Generally starting around one million and going up to around three million . You may be able to find a few that meet your criteria and are a little less than that but they likely have some issue or are intentionally on the market below market value.

Some of this (headaches, vomiting, visual symptoms---and if the headache seems to happen more frequently in the morning and feels better after your son vomits then I would be even more concerned) is concerning for a brain tumor. To rule this out your son needs an MRI of his brain. Yes, I saw that they did a head CT but unfortunately CTs will miss a significant proportion of pediatric brain tumors because they do not image the posterior fossa well. To be fair to whoever saw your son in the ED they may not have had access to MRI from the ED but they should have explained to you that you should follow up with your pediatrician to get the MRI arranged. I am praying that this is not the correct diagnosis but it needs to be ruled out before you go any further.

I kind of can't really embrace the dust bunnies because several of our children have asthma. To be fair, maybe I also can't really embrace the dust bunnies because I grew up in a very clean (but also very comfortable and warm) home and I've really internalized a lot of my mom's routine. I think my mom's system is probably very similar to SHE and I have developed a deep cleaning rotational schedule on the computer that we use to keep on top of things. In full disclosure, I will acknowledge that we do hire out a significant majority of our deep cleaning (the computer schedule is awesome because then DH or I can just print out the to do list for the cleaners when they come) so I'm usually not sacrificing time with the kids to deep clean (although we do enough task to ensure that our kids know what needs to be done but then we're usually cleaning together so technically it is time together). If we had a significantly smaller house, I wasn't working as a physician, and we had fewer children I would probably hire out less.

Feel free to PM. Our daughter's teen LDR eventually led to an engagement. To clarify, I am speaking about our DD20 and more than years transpired between the beginning of her teen LDR and the engagement. They are actually still doing the LDR thing for at least another year. He will be starting medical school next month and she is applying to medical school now. She is applying to the medical school he is matriculating at but she isn't sure it would really be a good option for her so we'll see how that goes.

Moll's Public Ivy List: -UNC (Chapel Hill Campus) -UVM -U Michigan (Ann Arbor Campus) -William & Mary -University of Texas (Austin Campus) -Miami University -University of California -UVA (Charlottesville Campus) He chose eight schools I presume in keeping with the eight schools in the actual Ivy League.

Ok point taken. Interestingly, the majority of people who have been talking or writing about public Ivies have not been referring to any of the eight schools on Moll's list. However, I suppose that list does help me understand why one of my DD20's acquaintances was adamant that he was attending an Ivy. His school is on Moll's list.

I see this tossed around all the time now (both on this board and also in offline conversations). I really have no clue what is meant by this (and when I consider some of the schools that are being considered I don't come up with any big commonalities) so can someone help me out?

I'm a physician (Emergency Medicine and Toxicology).

Homemade Strawberry Shortcake! We grow our own strawberries and they are in season.

Sometimes kids get their days and nights confused. There is some literature that suggests you can reset the clock by keeping them an hour or two later each night until you cycle back to an appropriate sleeping period. If this is the case, you might try this. Given that it sounds like this kid generally only sleeps for five or six hours at night I would be wary that there might be something a little more complicated going on. Have you discussed this with his pediatrician? You can also look at sleep hygiene issues. Things like a consistent bedtime routine, eliminating caffeine, avoiding screens for at least two hours prior to sleep, etc., really can make a big difference. We wouldn't have been allowed to do that. We needed caseworker approval to let DD12 and DD8 share a room (when they were originally DFD8 and DFD4). We hadn't originally planned for them to share as we had the space for them to each have their own room and were originally putting them to sleep in separate rooms but they were ending up in the same room before morning. They were full biological sisters so the caseworker approved it but we had to move them both into a third room because our county requires eighty square feet per child if they are sharing a room and neither of their intended original rooms were quite large enough.

This is hard for me to answer because we're blessed to have this really awesome pediatrician who sees our kids (unless she thinks they probably really need to go to the ED and then we do that) but I guess if I was in this situation then, yes, I would take my kid to the ED and I would let them do the LP. What you aren't going to want to hear is that if I was doing that I'd probably do that tonight (and, yeah, I know that in the event that this is some random viral syndrome then why? but the reason I wouldn't be able to not do that is because of the what if it isn't if that makes sense.

