Rules for Residents

It's that time of year again. We got a new crop of residents this summer and they're just now beginning to feel confident on our floor. This means that some of them have turned into flaming assholes. Some of them are not so bad, true, but this isn't directed toward the not-so-bad ones.

Please note that the nurse or lab technician will be referred to herein as "she". Nursing and lab teching are primarily female jobs.

The resident will be referred to as "he". While our resident population is split roughly 50/50, I have yet to meet a female resident who yells, uses profanity, or attempts to humiliate nurses in front of other people. Those who try such antisocial tricks have been, invariably, male. Suck it up, boys; it's life.

Rule Number One: Policies, procedures, and standards do not exist solely for the purpose of inconveniencing you.

There must, therefore, be some other reason for them to exist. Perhaps it's patient safety. Or worker safety. Or Federal law. If those considerations pale before the issue of your precious convenience, do not blame the nurse or lab tech who explains the problem to you. Do not complain to them that the policy is unreasonable. Do not threaten them. It will do you no good and only make you enemies.

Instead, express--civilly, please--your frustration with the situation, if you must. Ask for help. Ask for advice. We will then bend over backwards to help you out.

Rule Number Two: If You Are An Asshole, You Will Get Zero Slack From The Floor Staff.

Remember the resident who tried to tell me that an oxygen supply line was misconnected and berated me for same in front of a patient? He now gets called by every nurse on every floor to double-check every damned connection on every piece of equipment to which his patients are hooked. Every time.

He also was hard enough on a charge nurse I work with to bring her nearly to tears. This woman is tough, no-nonsense, and strong. I don't know what he said, but it must've been something. I'm sure he felt good when he hung up on her. I'm sure he felt less good when his attending physician called him on his behavior in the weekly ENT meeting.

Another case: A resident yelled at two nurses in the space of a week for not calling him with lab results. These particular lab results were within normal limits and there was no order to notify him with the results, so we let them go. That's our policy.

That resident got called at odd hours every night for six months by every nurse he worked with. We double-checked everything with him. We called for approval before implementing pre-printed protocols. We called for orders for suppositories and Tylenol. The pharmacists called before implementing pharmacy protocols. The lab staff called with every single lab result on every single patient. Around the clock. For six months.

His behavior has improved.

Rule Number Three: Being A Jerk Will Not Provide Your Patients With Better Care.

If you're personally unpleasant, we will delegate every interaction with you to whomever will accept the assignment. We'll take very good care of your patients--that's our job--but you'll get one, maybe two phone calls a day with all the results and news of the day rolled into three minutes.

Rule Number Four: Being A Nice Guy Will Get You Perks.

We play favorites, openly and unashamedly. If Resident A gets a nickname and plates of food set aside for him from the staff's potluck lunches, there is probably a reason. If Resident B is treated brusquely and with thinly-veiled hostility by the entire staff, you bet there's a reason.

Resident A is also much more likely to find people to help with bedside procedures than Resident B. Resident A will have a staff of willing nurses who will walk through fire for him if something is going badly wrong. Resident B will be told to find documents himself or call the lab on his own.

Rule Number Five: There Is A Very Strong Probability That The Nurses You Work With Know More Than You Do.

"Very strong probability" in this context means "virtual certainty."

Our hospital's average nurse has been working with a specialized patient population for more than five years. She spends hours with her patients several days a week. They tell her things they wouldn't tell their own priests or mothers. She sees them when they're sleeping and knows when they're awake.

She also understands the basic surgical techniques that doctors use and their effects on the body as a whole. She has a grasp of the lab values that she encounters on a daily basis and knows when trouble is brewing.

Most importantly, your average nurse has a good gut sense of when it's about to hit the fan.

Therefore, if a nurse calls you at eleven on a Sunday morning with the news that everything with Patient X is so far going well, but that she has a niggling suspicion that something terrible is lurking just beyond the bend, you should listen.

