My archives might be a little outdated especially the older blogs. My links above are all new and current.

I have only positive things to say about Permission to Mother, an autobiographical account of a thoughtful mother and clinician who courageously writes from her heart, soul, brain, and personal experience; who is open to change in her views and opinions and is not guided by the safety of rules of any group or the status quo; she is guided by love and openness to the experiences life brings her and her family. Her process benefits her and those around her and those who read her words. And to add to that, the writing style and story telling ability here make it a very enjoyable read speckled with both the humor and seriousness of life. ~Laura Keegan RN FNP, author of Breastfeeding with Comfort and Joy

Readers enjoy your feedback and Reviews (82!) on amazon. Kindle Version Available!

Please Join me on Facebook at Punger Family Medicine.

Saturday, December 26, 2009

Mastitis Consult-- finding solutions

I have hesitated posting this case of chronic breast pain (mastitis) because it might scare you off from seeking help or continuing breastfeeding. But I tend to admire the mom's who make breastfeeding a priority under all circumstances and go to unusual lengths to preserve their breastfeeding. It is important for you to know how strongly I support breastfeeding through just about any circumstance. You can imagine how many times this mother has been told to stop breastfeeding.

If you read and are familiar with my last post, this mom was referred to me after her OB did an excellent evaluation and had done several cultures on her milk and offered her several rounds of commonly prescribed antibiotics and she still had pain. Her cultures showed that she should have responded to some of the meds she tried (Augmentin, Bactrim DS, Dicloxicillin). She also had an ultrasound prior to seeing me to rule out abscess. Seeing that she did not improve with those antibiotics, I suggested a Quinolone antibiotic with continued breastfeeding. Most physicians don't prescribe Quinolone type antibiotics to breastfeeding mothers. Having tried everything else, her OB's recommendation was IV antibiotics per PICC line (a short term needle providing access to bigger veins that you can receive daily IV medication and go home).

Mom chose to accept both courses of treatment. My Quinolone and her OB's antibiotics (Or she could have chosen one option and if no result the other option.). She got the PICC line inserted and than she had a complication (clots in her arm) as a result of having the procedure and then needed anti coagulation (blood thinners).

At one time she was on Fragmin, Coumadin, Diflucan, Vancomycin, and Levaquin Domperidone and Motherlove herbals.
Putting her case aside for a minute, some moms stop feeding because they take just ONE medication. It drives me crazy to hear a mother tell me she stopped feeding for Tylenol, Amoxil, Zithromax. Keep breastfeeding while you are checking your facts!

The Fragmin and Coumadin were the blood thinners. The Fragmin particles are too big to pass into the breastmilk. The Coumadin binds strongly in the mother's circulation and is approved by the AAP for breastfeeding mothers. The Diflucan use is to prevent a fungal infection. Vanc is given IV. If it gets into the breastmilk it won't get absorbed by the babies stomach because if it could it would just be given to the mother by mouth and not IV (Fragmin also gets destroyed in the stomach.). The Levaquin my idea is not my first line of antibiotic, but I consider it case-by-case. The Domperidone and herbs to protect her milk supply during the breast pain, procedures, hospitalization.

The current medications are Coumadin, Domperidone, and More Milk Plus. The pain was better while finishing the course of medication. The clot resolved and the PICC line removed. In one update mom told me some pain came back. But she is still breastfeeding and working with me, and her local IBCLC and oral motor therapist.

Both moms with breast pain/mastitis are reading along and I/we welcome any feedback.

Friday, December 25, 2009

Mastitis Consult-- giving the courage to ask for what you need

This past week I worked with an out-of-state mom (and her 10 month old) referred by a local (in Coco Beach) oral motor therapist whom mom had been in contact with. This is the history I received:

· frequent bouts of plugged ducts (but not mastitis)
· constant pain ranging from sharp to deep to burning beginning with feeding and up to 15 minutes afterwards.
· Shooting pains deep in the breast tissue
· Mom is on week 2 of Diflucan 100mg, 600mg Motrin, occasional Nystatin on nipple (which burns according to Mom) and most recently alternating ice/heat per her ob/gyn with further instruction to wean entirely and “if the pain continues, a referral to a breast specialist for a possible ultrasound”.
· Baby, 10 months of age, receives Nystatin 4 times/day and is receiving increasing amounts of formula due to the ‘unbearable’ pain of nursing yet weaning is described as painful as well.
Mom had been treated with one round of Augmentin.


After talking to the mom, made these recommendations:

Bilateral Breast Milk Cultures, Gram stain, sensitivity, fungal elements. ( I can make specific recommendations compatible with continued nursing a 10 month old after I see culture results). I explained to mom how simple it is to send milk off for these tests. In my office we use a sterile urine cup. One for each breast. Labeled right and left. The lab only needs a small amount to complete the tests. I suggest a cluster of milk about the size of a dime or nickel collected on the bottom of the cup. (With this history I am less suspicious of a yeast infection and more suspecting a sub clinical (chronic ) mastitis requiring a prolonged course of antibiotic or stronger more uncommonly used antibiotic.

Bilateral Breast Ultrasound and breast exam (Rules out a mass causing the problem or an abscess that needs to be drained.)

The dose of Diflucan wasn't as high as I usually use. Diflucan 400mg first day and 200mg each day for a minimum of two weeks. I often treat up to 4 weeks.

Probiotics (Mom later told me she is also using Grape Seed Extract which re-establishes a normal flora and I agree with.)

All Purpose Nipple Ointment (APNO) per Jack Newman MD's website.

FYI- Lecithin is a supplement to help prevent plugged ducts. (Lecithin's value during an active infection may be minimal, but may be preventative towards future plugged ducts.)

Good Nutrition-- High Quality Grains and Raw Fruits and vegetables.

Attend La Leche League Meetings

The mom brought these recommendations to her ob/gyn and sent me an update.

Dr. Punger, Good news. My doctor agreed to test my milk today and also ordered me an ultrasound. I also am currently getting a prescription for APNO filled at a compounding pharmacist and also received a 2 week prescription for 100mg (2x a day) of Diflucan. I have asked to receive a copy of the culture and will forward you any interesting information. I thank you again for your time and giving me the courage to really ask the doctor for what I need. I am hopeful that these next steps will bring me closer to resolving this.

