I believe my neighbor has a peahen.

Nothing else makes that noise, save a lone raven with laryngitis, and there aren't any ravens here. With laryngitis or without.

It's been a nice two days off. Latest on the reading list is "Restoration London", by Liza Picard, which details (among other things) the story of a man named Nicholas If-Jesus-Had-Not-Died-For-Thee-Thou-Hadst-Been-Damned* Barbon, son of Praise-God Barebones. No kidding.

And that thing about the four-and-twenty blackbirds baked in a pie, that all fly out and frighten the king? That was apparently a common joke in the Restoration period. A pie crust was blind-baked (that is, baked empty), the birds inserted in the bottom, alive, the top stuck on, and then the dish brought to the table. When the guest of honor whacked off a piece of top crust, out flew the birds to general merriment. Those Restoration Londoners sure knew how to have fun, huh?

*My sister's comment: "I want a name that has the correct use of subjunctive case!!"

Insomnia project: The Nurse's Survival Kit, Revised and Updated.

1. Good shoes. I don't know how many times I have to say this. Good, heavy, LEATHER shoes with closed toes. And don't buy backless clogs unless you've proven in the past you can run in them.

Dansko, purveyors of dangerous Professional clogs, also makes a sort that are much more sane (with a wider heel base). They're called Dansko@Work.

2. A little tube of Lamisil, for when the skin between your toes begins to crack. This will happen, no matter how careful you are with cotton socks.

3. A little jar of Vicks Vapo-Rub. Good for achy feet, good for smearing under your nose or in your mask before that nasty dressing change. Trust me on this one; you don't want to be without it.

4. Good hand cream. Not that Corn Husker's crap; *good* hand cream. Like ShiKai or Burt's Bees or even Neutrogena. Use it every night when you get home.

5. Belgian ale. I strongly recommend Orval.

Tomorrow, a discussion: Does being in management automatically decimate your IQ?

The shutters come down.

Remember the patient I talked about with possible metastatic breast cancer to the brain?

Well, it might be breast cancer. It might be something else. Uncharacteristically for our facility, pathology is taking a long time with this one--reviewing slides and frozen specimens, sending bits of them out to different labs--in an attempt to figure out just what the hell is going on and how to treat it.

Meanwhile, the patient's lost quite a lot of weight and is still unable to swallow. She had a G tube (a tube that runs through the skin into the stomach) placed the other day for supplemental feedings, but she's been so nauseated that she hasn't been able to tolerate them. Her voice is almost gone--dysphonic and scratchy, so she talks in a whisper. She has pneumonia in one lung, since everything she tries to swallow heads down the wrong tube.

I've seen patients with metastatic brain cancer or even gliomas live for a couple of years after diagnosis, enjoying a fairly good to excellent quality of life. This is not going to be one of those patients.

When the doc found the lump in her breast--two months after a clean breast exam during her annual physical--the first thing the patient said was "it's gone to my brain." At that, the shutters came down.

You can tell when it happens. It's not necessarily that the person turns their head away or refuses to make eye contact or participate in care any longer. Sometimes they seem all right at first, and it's only after talking to them for several minutes or interacting with them through a shift that you notice something's wrong.

It's not depression. It's the decision to die. Or maybe it's the decision that nothing that you or the doctors or they themselves do will make the slightest difference. Either way, their eyes get shuttered. You watch them slog through day after day without hope or interest or the slightest bit of pleasure.

In this case, it's pissing me off royally.

This woman has (of course) a loving partner, a good career, dozens of caring friends, a *good* life. I say "of course" because it's always the people with everything going for 'em that get the worst prognoses.

I'd like to light a fire under her ass and get her to fight. Just a little. I can see that she's tired, that she isn't feeling well...but the total unwillingness to even entertain hope has got me peevish.

Nurses and doctors live on hope. We're the kings and queens of denial, when you come right down to it. All the treatments that we order and perform, all the surgeries, are based on the knowledge that, statistically, this thing has worked to solve that problem, and we hope it will on you, too.