If a nurse tells you that your new patient is a drug-seeking wacko with aggressive tendencies, don't be condescending. Remember that this nurse is, in all probability, older than you are and has not spent the last fifteen years in school. More than likely, she worked with drug-seeking wackos as a full-time job at some point. Listen to her. Take her seriously. Keep your eyes open. That way, when the patient hoards Phenergan in his bed or throws a chair through her window because she can't get morphine, you won't be surprised.

It's not rocket science, guys.

I promise that your balls will be just as big at the end of the day as they were at the beginning, even if you're pleasant and civil to everyone you see. I promise that your integrity as a surgeon will not be compromised by apologizing to someone that you've screamed at. I promise that things will be much, much easier if you treat those lesser beings who keep your patients alive and healthy with respect and honesty.

If you don't, that's your business. Please be aware, however, that most of us have been through much worse than you. We have no compunction about mopping the floor with your sorry ass if you step over the line.

TMI, TGDG

Too Much Information, Too Goddamned Girly.*

I should have a T-shirt that says, "My doctor put me on fucking Tequin and all I got was this lousy yeast infection." Not only did I pay $61.95--with insurance, thank you--for the privilege of eliminating a bacterial superinfection in my sinuses, but I get the added joy of trying to figure out which over-the-counter yeast infection remedy is comparable to bribing a Diflucan from the pharmacist at work. Not that I'd ever do that, or that he'd ever comply, you understand; this is merely an intellectual exercise.

The bacteria are gone, thank the gods, which means I'm left to deal only with the viral infection that started it all. I still have to finish the fucking Tequin, but at least I'm not running a high fever. I'm only producing amounts of snot that would make even the most hardened otolaryngologist quail. And I'm coughing like Mimi from "La Boheme," a reference that exactly none of my coworkers got today at work. Sucks to be the only one who can both sing "Mi chiamo Mimi" and get the joke.

Because I know how to have Big Fun on a Saturday night, I bought the following things at the grocery store this evening:

1. A bottle of Toad Hollow chardonnay. Not a bad little wine, even if it tastes like it's been stirred with a 2 x 4. The oak is pronounced.

2. Copies of "Scientific American" and "Allure: The Best Beauty Issue".

3. Generic miconazole cream.

4. Shoe polish (liquid) which I promptly squirted all over my kitchen table (not a big deal) and my carpet (a slightly bigger deal). However, my shoes are now shiny and scuff-free.

Allure's advertising-driven editorials tell me that Neutrogena has come up with some product that makes it possible to plane several layers of skin off your face--without redness or irritation!--while Maybelline has come up with a product that replicates the look and feel of the skin you've just removed. There's also a full-page ad for something called Brava, a breast-enhancement system.

This Brava thing deserves a paragraph of its own. Going to the website will give you no solid information on price, use, or configuration of the product, but it will provide scary hints as to all three.

Brava seems to be some sort of suction-based device that yanks on breast tissue until it expands and fills out. Why this is a good idea, or one which even the most desperate woman would consider, escapes me. Anyhow, you're supposed to strap on the Brava cups ("They're huge! They cover your whole chest!" says one review) in the privacy of your own home ("You can be as discrete [sic] as you like" says another) and then wait for the miracle to happen. In between uses, there are handy tips on reducing skin irritation (use cortisone cream) and fitting the product (strap the cups on with cut-up pantyhose). There's even an 800 number to call for help with financing.

Financing. For a pair of hollow half-globes that yank your tits out of shape until they give in. There is so much wrong with this that I don't know where to start.

Tomorrow morning, once I've got a little more energy, I'm going to attack the remaining shoe polish stain with rubbing alcohol (thanks, Beloved Sister!) and read "Scientific American." You just can't get the same effect from articles on the evolutionary benefits of siblings as you can from articles on peeling off bits of skin and self-curling mascara.

*Anybody who complains about the unusual Personal Squick Factor of this post can reference Belle, Diablo, Joe, or The Good Wife and kiss my ass. Thank you and good night.

Extra! Extra!

