Wednesday, August 31, 2016

Worst day, or worst day ever?

So we have this new thing at Sunnydale: the nurses from the neurocritical care unit charge for both the NCCU and an overflow surgical/med-surg/ortho unit on a different floor.

Right now we have our usual nine beds in NCCU and eleven beds on the other floor. (I'll call it "ortho," because it's mostly post-op and pre-op orthopedic cases, but there are important exceptions, one detailed below.) Once the NCCU expands to include epilepsy patients and an epilepsy monitoring unit, we'll have a total of twenty-six rooms to charge: thirteen on each floor, with the possibility of two of those rooms on each floor being double-occupancy. That's thirty patients, give or take.

On two different floors.

Yesterday I got saddled with charging both units. Tiny Dancer and Diamond Bright were on the CCU side, and Bender and Kali were on the ortho side. Thank God for good assignments: ortho was staffed with two experienced nurses, and Tiny Dancer, though she's new, is totally unflappable. She moves through life with her head held high, her posture perfect, and her hands and feet moving at a million miles an hour, if need be.

Halfway through the day I had two critically ill patients on the ortho unit, three different patients who needed blood (no overlap there), a very sick person on the neuro floor, two interns, no nurse aides, and no prospect of lunch. Did I mention that these two units are on different floors? As in, I have to ride the damn elevator to get from one to another?

I did? Okay. Just wanted to make that clear.

At about two o'clock, just as my blood sugar was tanking, I made a major mistake.

We were about to get a patient who was in the middle of a no-kidding psychotic break. His family had found him, two nights ago, wandering naked around the neighborhood, talking about death and God and angels, and had brought him to the ED--from where he'd been discharged and sent home with instructions to present to the psych clinic the next day. The next day he was no better, and was possibly worse, talking about going home to God and taking his kids with him. He still hadn't been able to keep his pants on. This guy was badly off and getting worse.

Obviously, he hadn't taken his meds in about ten days. Part of the problem was that he had had his thyroid and parathyroids removed about a decade ago, and had been well-maintained on replacement therapy until ten days ago, when he stopped taking everything in pill form. His TSH was 15. Because he had no thyroid. And no meds.

So psychiatry, rather than admitting him to one of the medical beds in the psych unit, decided he needed a bed on a med/surg floor. . . and sent him to us.

Suicidal, on an OPC, unwilling to let anyone touch him, combative, hallucinating, unable to settle to reality, on a med/surg floor. With only two nurses, no aide, and eleven patients (I took the eleventh patient, an unstable post-op, because nobody else could).

So, anyway: the mistake. I called the psych doc on call rather than the hospitalist on call, because we didn't have an accepting hospitalist yet. I wanted to ask a couple of questions, like "Is this patient appropriate for a general med/surg floor?" and "Are you sure you don't want to admit him to the psych unit?"

I called the wrong person. I should've called the hospitalist, even though one wasn't yet assigned. This was explained to me at length and in the most insulting, condescending way I have ever encountered, by the psych doc.

Here's how you respond if somebody fucks up: "That patient is going to be admitted under Dr. X's service, so you'd best call Dr. X's on-call for that question." In that situation, I would apologize and get off the horn asap, then call Dr. X's resident.

Here's how the psych doc responded: "I don't think it's appropriate or professional for you to blah blah blah blah wasting my time blah blah blah well you know thyroid storm can cause blah blah blah blah blah blah ad infinitum ad nauseum so very unprofessional of you blah blah blah if you really knew how to care for these patients you would realize blah blah blah. . ."

I finally broke in and said, "You know what? You're right. I was totally unprofessional and inappropriate, and I am so very, very sorry for wasting your time." I then hung up the phone, gently, and will probably get written up anyhow.

All I can go by is what the admissions folks and the computer tell me. You're listed as the admitting doc; nobody's bothered to let anybody else know that you've handed off your patient to a different service. What could've been a thirty-second conversation turned into a five-minute harangue.

Maybe she was having a bad day. I know I was by that point.

My boss walked in to the break room and found me crying tears of rage. She was completely un-fazed and asked me why I was upset. I told her I missed my teenaged flattop and bicycle chain and Doc Martens; that, if I'd had them, I would've gone and curb-stomped that cunt. She didn't even blink.

I love my boss. At that point I flat-out worshipped her.

So, yeah. That was my day. My legs are screaming from running up and down stairs (elevators are slow in our building), I'm incredibly proud of Tiny Dancer and Diamond Bright for handling tricky, delicate people without incident, and I wish I'd had a quart of ice cream last night.