**None of this is intended as medical advice. Medical advice should only come from physicians in real time who have the opportunity to examine the patient.** Ok I'm sure that there are some decent urgent cares out there somewhere (perhaps just nowhere near any ED I've ever worked in) but the bolded definitely doesn't score any points for the particular urgent care you had the misfortune to end up in. You really can't diagnose meningitis without an LP. Yeah, I'd agree that any kid with either a kernig or brudzinski sign is meningitic but what that means is that they need definitive care which involves transfer to somewhere where they can get an LP, IV antibiotics, and then be admitted for further treatment. Your urgent care kind of missed all the points there. They didn't proceed to make the diagnosis (or eliminate it) and they didn't provide adequate treatment, and honestly, I think they gave you erroneous information which didn't put you in any kind of good position to be able to make appropriate decisions for your kid. I'm really sorry about all of that. So now you're stuck because if you knew your kid had bacterial meningitis then you and any other properly informed parent would demand nothing less than 10 days of IV antibiotics (and in some cases with some bacteria you should demand more than that). But you don't know that your kid does so you kind of feel like what do I do. You also don't know your kid doesn't because perhaps they actually made the correct diagnosis even if they missed the day of medical school (or maybe NP or PA school because I guess I'm in a bit of denial that a licensed physician would be quite so negligent) where it was stressed quite clearly that oral antibiotics are not appropriate for treating meningitis. If I was a betting person I suppose that I might lean in the direction that it wasn't meningitis because they aren't worsening in spite of inappropriate treatment. The round the clock NSAIDs may be confounding the picture as well. The problem with all of this is that I never bet with patient's (or my own children's) lives. The stakes are just too high. So I guess I'll tell you if you and your child ended up in our ED when I was working and gave me this whole story I'd order a meningitic dose of Vancomycin and Ceftriaxone and a Head CT. If the CT scan said it was safe to do the LP then I'd do it and we'd go from there. If the tap shows no cells then it isn't meningitis and we've ruled that out. If the tap looks like partially treated meningitis then we probably aren't going to get much on the cultures (although sometimes we do, and sometimes bacterial antigen testing can be helpful) we would admit for IV antibiotics and the poor pediatrician on call would get to figure out how long to treat if they didn't end up with any culture data to guide that. As far as the Strep scenario--no, unless you somehow have Strep pyogenes meningitis (and I've never seen that clinically) you shouldn't have meningitic signs with that. Now I suppose I can see a scenario where a kid who just generally felt crummy and a physician/NP/PA who was not particularly skilled with diagnosis might misinterpret some of that as a Brudzinski but otherwise no. I was under the impression that the strep "diagnosis" was also made in a kid who did not test positive for strep so perhaps that is not the correct diagnosis either. (Although maybe I'm missing that and if the friend actually had a positive rapid strep or a culture then please strike that last statement). Generally rapid strep tests will pick up about 95% of cases. We're sending cultures for the 5% that the rapid test will miss. I'm really sorry you are in this situation.

Congratulations!

-An LP (aka spinal tap) is the diagnostic test for meningitis. I'm not sure what urgent care was doing but if it wasn't that then I think they were a bit confused, or dishonest, or perhaps a bit of both. -Yes meningitis can also be caused by viruses, or fungi, in addition to bacteria. In some cases of viral meningitis we do not have a specific anti-viral (like we do for HSV etc) so there isn't a treatment per se although patients with viral meningitis may still benefit from closer inpatient monitoring and supportive care (including ICU and mechanical ventilation in some cases). This is a bit of clinical decision (and in reality many of these cases may get admitted and started on antibiotics while awaiting cultures even if the differential looks viral and that is not necessarily wrong either). In the case of fungal and bacterial meningitis we do have antibiotics and antifungals that can be used to treat the infection. In order to get the antibiotics or antifungals across the blood brain barrier to treat the infection high doses (ie meningitic dosing) of IV antimicrobials are needed and usually for significant courses of ten days (or longer depending on the organism involved and response). If your son truly has bacterial meningitis he needs to be in a hospital receiving IV antibiotics. -You can end up with partially treated meningitis where someone is given oral antibiotics to treat another infection. The oral antibiotics won't be sufficient to treat the meningitis so patients may present somewhat more subacutely and perhaps less toxic. -Prophylaxis for meningitis is only relevant in cases where there has been significant exposure to a patient with known H. flu (in certain clinical populations) or N. meningitidis. There are accepted oral/IM prophylactic regimens endorsed by CDC. Is your son feeling better? If not, I would definitely have him re-evaluated, ideally in a non urgent care setting? Honestly, with the caveat that perhaps all of this was better explained to you than is coming across and you feel more comfortable and trusting of the physicians (or perhaps PA or NP) than I am getting reading between the lines, I would have my child re-evaluated by a physician I trusted. I would also be curious if they at least did blood cultures before starting antibiotics at urgent care? If so, have you had any follow up on the cultures? If he is bacteremic then oral antibiotics are unlikely to completely resolve the infection. I hope you get to the bottom of this and your son gets better quickly.