The Management is pleased to announce a new feature in this space, born of early-morning insomnia and the slightly hallucinogenic effects of Tessalon Perles.

Blog O' The Mornin'!

This will be an occasional feature, highlighting blogs and websites that The Editor has run across in her bleary-eyed InterWorldWideNet surfing.

Today's entries:

Sure thing, Babs

Spamusement!

Nominations are welcome.

Wow.

"Better than 'Scrubs'," he said.

Halfacanuck

"Mucus plugs sound really gross," she said.

Alexa's Escort Blog

Warning: the second link is more explicit than I'd normally put up, but it's also just cute as hell. Anybody who can talk about how much she loves Jimmy Choos at the same time she's mourning the lack of sensation that Viagra gives a 75-year-old man gets my vote.

Warning: the first link is to a blog whose author outdoes me in grumpiness. I mean that in a complimentary way. "I do not want a second pizza. I do not want 30% off." is how I often start my mornings.

Enjoy. I may have to start a Blog O' The Mornin'! feature.

Mucus, take two (now with addendum!)

I normally distrust physicians who have curly hair, dimples, and twinkly brown eyes. Especially if they have wire-rimmed glasses. Especially especially if they wear ties with little golf emblems on them.

I was therefore prepared mightily to distrust the doctor at the local Doc-In-A-Box this morning, until he opened his mouth and said, "Gee, you've had a lot of the same crud in the last year, haven't you? Looks like Tequin got rid of it last time."

Then he whacked on my sinuses and looked surprised when I jerked away (Yeeouch!), listened to my lungs, and nodded sagely when I told him I'd had a patient with pneumonia a few days ago. "Aerosolizing God knows what into the air, coughing in your face" he said.

Now I have a prescription for two weeks' worth of Tequin, a strong flouroquinolone antibiotic which my books assure me is good for everything from gonorrhea to Haemophilus influenzae and will take out methicillin-resistant strep as well.

David came over when I got back from the doctor. He took me for Chinese broccoli and soup, then brought me home. I crawled into bed and woke up a few minutes ago, hungry and disoriented.

I wonder what I'll take if Tequin doesn't get rid of this sinus infection. Leeches? Bleeding? Powdered frogs?


Addendum: I wrote my sister about the sinus infection and the way doctors test for it (by whacking your sinuses with their fingers) and she had this to say:

I remember once a doctor put her thumbs on either side of my nose just below my eyes and shoved, and I circled the ceiling shouting "wakwok" 57 times. On the 58th circuit I bumped my head on the light and fluttered down. This was at least a decade and a half ago and I still check every new doc out to be sure it isn't her.

Mucus, autonomic dysreflexia, and vaguely irritated bovines.

Mucus

I have a cold. Or a sinus infection; I can't tell which. All I know is that life is currently not happening without pseudoephedrine, a drug I normally avoid at all costs. It makes me do what I did this morning; that is, wake up at 2:20 and not be able to get back to sleep until six.

If I could just sleep standing up, that would be much better.

Autonomic Dysreflexia

Here beginneth the first lesson: autonomic dysreflexia is, according to Taber's Cyclopedic Medical Dictionary, a condition commonly seen in persons with an upper spinal cord injury that is caused by massive discharge of sympathetic reflexes from the sympathetic nervous system.

In English, what that means is this: A person with a complete or incomplete injury of the spinal colum somewhere high, usually in the neck, will occasionally have episodes of hugely high blood pressure, tremors, sweats, panic attacks, and other nasties. These are most often brought on by, believe it or not, a full bladder. A fecal impaction takes second place. Other causes might include positioning or bedsores.

I had five patients on Thursday. Four of 'em I cured by noon, which left me to deal with Patient Number Five. He's a high incomplete tetraplegic (quadriplegic) who had a partial transection of his spinal cord at about C6. Feel that bump at the back of your neck, just above your shoulders. His break happened just above that.