Tuesday, December 22, 2009

Artic Air and Holiday Lights

I have new walking partners on nights when there is no karate lessons. Scott and Max have been a great match for me. Scott used to do a casual walk around the .7 mile block with me. But now we have Max and he loves walking. And Scott loves anything Max loves. We've been going over three miles briskly. My husband walks like a slug (I don't get much excercise), but Scott and Max like to keep a fast pace and sometimes likes breaking into a run. It's been cool in the evenings, like Arctic air, and for us the walk is effortless and I'd go further with more time. Our neighborhood is full of holiday lighting keeping it nicely lit for walking and it's entertaining checking out all the lights.

Max walks on a loose leash with Scott. Tonight Scott tried something different. It was quiet tonight. No cars or other dog walkers. After we got our pace going, Scott took Max off the leash and he STAYED at Scott's heal as we walked and jogged three miles. Scott handles Max so well. Scott feels really accomplished to have such an obedient dog. Now Max gets his reward being all cuddled up on the couch with Scott.

Remodel Progess

We sat with permit pending and then demolition for so long. Now at least I get to see this project coming together. This is the view from the front door when I went by today. The tile is being set through out the house and next step will be to grout it. If you look at my photos at the end of the previous post, this photo gives a better perspective what we are doing from the front entrance. I thought the tile looked much darker in the photo in my post below. These photos today are more accurate. It was still daytime. It seems to always be dark over there: shorter days, no electricity, windows covered.... Notice the popcorn ceilings are gone. The ceiling was lifted in three rooms. Have you ever heard of that? My husband's idea.

This is my little butterfly and hummingbird garden. Despite no runing water, little rain and being totally ignored since demo, this area has done pretty good since we planted it in September. I haven't spent much leisurely time at the house since the electric and plumbing got disconnected and all the dust. Notice we recylced an "exclusive" double porcelian pot in this garden! Do you see it? My mother help me with this garden.

In appreciation I gave her a recycled pot for her beautiful garden!

Thursday, December 17, 2009

Remodeling Photos

Before (at time of purchase)
good-bye austin powers wall unitThis Morning
new book shelves are going in around the fireplace
and some deep colored paint on the walls
Before - BedroomThis Morning
primer is done, but no paintOld TileThis Morning
laying new tile
to see how it will look when grouted
We layed it different ways including diagonal and herringbone. This was the winner.
All the bright shiny stuff will be replaced with this. The carpeted bedrooms will be replaced with carpet. The diagonal flooring that looks like wood is unchanged (we did leave a few things the way they were).BeforeThis Morning
I couldn't find a before photo from this perspective of this wall. This is opposite the fireplace.
The above photo shows the color of the old walls. The entrance down the hallway that you see above was closed off in the renovation and this below photo is from inside the room not the hall. This will be a dining room and from in the before room the door exposed a bathroom in the hall... so appetizing. I need to take a photo of the new entrance. Much has changed!
Steve Rubin
Rubin Custom Homes
561-222-1392
fax 1-866-480-7498

There is a hole in my mouth....


David was eating corn as I was sitting here trying to download new photos.

"That's it! I am done eating corn. It's bending my tooth."

"David, let me see."

"I am going to the bathroom to look for myself."

I heard a scream from the bathroom, "There is a hole in my mouth!"

We found the tooth in the corn cob. His mouth was bloody. He was scared and crying.

"It's going to take a Scientist to fix this mess. I am going to be like this for years."

After Scott showed David his baby tooth collection and pointed out all his big teeth that grew in, he settled down.

On to the next crisis....

Thursday, December 10, 2009

Cute Little David

David in Palm BeachDavid and giving Eskimo kisses to Tory David in the front yard. David in a tree.

David and Scott in a tree house.

Wednesday, December 9, 2009

Scott's Reading Update

Sometimes I share our updates with someone in real life or other setting and I forget I didn't update my blog.

I finally finished Level 6 of BartonReading with Scott. We covered the 6 reasons for silent e. Now we are on to Level 7, Vowel R syllabyles. Hooked on Phonics supposively covered Vowel R. At the time, 2 years ago, Scott told me it made no sense. (In case you are a new to my blog, Hooked on Phonics is totally useless. I've tried it with three sons and it helped none.) Finally I am going to be able to explain the logic behind vowel R. We started BartonReading Mid February 2009 and put in time 5-6 times a week. It's easy to forget how far we have come and how much progress we have made in reading, spelling, and handwriting.

Scott's doing a good job researching his topics. He continues to read about dogs, but he also is reading about exotic pets ike sugar gliders, and hybrids like the wolfdog . I set him up with an email account this week to fascilitate his on-line research. His reading his fluent, but slower than the natural reader. He focuses and has great comprehension.

Despite not being a natural reader, he is a natural learner. I will be able to let him take the lead for his other subjects other than math ,and reading & spelling. When I come home from work he is just busting to tell me all that he has learned. This is what we strive for as homeschooling mothers! He is also researching career opportunities. He is looking into vet and exotic vet opportunities.

He really likes the Math U See approach to multiplication. For the most part, he mentally knows his facts. He has to learn how to communicate them on paper and learn multiple digit multiplication. Oh, he did know most of his facts before, but for 6, 7, 8, and 9's it wasn't a very organized approach and quite time consuming to wait for his verbal answer. Mr. Demme makes it so much simpler.

Max makes life so much better for Scott. Scott is handling and training Max well and takes much pride in his skills to be a pack leader. He's in the photo with our friend Misty. Misty is (was) afraid of dogs, but not Max! Not anymore! Scott really likes working with Max to bring pleasure to others.

If you are new to my blog and want to read more about dyslexia (or homeschool) click on my labels.

Saturday, December 5, 2009

Customer Service

This post may be totally irrelevant to some of you who have always had a good experience with the office, but for others I hope to open up some lines of communication and ideas for the future.

I value how important customer service is. There are many challenges of being in private practice. Many of the challenges are "external," but one of the hardest internal problems is providing the best in customer service. It sounds like customer service would come easy, but... it does not. Finding solutions is one more thing my mind has to think about during the day.

