can also cause bacterial pneumonia, meningitis, and epiglotitis (deadly bacterial croup that strikes fear into the heart of folks like me trained in the 80's because it can cause the throat to swell shut suddenly and kill a child very quickly).

So, in December 2007, several lots of HIB vaccine made by Merck company were recalled and the plant that made the vaccine was closed. This resulted in a shortage of HIB vaccine in the US because it left only one manufacturer, Sanofi Pasteur. We're still experiencing that shortage in the US.

Because of the shortage, the CDC has advised health care providers to give only the initial 3 doses of HIB vaccine to infants, and to skip the 4th dose usually given after 1 year of age. Health care providers and the CDC worry that rationing the vaccine like this could cause an increase in invasive HIB disease in the US. So far, we've managed to be lucky.

However, in Minnesota there were 5 cases of invasive HIB during 2008. None of the cases were associated in any way--the families involved lived in different counties and had no relationship to one another. The kids were ages 5 months to 3 years of age. One died.

The one thing they had in common was that they had not completed the first 3 doses of HIB vaccine (so in other words, this could have happened even without a HIB shortage). Three of the children were unimmunized because their parents refused immunizations. One of these children died of their HIB disease. Two of the children only had two doses of HIB. One of those children also had an immunodeficiency condition.

Infectious disease specialists believe that these cases represent an increase in numbers of children who are carriers of the disease. This means that children who are not immunized, or underimmunized, are at greater risk of contracting invasive HIB disease because we are experiencing a breakdown of "herd immunity." If the herd is not completely immunized, more members will be carriers (they harbor the disease but either aren't sick or have milder illness). The unimmunized are then at greater risk of contracting the illness. With no immunity, they have a greater risk of severe illness and death.

Washington State has a large number of unimmunized people, and depending on "herd immunity" has never been a sure bet out here. Shortages like the one we are experiencing with HIB vaccine are a serious threat to the health of our children. We need to consider the implications of the limited supply chain for critical public health infrastructure like vaccines. We can't afford to allow this to happen in the USA. It's actually scandalous, and I'm shocked that there has not been public outcry. I don't think I've even heard it in the news at all.

So, go forth after reading this and let our president know that our children can't be put at risk because of vaccine shortages in the US. Contact your legislators. Spread the word. How can we call our country great if it can't even ensure enough vaccine for the children who need them?

and be sure to check the references cited there as well.

Michigan, Ohio, Wisconsin recalls

2009-01-22T15:30:00.000-08:00

Nash Finch, the operator of stores named: SunMart Foods, Econofoods (excluding Wisconsin stores in Sturgeon Bay, Clintonville, Marquette, Holton and Iron Mountain), Prairie Market, Avanza Supermarket, Food Bonanza, Wholesale Food Outlet, Family Fresh Market, Family Thrift Center, and Pick'n Save (Ohio stores in Van Wert and Ironton only) is taking the precautionary measure of voluntarily recalling the following products made in the bakery departments of its corporate operated stores because they contain peanut butter that was supplied by Peanut Corporation of America (PCA) and has the potential to be contaminated with salmonella: Peanut Butter Cookies, Peanut Butter Chocolate Chip Cookies, Mini Peanut Butter Cookies, Monster Cookies, Peanut Butter Grand Brownies, Peanut Butter Blossom Cookies, Puppy Chow snack mix, Peanut Butter Rolls, Peanut Butter Rice Crisp Bar, Special K-Bar, Scotcheroos, Rolls and Cakes Iced with Peanut Butter Cream. All sell-by dates are included in this recall.

Salmonella Outbreak Summary

2009-01-18T11:43:00.001-08:00

As of January 6, 2009, 474 people have become ill because of infection with Salmonella Typhimurium associated with peanut butter and paste products across 43 states between Sept 8, 2008 and Jan 2, 2009. (see http://hellotxt.com/l/VbIc%22%3Ehttp://hellotxt.com/l/VbIc for a map and breakdown of how many people per state)

We may be near the end of the outbreak (hopefully), but as in any statistical representation of a disease outbreak, there may be many more affected people than are reported. This is because not everyone seeks health care when they have an illness. And not all illnesses are confirmed by lab tests and then reported to the health department. Reported illnesses are only those that have confirmation by lab testing, which is usually in the case of illnesses severe enough to require hospitalization OR that last longer than the average routine illness.

The CDC is collaborating with the FDA to identify the source of infection.Just under a fifth of the people infected required hospitalization. There have been at least 6 deaths that may be associated with the outbreak. The elderly and the very young are at greatest risk. Symptoms include stomach cramps and diarrhea.

The salmonella typhimurium outbreak is linked to peanut butter and paste produced by PCA-Peanut Corporation of America in their Blakely, Georgia plant. The health department in the state of Minnesota reported that King Nut Peanut Butter (a product of PCA distributed by King Nut company and sold to schools and institutions) had salmonella bacteria that was a genetic match to the salmonella involved in this outbreak. Because of these findings, PCA has recalled peanut butter product that was produced in the Blakely, GA plant after August 8, 2008. Peanut PASTE products produced in that plant after September 26, 2008, are recalled as well.
Production has been stopped at that plant as of January 2009 while the FDA investigates the source of contamination.

AT THIS TIME, no nationally produced brand name jars of peanut butter are involved in the outbreak.

The investigation is expected to continue throughout this next week and as long as it takes to remove all contaminated food from the food supply. However, you are advised to avoid institutionally prepared peanut butter foods (school, hospital, company cafeteria, etc) until further notice. And specifically avoid food that has been named in the recall. This includes peanut butter ice cream, candy, cake, cookies, crackers, sandwiches, etc.

I'll try to keep you updated as the investigation goes along. Be cautious and stay safe!

The information for this summary was gleaned from the CDC outbreak website: http://hellotxt.com/l/VbIc%22%3Ehttp://hellotxt.com/l/VbIc and the FDA outbreak website: http://hellotxt.com/l/xhGa

Picture of Salmonella Typhinurium from http://www.giantmicrobes.com/ca/products/salmonella.html

Wool Felt

2008-12-28T14:40:00.000-08:00

Well, I got some wool felt at the Spring Fair a couple years ago and have been hanging onto it for just the right project. I have a jacket pattern that I'd really like to use it on. But I'm worried about ruining it with something so complicated. So I'm going to try these mittens first.

The felt isn't fully felted so the first time I tried to sew it, it fell apart on me. So, now I'm working it in suds and bubble-wrap. This turned out to be somewhat hand-intensive. As a result, I'm going to have to do it in stages. I worked on this for about an hour and now am resting my hand, which still can't tolerate a lot of pressure, flexion, or extension. It'll probably not be mitten weather by the time they are done. But, hey, the fun is in the process...right? And most likely they'll go to Blackberry Patch for sale anyway.

Fir Creek's IT Grant

2008-12-06T22:52:00.000-08:00

The following was written by me for the class I'm taking this quarter: Introduction to Informatics about the acquisition process for Electronic Medical Systems

As the owner of a small clinic with the fortune of receiving an information technology grant, I'm right in the middle of acquiring Electronic Medical Record/Practice Management System. Last July my office manager learned about an IT grant for small clinics in Washington offered by First Choice Health and Washington Health Information Technology Collaborative. I've talked about this with respect to other topics in this class. And this week I'll describe the process that my clinic staff and I are still in the middle of in order to implement our IT project funded by the grant. Like so many projects, I learned of the grant about two weeks before the grant proposal was due. Because of this, I had to hustle to put together a plan in the format required by the grant funding officers. The plan for the grant actually included most of the steps outlined in this week’s reading.

