That's it. I'm effing moving.

I can't stand this any longer. People have a right to their own opinions, of course, but if these crazy, narrow wackjobs keep posting stuff like this where decent people can see it, I'm leaving the country.

This is just offensive. And blasphemous. I suggest you go to the blog and give the "writer" a piece of your mind.

Shrimp, I'm lookin' at *you*.

Back to Life

The paradox of palliative care is that sometimes, when you quit poking somebody, they improve.

She had come to us after a fall in the mall parking lot that resulted in a subdural hematoma. She also had a subarachnoid hemorrhage--probably what caused the fall--and had had a glioblastoma resected three years earlier. It was the nasty sort of glio, multiforme, that has a life expectancy (untreated) of three weeks. After conventional chemo and radiation, she'd gone to a clinic in Texas that, while it's mentioned on QuackWatch, has had some success in treating patients with brain and other cancers.

She was also septic. MRSA sepsis, which means it's tricky to treat. We'd had her on vancomycin and rifampin and she wasn't getting better. When I took over her care on Monday, she was globally aphasic (couldn't speak or understand speech or communicate at all). By Tuesday, she was tachycardic and moaning. On Thursday, her sodium had dropped to an eyebrow-raising 124 (135 is the bottom end of normal) and she was minimally responsive to pain. She was producing almost no urine and was swollen and blotchy all over.

The doctors ordered a nasogastric tube. I'd spoken to her family at length about what she and they wanted, and I was pretty sure an NG tube wasn't part of the plan, so I stalled until her family arrived that morning. They decided, with the doctor, to stop all interventions, put her on palliative care, and let things happen as they'd happen.

I didn't expect she would live through the weekend.

Imagine my surprise, then, when I walked in Monday morning and she sat up in bed, waved, and smiled at me.

*boggle*

The wave was a little messy, as she had a spoonful of mashed potatoes in the waving hand, but I was glad to see it anyhow.

We'd repleted her electrolytes and rehydrated her and dumped dozens of grams of various antibiotics into her. We'd put in a central line, taken it out, put in a different central line, pumped her full of drugs to keep her comfortable, sat her up in a cardiac chair, and generally been as unpleasant as caregivers can be to a patient who just wants to rest.

So, finally, she got a chance to rest.

I explained to her family that, since her sepsis was only about halfway treated, she could go rapidly downhill at any point, and would probably die from that sooner rather than later. Still, as the week progressed, she continued to improve. By the time she left later that week, her edema was gone, her urine output had normalized, and she was talking and (mostly) making sense.

Regardless of what happened in the end--and I'm not sure, even with no tumor regrowth, that she would've survived long--she got a week or two of mostly-compos-mentis-ness to spend with her family. That's enough.

Rule Number Seven Gazillion of Nursing: Sometimes just sitting down and shutting the hell up is enough.

Dear Joey,

I have decided what we need to do.

I'm tired of the South. I'm tired of the pollution and the hundred-degree days, and of the lack of calamari and itty-bitty grilled cephalopods.

So I'm going to learn French. I figure I can do it at the same time I'm losing this 40 pounds with the new trainer.

Then I'll move to Montreal.

While I'm losing 40 pounds and learning French, you'll have to take the art world by storm. I figure that your Spring 2007 show, "Where are you going? Where have you been?", featuring GPS-enabled dresses and blouses that will map out one's progress through any city, will be a big hit. You will make Montreal the center of the art-tech-fashion world and will become a household name. Meanwhile, I will figure out how to become independently wealthy. Maybe the exchange rate will improve.

Shortly after that, you'll buy an Audi TT. White. Six-cylinder, with Quattro all-wheel drive and a stick shift. You can drive a stick, right? Oh, what the hell...if I can lose 40 pounds and learn French, you can learn to drive a damn stick. If we work it right, you can put one tiny box of mine into the back of the white TT and help me move.

I will drive a refurbished Karmann Ghia or a mail truck. An old right-hand drive mail truck, painted with large bright polka dots. You may keep your condominium while I move in to something loft-like in Chinatown (hard to find) or Little Italy (slightly easier). I'll hang a swing from the ceiling like Marguerite has.

