Tuesday, March 28, 2006

Gettin' the mojo back.

Thank you, V.S. Ramachandran.

This book, Phantoms in the Mind, is one of those books you never knew you needed--badly--until it came along. I'm a bit late in reading it, like about eight years, but at least I've found it now.

He out-Sackses Oliver. He postulates interesting hypotheses on why people with partial blindness have hallucinations. He has a fantastic theory on phantom limbs that also addresses foot fetishes, and includes a couple of cool experiments that you can try at home with only a cardboard box and a mirror. He gets into the temporal lobe experiments that showed that religious experience is tied to electrical activity in the brain. He makes the connection between the left and right sides of the brain clear and discusses neglect syndrome in that context, brushing against Freud on the way.

In short, this book will get neuro folks excited again about what they do.

I think I'm going to order A Brief Tour of Human Consciousness next.

Thursday, March 23, 2006

The Slump

It's ironic, really.

Just when I feel like I've hit a slump, writing-wise, and that I don't have much new to say, a very nice person from a trade publication sends me an email saying, "Hey! We wanna reprint X, Y, and Z weekly from your blog? That okay?" and I say Yes.

After all, how much new can you say every few days about gliomas and spinal cord tumors and customer service initiatives?

The amount of paperwork I do for an admission has quadrupled; the amount I do for a discharge has tripled. That's not as a result of HIPPA or joint commission requirements, it's a customer service plan presented by management.

The risk factors for an incurable brain tumor still include a happy life with well-behaved, intelligent children under the age of ten, a fulfilling job and loving spouse, and a pleasant and even temperment. Mean people never die.

The crack team of transplant nurses a couple of floors down from us are doing a lot of MUDs these days, which is taking a toll on them as a team and individually. MUD stands for Matched Unrelated Donor--it's a bone-marrow transplant of the last-ditch-effort sort--and people generally die, from what I understand, in particularly horrific ways after one. One of their nurses finally cracked about a week ago and left, just like that, because she couldn't stand to see any more twenty- and thirty-year-olds with their skin sloughing off and grade IV diarrhea. We see the nurses, looking haggard and drawn, in the elevators sometimes. We send them anonymous chocolate bars and flowers and do what we can to help them hold it together.

But there are compensations, even when my writing bug goes away for a while and it seems like everybody is dying all at once.

I had two very pleasant, healthy patients yesterday, both of whom had things that were not only curable but curable quickly and with minimal fuss.

One of my other patient's mothers bought me breakfast. Yum.

Another patient took the time to write out complimentary notes for every nurse that had taken care of him, every tech who'd helped him to the bathroom, and every transporter he'd been wheeled around by. No, I wasn't one of those nurses; I just provided names and pieces of paper, but it was nice to see.

I learned yesterday that you have to see the compensations when they come. The compensations might not be on the same scale as the horrific stuff, though. Most people who die in the hospital are sick in ways we can't even imagine--every system they have has shut down, or is screwed up, and they're in pain for a long time before they go. It's an extended, torturous way of dying, and we see it a lot.

Two or three pleasant people who look happy to see you and cooperate in their own care might not seem to compensate for the unfair and unpleasant outcomes of somebody you really liked, but they do--if you let them.

I think all nurses go through whatever this is. It's not burnout. I still want to get up and go to work, I still enjoy what I do when I get there. I still feel incredibly fortunate that I'm able to do what I do, and that there are other people willing to pay me for it. It's just that days are beginning to look the same.

I know it'll pass--this has happened in other jobs before. It's interesting to imagine what'll snap me out of the all-days-the-same mindset, and I'm willing to wait for that.

In the meantime, you guys might have to settle for more posts on potroast and crafts.

Monday, March 20, 2006

This is post #326.

I like the symmetry of that number.

I haven't worked in days; all I've got to tell you is old gossip from the unit. Like, it must really suck to have your discharge paperwork in hand and then suddenly hemorrhage and fall over, just like (snaps fingers) *that*, and die. That must just suck.