Establish a project steering committee and appoint the project manager.
My clinic has four staff members including me. Therefore we’re all part of the committee. As the owner and the one with the most experience with information technology, I’m the project manager. Throughout the project I could delegate roles and tasks among my staff members depending on my perception of their strengths and/or things I think will help them learn more about IT and contribute to growth of the employee.

Define project objectives and scope of analysis
Screen the marketplace and review vendor profiles
Determine system goals and prioritize requirements
Thinking back to when I started the clinic in January of 2000, I had always wanted an integrated Electronic Medical record and practice management system. I've always enjoyed using technology and computers, and actually felt that they could be a big part of making my clinic more efficient. Initially, however, I only had three patients and a $10,000 loan to start the clinic. This kind of budget and optimism about the practice didn't allow for a lot of new technology or software. In fact, I brought in my computer from home and used my own creativity to develop forms for patient encounters, various letters, and patient statements. I consulted with a businessman that had started my previous employer’s clinic about billing and scheduling software, and because it was an extremely inexpensive but functional non-windows program, I purchased it.

Over the next few years, I kept my eye out for interesting new ways to integrate technology into the clinic. My home computer was replaced by a small network that I setup myself, consisting of a computer at the front desk, and one for my medical assistant and myself. I developed forms using Omniform (software that allows development of forms that include check boxes and pull-down menus, etc). I toyed with an old laptop computer for my house calls, but found it inconvenient and bulky. I experimented with PDAs for when I was on call. And also tried out some free electronic tools such as Allscripts eRx. Occasionally I would do an Internet search for inexpensive practice management software and Electronic Medical records. But none of them seem to allow for the collaboration with my referral network that was a very high priority for me.

At one point I was approached by a very large group of pediatricians that had formed an alliance to pool resources such as purchasing supplies, contacting out for billing, as well as joining to use an integrated Electronic Medical record. I gave their offer a great deal of thought, and was really tempted to participate, but just couldn't give up my independence. So I turned them down. This was a good decision in retrospect, as their alliance fell apart within a few years.

I also talked with my son who is a programmer. He suggested that his programming company could develop custom software for our clinic if we wanted them to. Although this was intriguing, it didn’t make sense to me to reinvent the wheel.

So, although I had not formally gone through the process of developing a committee, determining priorities, sending out requests for proposal, etc, I had actually a good idea of what I wanted. My priorities are:
1. A system that integrates practice management (billing, coding, scheduling) with the medical record
2. The ability to collaborate with my referral network by sharing files and secure communication
3. The ability to access patient charts wherever patients are seen--for instance at a house call, in the clinic, or during a phone consultation
4. The ability to see lab results, x-ray, and test results as well as ER reports
5. The ability to allow patients families access to scheduling and some of their medical record
6. Tools such as evidence based protocols, algorithms, etc
7. Interface with the state immunization registry
8. The ability to customize documents
9. Good tech support available round the clock

This kind of system should eliminate some of the duplication of documentation that happens currently with my paper charting. But it shouldn't form an artificial barrier between me and my clients.

Considering hardware: the way I practice, I am on the ground interacting, playing with kids while they have their examination. Or unseated next to a mother at her home holding an infant, while helping her learn techniques for breastfeeding. So, a computer station attached to the wall or on the desk isn't going to cut it. I need a system that is very mobile and flexible. About six months ago I purchased a tablet computer for myself. It's got a touch screen, and the monitor swivels and lies flat so that I can use it just like the paper chart. I've played around with it in various situations doing patient care, and I think this is going to work. Using my Omni form pages, I'm able to chart easily on the floor next to kids as well as at house calls with newborns.

Develop and distribute Request For Proposal or Request For Information
Explore options for acquiring system
Evaluate vendor proposals
Conduct cost benefit analysis
Once I began to develop my plan for the IT grant, I consulted with a patient’s mom, and friend. She works in tech support at MultiCare for epic CareConnect. She introduced me to the director of the program at MultiCare. After explaining what I had in mind, and showing him around the clinic, he went back to MultiCare and proposed a demonstration project. Because my concept at the clinic includes expanding our developmental program to provide house calls, and we already provide house calls for newborns, he was intrigued. My clinic style is very casual and homelike. My staff and I work hard to ensure that families feel like they're part of my family. And the care we provide is very personal. So, along with our grant of $20,000 for IT, MultiCare epic CareConnect offered us deep discounts for their program.

Epic CareConnect is being used by Mary bridge children's hospital, as well as Mary bridge specialty clinics. So, it will enhance my ability to collaborate with my specialists with Email and integrated charting. Essentially my patients’ charts will follow them from my clinic to the specialist, the lab, x-ray, or the hospital. MultiCare calls it “one patient -one chart." They offer practice management in the form of integrated billing, coding, scheduling. They have decision making tools and customizable forms. After the first of the year they will have a portal to the state immunization registry so that when we enter immunizations, they will be automatically uploaded to the registry once a month. And they offer around the clock tech support.

Prepare summary report and recommendations
Conduct contract negotiations
The epic CareConnect team has come through and looked at our current hardware and made suggestions to bring us up to the system’s requirements. I reviewed the contract and when all of my questions were satisfied, signed it. We've researched hardware vendors and ordered new equipment--tablet PC's for everyone who does direct patient care (me and a medical assistant--and eventually another nurse practitioner), two new desktop PCs with more ram and processor speed for the receptionist and office manager, and a network laser printer that can handle multiple work group tasks such as prescriptions or patient handouts or billing. We are keeping our old desktop PCs and making them available for patients to use while at the office. And I'm sending one home with the receptionist who doesn't have her own computer at home, so that she'll be able to access the network remotely. Our old laptop will go home with my medical assistant so she can use it to access the network remotely. The office manager has a tablet PC like mine already for remote access.

We're setting up docking stations for the tablets in the lab and on our desktops. And we’re putting a large monitor in the lab to view x-rays. We're keeping our mobile printers for the house calls and for the lab. And we're keeping our all in one printer/fax/scanner. And we'll keep our existing network router both wired and wireless. All this hardware should arrive in the next week or so. And I'll have my work cut out for me as I transfer data and settings and set up the new network. If I need help, I have a tech support company that I can call in.

For security, the new tablets will have fingerprint password, a backup regular password, and LoJack. The desktops will have regular passwords. We expect that in the first months everything is going to take a little bit longer. For example we aren't transferring all of our paper information to the Electronic System. But we will be entering information such as demographics (if it's not already in the system) and problem lists. We plan to use the paper chart along with electronic chart for a while as well. And, until we're confident that were being paid, we'll be using the old billing system while testing the new one.

My committee members are all keeping blogs to document their experience during this time of change in the clinic. We have a large notebook that serves as our project repository. Once the new hardware is in, we’ll transfer that notebook contents to an electronic file. In about six months and at a year, I’m required to prepare a report to the grant committee. I expect to provide them with a summary of the project activities to that date and an evaluation of how things have gone. For my own information I have planned to continue evaluating our offices experiences with the EMR, as well as some research questions that I have about patient use and whether the project has met our goals.

Allergy to surgical metal

2008-11-07T23:08:00.000-08:00

For three weeks I've had terrible pain, a prickly feeling, and a feeling of oozing beneath my cast. In fact, it's been almost impossible to keep the pain under control. One week, when I went to the Dr. about this, the cast was removed and I had a great deal of inflammation, and what appeared to be pus at the pin sites. Dr. Silas ordered an antibiotic, and recommended that I not " overdo it." She was right in a way, because I had been overdoing it. And that did help a little. But the pain was still pretty unbearable.