You may wear gorgeous old cashmere coats with huge collars. I'll wander around in ball skirts and men's sweatshirts and plastic pop-bead necklaces and collect Balinese dancing masks. We'll never have a bad meal and will eat tofu only by choice.

We will spend our summers on Ile d'Orleans, eating raspberries and drinking champagne and figuring out your next artistic coup. Aside from six weeks of summer, which will be warm and sunny and dry, it will always be either spring or fall in Montreal. Except right around Christmas, when it will snow in a picturesque fashion, but not long enough to get all dirty and awful.

By general decree, the river will not only become safe to swim in, but will become pleasant and just cool enough. We'll buy big straw hats and a parasol or two.

That's what we're going to do. Please get cracking on taking the art world by storm. I'm going out to buy some lottery tickets.

Love,

Jo

Fluff Life

Yeah, yeah, yeah. I have a patient who suddenly improved dramatically after she went on palliative care, and one who has an interesting bacterial infection, and I just saw a patient at the grocery store who was given a 30% chance of living four years ago, but I'm not in the mood to talk about work.

I'm in the mood for fluff, simply because.

So. On to the fluff:

Allure magazine might be the best fluff rag ever. Especially this month's, where they concentrate on hair. Who could do better than hair? I mean, there's a column by a redhead, and one by a blonde, and they go through the evolution of Debbie Harry's and Twiggy's haircuts. Go. Buy it. Get some Mallomars or some Cheetos too, while you're at it.

Being in Montreal during a heat wave left me with an addiction to two things: San Pelligrino mineral water and S. Pelligrino lemonade-in-a-can. The former is good for hydration before a night of bitty baby grilled octopi and endive; the latter is good for the morning after, when you're walking along the canal with a baguette and some triple-cream brie, looking for a place to stop and eat. Unfortunately, you can't get the lemonade within 30 miles of here, which means I'm going to have to make a pilgrimage to the Foncy Food Place on Sunday.

Who thought of the Ben & Jerry's flavor Black & Tan? I mean, really. Cream stout and chocolate? Yick. Vermonty Python, though, is excellent--and since the fudge cows are moisture-resistant, you and your significant other can flick them at one another. You can even make the little cow say, in a squeaky little cow voice, "I don't know!" before you flip it across the table with an "AAAAAAUUUUUGH!!"

I bought a Maybelline two-pencil set of eyebrow color today in the "Auburn" shade. Wish me luck. Review to follow.

Speaking of which, why doesn't anybody make straight brown stinkin' mascara any more? Used to be you could get the stuff, but now the only manufacturers are weird off-shoot brands that smear down to your chin after five seconds.

Burt's Bees Lip Shimmer, continuing the makeup discussion, is the best. Lipcolor. Evah. Get the "Coffee" shade--the others are too pink.

I have hired, wait for it, a personal trainer.

Yes.

Because I am tired of having my back fat rub against my hip fat, and because I don't want to look like a licorice jellybean while wandering down the aisle at Beloved Sister's wedding. More importantly, I'm beginning to fear for my health and my job security because of lack of muscle mass and achy feet. So I've hired a cheerful drill instructor to show up at the house three times a week and kick my butt. My first appointment is on Saturday.

Beer Review: Independence Pale Ale, out of Austin, Texas, is great stuff if you can get it. It's produced by Independence Brewing, which is a small enough company that they use plain bottle caps and (I think) put them on with an antiquated capper. (You can tell these things after dating a guy who brews his own.) Also, if you want to know what Chef Boy's Winter Warmer tastes like, pick up a sixer of Ten Years Alt from Victory Brewing, and increase the abv% to 10.1. It's like a Tootsie Roll with a kick. (Shrimpy, that last was for you. "Small dogs dipped in Maudite", indeed.)

