My archives might be a little outdated especially the older blogs.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

I enjoy reading your feedback and Reviews (81!) 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.

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