So this week at my appointment, the cast was removed and one of the pins appeared to be backing out. Dr. Silas decided it was time to remove the pins based on my xray. I still had a great deal of skin inflammation, granulation tissue that was building up around two of the pins, and drainage.

As soon as the pins were out, my pain level dropped from more than eight out of 10 to a four. As the week has gone by, the pain has lessened. The pins sites, however are itchy.

It appears that I have an allergy to surgical metal. Now, I haven't been able to wear earrings since I was a teenager. I have allergic reactions to lots of different types of makeup. I'm allergic to carrots, peppers, cilantro, sage, demerol, penicillin, miconazole, various types of grasses, trees, weeds, and animals, not to mention dust and molds. Whenever I report my allergies to a healthcare provider I usually just bring up the medications. Looks like I probably ought to include metals.

Broken arm

2008-10-28T21:10:00.000-07:00

Just a short note as I can't type well. 2 wks ago I was standing on a chair looking for things on top of a file cabinet when I fell. I landed on my outstretched right arm/hand. Immediately I felt a smoosh. Looking at the right arm, there was a growing painful lump at the distal radius. I couldn't pronate or supinate. Fracture. So, this is a die punch type fracture of the right distal radius. I had surgery and I have pins holding the 3 loose chunks of the distal radius. I have a cast up to my armpit. Life is more complicated. And painful. I also have an antibiotic because of infection at the site of two of the pins. Soon the pins will be removed (5 or 6 more weeks) and I'll have occupational therapy to regain function. And I'm going to need to baby the arm/hand for several months. Long term risk include impaired function due to ligament injury, and arthritis. We won't know how or if I'll have long term problems. Time will tell.

The BARF Diet

2008-08-31T22:52:00.000-07:00

Here's my boy, 5 months old. He's 56 pounds, and a real lover-dog. He mostly seems to have bonded to me, but also likes Dale. He's become closer to Sofie, who now licks his teeth and checks if new ones are coming in. Lady tolerates him still and occasionally will actually play with him. And Angus likes him and will also play zoomie dog with him in the back yard. His favorite treat are dried buffalo treats. He loves carrots (great teething treats). And he enjoys raw meaty bones of any sort.

We've recently joined a Yahoo list of people who have come together to pool resources and purchase raw meat dog food. This style of feeding dogs is called BARF (either Bones & Raw Food or Biologically Appropriate Raw Food). Many people find that their dogs thrive on this diet. The problem is usually the cost and the freezer space involved. Prior to the list, I'd just get bargains when I found them at the grocery store and supplement with lean leftovers. Our dogs are eating about 1/2 high quality kibble and 1/2 BARF diet. But I do cook some of their food and they get vegetables, leftovers that are low fat and don't include things that dogs shouldn't have (like raisins or onions). They are getting meaty bones at least once a week and sometimes twice (depends on weather and weekends as I don't really want them eating them inside on the carpet).

Dogs

2008-07-29T21:27:00.000-07:00

So, with Dale home a lot and not working, the dogs have had a great summer. They go to the park nearly every day. Here are Lady and Sofie at Swan Creek. As you can see, their swimming lessons at Happy Tails Resort and Spa have really paid off. They LOVE swimming.

Here's Teddy at 4 months sleeping with the bear. He loves his Teddy Bear still and amazingly it hasn't been torn to shreds by him or the other dogs. At 4 months, he's all legs and feet. The feet are huge compared to the rest of him. From hock to toes, he's just about 1/2-1 inches shorter than the girls' feet. He weighs in at 40 lbs now. And he's a joy to be around. He's a sweet guy, loves meeting new people, loves Jada, loves Angus, loves swimming and playing with his teddy bear and ropes. He's in puppy kindergarten but loves recess with the other puppies best. He can sit, lie down, and pose (stand) on command (with treat especially), and he does a "high five." He's working on come when called also.

And here's his bite fault. He's teething and losing his baby teeth. At 4 months, it's clear that the mandible is not going to grow and make his bite normal by any means. It's clearly HUGE. But the little fellow can pick up a dime with that mouth of his. (oops! he found one in the car--thank goodness I caught that and he gave it to me easily.) So, in his near future, he'll either have to have the lower canine teeth removed or capped to allow for normal eating and closing the mouth. His baby canine teeth have made little pits in his palate. When the adult teeth come in, they will be much bigger and could actually damage the palate. So, there we are.

15 Week Old Teddy

2008-07-18T14:14:00.001-07:00

Teddy's 35 pounds and getting taller too. Here he is in a rare cuddly moment.

Second Annual 4th of July Parade

2008-07-16T15:05:00.000-07:00

This year's annual kids parade around the block went off well. Teddy helped out by riding the cart part of the way around the block. Angus, of course, pulled the cart. Ever since the day I rode the cart and "drove" him around the block, he's been horrible with the leash while carting. He wants to take off and race around the block at his own big dog pace. So getting him to slow to Teddy's pace was really pretty exhuasting for me. All the neighbor kids and adults enjoyed seeing them performing. And it was fun to get out with Angus and the cart.

On another note, I had a physical exam just before we left to go get Teddy at the end of May, and was diagnosed with migraines. I've really had about 3 or so headaches a week for over a year, and thought it was sinus headaches or something. So my doctor prescribed Topamax as a preventive and Imitrex to take if a headache occurred. At first the Imitrex was fine and actually worked. But then the Topamax began to make me really tired, absolutely without any appetite, and I developed a headache that was debilitating and lasted 3 weeks. I lost 15 pounds during those 3 weeks. Until I gave up on the Topamax and said, "this is crazy, why am I taking something that is making me feel so horrible?" As it turns out, Topamax AND Imitrex have a drug interaction with one of my other medications that causes terrible neurological side effects.

So now, I'm back to a headache a few times a week. But I have a new appreciation of them since the 3 week headache. They are minor compared to that. And, I'm still losing weight (-20 lbs now). And I'm able to enjoy my puppy and my other dogs, and Dale, and everything again. Oy!

Death of a Dove

2008-06-10T21:05:00.000-07:00

Angus somehow caught a dove and killed it before we could stop him. It was behind the currant bush, so maybe it was eating the few currants that are already ripe. When I got to it, it was gasping but alive and I checked it over. It had a broken wing, and I thought it might be ok. But then it just died in my hands. I think that it probably had internal injuries that I couldn’t see. Poor bird.

Anyway, Teddy was beside himself with excitement over the bird. He was hopping around, growling, barking and snapping at it. I let him inspect it along with the other dogs. When I put it down to get a picture, I thought he was going to tear it to pieces! Good grief! I don’t know if it’s prey drive if the animal is dead already, but this dog is full of it! By the way, he weighs in at 19 lbs 1 ounce today at 10 ½ wks.

Teddy's Here!

2008-06-04T12:00:00.000-07:00

This is our new pup on his play date with Mona, a 4 month old Mastiff puppy. He's 9 weeks old here and 17 pounds. As you can see, he's happy to play with the big dogs and not at all intimidated. He's also very interested in food treats. We're still not getting a lot of sleep.

Last weekend we drove all the way to Hayden Lake, Idaho to pick him up at Von Marc Rottweiler's. This is a beautiful breeder's home in northern Idaho where a few litters are bred with an eye for conformation, temperament, health, and working ability (agility, obedience, therapy, and herding).

We are so thrilled with our little guy! He's feisty, but not obnoxious. You can tell he's going to be a handfull when he's older. Smart as a whip! He already asks to go outside to potty, sits for treats, comes when you call him, follows you, sleeps in the crate.......I could go on and on.....but I'm going to take this opportunity to get back to work cuz the little guy is finally napping. He does have a ton of energy when he's awake!