When somebody just plain gives up, we tend to take it as a personal affront. It's a defeat of sorts. We spend our days fighting against death and disease and all that noble b.s., and we assume that the people we're working with and working for have some interest in the outcome. When that person doesn't, it's hard to understand.

Hoping is hard. Slogging through is harder.

For the next two days I'll be thinking about this woman, about her dogs and cats and other family. I'll be wondering if she'll be there when I get back and if she is, what fire I can kindle under her hopeless butt.

Queen of Denial, that's me. Sometimes you win, sometimes you lose...and in this business, we tend to lose badly and take it hard.

You, too, can join the crew...

Tippecanoe and Nixon, too/Back with Barry's/Not with Lyndon, Ike, or Harry's/Back with Barry's Boys!

(Thanks to the Chad Mitchell Trio)


You are a Folkie. Good for you.


What kind of Sixties Person are you?
brought to you by Quizilla

On to the topical stuff:

Steroids, or, How To Have Fun With Potentially Only Minimal Bodily Damage

Steroids are versatile things. There are several different sorts that we medical types use all the time, for all different purposes.

Generally, corticosteroids (as opposed to the other sort, that build muscle and make you kinda grumpy) relieve inflammation and swelling, act as immunosuppressants, and can be used as diagnostic aids for things like Cushing's syndrome (where your body produces too much cortisol, a naturally-occuring steroid).

That's why I, who have the flu, am taking a prednisolone taper (a Medrol Dosepak). Even though prednisolone has immunosuppressive qualities, those are outweighed (at this dosage) by the anti-inflammatory effects. Meaning, in short, that I'm no longer walking around whimpering because my muscles and joints hurt so much.

It's also why I'm up at 3:37 a.m., typing on the computer, but more about that in a second.

In neurosurgical patients who've had bits of their brains removed, the usual starting dose of dexamethasone (Decadron) is four milligrams every six hours. Sometimes we'll go higher, sometimes lower, depending both on the patient and on the bits of brain removed. After a couple of days of that, we'll taper. It's amazing what that amount of anti-inflammatory can do; I've seen patients who weren't able to swallow improve markedly after 24 hours on Decadron.

You see a lot of steroids used in treatment of asthma and allergies, as well. Advair inhaler? Steroid. Big nasty rash I got those months ago? Treated with steroids. Certain types of arthritis can be treated with 'em as well.

Which brings me to the up-at-three-am-part.

There's a nifty little condition called "steroid hypomania". What happens in a person who's taken largeish doses of steroids (say 60 milligrams of prednisone a day) for a time is this: something flips over in the brain that makes them manic. Not leap-out-a-window, I'm king of the world manic, but pretty manic nonetheless. They get up early, the buzz around like bees all day, they tend to have insomnia.

Strangely enough, a milder version of that side effect happens in almost everybody I've seen who takes steroids. The other, nastier side effects like steroid-induced diabetes or weight gain or bloating tend to take a while, but push four milligrams of Decadron into somebody's IV and you can almost guarantee they'll be up at one a.m. humming old Madonna songs.

Which is why I'm blogging this early, when by all rights I should be lying in bed feeling as though I've been hit by a truck. A combination of steroids and aspirin has brought down my fever and taken away my aches and pains, and the steroids have done their magical work and made me peppy at 3 a.m.

This side effect will be gone by Wednesday, when my taper will have worked from 24 mg (yesterday's dosage, humming Madonna songs) to 12 mg.

Why do we taper? Ah, this is a good one. When you take steroids, even for a short period of time, your body gets lazy. Note that laziness is an evolutionary advantage: it keeps you from having to expend energy on things when that energy could better be used to reproduce or just hang out. Anyhow, expose the human body to steroids and it slows down production of its own steroids. Cut off the steroids abruptly and the body gets all grumpy--the steroid-producing bits act as though they've been shot with a rubber band.

So as you cut the dosage gradually, it's giving your hypothalamus etc. time to ramp up again.

