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.

Saturday, April 23, 2016

And, of course, as a child of the 1980's. . . .



"She led off alone on the intro to 'When U Were Mine,' her guitar thin and high and lonely. Then the rest of the band swelled up under that, with Willy on his electric demon fiddle. Carla and Dan had come up with a bizarre percussive patch for one of the synthesizers, and hung it on the end of the fiddle's phrases. The effect was that of a succession of violins being bitten neatly in half.

Eddi found that the single-minded frenzy of the first set had passed. She still had the crackling energy, but she had a clear head to use it with as well. She tried to make every note glow; she felt the rest of the band respond to that and stretch like a racehorse seeking that one winning length. . . ."

Emma Bull, War For The Oaks

Do not be this person.

This week I wanted to die, in a sustained and sincere manner, rather than return to work after my first shift back from vacation.

Why?

Because I had a patient. Who weighed six hundred pounds. That's a BMI of 79.9 if you're counting, and not something that you want to aspire to. However, the trouble was not the patient. The trouble was one of her family members, the one Person You Should Never, Ever. Be.

This Person was, she claimed, a cousin-level relative of my patient and, she claimed, a neuro ICU nurse. The fact that she was a neuro ICU nurse at a hospital in the most far-flung district of the most distant, inbred county of Back Of Beyond that Texas can provide didn't matter; she was, by God, an ICU nurse who dealt with brains and That was It.

She questioned why we were doing her relative's transesophageal echo under general anesthetic with intubation rather than at the bedside. They do them all the time at the bedside in her ICU, after all. I was forced to point out that with an airway that doesn't even register on the Mallampati scale (graded from 1 to 4, with 4 being the most difficult to maintain), a BMI of nearly 80, and the need for continuous BiPAP while awake, her cousin was not the best candidate for living through bedside sedation.

Then she accosted our doctors, asking why we hadn't either given TPA or done a clot retrieval on her cousin. Her cousin presented to her small-town ED ten hours after her symptoms began, thus making her ineligible for clotbusters. And she'd had a watershed stroke, which means that there are a lot of itty-bitty clots along one pathway that one large artery follows, so nothing to retrieve.

In short, the Family Member You Should Never Be knew just enough to be dangerous. We had it out when I found her increasing the rate on the IV pump. My patient had congestive heart failure, and CHF patients can't take a lot of IV fluid, even if their kidneys are working well, which this woman's weren't.

We all fell suddenly and irrevocably in love with Dr. Hernandez, who took the brunt of her questioning. When her voice reached near-hysteria levels as she demanded, "Why didn't you do MORE?? You haven't done ANYTHING!" he responded, "Why didn't *you* do more before your cousin reached six hundred pounds?"

Because, People, this is the thing: nobody weighs five or six hundred pounds without somebody helping them out. At that point, it's difficult, if not impossible, for your average five-foot-four woman to get her own food. Extreme obesity is like heroin addiction, but with family support and enabling. It's harder to treat than heroin addiction, but just as deadly. And the families of these folks have often been the go-to people for high-calorie food in quantities that would blow your mind.

So yeah, that happened.

It was kind of a long week.

Saturday, April 09, 2016

What I did on my vacation.

The benefit of selling your soul and most of your waking hours to a corporation like Giganto Research and Healthcare, Inc. is that you, eventually, accrue almost enough vacation time to feel like a human being for part of the year.

I just took two and a half weeks of vacation time. Getting it was surprisingly easy; all I had to do was widen my eyes slightly and mutter about evisceration, and my various bosses gave in and signed off.

So: I had two and a half weeks off. What did I do?

I got a new bed. King-sized, which means Mongo and the cats and I can all sleep comfortably at the same time, and so can The Boyfiend, when he's here. It's amazing how much difference those few inches make. Yes, it's a pain in the ass to change the sheets, and yes, I'll have to go to the laundromat to wash the comforter, but believe me: TOTALLY WORTH IT.

I got the mattress and box springs from Wink on the basis of reviews and their 101-day test period. The mattress is a hybrid--that means it has both memory foam (which I hate) and springs (which can be problematic in terms of motion transfer), combined in some highly-technological way.