Von Marc's Essential Cat Scratch Fever

2008-05-06T14:19:00.000-07:00

There's been an empty place in our home and hearts since losing Merlin to lymphoma 2 years ago. Whenever we see a rottweiler boy at the park, we glance at each other and think about our big boy.

The two years we've lived without him has given us time to work on improving Sofie's obedience. And time for Lady to grow to maturity and develop her personality and place in the pack. And time to work on socializizing, training, and essentially rehabilitating Angus.

Now it's time to welcome our new pack member. On Memorial Day weekend, we're going to Spokane to bring home our special puppy. His official name is Von Marc's Essential Cat Scratch Fever. We'll be calling him Teddy Bear. He was born March 31, 2008. Sire is AOM Multi V-Rated Am/Can. Ch. Clearwater's Black Tie Affair, CD, RN, HIC, CGC. Dam is BOSS/AOM Ch. Von Marc's Happi Hooker, CD, RE, CGC.

We can barely wait to bring him home!

Doctor of Nursing Practice

2008-04-28T20:45:00.000-07:00

Looks like I've been accepted as a Graduate Nonmatriculated Student at UW for the summer quarter. The ultimate goal of this new endeavor is to earn a Doctor of Nursing Practice degree. The impetus for this was the idea that I had to improve access to care for kids needing diagnostic evaluation for neurodevelopmental and behavioral conditions like autism or ADHD. In our area, there is an 8 month waiting list to see the local specialist. Because of this, kids and families have a long time to hang out and not receive important services they may need for success with school and relationships. So, I decided that adding a neurodevelopmental/behavioral component to the clinic would be beneficial to our current patient families, as well as increase the clinic's potential for growth. That also means more work, of course, but what an opportunity to learn more, grow educationally and professionally, and also help the community (at least that portion of it that includes kids with these problems)

So wish me luck. I've printed out the forms to apply for a class this summer as GNM student. This ONE class is going to cost a whopping $2042.00!! Gak! So, obviously this isn't going to be a quick degree program at that kind of cost......

Looms for sale

2008-04-19T16:22:00.000-07:00

4 harness Dundas table loom with 25 inch weaving width. Texsolve heddles plus billions of wire heddles. Take me home for $350. Also for sale, 4 harness 6 treadle Herald jack loom. Gorgeous maple wood. 45 inch weaving width. Includes attachments for sectional warp beam. $650 and she's yours!

Pavilion tx 2000 tablet pc

2008-04-08T15:35:00.000-07:00

Dale is moving around more and had his first follow-up appt today. Things are soon to be back to normal at home I hope.

Meanwhile, this is my new computer for home and work. And it will also be useful for going back to school.

I've decided to apply for the Doctor of Nursing Practice program at UW. The application process will probably be available toward the end of summer. And so that means the program won't really start until Fall of 2009. If all goes well, I can take some classes ahead of time as a Graduate Non-Matriculated Student. I've already applied for that but don't think I met the deadline to take a summer class. The program will accept 12 credits taken as a GNM student. I'm going to have to go part time and take as many credits as possible as a distance student since my clinic is full time too.

Also, I hope to have a new rottie pup to train as service dog. He or she will help carry my school stuff should I actually have to go to a class in person.

Busy busy!

Dale's Surgery

2008-03-30T10:25:00.000-07:00

Dale had back surgery Thursday. He's been out of work for a year & a quarter because he injured his back. It took this long for approval by the insurance company.

Here he is pretending to sleep right after he was brought to his hospital room. He stayed in overnight, and then came home. It should be an 8 week recovery process that includes a lot of walking. His doctor also said something about physical therapy. The goal is to return to work, of course.

It's been a long and painful journey for Dale, and hopefully he'll feel a whole lot better as he heals. Meanwhile, he's got our dogs and me cheering him on and trying not to be too obvious about taking care of him.

shibori dyeing

2008-03-17T11:32:00.000-07:00

Saturday was dye day at Elaine's farm. We're preparing for the Puyallup Spring Fair and so I wanted to do some shibori dyeing. We dyed 2 yard pieces in my everlasting indigo pot. This indigo was mixed up last October. When the Fiber Fun Day in October was over, we just cooled it down and stored it. To get it going again, it just needed some lye solution & spectralyte solution and to be heated up to the right temp.

To make this first one, I folded the fabric lengthwise back and forth about 6 inches wide. Then scrunched the length and tied it tightly with fabric ties in about 6 places. The ties act as the resist and keep the dye out of part of the fabric.

For this second one, I folded the fabric like a flag, then used the sewing machine to sew triangle shaped mazes (one for each end of the fabric).

And this third one was done by wrapping the fabric around a PVC drain pipe, then scrunching it up into a donut shape and then chaining a linen yarn in one inch or so spaces to hold the donut tight.

In between dying, Sofie had a chance to do a tiny bit of sheep herding (ok, she just barked at them through the fence...we're still rehabbing her leg from the cruciate surgery), chase a cat, and admire chickens and cows in the rare sunshine.

Xolair

2008-03-13T16:19:00.000-07:00

A couple months ago, I went to my allergist/asthma doc to find out if there was anything new on the asthma scene. I've had persistant asthma with frequent exacerbations with allergy and viral triggers. Working in a pediatric clinic exposes me to both, actually. And this has been a particularly rough year for the asthma. Could be the stress of losing my grandma & dad all in one year. But I really have had worse asthma this year, and have gotten sick a lot too.

Soooo, he suggested this shot-Xolair

My insurance actually approved the shot (it's really expensive). so we'll see if it makes my asthma a little easier to manage this summer.

Air Quality Index
0
Primary Pollutant
Ozone
UV Index:
2
Current Humidity:
85%
Current Visibility:
5
Mold Allergen Level:
0 (None)

Flatlocking

2008-02-13T15:31:00.000-08:00

The latest sewing project involved learning to do flatlocking with the serger. Flatlocking uses a decorative thread, ribbon, or yarn on the upper looper, a loose tension on the needle thread, and the lower looper. You lay your fabric with the wrong sides together and with the fabric folded or with two fabrics, serge just along the edge with knives disengaged or with a very narrow edge. You can piece different fabrics together as in the picture. Or you can make a decorative accent on the top surface of a piece. When you finish your "row," you tug open the fold and viola', you have a decorative line of stitches along the right side edges and "bars" or a "ladder" on the back sides.

Using this technique, I pieced together a bodice out of fat quarters. Then I attached a skirt out of larger pieces. creating a very cool jumper for Jada. This is a jumper called "Alittel Jumper" by Nancy Mirman with Design and Planning Concepts patterns. They have a similar item for adults too. (http://www.designandplanningconcepts.com/pattern.asp?id=257&categ=all&pnum=19 )

It looks pretty crazy on the pattern and lying flat there in the picture. But it looks amazing on Jada. I have to say that this was probably the most complicated thing I've tried to make of late. I've never done anything like it. The pattern directions assumed that I had a little more experience than I actually do have. So I had to work out some things to get them right. And then, I had to fit the jumper on Jada a couple times and adjust things before it was truly done. But it was all worth it, because it really does look amazing. Even Theresa, who doesn't really like mixes of colors and styles, likes it. Ha!

sewing expedition

2008-01-31T18:12:00.000-08:00

With the new serger in the house I've embarked on a sewing expedition. My first project was the roman shades with my mom's help. Then we made a jumper for Jada. Then I made a nightgown that didn't fit right.......so I bought a book on modifying patterns for better fit. And I bought a bolt of muslin and various other modifying and fitting tools.....And I made this great tunic top! And, wow, it actually fits, even though the darts are size 10, and the shoulders are a mix of size 16/18/and 20 (don't ask), and the hemline is .....that's on a need to know basis! Anyway, during the whole tunic top adventure, I also made a frilly top for Jada. Next is Jada pants and a whole another shirt adventure for me.............................oh boy!