When I go to a business, I want to be treated well by the whole team. Often I enjoy the dialogue I have with various players on another business's team. In my own office I realize that my staff can make me or break me getting patients on the schedule in a timely way, welcoming them, connecting with them, being tactful and polite, being knowledgeable of our services, etc...

Most of the time I get compliments from patients on how helpful my staff has been and I am satisfied. It optimistically lets my guard down a bit.

But to be honest, getting staff trained in top notch customer service is one of the most difficult challenges I've had. Things seem to go well for a while.... then I start noticing frustration in my employees voice and body language. Sometimes because I know what's been going on that day I understand. Then I get an e-mail or note telling me how difficult someone on my staff is.

If you think you've been hurt, I am totally crushed that situations in my own office would hurt my life dream. Sometimes *I* feel helpless over it. My dream would be to always have the right feel from the first point of contact and all the way through to check out for everyone.

Right now I have a clean slate of well seasoned employees. They've all been with me a while. They've learned how John likes it, and how I like it the opposite way. They've learn what questions to expect on the phones from the zillions of calls we get a day. They work like a team.

But I am down 2 staff members. We just let one go because she couldn't provide customer service. And we needed another employee even before that. I appreciate when my patients tell me how they are being treated. It gives me an opportunity to explain a situation. If it's a legit issue, I know it's time to take action.

It may seem like its an easy thing to let an employee go when it doesn't work out. But it's not always that simple. Why? I feel like I've invested in an employee. If I thought it was worth hiring, I want my employees to reach full potential. In a busy office there is a lot to learn and takes time. For me there is a delicate balance how long to keep training versus finding a replacement and working understaffed in the mean time. It adds a lot of stress on the rest of us who are left to divide the work.

Also, you'd think with the high unemployment rate it would be easy to find new eager people. Before private practice many people told me they would work for me if I ever went into practice. The truth is, it is hard to find medically experienced people, who know customer service, can handle ringing phones (all day long), referrals, John's way, my stubborn way, deal with terminal illness, deformity, client hardships, etc, etc,.... You got to admit that's a lot of skill a front desk person needs to have.

Fortunately I have someone new lined up to start in a few weeks.

It's interesting that when I worked for someone else, I don't remember patients complaining about the staff as they do now. That's a challenging part of private practice I am responsible for everything. It doesn't matter how good the medical care is. It doesn't matter how unique the medical care may be. I know the employees are very important to an office visit and retaining our patients.

Although most of the time I receive wonderful compliments on the staff , I am always keeping an eye out for negative trends (or a patient who may see things from another perspective) and try to act on it efficiently. I am sure my staff would appreciate hearing the good, but most importantly if you have any concerns let me know. I am sure you wouldn't want your concerns posted on my blog, so remember to email me privately.

If you know of a busy office with an efficient way to handle constant ringing phones, I'd like to know that too. Maybe our phones ring to much for any system?

Perhaps knowing my concerns will help with the ideas.

Thursday, December 3, 2009

Give-away winners announced

Thank you to everyone who entered and thanks for your comments. I suspected that the breastfeeding related posts may be some of your favorites, but now I know for sure. I'll definitely be giving some homeschool updates soon. All my boys activities are fun and educational, but I will post more about our more formal activites and progress. I appreciate Kelly's comment (below)because sometimes I even wonder if my own personal extended breastfeeding blog entries can reach younger mothers. Even if they don't (but I am glad it did) I like perserving my thoughts for myown record.


I decided to let each of my boys pick a name!

William picked Trish the Dish

"I love reading about breastfeeding and baby wearing. It helps me feel more prepared for what is coming any day now!"


Scott picked Kelly

"My favorite thing I read on your blog was about how you are still breastfeeding your oldest and not sure how much he is actually getting but you pointed out that breastfeeding satisfies more needs than just nutritional. I really needed to hear that the day I read it - and today. I'm struggling with my milk supply but don't want to give up the breastfeeding bond just yet. I've stuck with it this long, and I'm determined to make it through yet another obstacle. Oh, and I would love to read your book. Your insight has been much appreciated!"

David picked doctorjen

"I especially enjoy posts about your practice and clients - they give me ideas about the ideal type of practice I would like to have. I also realy enjoy your posts on homeschooling and all the discussion on dyslexia gave me some ideas for helping my youngest child (who I don't think is really dyslexic but was having some issues learning to read and you at least inspired me to look for ways to help her.)"



Feel free to post comment, but please send me your mailing address privately to denisepunger@hotmail.com


I will be mailing each of you a copy of Permission to Mother! It is filled with stories of me working through birth and breastfeeding issues.

Monday, November 30, 2009

Thanksgiving Weekend


My holiday weekend was productive and restful with my family.
We started by going to my mother's house for Thanksgiving. We always get a good meal there. It's a lot easier to drive to Orlando than to make dinner. :)
I didn't get stuck with too much cleaning either because I took Scott to my Grandmother's assisted living with the Max during clean up.

My grandmother hasn't been able to ambulate (walk a round) since she has broke her hip over a year ago. She is only up for quick short visits in between the card games she enjoys. She's 94!

Scott wants to get Max certified as a therapy dog which means he can (officially) bring him to nursing homes, classrooms and other places that request this service.

Scott got a prerequisite out of the way for therapy dog certification this weekend. Max was evaluated For the AKC's award, Good Canine Citizen this weekend and passed. To pass Max had to walk on a loose lead, sit, lay, stay, be handled by strangers and stay with the evaluator without Scott for a few minutes. She also pushed some carts by Max to see how he responded. Scott is Max's handler. He's go the knack! I am just the driver.

My mother also started a 4x6 square foot garden. I am hoping to do the same. I've been taking a bunch of notes on how to begin. She also helped me pick out paint colors for my new house. One day I WILL LIVE THERE! Seems like that time will never come!
The boys went to Dekker farms. We picked strawberries. The boys enjoyed the new goats there. And they like Laurens farm and horses and dog also. She's got a garden going, too. Everyone is making a vegetable garden look real easy....
My boys also had a karate promotion exam this past week. William and Scott will test for Black Belts in February. Dates to be announced (either the 13th or 20th). They have had over three years of training in this class, but also had a year and a half in Georgia in TKD.
We've accomplished alot this weekend. It was nice to not be on such a tight weekday schedule!

