Friday, October 07, 2016


"Are you on any medications at home?" I asked. He was in for a swollen wrist--and I mean a swollen. wrist. The thing looked like he had a half a softball in there.

"Nope. Nothing."

"What about for the pain in your wrist?"

"Oh, yeah, I mean, I take Tramadol for that."

"Okay. So. . . .anything for high blood pressure, anything like that?"


Okay. On to the next question. I know this one will be fun because he's got dozens of missed follow-ups and lit up his last utox like a Christmas tree. Two weeks ago.

"Any street drugs? Heroin? Cocaine? Weed?"

"Why you motherfuckers always askin' me about street drugs? I don't do no drugs! I don't smoke weed or shoot heroin or nothin'! What the fuck are you people goin' on about drugs? I never done no drugs! (random profanity)(random tossing things around the room)(stomping)(breathing heavily)"

"So all you take at home is Tramadol for your wrist?"

"Yeah. And Suboxone."

Thursday, October 06, 2016

Lieutenant Lumpy: An Update.

Another year, another clean set of scans and a pristine checkup with Dr. Crane and his Irrepressibly Cheerful Staff. (They always seem happy to see me? I guess because I don't look like Frankenstein's Monster?)

Next year, because the lung nodule I have has not changed in six years, I can start getting annual chest x-rays rather than an annual chest CT, along with my usual head/neck/orbits MR. I'll have to get all that every year for the foreseeable future, because (as Dr. Crane said), "These stupid salivary gland tumors have a really long fuse." And they tend to recur in both the original spot and met to really weird places.

Still, I'm happy. I didn't have to have radiation, I'm functional with The Bug, and I've discovered (and am still discovering) benefits to having an obturator for a palate rather than factory equipment.

One of the most interesting side effects of having CANSUH has been my failing to give a shit about a number of things that used to be really important. I can't believe, for instance, that I worried so much about how I sounded and looked after surgery. I mean, it's understandable--the first obturator was barely better than my postsurgical mouth, and the second one, while an improvement, left a *lot* to be desired.

(If I had it to do over again, I'd go back and tell myself that 1) a year seems much longer than it actually is, and 2) to go ahead and buy a Therabite prior to surgery, rather than waiting however many weeks I waited.)

I also Don't Really Care any longer about what people think about things I might decide to do. For instance, the headliner in my car is coming down. I'm going to repair it with these little twisty screw pin things, then cover the heads of the pins with little glow-in-the-dark stars. This is a good idea. I like this idea. Other people think it's a weird idea.

And SBAR. SBAR is a communication technique developed by the Navy and figured out independently by a number of smart people in other fields, and works like this:

In oral communication, it's important to get to the gist of what you're dealing with, explain the background in a few words, give your opinion of the problem, and suggest a solution. It's what we do, by instinct, when we call doctors for (say) medication orders for nausea:

"I'm taking care of Ms. Smith in 918. She's post-angio day two and has had intractable nausea and vomiting for the last eight hours. I've given her Zofran and Tigan, but it hasn't helped. She's currently not making a lot of urine, but has no IV fluids. Can I start gentle rehydration at 75 an hour and give her a dose of Decadron?"

It works great for oral communication. It sucks for written communication.

Which is why the Powers That Be at Sunnydale have decided that the nurses will now write an SBAR summary of their shifts, every shift, and include it in the shift notes.

SBAR is meant to be a crisis communication, or give information in the case of rounding or reporting. It's not meant to sum up an entire shift. Trying to chivvy a summation of what you did into a shift into SBAR form is just. Fucking. Stupid. The suggestion from TPTB is that we focus on the problem that occupied "80% of the shift," but come on: most nurses, even those with only three patients, have multiple problems to solve that occupy about 20% of each shift per problem.

It's a bad use of a really good tool.

So I wrote my SBAR reports in limerick form this week.

Situation: Ms. S is not making much pee;
                We wonder just why that might be.
                We think that she's dry
                And the prime reason why
                Is that she's in need of IVs.

Background: She suffered a stroke yesterday
                      For which she received TPA.
                      She's had bad reactions
                      To some medications (approximate rhyme; sorry)
                      And so she is barfing today.

Assessment: Lethargic, unhappy, and sore
                     With pulse running 144,
                     And 80 systolic
                     Abdominal colic
                     And puddles of gark on the floor.

Recommendation: Hydration is our biggest worry
                             'Cause she's gotten dry in a hurry.
                             To prevent AKI,
                             We really should try
                             To top her up *fast*, Dr. Curry. [had to change the MD's name to                                        anonymize]

Next week, it'll be haiku. Nobody reads my damn notes anyhow, so I don't really care what anybody thinks of them.

Sunday, September 25, 2016

I have all the time in the world.

It was not an easy day.

We were short-staffed, and I had a patient on palliative care, whose family needed my attention much more than the patient did. Let's face it: when their urine output drops below 20 ccs an hour (those Foleys are placed for comfort care, but it's more the nurses' comfort than the patient's--we can tell how close to dying you are by how well your kidneys are working) there's not much we can do. We turn and do a partial bath every two hours and wipe their faces and clean their mouths, but it's all for the family. The person who's dying has long since ceased to care.

So I had this palliative care patient, and a patient on a titrated drip, and a walkie-talkie woman, ninety-fucking-six years old, with a tiny lacunar stroke that didn't affect her at all. The most we were doing was tuning her up; making sure her blood pressure was okay and her electrolytes were within normal limits. We weren't going to try to change her diet or stop her from smoking. At ninety-six, you're running on genetics, and who am I to say you should give up the Parliaments for an extra, horrible year of life? Keep smoking and die at 102.

So I was in a hurry that morning, making sure her breakfast was to her liking. "My husband," she said, "always liked a poached egg every morning."

She hadn't ordered poached eggs. "I can't stand them. Slimy things" she said.

She had an omelette with mushrooms and sausage and cheddar cheese. I remember this exactly because I love that particular omelette. With hash browns and pancakes.

She had toast.

Anyway, I was in a hurry. I was hungry, I wanted my own 200-calorie breakfast, I had to take vitals on the guy who wasn't on palliative care and swab the mouth of the guy who was, and this woman said, "My husband always liked a poached egg every morning."

"I used to get up," she continued, "and make him an egg and toast, and then feed the baby. I didn't have much milk, so I had to give him goat's milk and cereal."

She reached out for the omelette and I cut it up for her. Hurriedly.

I was looking toward the door, wondering why the monitor was going off, when she took a bite of toast. "It was January when we stopped having milk at all," she said, spewing crumbs everywhere. "That wasn't so unusual. You know, cows only used to give milk when they were nursing calves."

I knew that from the Little House books and nodded, distractedly, wondering if the alarm I heard actually meant something or was just artifact.

"In April, the soldiers came and kept us from going out of the neighborhood."

That sent a prickle up the back of my neck. I looked at her, ninety-six years old, two children who came to visit and then had to leave to take care of their work, six grandkids, two great-grandkids. And I did the math and realized that this might be her and my last chance to talk about this.

We are losing them every day, those people who fought a good war, and the people who were caught up in it, or who were targets of it. I will never forget the man I took care of who had crude tattoos memorializing his jumps as a Russian paratrooper on his bicep.

"What was it like?" I asked, "not having any milk?"

She said, "You have more important things to do. People are sick."

I said, "I have all the time in the world."

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.