2008-01-15T11:52:00.000-08:00

There's a lot to update over the past month. My mom came for the Christmas holiday which was the stimulus for much of the activity around my house. I had a roman shade kit that I'd bought at JoAnn Fabrics, and was saving for her visit hoping she could help me make it. Then after Christmas I got a serger to go along with the sewing machine I got last year.

Mind you, I haven't sewed a whole lot since my kids grew up. I've been very busy with knitting, weaving, spinning, dyeing, etc. thank you! But actually, since Jada arrived, I have made a few things for her and for Theresa to use with her (like the baby sling for instance). But I have wanted a serger because I thought it would be useful for when I sew handwoven fabric.

Anyway, we bought fabric for the blinds and went at it. There were measuring snafu's because my window is bigger than the one the blinds kit is for. We forged on anyway, with patching and piecing of fabric to make it work. We had to go back and get more lining fabric at one point. And also more of the blinds main fabric too. Oy! Then we had the lady at Lowes cut the wooden "batten" too short, so we had to go get another one. And then we had to get special hardware to fit the window and hold up the batten. (though we eventually didn't use it, we just hung it on the old roll up shades holders)

And after about a week of struggle, sweat, and late nights sewing and serging, we had it finished. And it looks really great! And truly it wasn't all that hard. Though if you count up the time it took to make it and the cost of materials, we could have had custom blinds made by someone else cheaper probably. But WE MADE THEM!! Wow!

Unwelcome Guest

2007-12-12T13:55:00.000-08:00

Look what we caught beside our house! We've had trouble with racoons travelling from our yard to the neighbor's all summer. And now that it is winter, we're still having them. We somehow became the racoon highway. All night long you can hear them jump to the fence and clatter over to the next yard.

So, I decided to catch the little fellows in a nice live animal trap. I set this trap up with a roasted chicken wing. Then I put it on the cement brick wall just the other side of our iron gate that leads to the side yard. The next morning, when I let the dogs out to potty, they roared over to the fence like maniacs. They must have had a scent. I ran back and found some slippers and a bathrobe because it was a cold morning. There, in the trap, was this huge possum. It was hissing and showing its fierce little teeth to the dogs. The dogs, of course, were beside themselves with the thrill of the "hunt." So I put the poor possum in his cage over by the woodpile so that it could rest a little before being relocated. Later in the day, Dale took it to Chamber's Creek park and let it go. Hopefully it makes a new home there and never finds itself back in our trap!

So, now I have to reset the trap and try again for a racoon. Obviously they are smarter than the possum, since I haven't gotten a racoon yet......

Weather

2007-12-07T13:52:00.000-08:00

We've been deluged with lots of rain over a short period of time here in the Northwest. It was mostly an inconveniece for us because we couldn't take the dogs for their exercise at the park last weekend. But, I just got an email from Elaine. She told me that some of her friends with farms more south of us have really suffered. This makes our trivial inconvenience feel so superficial. My heart goes out to these families with small farm businesses. And I told Elaine that if there is anything my family can do to help that we'd be very happy to do so.

The family at Black Sheep Creamery lost over 75% of their flock. Here's what Elaine writes to me:

Miki, read her musings for december....it's heartbreaking to know that this flock
of 100 has been reduced to 20..drowned in the flooded Chehalis river. Now maybe
Randy wont be so interested in moving down there. The sheep we sold that went to
Doty also survived but the Thoroughbred horse farm a mile away lost over 30+
horses...drowned in their stalls and pastures.

Angus Relaxes on the Recliner

2007-11-23T15:39:00.001-08:00

Angus Relaxes on the Recliner
Originally uploaded by mikimm

Happy Thanksgiving!

Failed Grape Crop-climate change?

2007-10-23T10:49:00.000-07:00

After some serious pruning last fall, this year's Concord Grape crop seemed full of promise. All summer, we watched them grow and flourish. It really seemed as if we would have a bumper crop. Way more grapes than I could possibly turn into jam in the autumn. But the summer was short, and not that warm.

And then one day it was Autumn. Rain began. It got cooler. Usually the grapes ripen by the end of September or beginning of October. This year a few of them turned purple, but the rest remained green. Now the leaves are dying and the grapes have a white powdering of mold. Darn it! My wonder-crop has failed and we won't have grape jam this year!

Happy Birthday Daddy

2007-10-02T15:17:00.001-07:00

You know that book that I wanted to send to you for Father's Day? Well, it would have made a great birthday present too. It's also an Audiobook, so you could have just listened to it on the computer.

I hope you are happy in heaven. I hope they have fish, deer, streams, mountains, and dogs. I hope Sugar, Spice, Bandit, Schatzi, Smokey Joe, Barney, and all your dogs over the years are playing with you. And accompanying you as you fish and hunt. Don't forget to rest. Eat right. There's no need to worry about anything. We're all ok here. Well, as ok as one can be without you.

Momma said that you came to her a couple weeks ago. You were sleeping next to her and she was afraid. XXXXXXX said you visited her as a monster. I recognized the daschunds you sent to my door a couple Saturdays ago. Actually, I didn't even know they lived in the neighborhood. When they showed up at my door at midnight it was quite a surprise. I was really glad we could find their owner. Then a little while later it came to me that you might have sent them to me. I won't pretend to imagine what it could mean. But maybe you just meant to say, "hi, I'm not completely gone, don't worry."

I'll never stop missing you.

your daughter, Miki.

Note: post edited 1/21/08 to remove mention of my sister who disapproved.

The Long Walk to the Barn

2007-08-27T11:17:00.001-07:00

The Long Walk to the Barn
Originally uploaded by mikimm

On Saturday, Peach and I helped Elaine shear Judy's alpacas. They had been boarding at Elaine's while Judy travelled about visiting her family. After the shearing and some shots, they were walked back over to Judy's. As for the wool, at least 50% was waste because of vegetation stuck in it. The rest was bagged to be cleaned and roved. Some of Judy's previous fleeces were given to me as commercially spun yarn. Elaine wants me to weave it into scarves for Christmas sales. Soooo....off to wind some warp.....

Wal-Mart: Tests find melamine in dog treats - Pet Health - MSNBC.com

2007-08-22T12:19:00.000-07:00

Wal-Mart: Tests find melamine in dog treats - Pet Health - MSNBC.com

More poisoned Chinese import dog items.

Second in Show

2007-08-17T16:43:00.001-07:00

Second in Show
Originally uploaded by mikimm

Angus got his Carting Started title yesterday at the American Rottweiler Specialty carting trial. They allowed other breeds to compete. Angus got around the mid-range place among all the dogs, and 2nd Reserve High Score in the Other Breed category (losing out on 1st to a smooth coated collie). (so essentially he was second place....or last place...among the non-rottweilers competing) ...depending on if you are an optimist or a pessimist). We're both really tired now and you can see he'd rather not be posing.

1850's Fort Nisqually Camp

2007-08-15T13:11:00.001-07:00

1850's Fort Nisqually Camp
Originally uploaded by mikimm

This past weekend, Elaine and I camped at Fort Nisqually for the Brigade Encampment. This is a 1850's historical reenactment. We moved into our Baker tent Friday afternoon and camped until Friday. During the day we interpreted our camp to the public who came through the Fort. In the evenings, we enjoyed visiting with our friends. The Fullers (a family from Oregon) always camp by us, and we shared a cookfire and shade canvas between us. They had two tents this year (teenagers in one, parents & preschooler in the other).
It was great fun as usual, but I didn't get much weaving done (again).