Saturday, November 28, 2009

Vampires vs. Werewolves

I promised my kids last weekend if they could hold out on opening weekend, I'd go see New Moon with them this weekend. On the way in to the theatre the kids were playing and asking me if I was on the vampires team or the werewolves team. (I'm now such a dog person, I picked werewolves.) I was also trying to remember the last time I went to a movie theatre.... I couldn't remember being in a theatre since being back in Florida.... the last movie I could remember was Cold Mountain while I lived in Georgia. I had 2 month old David nursing through the show, and I remember bawling when the baby was exposed and abandoned in the cold night. I did go to private showings of Business of Being Born and Orgasmic Birth since than.

So, my kids thought it was really special that I went to the movie with them! John takes them all the time. I don't care for the loud speakers, the junk food, and I especially hate being packed in like sardines in a theatre. The theatre fortunately wasn't packed. And the rows were pleasantly elevated. Also, I often don't "get" movies. There is usually way to much drama for me.

William read all four books in the sequence. Scott listened to the audio version and I enjoyed listening to most of series with him as my time allowed. Enough to get the drift. David has the Twilight DVD. I don't get to sit through movies much at home either. I only caught little bits and pieces of it. Am I the only one who hasn't watched Twilight (but listened to the audio)?

So what did I think of the movie? I liked the werewolves. Jake's facial features and coloring are similar to the Peruvian features of John and his brothers and cousins and even William, in my opinion. Yep, I like the werewolves. That's my favorite part. Blush. I liked and even laughed at the dog jokes.

If I had not "read" the book, I don't think I would of understood the movie. I don't think like "Hollywood." Listening to the audio I thought how powerful the prologue was that Bella dreamed she was her grandmother. I would have never realized that was her if I only watched the movie? So right from the start I found myself recalling the book rather than watching the movie. I thought the movie story, moved a little slow, but each scene was quick and bounced around and if I didn't know the story I would have not kept up. I talk with my boys a lot about movies vs. book. I enjoy getting to have those discussions.

I am glad I listened to the audio. I actually thought it was a great story for both my boys to read. I thought the character, plot, and dialogue were very descriptive and imaginative. Like William told me then, "You know everything she is thinking." I like how the books described facial expressions and body language and the meaning of eye color and how it relates to mood and plot. I missed that in the movie. Hollywood mostly concentrated on lips flirting and brushing up with one another. :)
There is good lessons in the book about mortality, aging, and value of life. This series is excellent teen reading, especially because teens think they are invincible. I like how much detail the book gave to the history and background of the vampires and wolves. I like how the Cullens were human friendly and wolves persued evil vampires. Nice balance.

Our movie audience was interactive. For example, they "whewed" and "whistled" when Jacob took off his shirt. (For the record and unfortunately my Peruvians don't share his ripped physique.) The audience "awed" when Edward gave Bella the condition in which he would change her. William goes to a lot of movies and never sat in an interactive audience. He was very impressed. (He obviously hasn't gone to see Rocky Horror in the theatre!)

When I told John that I thought his brothers look like the werewolves, he tried teasing me and telling me they were part wolves.

And one more kind of related story. John ran in to my first obstetrician a few days ago. My birth was traumatic, but he was a good guy. John announced at dinner he saw Dr. Collins.

"Who that?" the boys asked.

"Evan Collins, he delivered William."

You know in the next book, Bella's baby gets delivered by the Vampire doctor. David thought John said Edward Cullen. I love his little perspective on ALL that he's seen and heard.

" YOU mean William was delivered by a vampire?"

Friday, November 27, 2009

I am having a give away

I'd like to give-away one of my books, Permission to Mother. Please leave me a comment, short and sweet, what your favorite topic(s) are that I blog about. In a few days, I will choose a winner and post it. If I have a have a great response I may pick more than one winner.

You can go here to learn more about my book.

Please be sure you leave your comment on blogspot (not facebook, twitter, wellsphere, etc...)

Saturday, November 21, 2009

Types of Office Visits

My sister lives in New York and she just told me how her doctor is swamped with so many sick people that the office has cancelled well visits, so they don't make the well-people sick-people. Maybe we have lots of urgent care and emergency rooms here? Maybe her area is more populated?

I was wanting to summarize my practice in words. After 5 1/2 years most visits fall into one of these groups:

Lactation visits - in this category I include well-baby visits where the focus is breastfeeding and families where lactation continues to be a current priority. Also includes the prenatal visits to plan for breastfeeding and inquire about my well-child care philosophy.

Bio-identicals - this includes treatments for hotflashes, libido, cycle irregularities, hormones, and stabilization of mood. I work in collaboration with a compounding pharmacy.

Medicare replacement - this includes primary care for seniors (mostly) 65 and above who have chosen a medicare replacement. I have straight medicare clientele also.

Primary care for adults beyond reproduction age not yet medicare age.

Urgent Care A part of my daily schedule is set aside for same day appointment requests for skin & rashes, UTI, acute pain, Respiratory illness, and pre-op clearance.

There is a lot of misconception what I do. The distribution of my practice is evenly divided amongst the above areas. When I opened my practice I never heard of bio-identicals and subsequently that's been the fastest growing part of my practice in contrast to other areas that have seemed to plateau. The busiest times in my practice are January, February and the two weeks before public school starts.

My staff schedules patient:


Monday and Tuesday 9-3:40. I'd rather schedule through lunch first than to schedule later afternoon appointments. I stay till finished and that time can vary. On M, T, W evenings my children have heavy schedules out of the house (especially b/c the details of the karate schedule changed) and I often don't get home untill 8:30.

Wednesday 12:30ish -3:40

Friday- varies from all or none depending on the season.

Note: these times aren't office hours. They are the times my staff can schedule for me. Other requests by special arrangement. (Staff clarifies with me on my day-to-day schedule.)

I've done my best to bring honesty and integrity to medicine within my practice (and beyond with my writing). I try to speak boldly on topics allowing families and couples to make personal choices. My focus and interest is on areas where there is little understanding amongst other health care professionals and others in general.