He's a nice guy. He's been a quad for about six years and has been married to his equally nice wife for three. (Note to the gaping masses: quadriplegics can and do have perfectly satisfying lives, including sex lives. It depends on the injury, the deficits, and the person.) He came in because he'd started having odd pains in his belly when he laid down in certain positions. His doctor figured it was his implanted muscle-relaxant pump malfunctioning.

(Note to the interested: baclofen pumps can be implanted in the abdomen and programmed to disperse small amounts of baclofen or baclofen in combination with other drugs to the spine, thus reducing muscle spasms and pain.)

At about one o'clock, this poor guy went into an almost-endless cycle of autonomic dysreflexia. His bladder wasn't full, he wasn't impacted, his positioning was fine, he had no bedsores. *Nothing* could explain what was going on...

...until I took a look at his labs with Sparky, his doc. "Sparky," said I, "I know his urinalysis shows colonization, but is it possible that that colonization could've turned into an active infection?" Sparky pondered for a minute, then decided that I might have a point there.

People who've had bladder infections will tell you that even a tablespoon of urine in an irritated bladder can drive you to distraction. I think that was what was happening with this guy, though I never got a definitive answer. The rest of the day I spent giving him huge doses of baclofen and Demerol in an attempt to break the spasms and the blood pressure problems by breaking the pain cycle.

The trouble with a high spine injury is that the body wants to work on a positive-feedback mechanism. Any mechanical engineer will tell you that that will lead to a burnout in machinery. In a human, it leads to blood pressures of 290/155.

It was not a fun afternoon. He stabilized during the night shift, though, and presumably is on his way home now.

And vaguely irritated bovines

Question: what do you call it when a person has a brain biopsy that comes back inconclusive for Creutzfeld-Jakob disease?

There is no answer for that one. If I knew of a good punchline, I'd've used it already.

Yet another patient came in with some indefinable brain problem that causes them to shake, become nonresponsive, and curl up in a ball. The biopsies we did don't show anything definite, so the diagnosis will probably be made on autopsy (as so many of them are with troubles like this).

CJD is different, by the by, from "mad cow".

Mad cow disease, or variant CJD (vCJD) hits early in life, in a person's twenties or thirties. It starts with odd neurological defects that often involve quite a bit of pain and takes several years to kill the victim. It's transmitted by--and pay attention, here--eating the neural tissue of infected animals. Chuck roast is fine, filet mignon is safe. T-bones are a little tricky, and ground beef (especially the mystery-cut ground stuff in the prefab chubs) is most dangerous, as it's extracted by a process that often mixes in bits of spinal tissue by mistake.

Creutzfeld-Jakob disease, on the other hand, is spontaneous. It has no recognized trigger, though genetic mutations might play a role. For some reason we don't understand, tiny proteins in the brain called prions suddenly start flipping over and turning into what's essentially a mirror image of their old selves. They induce other proteins to do the same, and you eventually end up with a brain full of holes like Swiss cheese.

It hits people in their 50's to 70's and takes about six to eight weeks to finish them off. As far as we can tell, it's relatively painless.

(Tangent: People often ask me if I'm worried about getting vCJD from eating beef. My answer is this: I commute 40 miles a day on a hugely busy highway and cross a busy street to get to work; I stand a much higher chance of ending up pasted to the front of a city bus than I do of getting vCJD. Go ahead and eat your steaks, people.)

CJD is quite rare. Only about one person out of a million will get the disease, which means we've got the area's biggest CJD population rotating in and out of our hospital. You know it's bad when all a nurse has to say during report is, "Well, it's typical CJD" and everybody around the table nods in understanding.

And finally, a piece of good news

Georgia of Odious Woman has been kind enough to link this blog from hers. Omigoodness!

I urge you to check out Odious Woman. Georgia is a crack writer and makes even lifting weights and running sound fun.

I saved somebody's life yesterday

Well, I helped, at least.

I sucked a mucus plug out of a patient's trache, no big deal. But it's left me unexpectedly shaky and flipped out.