Oh yeah one of the things that does work in sepsis (with the caveat of the high mortality rate I mentioned above) is volume support with fluids. I also think that most prudent physicians will be concerned about urine output (perhaps even more because making urine is a good prognostic sign than because they want the I/O to be balanced because honestly, in the first 12-24 hours with severe sepsis that really isn't the biggest goal. What I was referring to was more the CMS Sepsis Bundle requirement where in order to meet the core measures you need to do at least two of the following four: 1.)Measure CVP (which requires putting in a high CVL---which may be necessary for inotropic support anyway and if that is the case then I think trending CVPs can be very helpful as another objective measure but please don't ask me to sign a consent so my husband or child can get a CVL just so you can measure CVP if they don't have some other indication. In that case, I feel that the risk of the CVL likely outweighs the potential benefit and I'm not in favor. I practice similarly when it isn't my family member and I'm just a lowly EM physician. Having said that, I do put in a fair number of CVLs in the ED because often patients will need inotropic or vasopressor support or because I'm not confident they won't and I opt to be a bit proactive in case I'm in the middle of a major trauma (and thus not in a good position to place a CVL) when we actually get to that point. Sometimes I'll also do it because the admitting physician requests it because they think they will probably be going that way and they don't want to be putting a line in emergently. I can respect both of those scenarios (and I would probably sign the consent in that case for a family member) but just putting a line in so our hospital doesn't get dinged by CMS is hard to justify. [Of course when the hospital gets dinged then they get paid less or don't get paid at all so yeah...] 2.)Measure Central Venous O2 (CVO2) (which requires placing a Pulmonary Atery Catheter i.e. a Swann---now I do sometimes place these in our ED and sometimes they can be helpful but often not and multiple studies have pretty much showed this as well). 3.)Bedside Echocardiogram (Now this has the advantage of being pretty safe---it often isn't as helpful and getting your cardiologists out of bed in the middle of the night to read this may or may not be fair--it also may or may not require that you have more than one cardiologist on over night if you have a large enough STEMI/unstable NSTEMI population. Our hospital is facing this scenario right now because we do have a high volume cath lab and expecting our interventional guy/gal to read these middle of the night STAT echos is not always realistic if they're doing back to back PTCA/stents.) 4.)Passive Leg Raise/Fluid Challenge

Our STBADD7 has a seizure disorder. Right now she is doing quite well. We aren't seeing breakthrough seizures unless she gets sick so we haven't made too many adjustments. We're a pretty low screen time family in general and we've always put a lot of priority on adequate sleep and consistent sleep/wake times so we didn't have much to adapt there after her diagnosis. If screens seem to be a seizure trigger for your daughter (and they can be) can you take advantage of homeschooling and really reduce the screen time? Obviously you may need to adapt this as she gets closer to college but this might really help for a few years now.