Amusing Montreal Story: as Jennifer and Joey and I were walking through Little Italy at 10:30 pm (things really begin to get started then), we passed a restaurant with a rooftop terrace. There was a man playing accordion amidst the diners--and playing "Volare", believe it or not. Just across the street was another restaurant, this one with awnings over the window and a second-floor apartment with a deck in the back. The deck, therefore, was even with the awnings. A small dog, a Jack Russell terrier mix by the looks of him, had come out to run along the awnings and inspect the restaurant's patrons and bark at them until he was called back by his owner.

It's scenes like that that make me thankful for whomever it is that's writing the soundtrack for my life. There may be nothing better than being full of home-made pasta and ricotta cheese and basil tomato sauce and walking with grocery bags full of nifty things past groups of gazing men in the warm summer evening. Unless it's doing so in the company of two of the coolest, smartest, wisest people you've ever met.

And finally, a note for any north-of-the-border readers I might have: What It's Like When It's Really Hot....

(Trying to explain 42* C to a Canadian is difficult. This is the best I can do.)

1. Everything dies. Even if you water it. Even if it's in the shade.

2. Nobody goes out between 1100 and 1700, or else they'll die, too.

3. Your produce wilts in the car on the way from the grocery. At 6 am.

4. Learning French seems preferable to getting into a car whose steering wheel is so hot your palms will blister if you grab it.

Medical Stuff next time, I promise.

Back in the English-speaking world again...

Montreal was, as always, lovely. Hot, though. It gets to a whopping 90 degrees about a week out of every year, and I was there for five days of it. With 70% humidity. And wind. Quebec's motto is "Je me souviens", which translated from the French, means "Hey, who's the fat sweaty chick with the frizzy hair?"

Joey has a sweet condo just across the canal from the Atwater Market, with brick walls and a soaring ceiling and a loft. It also has the Quebecois version of "central air conditioning"--a Japanese-made widget about one foot by three that somehow cools the air without actually exhausting anything to the outside. It was placed in the stairwell facing the western exposure of the condo, facing the glass doors to the deck. The top two stairs of the stairwell were therefore very cool indeed. I spent most of my time between showers there.

We went to a wedding on Ile d'Orleans, which is a bit east of Quebec City and smack in the center of the St. Lawrence river. It's beautiful. That's all there is to it. Not only was it cool, but there were little stands advertising pick-your-own strawberries and raspberries (heaven), and a really good pub with homemade beer--some of the best I've ever tasted. We partied all night long with the bride and groom, then drove to Quebec City afterward, which was (if this is possible) even hotter and stickier than Montreal.

QC's old portion, where the wall and Parliament and all the old buildings and cannon are, is interesting and lovely and European and hot and sticky and sunny and crammed with tourists from all over the world. It also takes the prize as Most Inconveniently Hilly Place Ever, even worse than San Francisco. There's one SF-style hill, and everything spills down and winds around it, effectively a) blocking any breeze and b) ensuring shinsplints and fractures in the unwary. What vertiginous spiral staircases are to Montreal, That Damn Hill is to Quebec City.

Everyone in Quebec City greets you with a cheery, "Bonjour, Mademoiselles!" which, translated from the French, means "We weren't able to Darwinize you with the staircases, but we'll get you with the hill, by God!" They then charge you two dollars for a soda and laugh hysterically as you immediately turn said soda into sweat.

(I was pretty exhausted and cranky in QC, having stayed up all night for the first time in my life. Don't let my grump dissuade you from visiting.)

It's impossible to get a bad meal in Montreal. Well, I suppose you could if you tried hard enough, but it would take some doing. La Banquise is, of course, the classic poutine shop. Cafe Internationale in Little Italy has some sort of salad that combines grilled calamari and baby octopus with capers and endive and is heavenly. And, of course, Marche Atwater is good for cheese and bread and fruit and veggies and chocolates and fizzy water and San Pelligrino lemonade and meat and oh, my God. And, as always, there's Le Pied De Cochon, for all your piggy needs.

Everyone is fit and beautiful and very, very tan there. They all speak some lovely but unintelligible version of French. The men shake your hand with an "Enchante" which, translated from the French, means "You may be a fat, sweaty American, but I'll be nice to you anyhow and speak English, because I am so much better-looking and cultured than you are." Joey has just won a Maclean's Magazine award for being a person who makes the world a better place to live in, so she was even more impressive than usual. All her friends greeted me with a double-cheek kiss, which, once I got used to it again, made me feel very cosmopolitan and not at all silly.