Monday, August 01, 2016

Minor corrections.

It is "welt," not "whelp." A welt is something you get on your skin. A whelp is a newborn puppy. If you tell me your patient gets covered with whelps when they take penicillin, I will be momentarily charmed by that mental image. I might miss what you say next.

It's "stent," not "stint." I don't want you to stint somebody's heart, as that means that you've given that organ less than it deserves. You can stent it, however, in order to improve blood flow and muscular function.

It is pronounced "lairINKS," not "lairNICKS." Likewise, it's NUClear medicine, not NUCUlar medicine. I can forgive G.W. Bush everything except this perversion of pronunciation.

I know that "menstrual" is a difficult word. Men-stroo-al. It requires that you do the difficult "str" move with your mouth. It's not "mensurral" or "mensril" or "mensrahl," however. Men. Strew. Uhl.

(Also, while we're on the subject of things that sound like other things, I am Ms. Miz. Rhymes with "his." That should make it easier.) (If you really have a hard time with "Ms.," might I suggest "The Great And Terrible Jo, Ruler of the Five Kingdoms, Holder of the Shadow Proclamation, Destroyer of Worlds, Boss of All of You" as an alternative?)(You'd have to prostrate--not prostate--yourself.)

(Do I really need to mention that it's not a prostrate gland? I don't know of a single gland that lies down on its face.)

It's really, really important to know the difference between micrograms and milligrams. If you tell me you gave somebody twenty-five milligrams of a drug that's normally dosed in micrograms, I will assume one of two things: either that you're a large animal veterinarian or that you're a dope.

Likewise, the difference between liters and milliliters is kind of important. Please don't chart that you gave five hundred liters of normal saline to a patient intraoperatively, unless you really, truly did have them floating in a small swimming pool.

If I'm giving you report and I tell you that the patient's t-max is thirty-seven-point-two, don't ask me to convert that to Fahrenheit. You have a converter in your charting program, or on your phone, or via Google. (It's 99F.) You're an ICU nurse. Use your converters.

I should probably make it clear here that I don't mean to rag on civilians. If you're not a medical person, I don't expect you how to pronounce words, or spell them, or even use the correct term. Remember that patient I had who reported a fibroid tuna in her uterus?

I will not laugh, smile, or even rub my upper lip if you're a patient or other civilian and you use the wrong word or say it wrong or don't even know what that widget at the bottom of your whatever is called. You're not supposed to. This is specialized terminology, used by people in a specialized field. It saves time and increases accuracy for us, but it's confusing and discouraging for you.

However, if you're a nurse giving me report, or calling me report, or a doctor, or somebody who's paid to know how to express themselves clearly about a given situation in nursing or medicine, I will quirk one eyebrow up slowly if you use the term "whelp" or "stint." And I'll stare at you.

While I imagine your patient covered with puppies.

Sunday, July 24, 2016

OMG, y'all. SEATTLE.

Mom's birthday was last week, so I spent last week in Seattle with Beloved Mother, Sainted Father, Beloved Sister, and The Boyfiend. Other participants included Der Alter Jo, her husband, Archie the Mastiff, and A Number of Wild Animals.

Mom and Dad are well, thanks for asking. Dad, after his last tumble-thump, tumble-thump-tumble, has been prescribed a neck brace (to be worn for 90 minutes at a time) and physical therapy three times a week. Mom is still dealing with the occasional Moment when her a-fib gets snarky, but otherwise is okay. Dad has a number of complaints about Seattle and its political leanings, but that's fine, because that's how you know Dad is okay.

Boyfiend and I made it a priority to stop by the pond near M&D's house at least twice a day, to ensure that the Baby Duck and the Baby Raccoon were okay. Baby Duck survived the week (although, on my last day there, his mother went to the bar and left him peeping furiously until she returned). Baby Raccococoon fell off a log while trying to wash his hand-paws, with a despairing "gronk," and had to be hauled out of the pond by Mama. Archie the Mastiff was overexcited, according to his size 00 owner, but all I saw was a gently waving tail. Hermione the Heron caught two fish and one bullfrog that I witnessed.

Der Alter Jo and her hubby are blooming like roses. It's rare that you see two people so obviously suited to one another, doing things that they're so obviously suited for. At one point, DAJ said "I'm not sure I've stopped being a nurse; maybe I just have to turn those skills to other things." Being that she's doing the ADA program right now, I think she's got it covered.