And it gives your right temporal lobe a break from rerunning all those mid-Eighties MTV hits, too.

Fascinating, Doctor.

I have the flu.

The real, live, honest-to-God flu. The sort that gets you a prescription for Tamiflu and a little mask to wear out of the minor emergency clinic. The sort that lets you know it has you the moment you wake up in the morning and start to move--or start to *try* to move.

It surprises me not at all that people die from this. I was wanting to quite enthusiastically while in the doctor's office. When the nurse practitioner walked in, I had just burst into tears, I felt so incredibly bad. She was very kind and swabbed my throat, gave me a Sprite, and sent me on my way.

Two aspirin, a Tamiflu, some toast and guaifenesin and a nap later, I feel almost human. What gets me is that this is apparently one of the mild strains that showed up too late, or something, to be included in the flu shot this year. I'm glad I didn't get a *bad* case.

Please disinfect your computer now.

A PSA, of sorts

This is a handy-dandy link for everybody who's currently asking themselves the question "Is it a cold, or is it the flu?"

Of course, the symptoms described here might not apply if you've had a flu shot, or if you actually have a sinus infection, or if you've just got some sort of gark that nobody's bothered to catalogue.

My current list of symptoms range from the nasty to the really sort of cool. The nasty include a moderate fever (100.5 F), a hacking cough that's soothed only by ice cream and some leftover Tessalon Perles (bad nurse, keeping Rx meds around! Bad nurse! No donut!), and general body aches, headache, and malaise. The kinda cool symptoms are the hallucinations out of the corners of my eyes (is that really a binturong on my couch?) and a voice that rivals James Earl Jones's. I'm walking around saying "I find your lack of faith...disturbing" a lot.

The fact that I sound like Darth Vader, complete with breathing, almost makes up for the small furry things that keep darting around at the edge of my vision. Almost.

At least there's plenty of bad TV on, and nice guys down at the Quick-E-Mart who say things like "Helllooooo, dear! My, my! You look not so good today! And how are things?" as they sell me NyQuil.

This is why work-hour limits are a good idea.

I worked a sixteen-hour day--or what would've been one, had I not fallen over after the fifteenth hour--the other day. We were short-staffed and overrun with complex patients, so I stayed on for the first three hours of the night shift.

And gosh, am I ever tired. Tired, and running a low-grade fever, and with the sort of general achiness and coldness that makes you feel nasty. Not nasty enough to take medicine that might cause sleepiness, dizziness, sleeplessness, seizures, spontaneous amputation of your head, or palpitations, but nasty just the same. It must've been the schedule disruption that laid me open to this bug.

I got to thinking at about 2130 (9:30 pm for the civilians) that I'd been up since 0420. I'd commuted 45 minutes in the morning and had at least that long to go home. I'd been running my ass off all day long with five patients with fairly interesting and complex problems. My last admission needed transfusions of clotting factors, the close monitoring that goes with that, and every-two-hour pulse checks on one leg. And I was exhausted.

I was so exhausted that I forgot which medications are routinely kept in our lockup. I fumble-fingered equipment and misread orders. I stared with incomprehension at a ringing phone and cursed when my beeper went off. When I did finally get home that night, about 11:30 pm, I fell straight into bed and slept for ten hours.

Which makes me wonder how the residents do it. In the past there were no limits to how long residents could work in a week. It wasn't uncommon to hear tales of 20-hour days, week after week, with a brief break or letdown in the summertime or when a resident switched to a less-demanding schedule for a bit. Now, technically, residents are limited to 80-hour work-weeks.

Some of the older attendings are grumpy about this. They say that it makes residents soft, that they never learn how things Really Are in the Medical World. For the most part, our residents--especially the ones in orthopaedics and neurosurgery--are still tired enough to occasionally sleep straight through constant paging in the call room. I've not heard them celebrating the shorter work week. I have the distinct impression that a number of 'em just keep on working, technically breaking the law, when they're supposed to be off the clock.