My previous mattress was a Sealy Posturpedic metal-frame deal with a pillowtop. The only way in which that mattress was better than this one was in the sag when you sit on the edge. This mattress has some sort of plastic framing that allows you to use it with an adjustable foundation, but it sags a bit if you sit *right* on the edge.

Other than that, this mattress is TITS. I lie down, I turn over twice, I know nothing until the morning. They've somehow managed to combine springs so that it doesn't feel like memory foam and memory foam so the whole thing doesn't shake when Mongo turns over. Yes, it cost hinty-bazillion dollars, but every half-cent of those dollars was worth it.

I cleared two or three years' worth of weeds and dead shit and mulch and crappy low-end weedblocking cloth out of my front beds, then dug in several hundred pounds of composted manure, then re-weed-blocked it, planted things, and laid down mulch.

That alone took me two of those weeks. I have two beds, one 9 x 13 and one 9 x 11, and they hadn't had any attention in a couple of years. (Don't ask me what happened; I don't remember. All I know is I got a nastygram from the city about my weeds and kind of gave up after that.)

Now I have several dwarf yaupon hollies, something grey with purple flowers and the common Latin name "vomica," and a selection of other perennials growing in those beds. There are more plants coming, things like lavender and pentstemon and salvia and honeysuckle. I even planted a rose bush to balance the rose bush I planted when I moved in here. It's all very nice.

And I hung three dozen miniature mirrored disco balls in cascades on either side of my porch.

And I planted herbs in pots and then put tiny, brilliantly-colored plastic dinosaurs in the pots. (Did I mention that I spray-painted the pots' rims different colors? Well, I did, and it looks like Pinterest barfed on my porch.) Oh, and today I built a brick pad with antique bricks I dug out of the back yard so I'd have a dry, stable place to put the trash cans.

Gardening Fever has me by the throat now, so of course I have to build a TARDIS for the yard (a YARDIS) and hang mirrors off the trees and get a bird bath at some point.

Monday I go back to work. Apparently we have a new intern; she has a degree in English lit, which is good.

And I have two weeks off in July, which I will be spending in Seattle, which is better.

Friday, April 01, 2016

Half laughing, half gritting my teeth.

Years ago, I wrote briefly about the experience of being a synesthete and how I discovered synesthesia. I had kinda always figured that everybody saw the number eight as a nice, round, juicy blueberry color and that Katy Perry tasted like burned cheese and was burnt-orange. It took an NPR story and a conversation with my sister to prove me wrong.

And I had thought about it exactly zero times since. The way you experience the world is the way you experience the world; it's not something you consciously analyze unless something is brought to your attention. Thankfully, my synesthesia (and that of my sister) is not crippling; it's just an interesting party trick. It's utterly consistent and so completely a part of the way I move through the universe that I don't even notice it any more.

Until today. Today, when my pill case showed up from Amazon.

See, my NP got on my ass the last time I saw her (Tuesday) about not being consistent with vitamin D and fish oil and all that stuff. I really need to take certain things every day, I know, but for some reason my hand just floats over the big bottle of fish oil capsules every evening. So she yelled at me a little, and I went home and ordered a seven-day pill organizer. The box for each day has four little compartments, and each box is a different color.

THE BOXES ARE THE WRONG COLORS.

And, dudes and dudettes, this is a problem. Tuesday is lavender when it should be acid green. Sunday is a soft magenta, which does not appear in this set of boxes. Monday is *not* supposed to be purple.

It's bad enough that I got all confused while I was sorting vitamins out. There are some things I'm only supposed to take three times a week, and those went into the wrong boxes. I put all the boxes back together in the holder in the wrong order. It was a physical effort to make the colors match the labels on the boxes.

I am a partial synesthete. I will soon be a partial synesthete with a label-maker, as I relabel all the boxes so that they match, or at least come close to, the days of the week.

Wednesday, March 30, 2016

Things For Which I Will Never Apologize, Part One:

1. Not answering phone calls from work or checking work email while I'm on vacation. Leave me voicemail if it's really important and I'll call you back.