It will be interesting(?) to see how my practice changes over the next years.

Friday, November 20, 2009

Max's Sleepover (AKA Scott's first dog job.)

Max went to visit Lauren's farm with us. He made a friend name Tory.
Tory looks a lot like Scott's Grandma Irma's dog who he use to live with.Max had to have a sleep-over. :)
Really, Scott is watching Tory for the weekend.

When all went to pick Tory up and when we got back we found dog vomit on the floor. David jumped up to see the mess and smashed his chilli and bowl on the floor. It was a little crazy cleaning up and keeping the dogs out of the mess.

Fortunately the rest of the evening was quiet.

Scott and I took them both out for a walk.This is both the dogs sitting quietly in front of the open door patiently waiting for a signal from Scott that it's ok to walk. Scott is truly a boy dog whisperer!
Good Night!

Regular Flu Thoughts

6/7/12 -update. My practice does not recommend routine flu immunization to breastfed babies.

It's not just young families who ask a lot of questions about vaccination, but also a lot of older folks do to. The seniors fall into two categories: would camp out to be the first for a shot or the "no thanks" group.

I feel it's my responsibility to up date my practice with trends in vaccination and preventable disease and I am always open to talk about these topics in the office. I find that those that insist on vaccination probably need it and those that decline are well-informed. I feel like I am pretty in tune with this and can guide families to make the best decision for themselves.

I prefer to optimize my own health with my good nutrition which includes lots of fresh, seasonal, organic, fruits and vegetables. Exercise, good hand washing. I don't weaken my immunity with fast food, tobacco, or alcohol. I do my best to watch my labels closely for caffeine, sugar, and enriched flour. I am fortunate that many in my practice also take personal responsibility for their health.

 The last flu shot I received was 1994 in Georgia. I was the only one in my household that received the vaccination. Mid December, John and William got the flu. They were totally miserable. William's legs were so weak, he wanted to be carried around. Scott was still nursing (at 4) and had mild illness. I wasn't yet pregnant with David. I was unaffected. Prior to that year I worked in Urgent Care for 8 years, I decided year-by-year if I wanted the flu shot depending on circumstances. I probably got it 1/2 the years. I have never noticed a reaction from the shot. Since 1994, I've been in private practice, I have not had much of my patients come in with flu. I opt out because I never felt at risk. My kids haven't had a flu shot and I am not sure about my husband. We get one virus that hits my family about once-a-year. But if I get a cough... it lingers forever...

This year one of the Medicare Replacement HMO's supplied flu vaccination for their own patients to be administered by my practice. We ordered flu shots to offer other patients who requested them, but could not obtain them. We don't order enough to be a priority to distribute flu shots to. A vast majority of my practice doesn't want the flu shot, so it's not a big deal to me that we don't get them. Two seasons we had enough demand for ordering a few pediatric flu shots, but the interest has decreased and this year and last have not offered pediatric flu shots.

Wednesday, November 18, 2009

Swine Flu Thoughts

I'm weighing in a little late on this topic. Since there is so much hysteria over swine flu, I thought I'd share my experience.

My background is urgent care before going into private practice and for the most part I leave time in my schedule for same day "sick" add-ons. In other words, you would think I am on the front line for treating the flu. According to the media, you would think I would be inundated with swine flu cases. In reality, I have not seen what I can call swine flu. (Is it just my practice?) The only exception is a 6 year old boy with chills and fever last spring (at the beginning of this "epidemic") who was very sick. His flu (regular flu) test was positive. Since it was out of season, we CONCLUDE it was swine flu.

I have seen enough colds, strep, bronchitis. If I have seen swine flu in the office, it's been mild and not something to cause as much hysteria as the media would lead you to believe. Some people have asked for Tamiflu, the antiviral. I am fine prescribing it as long as the patient realizes, I can't confirm the swine flu. I don't mind providing coverage if there is doubt in exposure history.

John said at his hospital there has been a few cases of confirmed swine flu. One case he recalled for me, the patient had underlying problem -- weighing 400 pounds.

At one point John thought he had swine flu. I didn't agree. He tends to think he gets everything that goes around. He wanted to take Tamiflu and wanted one of our boys to take a few doses.

I don't have confirmation test for swine flu. Most small practices can't confirm, so I don't know where all the documented confirmed cases are coming from. Small offices can preform a nasal swab for flu and if it's out of season for flu call it the swine flu.

I can't remember when exactly the swine flu became well known as H1N1. H1N1 sounds so much more clinical. It puts another spin on it. Perhaps when the vaccination was being developed?

Most of you already know my office is not giving H1N1 vaccination. John's practice for the most part is over the age at risk. My younger practice doesn't really demand vaccinations. I thought the few who really wanted it had other opportunities to get it at the Health Dept, Walgreen's, or through employer, at their own discretion. It's an expensive vaccination for a private practice to invest in. Since I feel the vast majority of my clientele did not want it or do not need it, we passed on the opportunity to provide H1N1. I'd rather provide Tamiflu early on if flu like symptoms present for those that want something.

Like everything else I do try to provide individualized care. Perhaps a person travelling to colder climates may have other considerations? I've talked to several pregnant women and have given them "permission" to resist pressure to take H1N1. I suppose the thing that bothers me the most is how fast it was developed and came out. I have written one script to be picked up at a pharmacy for it for a biologist who wanted to analyze it in a lab. Me and my kids did not get the shot. I don't think John took it, but he mentioned the ID nurses had his ready for him.

There is so much media coverage and fear surrounding this. Most of my patients are relieved to hear I am not caught up in it.

Tuesday, November 10, 2009

Questions about Breastfeeding at our House

Q: Do your older boys make fun of your youngest son for continuing to breastfeed.


A: Absolutely not! Extended breastfeeding is the norm for my boys. Although I don't know anyone in real life who admits to breastfeeding a single child as long as mine go, my boys know that many of my friends nursed their friends 3 or 4 years. My older boys also see that breastfeeding is calming for their brother. There is also secondary gains for the older boys; it sometimes works to get their baby brother out of their way. :)


Q: Do you still produce milk?