I still think it's a good idea to limit the amount of time somebody can or should spend taking care of sick people. For myself, I get idiotic after about fourteen hours straight, and I'm not even incising people's bellies. I shudder to think what an underslept neurosurgeon could do.

For another thing, you get emotionally exhausted as a caregiver after a certain amount of time. Most patients aren't going to confide in their doctors the way they do in their nurses, and most doctors don't have to spend twelve hours answering call bells, but the point remains: If you're caring for people, you have a responsibility to them that's gonna weigh more heavily on you during Hour 14 than it did during Hour 1. And the more Hour 14s you have under your belt, the harder it is to be responsive to another person's needs.

And finally, if you're going to be a decent caregiver, whether it's as an MD or RN or LPN or whatever, it helps to have a life. Nobody wants a robot to take care of them. Even if you can't switch easily from discussing sports to discussing opera (depending on the patient), it's nice for the patients to get the sense that you don't spend *all* your time up to your elbows in other people's guts. Gives 'em confidence.

I'm going back to bed. I'm going to wonder as I fall asleep how on earth those residents do it. And I'm going to be thankful--*very* thankful--that I can punch out at the end of twelve or fourteen or sixteen hours and go home, leaving my beeper on the desk.

First Full Week Back At Work

Holy. Mary. Mother. Of. God.

I was off a lot--a LOT--during the holidays. So much so that the week between Christmas and New Year's, and the weekend after New Year's, was spent lying around in bed, reading mystery novels, eating good South American food, and generally Hanging Out.

In other words, mama lost her groove.

Wednesday kicked my ass. Thursday kicked several asses. Today kicked our collective ass, then pasted its remains to the wall.

For those of you versed in hospitalese, we have a floor of 28 beds. We started with 18 patients, sent five home, and got sixteen admits. I'm not entirely sure where we put that last extra patient; there were apparently fistfights going on in admissions over our beds.

My day was crazy enough that I'm sitting here typing, eating slabs of cheese and Fritos, drinking a beer, and wishing desperately that I'd caught the hang of smoking as a teenager.

My first patient came from the rehabilitation floor. We'd sent her there two weeks ago. Night before last, the nurse had given her enough oral morphine concentrate for pain that she'd become nonresponsive and Narcan (a drug used to reverse the effects of narcotics) wasn't enough to bring her out of her stupor. She also had a temperature of 102 and pus leaking from her scalp incision.

No, not leaking. Oozing. Ooking. Yarking me out at 0700.

Anyway. She had a sodium of 126 (135-145 is normal), so off she went to ICU. We can't replete sodium with a high-salt intravenous solution on the floor; we have to do it in ICU. She was out by 0800.

Second patient is 42 with metastatic adrenal cancer. His prognosis is grim, to put it nicely. His pupils were two different sizes when I walked in, but the rest of his exam was okay, so we put it down to the morphine he'd been getting for pain. Luckily, we were right.

Third patient is 43 with what looks to be metastatic breast cancer to the brain.

Fourth patient is so manic I nearly killed him. Who on earth has myasthenia gravis and still files paperwork all day?

Fifth patient is a long-term IV drug abuser; smack and crank are drugs of choice. Guess who wants her two milligrams of morphine every hour?

We, as a floor, pride ourselves on getting out on time every night. It's rare that somebody has to stay to chart past the end of the shift. I was the first nurse out of there, having had one very early and one very late admit, and I got out at 7:30 pm. Everyone else is probably still there.

Best moment of the day: A surgery resident of the unusually arrogant type keeps answering the phone, then hanging up on the person when he finds that it's not the person he wants to speak to.....

Nurse Jo: "I need you not to hang up on my consults."

Resident: "Well, I paged *my* consult to this phone; what do you want me to do?"

Nurse Jo: "Let me answer the phone. And keep your paws off our snack foods."

Silly quiz of the day, since I am off work:

Which Extremity of the World Are You?
From the towering colossi at Rum and Monkey.

I'm apparently somewhere in Libya.