Just as it must suck to be the nurse whom the priest berates (and this is not gossip; I was there to see it) because said nurse called said priest in on a Sunday to give Holy Communion to a patient. Seems the priest didn't want to have to fight traffic.

Which made Gina, my six-foot-two-inch-tall, Baptist chaplain friend remark, "Well, some get called by God. Other people just get a text message."


I've spent the last couple of days doing very little, and today doing quite a lot. For several days this week, it's rained and rained and rained, which we needed badly, and which gave me the excuse on Saturday to stay home in my pajamas, sample a new beer (Konigsberg Haven Quadrupel), and read. Today I hung out with Chef Boy at the grocery store and then went book shopping. I'll fill you in on my neurologically-flavored selections once I've had a chance to read 'em. Right now I'm unapologetically reading James Herriot and waiting for my potato to finish baking.

And I'm kicking myself, because there was a guy selling unidentifiable bits of Hispanic food from a handcart this afternoon, and we didn't stop. Of course, I had tacos carne asada with cilantro and onion in my lap, but who knows? Perhaps he could've had an appetizer in his cart.

Speaking of which, I recently made a mental survey of my neighborhood and found this: it is possible to get elotes from a cart, cabrito, kim chee, baba ganouj, fresh pita and tortillas, and fresh French bread within a two-mile radius. As well as your windows repaired, ironwork done, your saltwater aquarium dealt with, and your Christian bookstore needs taken care of. Oh, and you can get run over by a train, too.

You can keep your lily-white suburbs. Gimme the 'hood, any day.

Saturday, March 18, 2006

Good news, bad news.

The good news is that one of my patients whom I thought wouldn't live last weekend is now sitting up and talking. Not making a lot of sense yet, but talking. She knows she's in the hospital and she recognizes people. Two weeks ago I had her in the ICU stepdown unit; one week ago I thought we'd have an empty room when I came back this week.

The other good news is that I'm off for three days, it's pouring rain, and I have ample supplies (Belgian quadrupel ale, science magazines, Good Omens, and French bread) to last out the weekend in my pajamas.

And The Cat is seemingly content. This is *very* good news indeed, as The Cat tends to draw blood when things aren't going her way. (How did I end up with a neurologically-damaged cat? Someday I'll tell that story.)

The final good news is that my pal Heather, Wielder of Hammers, had to bow out of a retail madness get-together today. I wasn't feeling real up to retail, let alone retail in the rain, and Heather shops like the Luftwaffe blitzed London, but with a smile. So here I am, in my pajamas with my quadrupel, pondering the bad news.

The bad news is this: a patient's sister felt it necessary to come see me at work, to let me know that my patient is on life support--or was, since she's probably dead by now--at a different hospital, fifty miles away.

You try really hard in this business not to like people. I mean, you *like* people, otherwise you wouldn't be a nurse. What you try to keep from doing is realizing that a particular patient would've made a really, really good friend had you two not met when she was diagnosed with a rare and aggressive degenerative neuromuscular disease.

You try really hard not to like people that you know you're going to lose soon.

Devic's Syndrome is often referred to as a type of multiple sclerosis, but it's really not. It's much more systematic than MS, and in its way is crueler. First it takes your eyes--the primary symptom of Devic's is a preference for the optical nerve--then it takes your legs, then your bowel and bladder control, and finally your ability to breathe.

All of this happens quickly and without the changes in mentation or personality that happen sometimes with MS.

There isn't really any effective treatment. You can start the person on chemo, and they'll lose their hair (a long-standing joke was that her hair was longer than mine before mine started to grow out), or you can put them on various pheresis therapies that might make them feel better for a time (another long-standing joke was that I used the same vein over and over, in an attempt to carve my initials into it), but really...nothing much will make a difference.