Tomato plants

2007-08-07T15:57:00.001-07:00

Tomato plants
Originally uploaded by mikimm

An update on the hydroponic tomatoes. Aren't they pretty? They all have tomatoes on them except one.

Proctor Art Fair

2007-08-07T15:04:00.001-07:00

Turning into Position
Originally uploaded by mikimm

This weekend, Angus got the opportunity to practice carting with lots of distractions at the Proctor Street Art Fair. This picture shows us turning into position for the Top Dog Parade. Jada was princess-like in her car seat on the cart. She enjoyed herself just about as much as Angus did. Plus, we got some free advertising for the clinic with a poster that Theresa made for the back of the cart.

First Annual 4th of July Street Bike Parade

2007-07-04T12:51:00.000-07:00

We have 5 children from about 3 yrs old to 6 years old living on our street. One of the families has teachers for parents. This family decided to organize (at the last minute) a parade with the kids for the 4th. The kids' cousins came with

their bikes, and all the bikes were decorated.

They invited Angus to pull his cart in the parade too, so they decorated his cart. At one point, they thought that a relative with a baby would be coming too, so we attached the car seat to the cart. When the baby didn't come, we put a pink panther toy in the car seat.

One of the moms had an ipod with speakers playing patriotic music. The older kids were chomping at the bit and having a

terrible time staying in a line and not racing each other. They spent most of the parade way ahead with parents yelling for them to "slow down, watch for cars, come back!!" The younger kids rode wagons or trikes or walked. The little boys were afraid to ride in the cart. Rachel, the next door neighbor, wanted desperately to ride the cart, but she had started out with a bike and so couldn't abandon it.

At the end of the parade, we all gathered at the teachers' house for cookies and water. It was actually a fun event, and everyone agreed to do it again next year.

Jada Spends the Night

2007-06-29T20:45:00.001-07:00

Jada's having her first overnight stay at our house while her mom and dad take a romantic trip to the Olympic Peninsula. Here she is chilling with her new baby and her Grandpa. So far the evening hasn't been too traumatic for anyone. She's melted down a couple of times. Didn't really like her dinner but ate cheerios, grapes, and chocolate pudding like it was the best food ever. She played for hours with her new baby and stroller. Watched her Little Einstein movie's beginning about three times. Took a bath. Fed the dogs. Then she melted down when it was bedtime and cried for a good 30 minutes (between stopping to listen for us, coughing and choking some for effect, then listening again). Now, thank goodness, she is actually asleep and I intend to go back out to watch TV with the dogs and knit. Bye.

Racoon Poo

2007-06-20T15:16:00.000-07:00

Dale found this pile of racoon poo on our roof yesterday. Our neighborhood has a little wildlife preserve that's located just at the end of our road. Racoons live down there. About a month ago, we learned that the family across the street from us hired a Critter Getter company to trap racoons eating grubs in their back yard. We thought it was pretty funny at the time. Then we heard that a mother racoon had nested under another neighbor's deck. We thought that was hilarious. Since we have big dogs, we didn't worry too much about something like that happening to us.

Then one day the next door neighbor called to say a racoon was on our roof. We ran outside to find that a large racoon had climbed the rhododendron in front of the house, leapt to the roof, and was casually walking along the roofline to the side of the house closer to the neighbor with the nest under the deck. This racoon actually then jumped to our fence, walked along it until he reached the back yard, then jumped into the neighbor's yard and walked to the nest. Again, we didn't think it was a routine thing, so we didn't worry too much.

And now, the evidence is clear. This massive pile of racoon poo shows that our roof is actually a happy little racoon waystation between the nature preserve area, the neighbor with the grubs in the back yard, and the other neighbor with the nest. Sort of a rest area, where the critter can stop, take a dump, and then travel onwards in peace and tranquility out of reach of the big dogs.

I'm not sure what Dale has decided to do about this, but I'm considering a live trap. We can catch the little fellow and take him or her far away to a new home in the forest.....say Fort Lewis area or somewhere like that. Surely the babies are big enough to be traveling now too. I guess we should consult the nest neighbor about that first.

Meanwhile, we've got some cleaning to do.

Pup

2007-06-17T09:48:00.000-07:00

My bromeliad at home has a PUP!! There it is, a tiny baby bromeliad. The plant, itself, looks horrible. My mom says that she thinks the pup sucks the life out of the mother plant. They apparently do take some nutrients from the mother. But I also spray fertilizer water on the plant periodically.

Here's a link to a site that talks about when to remove the pup. I'm letting this pup grow a bit before taking it and planting it in its own pot. The bromeliad at work hasn't got any sign of making a pup. It's smaller than this plant, though. And doesn't have an inflorescence...unless those top leaves that have pink in them are it. This one has a red flowery looking top.

Basket Weaving

2007-06-09T14:23:00.000-07:00

I've never woven a basket before. But this year, at the Spring Fair, WeavingWorks had a booth next to ours. I kept wandering over and looking at their things. In the corner they had a few basket making kits. Somehow, they kept calling my name. But I resisted. After all, I really don't need a new hobby that includes lots of rolls of reed, twigs, etc. lying about. Weaving on looms creates enough clutter all on its own (several types of looms, projects in various states of incompletion, hanging warps already wrapped their intended projects forgotten about, yarn cones, shuttles, strips of rags stuffed in corners). Yet, I also spin (more clutter of wool, spinning wheels, niddy noddies, bobbins, dripping yarn in the bathroom, whole fleeces in bags on the front room furniture). And I knit (knitting equipment including two knitting machines, a huge tackle box of knitting needles, half knitted things, THE YARN STASH). You see my dilemma. But I couldn't help myself and kept going back again and again. Finally, on the last day, they marked everything down in price. I had to buy a basket kit. Just to try. Maybe I'd hate making baskets. Maybe it would be too complicated and I'd give it away to a more suitable basket weaving friend.

I took it home and it hid in a corner of the front room near the 6 (or 8) fleeces I had also bought, the pretty shuttle I couldn't live without, the loom that was for sale on Craigs List for the most ridiculous price that I knew I had to buy it just to resell for a more reasonable price (thus making a profit to support my habit....I mean hobby.

Finally, last weekend when it was too hot out to do anything else, I took out the kit and started weaving my first basket. Weirdly enough, it wasn't too complicated. In fact, it was kind of soothing and very similar to other weaving I've done. I kept stopping to look at how amazingly basket-like my basket was turning out to be. So symmetrical and smooth. So intricate, yet simple. And here it is, completed in all it's basket glory. Amazing. I still can't stop looking at it. And now, of course, what I feared would happen is happening. I'm looking at the grape vines differently....the stems of the hydrangea sure look straight and woody.....oh dear. I think I might have a new hobby after all....