Here's the deal: I had a patient of a sort I'm not used to: a radical neck dissection for laryngeal cancer, with a tracheotomy that was fresh. Frech traches are nasty, since your body produces lots of mucus to try to deal with the insult of having a hole cut in your airway, plus you have lots of swelling. Those issues combined with the fact that the trache tube can come out make a fresh post-neck-dissection patient a bit of a worry all around. I was paranoid-ly checking on her every fifteen minutes all morning.

The patient's daughter came out of the room at 0918 and said, "Jo?" in that tone of voice that means "I hope whatever's happening isn't really happening." I flew into the room to find my patient panicking and unable to breathe--no breath sounds in the chest, no air movement through the tube. So I called Dave, our charge nurse, and he brought in an ambu-bag. (Ambu-bags are those squeezy things that pump air into your lungs when you're on "E.R." on a gurney being rushed down the hallway by Noah Wyle.)

Her oxygen saturation had gotten to 25% by the time Dave and I managed to knock that plug loose, me with suction and him with the bagging. 80% is considered a critical level.

At 25%, a person goes limp. Her mouth falls open, her eyes dilate, and she doesn't respond. Her heart kind of flutters around in her chest, unable to keep beating without the stimulus of the lungs.

Then, when you finally knock that damned plug loose with the bag and the suction, her breath rushes back into her throat with a huge rattling sound and she starts to grimace. That's when you come back into your body and realize dimly that everything you've done for the last two-and-a-half minutes has been totally automatic, without thought, without conscious action. You realize that you've ordered a crash cart and that it's appeared from somewhere without your noticing, that Daughter and Son-In-Law are looking a bit tense, and that you're shaking.

Then you look at the clock and see that it's 0922. It feels like 1630.

Like I said, a mucus plug is officially no big deal. They happen a lot, so you're prepared for them: the fresh trache is near the nurses' station, right across from the cabinet where the respiratory team keeps its supplies. I didn't have to call a code (thank you, God, thank you), and my patient came back fine and dandy, if a little tired.

It affected me much more badly. When her O2 sats dropped to 25, I thought "Fuck." That was all. Just "fuck." Not "Fuck, now I'll have to code her" or "Fuck, now she's dead" or "Fuck, her pupils aren't reacting" just "Fuck." With everything else rolled into it.

Dave looked at me afterwards and said, "Good job." From him, that's high praise.

I went and got mashed potatoes and green bean casserole and buttered carrots for lunch.

Cholesterol

I am turning thirty-five in a few months. That means I'm older than Britney Spears, thank God, and still younger than Daniel Schorr.

Beloved Sister just got her cholesterol back from the lab. It's high, and her LDL and HDL suck, as she put it, dead rat. This makes me nervous, since Beloved Sis has much better lifestyle habits than I do. She doesn't work 14-hour days, doesn't drink to excess, doesn't eat Sonic. She also works out constantly and can donkey-press something like 700 pounds.

35 is the benchmark age for a lot of stuff. First mammogram if you have a first-degree relative with breast cancer, baseline cholesterol, aneurysm territory. It's osteoporosis risk and think about retirement funds, why don't you own a house and a working car time, oh you never had kids, risk of thus-and-so jumps mightily. You're more likely to get hit by a bolt of lightning than marry a terrorist, Toyota Scions are too young for you and the Mini is pushing it, why don't you get an Accord?

However, it's okay to like Garrison Keillor. You don't have to wear neon colors. Blue eyeshadow is beyond the pale, and nobody expects you to be really, really skinny and flat-chested. Long narrow skirts are acceptable. You get very strong in your thirties, and 35 is when you can show off your amazing biceps and deltoids. Coffee becomes a way of life rather than just a beverage. Drinking no longer carries with it the fear of hangovers, and nobody looks at you funny if you say you like Scotch, neat. You become much more interesting than a 20-year-old.

Still, I won't be a healthy forty-five year old unless I find out what my cholesterol levels are and start exercising again. *sigh* Time to forgo the donuts and start the cardiovascular workouts again.