This policy stems from the time the house supervisor called me and asked me to come in one morning for an "incentive shift." I replied that sorry, I couldn't come in, and got subjected to a lecture about how not-a-team-player I was and how my coworkers were going to suffer. I said, "Yeah, yeah, but I'm in CANADA" and that was that.

2. Being paranoid about the weather this time of year.

Bad enough we get hailstorms and flooding that wipes out entire towns, but add in the "Oop, another tornado" element and yes, I will stay glued to the NOAA webpage.

3. Thinking that "Burlesque" and "Spice World" are the pinnacle of Western movie-making.

Those two movies are the closest thing we have to Bollywood, unless you count the "Step Up" series, which I have never seen.

4. The things I keep in the fridge, like stinky cheese and kimchi.

I live alone.

5. Liking my animals much much much more than I like most people.

*They* don't complain about my stinky cheese, and an incentive shift for Mongo means lots of fuzzy, snorting hugs.

Wednesday, March 16, 2016

Mongo has a bone!

I was wandering around HEB today (I hate shopping without an appetite; it leads to a weird larder) and saw GARGANTUAN BONES for sale. There were weeny, teacup-Schnauzer sized bones (about twelve inches) and GOLIATH BONES (that was the name), so I bought a GOLIATH BONE.

Mongo took it from me with mingled excitement and trepidation. He chewed it for about ten minutes on the back deck, then walked around the back yard, stepping very carefully, with his head on one side as he carried it off-center in his mouth. He made sure Rocky next door and Gracie two yards over saw it, and plumed his tale out when the boxer mixes on the other side of Rocky began to bark.

He couldn't figure out where to hide it. There are two trees in the back yard: one is property of a cat, the other is a peach tree that, as yet, is not big enough to hide anything under. So he tried by the shed. Then he tried next to the deck. Then he tried by the bushes on the northwest side of the yard. Nothing worked.

So he brought his GOLIATH BONE indoors and, after a drink and a little toes-up on the living room rug, proceeded to look for a place to hide it inside. So far it's been in the bathroom, behind the toilet (no go; Humans peeing apparently are not conducive to a hiding place), in the office where I type (but he can't get to the couch at the moment, dammit), and in the linen closet. The linen closet is okay for now.

The previous three dogs I've been owned by were all either northern breeds or working breeds, or combinations of the two. That meant that Elsie would happily crunch the trochanter off a cow's femur, or Max would cheerfully, between tail-wags, chomp the bone in half at the middle, or Strider would simply make the damn thing disappear in under an hour. It was a short-lived, if dramatic, way to entertain a dog: buy them a bone much larger than anything in the human body, then wonder what would happen if I died in my sleep.

What Mongo lacks in barely-civilized, wolflike instinct he makes up for in entertainment value. I felt kind of bad for him as he pranced around the yard like a Tennessee walking horse, trying to keep The Bone from falling out of his mouth, but also amused by the fact that he grabbed it by the meatiest part rather than in the middle. And he's barely gotten two bumps chewed off since noon; this bodes well for the possibilities of an open casket funeral should I kick off during the night tonight.

Speaking of open caskets, I have started a BSN program (yes, my dears; I'm finally giving in to corporate pressure to have letters after my name) online. Tests are done with a webcam provided by the school; I have to be in sight of a proctor and with my entire workspace visible by same during the testing process.

So, I was wondering: is this the appropriate time to pull out the strapless ballgown, elbow-length gloves, and tiara I've been storing for a special occasion? I mean, my Psychology Through the Lifespan test is important; should I dress for the occasion? Would it be worth it to make the proctors crack a smile? Surely they could use a little levity in their jobs.

Mongo is yelping at one of the cats, who had the temerity to investigate His Bone. Gotta go.

Tuesday, March 08, 2016

There is a bloody bite block on my wall, just above my desk.

It's in a biohazard bag, don't worry. It's pinned to my wall, just above my desk, so that I can see it every single morning and remember why the hell I got into this crazy business in the first place.