Admittedly there are many nuances and details you aren't sharing in your post. To be fair, I'm not suggesting you are attempting to be deceitful, rather that you may not really understand. Having said that, I can imagine that those missing details and nuances may be quite important in terms of how poorly (or perhaps well) this was truly handled by any involved physicians and nurses. If we break your initial post down a bit. "My other-wise healthy, 88-year-old father came down with e-coli pneumonia. He was extremely dehydrated and had very low blood oxygen. He was taken by ambulance to the local hospital late morning, where they immediately put him on oxygen, antibiotics, and an IV for the dehydration." For what it is worth, gram negative pneumonias are not common community acquired pneumonia pathogens. Sure we see them but more commonly in debilitated patients, nursing home residents (or patients with recent prior admissions, or in ventilator associated infections. The rest of this statement makes me strongly suspect that your father was likely septic. Goal directed therapy for sepsis involves volume resuscitation with crystalloids. Generally we start with 30mL/kg (so at least a few liters in a 70kg adult) and go from there based on clinical response. If you add in another liter or two to correct for the dehydration your father probably should have received at least 3L of fluid in the ED/early hours of his admission. "Within just a few hours, he felt so much better. At least at first. They kept him on an IV for dehydration throughout the day and then all night. But they never weighed him or kept careful track of the liquid." Ok, if this is the case then this is a poor idea (although technically assessing volume status with weights and or I/O does not fit into the CMS sepsis bundle but I digress) but I wonder if perhaps they were aware of how much fluid they were giving (on some level they must have been because some physician wrote an order for that fluid) and the nurses actually were recording I/O and perhaps even using bed weights and the physicians involved felt that they needed to give more fluid because they had other evidence of poor perfusion (i.e. elevated lactate, creatinine, borderline or even low BP etc). "Turns out all the liquid they had been putting into him since the day before, never came out. Finally near morning, when he could barely breathe, he called a nurse. He had gone into heart failure, because basically, the liquid was flooding his heart and lungs. 14 pounds worth of liquid." A few thoughts--in a patient with fully functional kidneys and normal cardiac function (which I admit may be a poor assumption for most octogenarians) fluid will not accumulate. So when you have a mismatch of fluid in and fluid out then either you started out with a volume deficit, which it sounds like your father did, or the body is struggling to maintain homeostasis due to some degree of organ compromise, or both. What the scenario was, what else was going on, and the rationale for the continued volume will be the critical pieces of whether or not any of this was inappropriate care. I will say that in someone who is septic receiving 5-6L over the initial 24 hour period is not outside of reasonable. Some patients may actually require more aggressive volume resuscitation than that. I'm not saying what was done in your dad's case is automatically right (or wrong) but a weight gain of 6L like your dad had from ED admission to hospital day #2 doesn't automatically raise any red flags. As far as going into heart failure, this won't happen if your father has normal systolic and diastolic function. I suppose it is possible that he did prior to admission and the cardiac dysfunction was just part of the end organ damage from sepsis. I suspect it is more likely that your father had some degree of chronic CHF prior to admission. Perhaps he wasn't aware of this and or didn't make the physicians caring for him aware of this so they could be more judicious with volume. Or perhaps they realized he had a subnormal EF and felt that they would provide volume to prevent further damage to his organs and deal with some degree of pulmonary edema as they went along. It sounds like ultimately that is what happened. You don't mention that he required intubation/mechanical ventilation so I'm guessing that once he was out of sepsis they were able to diurese him and he did reasonably well. "It set him back so much, it almost killed him. Fortunately, a family member who is a doctor (in another city) stepped in at that point and pushed to have him placed into ICU and observed carefully for 48 hours. It was touch and go, but he survived, and thankfully, is home now after a week. He wants to forget it all, put it all behind him. The rest of us feel the hospital was so negligent, we shouldn't just let it be. It was a horrible situation and they should be made aware of it." I'm sure this was all very stressful and difficult for you and I really am sorry about that. If this was my family member, I would respect their wishes regarding complaints and further action. As far as the hospital needing to be aware, I would guess they probably are. Most hospitals track ICU transfers, rapid responses etc. If they are using sepsis as their coding diagnosis then they will definitely be reporting their performance against the sepsis bundle scoring for CMS so that will be looked at. Just for a point of reference, the mortality rate for sepsis is somewhere between 25-50% depending on study so your dad may be generally appreciative that he did make a full recovery and walked out of the hospital. In answer to your WWYD, I guess I would just thank all involved that my family member was alive. We buried a child due to sepsis and she had amazing physicians, textbook care, but sometimes bad outcomes happen in spite of all of this.