And so, blind and bedbound, with the same interests and intelligence and humor that she had before she got sick, my patient told me that I'd better shape up--or else she'd come kick my butt when she could walk again.

I think both of us knew at that point that she wasn't going to get to kick my butt. Neither of us wanted to admit it.

I had to pass the news on to other people who'd worked with her. That's not fun, either.

"Somewhere, somehow, I know she's going to be healed" said her sister.

I know she will be, too. But what happens to the almost-friends she leaves behind?

Wednesday, March 15, 2006

Yes, I removed some comments.

Because I don't believe in trolls.

I know they exist, but I prefer to stick my fingers in my ears and sing la la la la until they go away, or until such time as they stop ignoring civilized rules of behavior.

Such civilized rules include:

No calling other posters names. That includes everybody. "Stupid" is no better than "cunt", but I'll remove the most offensive posts first.

No infighting.

No pissyness. That is reserved for me, and me alone, when I'm talking about residents.

...play nice, or go home.

Edited to add: Anon, if you'd like to know *why* nurses at my facility bathe & bag on a regular basis, without our being understaffed, and why we don't have a problem with it, you're welcome to email me. I'm even forgiving the cunt comment for this.

"You ought to be kinder."

That was the ultimate line of an email I got this weekend, from somebody who'd read the blog but hadn't commented.

The gripe the correspondent had was that I, apparently, am not kind enough on my blog--that I bitch and rant and moan and generally take people to task here.

Hm. Let's see why. In the last seven working days, I have:

*Been physically assaulted (thankfully not injured) by a demented patient whose family stood by as he lifted me by one arm and tossed me around...

*Been threatened with shooting by a young man who thought we were being mean to his father by not letting Dad smoke in his room, with his oxygen mask on. (For those keeping score, this now makes three-of-three in terms of times I've been threatened with shooting in healthcare settings.)

*Had to have a little heart-to-heart with a tempermental attending, revisiting points I've made before, such as the concept that calling a nurse a "stupid bitch" isn't going to win friends and influence people...

*Had to mention legal terminology in order to get action on a personnel issue; no further details until later...

*Dealt with a patient who left AMA after it was revealed to him that no, he wasn't going to get any more narcotics...

*Done the work of two people after a nurses' aide simply wandered off the floor in the middle of the shift and couldn't be found for two hours...

*Scoured the hospital complex for a confused patient who was allowed to leave the floor in a wheelchair despite orders to the contrary...

*And was verbally abused by a family member claiming to be a nurse who couldn't understand why we might actually enforce isolation rules.

In between I clarified orders written by residents who don't understand the concept of "PRN means *for* something specific" and "legible handwriting makes the difference between digoxin and Demerol", moved patients up in bed, out of bed, from one bed to another, handled countless bedpans, showered a few people, gave pain meds, passed dinner trays, answered the phone approximately 10 to the 23rd time, comforted the sister of a patient on life support, and bathed and bagged one dead body.

During all of that, except for the bit about being blown away with a shotgun, I managed somehow to keep a cheerful expression on my face and not give in to the temptation to strangle somebody. I didn't yell, I didn't call anybody names; I even threw a few jokes in there now and then. I managed to do a few nice, kind things for a few people that were not included in the daily plan of care. And I made at least one person feel better.

I think I'm kind enough at work, thanks.

Tuesday, March 07, 2006

Sunday, March 05, 2006

The Bugaloos: They're in the air and everywhere.

(Inspired by the PGY2 resident who now refers to me as "Bugaloo", a nickname I find simultaneously charming and disturbing.)

I am not fanatical about bugs.

Yeah, I scrub my countertops and cutting boards with hot water and soap after I cut meat on 'em, and I wash my hands about forty times a day at work. But when it comes to hugging a patient with HIV, or touching a person on their skin with my bare, clean hand (provided they don't have any open areas, of course), I don't flip out.

Which is why I got so irritated with a couple of coworkers this week.