A: I get mixed and very unreliable answers from David when I ask how much he gets. I can't express a drop. I suspect he isn't getting much if any. Yet, he continues to request to nurse. Several mothers of (young ) toddlers have concluded that it's time to wean because they don't produce milk anymore. I recently thought of an analogy; Kids still want Capri Sun even though not much is in that pouch. There's definitely more to both than just abundant liquid. Nursing meets other needs.

Q: Does David show any signs of weaning completely?

A: One night his really cool teenage babysitter stayed with him overnight when I went out-of-town. David shared that Nate was better than having night-nights.



I see Scott, nurturing his dog in AP style. We often talk about caring for a dog like we are taking care of a baby. That dog is worn out at the end of the day after the boys run him around and take turns playing. Last night Max got right into bed at 9:00. He's always quiet at night. I asked Scott if he liked having a baby that sleeps through the night rather than being real needy. I love Scott's answer:


As long as my dogs happy, it wouldn't matter how he sleeps at night.

Saturday, October 31, 2009

Faceless Chainsaw Zombies

What I liked about this evening is how much my boys have been looking forward to being cast in Heathcote Botanical Gardens haunted gardens. Remember, my boys, particularly my oldest, likes nothing to interfere with his Xbox and food, so wanting to do something involving some creativity and getting out is a very welcome change. They recruited a friend to come along. Little David wanted to look just like the big boys with a dark cloak. Scott told David he was too small that he would never scare anyone. He actually did really good with young visitors because the big boys were almost overwhelming to young guests.

They tried some acting in the forest.

But where they finally ended up spending most time was in the graveyard (which had no cast members scheduled). They seem to fit right in and personally, I think, was the highlight of event.

Tuesday, October 27, 2009

William's 2nd Semester Essay: Chaos at Dinner

This is the last of the essays. It's funny and unfortunately it's mostly true. Which one of William's papers did you like the most?

Chaos at Dinner

by William Coquelet

Dinnertime in my house is full of chaos. Let me explain to you what happens at dinnertime. ‘A note to the wise’ this isn’t pretty. The kitchen is usually a mess. My brother, David, is usually screaming because he wants to watch T.V. and also everyone hates my mom’s cooking.

The kitchen is usually a mess so my mom cannot find a pot, or a pan. As the oldest boy in the house it’s my job to unload the dishwasher but I procrastinate and my mom gets mad. The sink is usually stacked full of dirty dishes by the time I get to the dishwasher. My mom first has to clean the kitchen when she comes home from work in order to have space to make dinner and find the pots and pans.

David, my 6 year old brother, is always screaming before dinner because he wants to finish watching his T.V. show. My mom hates when he misses out on dinner and he wants to watch something stupid like Icarly instead. Besides, David is always full because he eats snacks throughout the entire day. He has such a big temper when he is hungry that we can’t hold him off. When we have to turn off the loud T.V and drag him to the kitchen he starts to scream and knocks things down. My mom wants a master remote control to turn off all the TV’s and computer at mealtime so there will be peace.

Usually when my mom cooks everyone hates what she is cooking. She likes to cook organic vegetables and things like Quinoa. It smells horrid. My Dad demands meat in all his dinners otherwise he thinks it isn’t a meal. When he was a kid there was huge dinners with meat and whatever was served with it. That’s how he was raised and he’s not going to change. She switches small details in Grandma’s recipes that ruin the entire dish. She tries to make the classic recipes healthy. There’s a dish called “Chinese rice” and it’s awesome it has brown rice, eggs, turkey meat, and soy sauce. It makes my mouth water. A month later my mom ruins the recipe by adding small crunchy carrots and disgusting onions. I hope she never changes my grandma’s yummy empanada recipe.

So when the kitchen is a mess, my brother is screaming, and the cooking is nasty, every one may seem to hate each other. But there is one thing everyone agrees on. Hey! Let’s eat out!

The only thing not true is my agreement to go out and eat, but you get the drift. I also was thinking how chaotic the evening is because we have karate or Hebrew in the evening. We are coming and going at the same time.

Monday, October 26, 2009

William's Bio about ME

A Biography of my Mom

By William Coquelet

My mom, Denise Lynne Punger, was born in Queens, New York, XXXXX X, 19XX.

She’s lived in different states like Long Island, New York, all over Georgia, and Florida. She’s a New Yorker and still has that accent.

She has traveled to many Eastern states, the Islands, Washington, Vancouver, and Alaska.

She married my Dad on October 15, 1994. They had a double wedding at my Grandma’s house with her sister, my Aunt. My mom and dad met in medical school.

She became a doctor so she can teach people about babies. She also likes writing about her experiences. She authored a book, Permission to Mother. In her book she wrote about me and my brothers when we were babies. She likes to write about our births so other women can have better births. She compares the births of me and my brothers to what she was taught in medical school.

I hear my birth story a lot but it’s really my third brother’s birth that was amazing. She planned a homebirth. I was six. One of my jobs was to tell her what color the baby’s hair was when I could see the head. Well, I saw toes. “It’s toes!” I said innocently. My dad flipped out when he saw the toes. But my mother’s midwife acted like everything was normal and my brother was born just fine except he had a lump on his head. It went away on its own and he’s just a cute brat now. My other job was to take pictures and I took a picture of what I saw and it’s my mother’s favorite birth photo. I took better photos than my dad and her friends that were there. My mother also likes taking photos and taught me a lot about her camera.

My mother, already questioning the whole educational system, really questioned it after my brother’s birth. This might explain why she started homeschooling us. She takes me and my brother to the same karate and Hebrew school, but at home we are in different books and different curriculums. She never expected how differently each of us learns. I like computer stuff and virtual school. My 11 year old brother is dyslexic and she taught him to read and do math a totally different way. She wonders how you could put all kids in the same school system and expect them to be equal learners. She says I’d probably do okay in any learning system, but is convinced that my brothers would not adjust. She is very happy that there is virtual school. My mother also likes computer stuff. She also has a blog as the same title of the book.

She is inspired by her patients. She writes in her book about some unique lessons her patients teach her. In the book the stories are all related to birth and breastfeeding. Now that we are older she writes more about teaching us. She also is trying to feed us healthy. She tries to make us eat organic vegetables and salads. I prefer barbeque pork and chicken. Her next book will probably about older kids.