Hydroponics

2007-06-03T09:16:00.000-07:00

Dale set up a hydroponic garden system on the back of the house for me. Last year our nephew, Geary Jr. had one with monster tomato plants. He had so many tomatos that he didn't know what to do with them all. So, after looking at that, we decided that this year we would give it a go. Geary came over and helped Dale figure out what we needed to set it up. Then over the span of about a month, Dale collected parts. There's a long plastic chamber like a hollow fence post. It's capped on both ends and has squares cut out along the top of it for plant containers. And it has holes drilled for tubing to spray nutrients and water at the roots. And there is a drain hole underneath at one end. Then hoses are attached along the back side to deliver the nutrient/water solution to the little spray hoses. And there's a pump, like a pond pump, connected to the delivery hose. And a big plastic garbage can with holes drilled for the delivery hose & pump, and for the return hose. Initially we used a big plastic box, but the pump had trouble sending the water up out of the box and then all the way up to the plants. The solution goes from the garbage can reservoir and gets sprayed at the roots of the plants, then drains along the inside of the fence post chamber to the drain hose, which is gravity fed back to the reservoir. We have the reservoir insulated with a big silver bubble wrap sheet to try and keep the nutrient solution cooler than the ambient environment. I test the pH of the water and try to maintain it at a constant slightly acidic level. And I test the ppm of nutrient solution (with a meter purchased for just that purpose) so that I can monitor how much water or nutrient the plants have used (or evaporated) and then add nutrient or water as needed. So far I've had to replace four of the plants because they died while working out the problem of the pump and reservoir. We had a couple of days when the system leaked and so we've wasted about a jug of nutrient (fertilizer). And we had about 24 hours when the pump kept shutting off because it lost siphon when we were using the box as a reservoir. And then there was about 24 more hours with the pump off while we took it back to the store thinking it was defective. The guy at the store is a real piece of work, but after describing the system to him, he came up with solutions to the problem of maintaining siphon to keep the pump going. I'm certain he thinks everyone who comes in the store is either a police officer to shut him down or a marijuana grower to get him into trouble by selling hydroponic supplies for the purpose of manufacturing drugs. So, now I have 9 tomato plants of various types. They look pretty good during the evening and morning, but some look wilty with the sun on them. I hope it's just shock from having the dirt removed from their roots in preparation for a new life as hydroponic plants. Hopefully they will adjust soon and will thrive and make millions of tomatos. I'm planning to can lots of spaghetti sauce for the winter, so I need those tomatos!

Carting

2007-05-23T15:10:00.000-07:00

The American Rottweiler Club (ARC) is having trials in August in Enumclaw, and will have carting trials too. So, since we have the cart from when Merlin was carting. And since it fits Angus (and I did buy him a harness).....I'm training him to pull it. Here he is at the carting practice on Mother's Day. Fortunately for Angus, all breeds are welcome. I try to pass him off as a Great Danish Rottweiler, but of course the real Rottweiler people will know I'm full of it! *G* Angus is doing well with his training, and accepts passengers on the cart without any fuss. He still needs practice with turns and the down stay (apparently he has to down stay with me out of sight for 3 minutes). I think I'll practice that without the cart first. Then move on to doing it with the cart.

Visitation

2007-05-19T10:54:00.001-07:00

Theresa, Jada, and I returned from South Carolina Thursday. We're all pretty much exhuasted since we somehow managed to stay awake for over 36 hours. We left for SC on Tuesday and arrived in the evening. I had my GPS and pocket pc to find the way to everywhere we had to go. After checking into the motel and changing clothes, we drove to my mom's. Somehow the GPS managed to put us on the mountain behind their mountain in Sunset, SC. In fact, it seemed that every time we asked the GPS to take us somewhere, it took us a different and more scenic route. http://www.mapquest.com/maps/map.adp?latlongtype=decimal&latitude=34.9775&longitude=-82.79917&zoom=7 Wednesday was the visitation, when we all hung out at the funeral home in a parlor-like area in true Southern style. Daddy was propped up in a casket surveying the visitors (I couldn't look, but kept getting scary corner-or-the-eye views of his nose and forhead). I tried my best to stay in the outer parlor. Lots of relatives I hadn't seen since childhood came to pay their respects. Amanda, my neice (brother, Mike's daughter) made a DVD of daddy's life and played it on a DVD player. My poem was also displayed thanks to Amanda. Aunt J. and others had sent really gorgeous flowers and plants. It was actually nice, even though it was horrible (I can hardly think about it all without choking up). After the visitation, we went to my parents' house and hung out with neices (Lindsey & Amanda) , nephew Chris (and wife Kristie & baby Isabelle), brother Mike, his wife, Sophie, my mom, her two dogs (Susie and Toby), Theresa & Jada. We told funny stories of our childhood memories, etc. By the time we left and made it back to the motel, it was really just about time to pack and go back to the airport. So we did. We got there about an hour or two early (who knew that we'd make it there without an hour of GPS touring of the countryside??) so we hung out in the car for a while. Then we had an hour flight to Atlanta and a five hour flight to Seatac. And a drive home, and etc.... So in all we ended up pretty darn tired and I don't think I'll ever get my sleep caught up. I feel like a zombie. Anyway, I have to go to work so I'll fill in details (or not) later.

Edited 1/21/08 to remove references to my sister who disapproved.

My Dad died today

2007-05-12T10:06:00.000-07:00

This Daughter's Tears

There's distance in my eyes, my feet turn south,
I feel the need to reconcile opposing points of view.
Definition blurs with time & space, but still I think I see
a mountain man who shakes his fists at storms.

This man, soother of skinned knees & bruised hearts;
he brought back puppies from the very brink of death!
Speaker to God from the sanctity of duck blinds and river banks.
I watched him talk the birds down from the vast blue sky.

Who's that? Who's forced to lie there, meek & chained-
a helpless prisoner trapped among the healer's wires and tubes?
Could that be him? I squint my eyes to try to see the man;
that great ship's captain, mutinied by his own too fragile heart.

I long to go to him, to kiss his grizzled cheek,
to linger by his side, to set him free!
A length & breadth of life and love is measured, resolute,
between the salty spaces of this daughter's frightened tears.

--written by me in 1992 when my daddy had one his first major heart attacks.

Theresa and I are flying down Tuesday for a funeral on Wednesday. My brother, Mike is already there. My heart is broken today.

Barbecue Debacle

2007-05-05T21:56:00.000-07:00

So, here's how it all begins: Our barbecue died just about the end of last summer so Dale hauled it off to the dump. Then finally after a long rainy winter, spring finally arrived. Today Dale decided we should go to Costco to get a new barbecue. I really prefer to cook on the grill when it gets warm out. First off, I hate to heat up the house with cooking. And secondly, it seems like less of a mess in the house when you cook outdoors. And thirdly, it's fun to be outside with the dogs and all while cooking. And fourthly, who doesn't like to eat yummy barbecued food? So, he'd seen a barbecue at Costco that had an oven in it. What a great idea! So we went to look. Whoah, that thing cost nearly a thousand dollars! So, after measuring how close the rotisseries were to the grill (maybe 2 inches...you could cook a thin chicken on it maybe) on the other two choices at Costco, we decided to go to Lowes. At Lowes,they had a bunch of barbecues outside, but it was hard to look at them because they were all chained together. So we went inside. There,the helpful Lowes guy showed us the options. One had a nifty smoker insert. (I nearly died of an asthma attack the last time I tried to smoke chickens so I decided that might not be the right one for us). The other option looked just right. So we loaded it up into the dogmobile along with a rotisserie attachment and some other must have attachments. When we got it home, we struggled it out of the car and into the house and then back out the back door. With dogs swarming around our feet the whole way. Then we unpacked the million parts that it came with, along with tons of plastic and foam and cardboard. I found the instructions, and we began to put the thing together.

About 1/2 way done, we had already determined that it would require the assistance of a capuchin monkey to put in some of the tiny screws into the impossible holes in the bowels of the barbecue. Then we found that parts were broken, pieces were chipped and bent, and basically Dale had spent a lot of money for a broken barbecue. So we packed up our partly assembled pieces and hauled it back through the house with dogs swarming around trying to help in their doggy ways. Then we struggled it back into the dogmobile (this time the back door wouldn't close all the way) and took it back to Lowes. We confessed to the Lowes guys that we'd had just about as much fun as possible over the past 4 hours trying to assemble a broken barbecue, so wouldn't they just rathery take it back and sell us an assembled one instead? (We didn't care if it cost money, just have someone else's monkey climb deep inside and attach those teeny tiny screws. Turns out that assembly was free. Hmmmm. We're going to pick it up fully assembled Monday. Barbecue anyone?