Beloved Sis and Boyfiend and I spent one afternoon with really old family friends--and by "really old," I mean that the male half of the couple showed up with a toothpaste squeezer on my folks' doorstep when I was but a fetus. We had enormous amounts of coffee and multiple salads and some roasted chicken, and entertained a three-year-old who looked so much like her mother (whose birth I remember) that I thought, when she opened the door, "I'm in the right place, but the wrong decade."

It's weird, seeing faces you recognize reproduced on babies' heads.

Anyhow, it was lovely. I scored a Seattle Trifecta: I had a coffee at Google, then caught an Uber in the rain (it was a Prius, of course). My skin changed to plaid flannel and I grew a beard instantaneously.

I also walked up and down hills so much that the outsides of my ankles swelled up and my butt muscles complained. I drank some amazing pale ales (Botany Bay is a good one, if you can get it on tap) and ate really good, really fresh food. I slept well and woke up early, in time to hear the Stellar's jays being annoyed with the crows, and regretted not bringing string cheese on my walks in order to feed those crows.

Oh, and I got sunburnt. Of course. Because that is how I roll in Seattle: sunburnt.

Thursday, July 14, 2016

Do NOT go there.

An incomplete list of websites I strongly urge you to avoid:

Urban Remains Chicago

Hygge & West

Plant Delights

Ivey Abitz

On the upside, I know what I'll be doing with my lottery winnings.

Tuesday, June 28, 2016

A well-oiled machine.

"What you need to do," the house supervisor said to me, "is learn to lower your expectations."

"Fuck you," I replied, with a sunny smile.

We'd just gotten a patient in, a guy in his fifties who was, according who what we'd heard from the house soup, status post-TPA, hypertensive as a habit, with a dense left hemiparesis. We'd heard that from the house soup because there had been no report from the outside ED from which he'd come. There had been no warning that the patient was on his way; we'd been waiting since early afternoon and it was now five minutes from the end of the shift. Of course.

Luckily, the dude could talk. Peej and Bethie moved him on to the bed and Peej took a first set of vitals.

His blood pressure was 80 over 44.

(Note for the non-medical among us: 80/44 is a perfectly respectable blood pressure for, say, a teenage girl who runs track. It's not good for a guy in his fifties, and it's *especially* not good if said guy has been running, since time immemorial, in the 150's over 90's or higher. Your body gets used to a certain amount of blood going at a certain pressure to all your organs, and something much lower or higher than that usual can cause problems.

A low BP, in particular, can lead to hypoperfusion of the brain, especially after an ischemic stroke. That means that all your stroke symptoms come back and further damage is done because there simply isn't enough blood, at high enough pressure, to fully supply the brain tissue.

To give you some idea of how important perfusion is, we normally allow our patients to run as high as 180 systolic [the top number in blood pressure] and 110 diastolic [the bottom number] after a stroke that's been treated with TPA. We definitely want to keep them above 100 systolic.)

Peej read out the number. I called to Bethie to bring a bag of normal saline and tubing, and started to trend the bed such that New Dude was lying with his head down and feet up. After determining that he didn't, as far as he knew, have congestive heart failure or any allergies, Peej started a bolus of fluid. Bethie called the doctor's lounge, trying to raise somebody--anybody--with an MD after her name to come and check New Dude out.

Just then, New Dude's left side started working again. He said, "Hey! I feel less dizzy! And I have to pee."

And with that, Doc Paul showed up and the night shift took over.

The unusual part of all of this is that both Bethie and Peej are new to stroke. Peej is a new nurse, flat out, having just finished her internship. Bethie did epilepsy stuff for years and worked on an HIV unit in the bad old days before protease inhibitors, so she's experienced, but strokes aren't her thing.

Peej is tall and slender and graceful and serene. She wears her hair in a bun, but that's not why people ask if she's a ballerina--it's her unshakeable poise and excellent posture that makes them think she dances. Bethie is me in a few years: foul-mouthed, fratchety, sarcastic, and with an amazing collection of weaves and wigs. Nobody, looking at the three of us, would ever suspect that we could work together well, let alone be friends.

But we did and we are. It was a minor crisis, not somebody spraying blood all over the walls, but Peej especially handled it beautifully. When I was six weeks out of my training, I panicked when faced with the same situation. Peej never broke a sweat, even taking time to explain to the recently-arrived family what was going on. I am very proud of her.

And we are, in my words, a well-oiled machine.

Or, in Bethie's words, "A fuckin' well-oiled fuckin' machine, man."