Oh, and a few more things....

Fluff segregation

Yet another person has expressed disbelief that my entire winter wardrobe has been assembled from scratch in ten minutes. Note to the general public: all girls are not clotheshounds. I may show some alarming tendencies in that direction, but I rarely follow up on them.

Irregular Choice shoes might be the new followed-up-upon tendency.

I woke up this morning with Fruvous's (Moxie Fruvous) "Fly" going through my head. I don't know why. This, of course, brought back sitting on the roof of Lloyd, singing snippets of "My Baby Loves a Bunch of Authors" and hearing jhave say, resignedly, "You know the Fruvous." (Well, duh. They're the choice of bookish nerdgirls everywhere.) That was shortly after we watched the bald eagle spiral out of sight over the mountain and shortly before I had far too much wine.

The hospital cafeteria has come up with something surprisingly good for breakfast. I forget what it's called, but it seems to be a mixture of egg and maybe masa flavored with cumin and chili and topped with salsa and cheese, then baked in a water bath. It's kind of like Migas for the Masses.

Speaking of migas, I have a surfeit of good corn tortillas and some excellent jack cheese. Hmmm. Breakfast.

I opened all the windows this morning (it's only about 60 right now) and the cat is loving it. She likes to sit on the bedroom windowsill and feel very butch.

Interesting is a curse.

God and I are going to have a little come-to-Jesus meeting.

I found out Monday morning first thing that the intelligent, polite, charming 21-year-old man I took care of prior to his brain surgery had a metastatic tumor, not a primary tumor as we'd hoped.

Quick definitions: "metastatic" means "arising from somewhere else in the body." "Primary tumor" means "started wherever it is and might go somewhere else if it gets the chance."

Metastatic brain tumors are bad news. Because of the way the body works, the brain is segregated from the rest of the body by something called the blood-brain barrier. This is, in short, the thing that keeps you from getting an infection in your brain every time you get sick. It's very difficult for critters, viruses, cancer cells, and drugs to cross the blood-brain barrier (with a few exceptions that I won't go into here).

See, cancer loves the brain. The brain uses pure glucose for energy--nothing else. A PET scan, in which slightly radioactive glucose is injected into a person's body to show the areas of high cellular activity, will show the brain and various glands as bright white. That means that there's a whole lot goin' on in those areas. It'll also show cancerous tumors as bright white. That's because cancer cells are normal cells with their inhibitions removed: they reproduce and use glucose at phenomenal rates.

If a cancer cell gets into your brain, it's in heaven. No immune response to speak of, nice soft tissue that won't keep it from forming a tumor and expanding, and all the food it wants. It's a tough trip to get there, but once you're there, man, you've got it made.

So this fit, handsome, charming young man has cancer *somewhere* (we don't know where) that's gotten jiggy enough to move into his brain.

And this is patently unfair. Mean people, I've noticed, tend to live for damn near ever with very few problems. The good ones get shafted.

Still, the fact that this kid is healthy and fit and has a loving family and a wonderful girlfriend works in his favor. I am remaining resolutely optomistic and refusing to believe that he won't get better. So many of our patients *do* get better that it's hard to take when one doesn't. I am therefore avoiding pessimism.

But God has got some explaining to do, and I hope He's ready.

Other things I'm avoiding

I'm avoiding replying to an email at the moment because I haven't found quite the right casual, insouciant tone to use in it. It's one of those emails that could be the fuse to a powder keg, and I don't want things blowing up in my face. Not in a bad way, you understand, but in a complicated way.

I'm avoiding thinking about how hard it is to get used to not being constantly off-balance. For years I was off-balance on a regular basis--not in a bad way, but in a challenging, interesting way. Things have settled down and gotten peaceful lately, and it's a bit tough to get accustomed to.

I'm avoiding wondering why creditors are calling my phone number looking for other people. With my luck, my identity has been filched and some bad guy is running up tons of debt buying junker cars under my name.

And, right now, I'm avoiding cleaning house.