All in all, a lovely time. Next time, however, I am visiting in the spring.

Saturday night, old meme

Five things nobody knows about me:

1. I'm a total snarky bitch at work, but I cry at "Extreme Makeover: Home Edition." And "Cold Case." Hell, I just watched "The Princess Diaries" and cried at that.

2. I have no clue what to do with my hair.

3. I lived in a commune--and got college credit for it.

4. I know quite a lot about engines.

5. I often fantasize about having a high-precision rifle with a laser sight in order to get rid of people who bother me. The gentleman who garages his car downstairs (that would be a Pontiac with glass packs) is first pick.

Five things in my car:

1. A trash bag.

2. Two silver spoons I used to eat yogurt that I haven't brought in yet.

3. A security card for the hospital parking garage. Ditto the apartment.

4. A jug of laundry detergent.

5. A copy of the book "The Evolution of Useful Things."

Five things on my desk:

1. A small garden gnome with a basket of flowers over one arm and a bouquet of flowers in the other. My friend Jeanie from the 'Net sent him to me. His name is Alan.

2. My passport.

3. A cartoon of two snakes with snaggle teeth, one saying "Where *is* everybody?" and the other saying, "I have the *snacks* all ready!" with the caption "Your typical nest of vipers has an undeserved bad reputation."

4. A pair of speakers I keep turned down.

5. A jar of Carmex.

Just...ew.

***Beloved Sister, Scroll Down.***

An hour and a half into the process, I was getting a little tired of things. Three urology residents were bent over my patient with speculae and a headlamp, trying desperately to find her urethra.

Things had started to go badly when the fourth Foley catheter came out. (For those non-nurses in the audience, a Foley catheter is a long tube that goes into the bladder through the urethra and sits there, held in place with a little balloon filled with sterile water. It drains urine.) The damned thing actually shot out of her urethra and flew to the end of the bed, splattering urine as it went. I'd seen some interesting reactions to Foleys before, but never that.

I couldn't get the thing back in, primarily because I couldn't find her urethral meatus (opening). Normally, with women, this is not a problem--although bodies differ, I can usually manage on the first try. But this time? No go. No go, either, for the second-year resident, who found the ridge of muscle that usually marks the urethra, but whose attempts at inserting a Foley ended when the catheter coiled up time and time again.

So in came the third-year. He didn't have any better luck.

By this time, I had a lumbar drain that needed opening, so I went and did that. I came back to find the fourth-year in my patient's room as well, complete with OR headlamp and a variety of other...stuff.

No go. Still, with three people working away, sweating and cursing under their breath, no go. Things were complicated by the fact that my patient couldn't move her legs at all, and had some pretty amazing contractures.

Finally, the doctors figured out why they couldn't insert a catheter into this poor woman:

She had no urethra. And no neck to her bladder. They'd been worn away after twenty years of wearing an indwelling Foley catheter. The only thing left outside her bladder were three fistulas to the outside.

We put her in a diaper and scheduled her for a suprapubic catheter placement.

***You May Now Resume Reading***

Speaking of things you wish you could forget, I left a lumbar drain open too long the other week. Although my patient drained nearly double what she should've into the drain, her brain did not herniate down through her skull. I got very lucky, and so did she. There is no feeling worse than the feeling that you could've irrevocably fucked somebody up--unless it's the feeling of waiting to see if that's the case.

New nurses, take note: You will make minor mistakes on the average of once a day. Major mistakes might come as often as twice a month. A really huge mistake, like leaving a lumbar drain open for an hour, will happen at least once a year. The first time it happens, you'll be crushed. Later you'll learn to manage the mistake, figure out what caused you to make it, make changes in your practice, and keep going. Have faith.