Wednesday, June 08, 2016

The Human Body: Major Design Flaws Edition

Knees: Why do knees have to bend the way they do, and why are they so out-there and unsupported by something stronger than ligaments? If you go sideways just once, everything stretches out of shape and you're left with a dicky joint forever. Plus each joint has to handle all the weight of the human body on an angle (especially if you're female).

Elbows: Same thing, but with a really limited range of motion. Silly idea.

Temporal Bone: Why such a thin casing over the brain in just a couple of spots? If you're gonna have a solid barrier of bone, make it thick all the way around.

Cervical Spine: "Hey! Let's put an eight-pound lump of bone and meat jello on top of this stack of bones filled with meat jello, and make it really vulnerable to breakage or stretchage!" As an extra added bonus, nothing else in the body will work if you fuck part of this system up.

And we can't turn our heads 270 degrees the way owls can, and we have a bad layout of large vessels in the neck. It's just a fail all the way around.

Urethra, female: Who thought of putting the opening to a system that must remain sterile in the middle of a soup of bacteria, some good, some bad? Who, having done that, would think it wise to make the entrance to that sterile system only a few centimeters long? This is, mind you, without the acidity of the mouth or the protection of mucus to keep bad bugs in check.

Prostate, male: Oh, come *on.* How did "secretory gland inclined to swell and block the flow of urine" get design approval?

Any area through which a nerve has to pass: Let's make it really, *really* small, then add a bunch of stuff around it that's likely to swell and irritate the nerve. Brilliant.

The lack of regenerative capabilities: IKEA could design a better body overall. If something breaks, you just limp on in to the Meat Part Store and buy another bit to screw on with a teeny Allen wrench.

No, I'm not feeling bitter today. Why do you ask?




Thursday, May 19, 2016

Ch-ch-ch-ch-changes. . . . .

It's been a rough couple of weeks on the neurocritical care unit.

Marcie left; she went to neurosurgery's clinic, to cat-herd all their patients into craniotomies and gamma radiation. Kitty is in Europe as a whole for a month--actually forty days--and I'm wondering what the fuck I'm supposed to do without her, since I can't get the EKG printer to work correctly. Deej is going to work in a post-surgical ICU near The Schwankiest Mall Ever. And I'm left, oddly enough, as the nurse that everybody turns to when they have a question.

I wasn't expecting this. First I was a new nurse, but with experience in places much weirder than Sunnydale (Healthcare For The Hellmouth)--thirteen year olds with a methadone card and a 17-week uterus, or a bookstore where people might actually pull out a gun if you didn't buy back their obviously stolen books. Then I was a slightly experienced nurse, with some questions about the finer points of, say, Mobitz blocks or pseudobulbar syndrome.

Then, all of a sudden, I was that nurse everybody turns to.

There's Beth, but she's more cardiac than neuro. And there's Shiny, but she's not particularly forthcoming, although her smile lights up her face and she's always ready to help. She thinks her English is worse than it is, so she keeps to herself.

So I'm the one everybody calls when they have an IV they can't start. Or when they have a patient who's suddenly satting 80 percent on a nonrebreather. Or when the 97-year-old granny who's on palliative care decides to stop breathing, but nobody's sure she's dead.

Protip: If they're cold, and their pupils are fixed, they're dead. Just sayin'.

We had a lovely, amazing, talented 27-year-old dancer with a barely-week-old baby in. She had given birth, and then suddenly stroked out. Not because of her pregnancy, but because of a rare autoimmune disorder. She stayed with us until Tuesday last week, when she projectile vomited and became unresponsive. And we discovered that she had stroked out the entire left side of her brain, full stop, no hope.

So we brought her back from CT and suspended treatment, and allowed her little boy in to see her.

At the same time, our 97-year-old granny was giving up the ghost after a right MCA stroke that had led to aspiration pneumonia.

I didn't have them at the same time; I was busy with a crack-addicted heavy drinker who came in with a potassium of 6.7 (insulin drip ahoy) and a sodium of 117 (oh hello hot salt). Still, I was the person that the other nurses came to when people stopped breathing.

And so I got to pronounce one patient with another RN and notify the doc for a second patient at the same time. They stopped breathing, both of them, at 0936 am. I hope that grandmama showed the young mom the way toward the light. Any other thought would be too much.

Patients transition without pain if we do our jobs right. I am transitioning from the bumbling medium-experienced nurse to the Old Salt With Tales To Tell. I hope I can do it fairly painlessly.