We aren't paying for any of our daughter's tuition or room/board expenses during the school year (thank you athletic scholarship!), however, I'm not sure that changes things. I guess we hope and pray that we have given her the skills, confidence, knowledge, and self respect to do the best she can in the situations she finds herself in. We also do a lot of praying that she is making safe choices (and we definitely focused on this in a graduated fashion throughout her early adolescence and in the context of her own special reality given some of the medical problems she has to/ had to contend with). As far as visits home, we wish that she had time for more. She attends a school quite a distance away, she is a college athlete, and working on thesis research for her honors thesis this summer so she won't be home except for a few short visits this summer and then we may not see her until Christmas after that. [Her sport sometimes messes up traveling home for Thanksgiving and likely will again this November.] I suppose I should say that when she is home we expect her to treat us and her younger siblings with kindness and respect but that has never been an issue.

I tried to join the learning challenges group but I think it didn't go through. (It looks like maybe the invitation you sent me may have expired by the time I saw it.)

I would love to join. I think we've moved into the sweet spot with DD16 although college looms and she has five younger sisters at home. STBADD11 will start 7th grade in the fall.

Our Easter Bunny rarely brings candy (STBADD11 is currently in braces so jelly beans, Peeps, etc are out; DD20 can't have caffeine so chocolate is out, and we have a few more food allergies in the mix as well). Baskets generally contain: -Something sports related that they "need" (So DD16 will get grips in her Easter basket, DD6, & DD3 will get a new pair of goggles and a few training suits, STBADD11 has gotten a new riding helmet with her goodies inside instead of the more traditional basket---I may do that again, etc. Deflated soccer balls, jump ropes leotards, and therabands also work well) -Bananas -Fun socks -A book or two -Stuffed friends -Sidewalk chalk, bubbles, kites, -Toothbrush -Bath/shower products -Some preferred treat (ie gummy bears for DD16, B&J gift certificates etc We do an extended family egg hunt. Each child has their own color and they get a bonus if they find all their eggs. The eggs have small amounts of money, experience coupons, or other small items.

Yes, as you will see below it is very much what we do now. We've had times when although we were both working the balance was shifted towards one of us working very little (ie I did one ED shift a week or something like that) because that was how things settled out. I also agree that it sends a good message to all of our children.

Honestly, I think if it works for a particular couple to have one half of the couple/ or one parent at home then it is valid. What works for one couple/family may not work for another. Ideally we are focusing on what works for our family, adapting to make things work better for our family, and not wasting time thinking about or judging the choices others make for their families. Usually we are in a pretty poor position to effectively evaluate others' choices because there is so much about their situation that is just none of our business. If you're asking about common or popular more than valid, I will say that most families in our neighborhood are comprised of dual career parents. In some cases one parent may work less than full time or perhaps may be able to do a lot of work from home. DH and I have tried to adapt and do what worked for us and our kids and what that has been has changed over time. We've had periods when we've both worked full time, we've had periods when one of us has worked full time and the other part time, and scenarios where we both approach full time (and perhaps maybe even both hit it) but work around each other's schedules. We are fortunate that I'm a physician in a field where shift work is the rule and employed by hospital and medical director who want to make things work for me. DH currently owns his own law firm in a rather well compensated branch of law. He is able to adjust his work load over time based on what else is going on in our/our children's lives. A chunk of his work is also a bit geographically transportable (or at least much more than mine) so he can do things at home around court appearances and meetings. It works for us. We hope that all of our children will find spouses who will work with them to figure out what works for any families they may create.

How would you feel if one of your sons opted to be a stay at home dad after his wife set herself up to be the sole breadwinner of the family? How would you feel if one of your sons figured out how to work around his wife's schedule so one of them could be home with the children at all times?

I think dad more accepted than agreed to visitation being suspended. The mom had not been sending any of the children for visitation for at least three months prior to the hearing and I'm pretty sure it actually started out as a contempt hearing. It is my understanding that other issues (including a re-evaluation of support payments) were then tacked on by the mom. From what I understand the eldest stated that they did not want anything to do with dad, the middle child stated they missed dad and would prefer to live with dad, and the youngest is in kindergarten. There is also the issue that dad has remarried and has a one year old daughter with his second wife who has some concerns with the eldest being around their baby. The last visitation that dad had with children which included the eldest was intentionally planned for a weekend when his wife would be visiting out of town relatives with the baby. Given all of that (and perhaps more that is none of my business) the judge opted to suspend the required visitation, and grant custody of the younger two to dad and stepmom.