And speaking of things new nurses should know, I have become a more-than-respectable IV starter. For the first three years, I sucked. There is no other way of putting it. Unless I was presented with a vein the size of a firehose on a comotose patient, I would dig and stick and fumble around and generally cause horrible bruises without getting a blood flash.

That seems to have changed, hopefully permanently. For some reason, over the last few months, I have had The Mojo. Even people with tiny threadlike veins that hide present only a minor challenge. I can't point to any one thing that changed in my technique; the only thing I can come up with is that the process finally got so routine that I was no longer spooked by it.

And finally, go read this. I tried to leave a comment, but was speechless. (The rest of her blog rocks too.)

Random Musings

Gosh, it's nice to have my brain back.

*** *** ***

Buck's traction for a dwarf is not easy.

For those of you who don't know or don't remember, Buck's traction is a type of traction used for femur (thighbone) fractures. You get a one-size-fits-badly foam rubber boot with a metal bar across the bottom and velcro straps across the front, and once you put that on, you attach the traction ropes and weights.

Unfortunately, there are two problems when you're doing that for a person who's smaller and differently-shaped than the creators of the Buck's traction setup anticipated. First, dwarves' legs are shorter and usually a bit bowed. Second, they're short people. Traction depends on a straight run of rope to hold a fractured leg properly; if the person in traction is only about three feet tall, there's a lot of rope that can catch on the bed and in the sheets. Unless you put the person more than halfway down the bed, you're going to have Trouble, with a capital T, and that rhymes with M, and that means I had to be the MacGyver of Traction yesterday.

It works like this: grab the Buck's boot. Note that the metal stabilizer bar comes only halfway up the boot and then runs across the bottom. Good deal. Cut the top part of the boot away with a #11 scalpel. Now we have a shorter boot. Excellent. Grab two catheter leg-bag kits and scavenge the Velcro wraps out of them. Use those to help tighten the boot around the lower leg. Now you've got the boot on.

Remake the bed so that the bottom sheet lies flat and is held in place with a top sheet, folded lengthwise and tucked very tightly, so there are no wrinkles across the bottom third of the bed. Then fold another top sheet crosswise and lay it across the patient. This covers them without smothering them. Do the same with a blanket. One of the patient's feet will necessarily be outside the covers, but oh well.

Snag a fresh coil of traction rope. Measure twice, cut once. Set up traction. In order to keep things clear, use paper flags marked "TRACTION ROPE" to label the, you guessed it, traction rope as it goes down the length of empty bed. Adjust weight to be sure it's hanging freely.

Pat self on back. Collect accolades from co-workers, the patient in question, and the orthopedic surgeon. Eat a bar of chocolate.

*** *** ***

Somebody put a lock cap on a lumbar drain the other day. They disconnected the lumbar drain (which is supposed to be a sterile, closed setup) from the bag, locked off the drain with the cap from a syringe, and sent the patient out to have a smoke. This did not happen on the neuro unit, obviously.

*** *** ***

New squick I never thought about before: watching a doc put in a couple of really deep retention sutures, through skin and subcutaneous fat, with a curved needle and 2.0 vicryl. I felt a little queasy.

*** *** ***

Speaking of squick, this is probably the single most potentially-gross thing I've run across in a while...

I had a patient in a few weeks ago for a shunt. We use them when the pressure of fluid in the brain gets to be too high; the shunt pulls fluid off the brain and sends it into the abdominal cavity. Anyway, this guy had a shunt placed and came to me post-op. I knew he'd been in prison a couple of times and had had some close calls with regards to bullets.

One of his shoulders had a patch about the size of my palm. The skin was thickened and whitish, with what looked like embedded pieces of doveshot or gunpowder in it. The whole thing looked for all the world like Dick Cheney had taken a bead on him. I thought it was a gunshot scar. So, "Did you get shot here?" I asked.

"No," he replied, "That's a big ol' blackhead. Last time I was inside, my cellmate squeezed part of it, and something popped out and hit the wall of the cell."

I managed to warn him against doing that again, as sebaceous cysts like that are sterile as they are, but can get badly infected if you try to pop them. Then I got a wheelbarrow and took my jaw out of the room.

Eugh.

*** *** ***