We do a significant number of what are called transesophageal echocardiograms on our unit. Unlike transthoracic echoes, which take place when a tech holds an echo wand against your chest, a TEE takes place under moderate sedation, with a cardiologist feeding a long, skinny tube with an echo camera on the end of it down your throat.

You can't do this without sedation. Try, and you'll end up with a retching, fighting patient and a poor-quality image. It's just flat impossible to ask an alert human to stand for having a two-foot length of something the thickness of my index finger inserted down his or her throat and manipulated. So we sedate. We're a critical-care unit; we're all trained to administer sedation and recover patients who've been sedated.

Then, one day, Doctor deSade showed up. Dr. deS. was a new guy for us, from a different branch of cardiology, and nobody had worked with him before. The initial signs weren't promising: normally TEEs are done early in the morning, both because we want our patients to have time to get over their sedation and because they've not had anything to eat or drink since midnight. This dude promised to show up at around eleven, which is pushing it, but then didn't show up until past two o'clock.

Kitty and I each had a patient undergoing a TEE that day, so we gathered our sedation meds, our throat-numbing sprays, and our sedation-med-antidotes. The first patient was mine.

Dr. deSade put the bite block (a firm foam widget with a hole in the middle that keeps a person from biting on whatever's placed in her mouth) in, after spraying the patient's throat with benzocaine, and began to feed the probe down. "Do you want any sedation?" I asked.

"Give her one and twenty-five," he replied.

(Now: "one and twenty-five" refers to the milligrams of Versed and the micrograms of Fentanyl that the patient is getting. We normally sedate at two and twenty-five, going up from there in two milligram and twenty-five microgram steps. It's not unusual for a patient to soak up five of Versed and a hundred of Fentanyl. Both are short-acting and easy to reverse, so we prefer to front-load the patient, as it were, giving them more sedation at the beginning, and letting it wear off gradually toward the end of the procedure. So one and twenty-five was weird.)

She fought. She gagged. She cried. I had to hold her hands down as the procedure continued, and I got very nervous about her blood pressure--up into the 260's systolic, which is a dangerous place for a post-brain-bleed patient to be. Eventually, Dr. deS. agreed to let me give her another milligram of Versed, but no more. Absolutely no more.

So, at the end of the case, after I'd pulled the bloody bite block out of her mouth--and you really have to work to bite hard enough to draw blood with a block in--I stuck the block into my glove and then into my pocket. And I took Dr. deSade aside, where nobody could hear us.

"Listen," I said, "I understand you have a personal protocol for your TEEs, but we also have to make sure that our patients don't have to deal with a lot of discomfort. This woman's blood pressure was far, far too high for safety. You might consider administering more sedative before beginning, so as to lower the risk of complications in this patient population."

I had been formulating that speech for the entire twenty minutes of the TEE. What Dr. deSade did flipped me right the fuck out: he started shouting.

He continued shouting all the way up to the nurses' station, where he leveled a finger at me and shouted, "I want to write this nurse up for unprofessional behavior and for questioning my orders!"

And that, my chickens, was when the line I'd rehearsed every day in front of the mirror for more than a decade came unbidden to my lips: "Just make sure you spell my name right."

I think I hissed it.

Poor Kitty had to do a TEE after Dr. deS had had his tantrum, and guess what? Her patient did the same thing. Moreover, the guy had had another TEE a few months before and unfavorably compared Dr. deSade's to his previous one, within the doctor's hearing.

And I got written up.

But Dr. deSade got written up twice, independently, by both Kit and me, for being a fucking jackass when it came to sedation.

My patient cried when I told her how sorry I was. She was expressively aphasic, but could understand everything that was happening. I have never felt so bad as I did that afternoon--I wasn't able to protect her from somebody with an ego problem and an attitude.

Both the TEEs came back, read by a different cardiologist, as having poor image quality due to patient agitation. The write-up Dr. deS filed wasn't acted on; the ones Kitty and I filed were. Dr. deSade is no longer welcome anywhere near our patients.

Sometimes doing the right thing is why you get into a business as irritating and emotionally draining as nursing. And sometimes, to remind yourself of all of that, you keep a biohazard above your desk.