Working Dogs

2007-05-03T20:33:00.000-07:00

Sofie is 4 months out from Tibial Plateau Leveling Osteotomy (TPLO) surgery for a torn cranial cruciate ligament. She's going to begin swimming at Happy Tails Resort & Spa this weekend : http://www.happytailsresort.com/pool.htm where we took Merlin after his TPLO surgery. Swimming is a great way for a dog to rehab after this surgery, because they have to be on limited activity for at least 4 months. This surgery is really quite major. The cranial cruciate ligament in a canine is the same as the ACL in a human. It's job is to prevent the tibia from slipping forward with walking. For a dog, the surgery involves making a new angle on the top of the tibia to realign the way the femur articulates with it while walking. A metal plate and screw are usually placed to secure the new alignment and prevent the tibia from slipping forward during the walk. This whole procedure eliminates the pain felt while walking around with a torn ligament, stops progression of arthritis (a complication of ligament injury), and eliminates the need for the cruciate ligament. So, anyway, it takes about 4 months for the bone to heal and the hardware to become secured by the healing bone. Meanwhile, the muscles atrophy and the leg itself becomes weaker. One of the biggest complications of TPLO surgery in the dog is CCL injury in the opposite leg. One possible reason is compensation for the weakness in one leg by overusing the opposite one. Of course, in the rottweiler as well as other dogs, there is probably also a genetic component. We're going to also swim Lady, whose foot injury as a puppy has resulted in one smaller rear foot, increased stiffness of that knee, and smaller muscle on that leg as well. Lady loved swimming when she swam as a baby after her cast came off. She and Merlin could barely be convinced to rest periodically as they swam. Sofie, on the other hand, only swam to compete with Lady and Merlin for the pool toys. So, we'll see how it all works out Saturday morning.

Knit-In

2007-04-26T15:19:00.000-07:00

Today was the Fir Creek Pediatrics Knit-In. We hold a Knit-In every Thursday morning from 10-11:30 am. Moms (or Dads) of our patients are invited to come, hang out with us, and work on a craft project for a while. It's very informal and fun. Since I am a fiber addict, this is perfect for me. I can check out what everyone else is working on....help if someone has trouble....and we can snack on things and drink tea.

So, Peaches (my medical assistant) is making a sweater from the Reynolds Yarn Best of Lopi book. She has never knitted anything quite so complicated, so she's needing a fair amount of help. She's getting really good at "frogging" to fix errors, unfortunately. *G* But that's all part of the process. She's going to be so proud of her sweater when she's done.

Theresa (my beautiful daughter and mother of Jada) is making a fuzzy scarf. I tried to entice her to knit a sweater or some other larger project, but she wants to use this amazing yarn she bought when we were in Spokane this winter. We had a quick weekend trip to go to my grandmother's funeral. Grandma was an avid knitter as well, and so it was only fitting that we went to a local yarn shop in Spokane before flying back home.

And that cute mom with her baby is making a scarf too. She comes every week without fail and is making tremendous progress on that scarf. It's out of some commercial wool and is for her partner. That little guy with her is a handfull, so I wonder how she can get any knitting done at home! I know I had trouble getting any knitting done until my kids were older.

I haven't been making anything consistently yet at the Knit-In. I did weave a mohair scarf on my table loom here during the knit-in.

And I have brought in my tapestry that is 1/4 done and hasn't been worked on in 1 1/2 years (oh no!!). Maybe I'll work on it next week......

Today, though, I helped untangle some really fuzzy feathery unruly yarn for someone.

And I also fixed the warp on the rigid heddle loom that my student, Beth, will make a scarf on. I've never warped a rigid heddle loom before, so I had Beth warp it with the heddle upside down (oops). So today I undid the warp and resleyed the rigid heddle the right way. Did I mention I'm teaching Beth to weave? In between teaching her about being a pediatric nurse practitioner......*G* My mom sent it to me and I'm going to sell it to Beth. I'm giving her a warping board and that belt shuttle too to go with it. Plus free lessons of course.

So it wasn't really a completely wasted Knit-In hour and half for me. And it's always relaxing, rejuvinating, and fun.

2007-04-23T20:10:00.000-07:00

More Lady Therapy Dog Pictures

Therapy Dog

2007-04-23T19:59:00.000-07:00

Here's Lady earning her keep as a therapy dog in my pediatric clinic. Kids usually adore her because she's so mellow. She usually lies down and rolls over for them to pat her belly, but she so tolerant that she will allow them to lean on her or look in her mouth/ears/nose or whatever. She was born a sweetie-pie. We rescued her from the local humane society shelter at the age of 3 months. She had a torn achilles tendon and broken heel bone at the time, though the vet at the shelter had spinted her foot instead of the heel because he/she thought it was a broken toe. After bringing her home, it was obvious it was the tendon because her foot just flopped around. We took her to our vet, who advised immediate surgery to attach the tendon and pin the heel bone. She had that surgery before she'd been with us for even a week---to the tune of nearly $3000. Then she proceeded to live with a cast on the leg until she was about 7 months old. Because the injury happened at the growth plate, her foot never grew to its full size. So she has one leg about an inch shorter than the other, and she has some limits on her range of motion of that leg too. But she gets around as if nothing would stop her! She'll probably have arthritis problems in the knee or hip when she's older, though. We feed her glucosamine, MSM, fish oil, and vitamin E...as well as super premium light dog food, carrots, apples, potato, and other healthy snacks. We work to keep her weight on the lean side to help stave off the joint issues too.

She is the "gorilla glue dog" who ate glue a couple months ago and was on the news. Had to have more emergency surgery to get the glue out, which makes her a $6000.00 dog. Hopefully she'll grow to a ripe old Rottweiler age without any more serious problems.

Disturbing News about Pet Food

2007-04-20T11:59:00.000-07:00

Here's Jada playing outside at work today. It looks like she's digging up a flower but actually she's sort of using the shovel as a cane to help her walk on the uneven dirt.

On another note, I'm thinking about dog food today because another ingredient has been added to the list of contaminated dog food recall list. So far we've managed to dodge the bullet and our dogs haven't eaten any of the listed recalled foods. But it almost seems that every day more food is added to the list. And now it appears that the contamination could have been deliberate in order to boost the apparent protein content of the ingredient. I'm so outraged and concerned about this that I don't even know what to say about it. So now I'm researching feeding people food to my dogs. Except Angus, the Great Dane, gets diarrhea with anything other than Royal Canin Giant Breed. Even a taste of people food will wreck his digestive tract for several days. So anyway, it's a quandary.

Bromeliads

2007-04-17T19:30:00.000-07:00

http://en.wikipedia.org/wiki/Bromeliad; http://hgic.clemson.edu/factsheets/HGIC1501.htm

2007-04-17T16:27:00.000-07:00

This is my pretty little Bromeliad. Her name is Cryptanthus and I got her after seeing my mother's Bromeliads. Apparently they are supposed to be easy to care for and also they reproduce after making a spectacular flower like thingie called an inflorescence. They have one inflorescence, then live for one more year while meanwhile making "pups" which are baby Bromeliads. Who could resist a plant like that? So, I'm going to monitor this little plant and document its life as we go along here.