Even though she has a career she says that being my mom is best of all.

Sunday, October 25, 2009

Special Time with David

Last night William and Scott both went to a sleep over birthday party. This was Scott's first time. He was pretty worried about missing Max. Scott said good bye to me, Max, and David. Scott of course, did fine, but I can tell Max really missed Scott being around. William goes right int his friends house. No good bye.

David was the only child last night. He did pretty good also. I took him and Max to the pumkin patch. David had a great time running around, picking out a pumkin and finding the right place for it on our porch. Then we took the old baby seat off my bike and attached the tandem bike, so David could ride right behind me. We went for a bike ride looking at decorated houses and to the playground.

David had fun helping me clip back some bushes and jumping in the pool.

David wanted to do a lesson like Scott does. I pulled out the first set of tile letters in Barton and with much repetition and Barton approach, David learned the sound that these letters make. yeah! he even sounded out S.A.T. We read a few books. He likes the book, Old MacDonald had a Farm.

David has been wanting to sleep right next to Max and he did last night.

Morning came fast and we went to pick up his brothers. Everyone missed each other and it was a quiet day. David was excited to show his brothers what he did. William missed his computer and Xbox games the most.

I also wanted to add that before the sleep over the boys and Max, went to the Mutt March sponsored byt the Humane Society. This was the boys first "walk-a-thon" type activity. They loved getting to see all kinds of dogs in real life.

William's Haiku

Xbox is like joy,
I like to play all night long,
My friends come over.

I was surprised to see him change topics!


Batman’s vehicle
Not an ordinary car
The swift Batmobile.

Here is an excerpt from his speech he presented to our family and than read to his teacher over the phone.

Let me tell you a story. For as long as I can remember I’ve always wanted a dog, since I was about five or six maybe. I would always ask my mom for a dog. She always said no and she said “If a dog comes in this house I’ll move out.”

I thought this was strange. My mom grew up around dogs in her family all the time. So did my dad. They both had dogs throughout their child hood. I just didn’t understand why my parents wouldn’t let me get a dog. It didn’t make sense. Now just about two months ago my brother asks for a dog. I was hoping my mom was going to say no to my brother. Luckily enough for my brother he got my mom to say yes. I was extremely mad. Not only because my brother is getting a dog. But because I’ve wanted a dog almost half my life and the first time he ever asks for a dog he got a yes from my mom.

Saturday, October 24, 2009

William's Huge Allowance Essay

William was assigned a topic to write an expository essay... Notice how food and gaming is always on his mind.


My Huge Allowance

I have huge dreams for when I get a bigger allowance. My plans include adding a whole addition to our house and putting TV’s, Xbox’s, and surround sound in to the new room. I would decorate my room with a bunch of Halo and Call of Duty posters. This would be awesome if I ever get the chance to get a bigger allowance.

First, if I had a bigger allowance I would add an extra room in my house. To get in the room you would have to go through my bedroom. Then you would enter through a private door, and that would be the gaming room. But of course I would have a password so only my friends could get in and I could keep baby brothers out. On the other side of the gaming room there would be a secret slot in the wall like a bar and my mom could serve us food and refreshments.

The second thing I would do with all my allowance is buy four, fifty inch TV’s which would be the best quality TV’s for playing video games on. They would also be high definition. I would also buy four Xbox’s so I can have “all-nighterXbox parties.

The third thing I would do with my big allowance would be to buy a surround sound speaker system, like Bose or Digital Dolby. I would also buy a ton of Halo and Call of Duty posters to cover the walls. I would try to buy as my friends would say, “the most ‘epic’ posters ever”.

If only I had a bigger allowance and could afford all this stuff! I could actually have these ‘epic’ “all-nighterXbox parties. I’ll even host a gaming tournament in that room or a surprise birthday party for a friend, or something like that. My mom would make us a bunch of cookies and sweets. We could even order chicken wings. YUM! Oh, but of course I’ll do my daily Language Arts lessons before going to the game room!

William Coquelet

Friday, October 23, 2009

William's Writing (My Intro)

William is almost done with his 7th grade Language Arts class. I am going to share a sample of a few of his best writings. This was the introduction he wrote for class at the beginning.

My name is William Coquelet. I am an American child with some Peruvian ancestors.

It all started on September 18, 1996. I was a very cute baby boy. I immediately started into gaming and computers as a baby. I lived in Palm City in the community of Monarch in Florida. After a while of playing and growing my Mom and Dad told me we were moving to Georgia. I met a few good friends there. Then one day we found a school of Martial Arts and I had a test run there and I loved it! It was one of the best things about Georgia.

My Mom and Dad once again told me we were moving and I had to quit my Tai Kwon Do classes. I was very sad about the class, but we were moving back to Florida! It took a while, but we finally found a small house and we moved in.

The house was nice, but then things started to get a little messy. After a while my Mom said she found a new Martial Arts class and it was right in our community. My Mom got mad when I said that I didn’t want to do more Martial Arts. But she “enrolled” me and my brothers regardless. I’ve been in this class three years. I am almost a Black Belt.

So now it’s time to look for another house. This time it took two and a half years to find a house. In the house we are getting a dog and we can dock our boat in the river in the backyard. So we finally buy it and about a month later I start Language Arts 7th grade class. So then my teacher Karen Hoenstine asks me to write a biography about myself. So here I am!

Tuesday, October 20, 2009

Diary of a Wimpy Kid, Dog Days

Great News! Scott is READING the newly published, Wimpy Kid book. This will be his first chapter book he's read. He is reading it out loud (to Max) in a quiet mutter. Scott is reading at a nice comprehensible pace. I am totally enjoying hearing him read and hearing him laugh at the funny parts. I see him improving each night as he gets further along into it. It took to being midway in Level 6 BartonReading to have enough reading vocabulary to have the ability to read an ordinary book for kids his age.

Scott is also doing Math U See, Beta level. Although he could add and subtract (and multiply) in his head, he has never put it on paper before. So for the visual part of math (and his confidence), I chose to start him off at this level. He is doing excellent. He has a strong foundation now in both math, reading and spelling. Last year he could not read the directions on any work sheets, let alone do the math problem. When he started doing the Math U See sheets, he asked, if Math U See and BartonReading were a conspiracy working together to form a curriculum. ((No, I told him, its just called language :) !)) He reads all the directions and word problems himself.


Scott is so curious, fortunately he is able to pursue his curiosity now and teaches himself by watching documentaries, asking everybody questions, and the Internet. He browses non-fiction books, too.

William is moving a long in his Language Arts class. Since all the reading, spelling, and language arts both boys are doing doesn't leave me much of my own creative time, I may post some of William's best writings.

Both boys are still in Tuesday night Hebrew school to keep them involved and Karate. Karate is no longer being offered in my neighborhood. Now, I have to drive them across town to their instructors other class. In the long run, we were going to transfer to that program anyways. The class is longer and more intense.

David is on a Math roll right now, so I am going to go with that while the force is strong. I don't see much progress in reading, but he likes his Scratch and Sketch books and activity books. He doesn't let me read out loud to him much. He also likes Tic Tac Toe and Connect Four.
The boys are all enjoying Max.

Tuesday, October 6, 2009

Before and Not-quite-after Photos

Today, I finally feel like showing some photos of our remodeling project. I've been taking lots of photos. Here is just a few. This WAS the wall unit in the biggest room of the house when we purchased it. Nice if you like Austin Power's stuff. There was a lot of eccentric shiny stuff. I was pretty excited to see what this unit taken apart and see what the room
would look like without the shelving.We found doors and paneling. It makes me wish I knew how the doors were used before covering them. I wish I had more history on this house. It's 35 years old. We got a photo album of the house at closing, but it did not show how this wall originally looked.

It's a gorgeous brick fireplace to the ceiling! Why was it ever covered? It's going to be cleaned this week and it works. When we first deciding if we should remove the wall unit, I never thought about removing the front glass doors (look back at the first photo).The glass and metal covered so much of this. I can't wait to see it cleaned.We knocked down a kitchen wall. Now you can see the fireplace across the house. Now, let me show you the foyer. The white door is a coat closet and it is going to become part of the laundry room which backs into it.From this view standing in front of the fireplace we have opened up that area and removed the jams closing in the foyer. We've opened up the separation from the foyer to the great room.


And notice the tile and ceiling is gone. The house is almost a shell only.

This is going to look SO different when we put it back together.

Maybe we'll be in by the end of the year?!

I can't wait to show final photos!

After The Cut


I took the boys to get their haircuts tonight. David went first, then William. In the meantime Scott entertained himself by reading the posters on the wall out loud, "Take Years Off in Just a Few Minutes." He analysed this. "How can a haircut make you younger. That's BS."
During Scott's haircut the other boys were getting restless and by the time they were all done they were running around (even William), getting louder and grabbing 5 lollipops instead of 1. (This was another proud mother moment. Not.)
"BE QUIET!!!" I insist.
Scott justifies their behavior. "Mom, it's true! You really do get younger after a haircut!"


They are darn cute, aren't they???

Monday, October 5, 2009

Feedback from new moms

I especially love hearing how my book Permission to Mother is still helping moms with new babies see things for the better of the baby.

Here's from two moms who shared their thoughts! (Click on the title to take you to the full review.)

5th Baby and we finally are figuring things out....,

It has made me a stonger mother.

Wednesday, September 30, 2009

It's a Dog's Life

You can see what kind of life this doggie has. He easily goes to William for shared sleep. He's had a good time with the boys in the pool.
I thought this long shallow step in the pool was good for toddlers, but its looking like a
good step for a dog with short legs (and large abdominal girth) to cool off.(This photo is horizontal, but it would upload vertical, weird.) The boys have taken him almost everywhere. He is quiet and rarely barks. Scott has taken him to the pet store and karate. He loves long walks. He rides in the car easily.I'd like recommendations for a Vet. So far no health problems,
but in case we have an emergency or if we do keep him permanently.
I'd also like recommendations for books or websites about dog nutrition and holistic care.
If processed food isn't good for me, I'd like to know more about feeding dogs. Interestingly,
he has been trained so well, he hardly begs or demands other food then what he's been on.

Sunday, September 27, 2009

Will I ever blog again?

My blog posts are rare these days.
I seem to be having a hard time concentrating long enough to blog. On top of working at the office and the freelance lancing writing I've done recently, the boys lessons have been consuming a bigger proportion of my time. William and Scott are both absorbing like sponges. Yet, sometimes they don't come to the desk right away and a quick lesson becomes dragged out from the time it takes coaxing them to come to the table. Scott is finished Lesson 3, in level 6 in BartonReading. I can see a light at the end of the tunnel. What will I do with myself when I am done with his all his reading and spelling lessons? :) This year especially I am glad they are homeschooled . I am seeing results I am proud of. I am enjoying teaching them. I find it rewarding.

Between tutoring the boys and work, I am involved with our new house. (In case your wondering, we don't live there yet.) The house is totally gutted now. (Three rooms have no ceiling, much drywall is down, all cabinets in kitchen and bathroom is out. Old tile and carpets have been pulled out.) We have a building permit as of this week. Next week we begin the putting it back together phase. One day I'll share more photos of the interior. You'll appreciate what we are doing more when I have "after" photos. For now, I spend so much time with this house's planning, I don't really feel like regurgitating all the details afterwards on my blog. All this work doesn't come natural to me. I am not a decorator or designer. At first it was fun and I eagerly waited to see what the rooms looked like with out the ugly cabinets, but seeing all the demolition has also been emotional. I didn't expect that.

Another reason I lack some inspiration to blog is that I don't like my new camera, so I can't say I am real inspired to share lots of photos. (That dog does take good photos, though!)

By the time I get to have my time at the computer, I can't seem to focus on composing any thoughts (although, I have a lot of thoughts) . Plus, I get lost reading other blogs and facebook and news, especially opinions on health care reform. I seem to spend a lot of time wondering about the outcome of HCR and what the impact will be, either way. Then my usual blog topics seem so minor and insignificant to the thoughts and concerns I have. And I can't write.

But I really do want to keep my blog up-to-date because I like having a journal of my thoughts.

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