One of 'em asked me if it was safe to let a newly-diagnosed HIV+ patient to use her pen. For her, not for him.

Once I was done goggling, I said yes. That coworker's trepidation might've stemmed from the fact that this poor guy had herpes lesions *all over* his skin, a result of being undiagnosed for a year or more after infection. Note to the wise: if you end up with a huge skin rash that defies dermatologists, go 'head and get an HIV test. It can't hurt.

Anyway, this guy was quite pleasant, dealing pretty well with the shock of having just been told he was poz. But the HSV lesions presented a problem, one which I dealt with by wearing an isolation gown any time I had to get up close and personal with acreage of his bare skin.

Why? Two reasons:

First, even though herpes is not a tough virus in the sense that molluscum or smallpox is, there's the offchance that a virus or three might survive on my scrubs. I could then conceivably shed that virus elsewhere.

Second, and much more important in this case, my patient has a combination of open sores on his skin and a compromised immune system. Since he hadn't begun any sort of treatment yet, it's a rational step to reverse-isolate with him, especially since I had another patient with Clostridium difficile infection. Bacterial bugs are much more robust than viral particles, and I didn't particularly want to expose Mister T-Cell Count at 2 to any sort of bacterial veneer I might be wearing.

Then came the coworker who commented, as I was briefing a couple of students on the HIV+ patient over lunch, that she'd moved out of her dorm room in college because her roommate had contracted herpes.

God love the nursing students . They all looked carefully blank as I explained to cow-irker that, unless she and the roommate were sharing toilet seats in a way as yet undiscovered by Hustler magazine, she had nothing to worry about.

That sort of thing drives me absolutely up the wall. Even with modern education, I *still* run into nurses who are unwilling to touch HIV positive patients, even as they wander in and out of isolation rooms whistling, not wearing gowns. I *still* run into nurses who haven't the faintest idea how things like Chlamydia, mononucleosis, pinkeye, and hepatitises are transmitted, or who get it all wrong.

Maybe I'm oversensitive, having spent a good deal of time in the past with people who had varying degrees of infectious disease (ooooh, I like that rhyme!). Maybe I'm peevish because I don't like to see people isolated from touch and contact because they have a Highly Publicized Infection That Still Carries A Huge Social Stigma. Maybe I'm grumpy because I wonder what on earth these people were doing in class while I was absorbing information about how and why to keep my patients and myself safe.

The single most important thing we can do for our patients is to touch them without hurting them. Most people they see in the hospital, us included, do many unpleasant things to them. They can go an entire day without being touched in such a way that doesn't cause pain. That's why it's important for us to hug, or squeeze a hand, or stroke somebody's hair: without painless, pleasurable touch, the human soul starts to die.

So yeah, I 'm not fanatical about bugs. I cover my mouth when I cough, I wash my hands, I use standards when dealing with blood and body fluids and nasty oozy things.

But once in a while you have to take off the gloves and be human.

Dull is good.

The past week at work has been dull. Dull is good.

Status Migraine Guy is back, but he's calm and his pain is controlled. I don't know about you, but if I had a migraine that had run for two and a half weeks, I'd just chuck myself out the window and be done with it. I've only had one, but that one (and not a bad one, from what I hear) was plenty.

Our Customer Service Scores Tra-La are down for the months of December and January. This is a Big Deal to the management. Consequently, we're neither getting TEAM t-shirts this month (a good thing), and they're putting in place all sorts of bizarre procedures in order to improve Customer Service (a bad thing).

Part of the problem is that the CS scores are determined by questionnaires sent to the patients or the families after their stays. If somebody's either dead or gorked from a major brain injury, there's not a lot of hope that the person or people will find the time to fill out a thirty-question form, rating everything from the food to the cleaning staff on a scale of one to five. One would hope that they'd have better things to do.

Now, when you study mailed questionnaires in sociology class, it's assumed that a forty percent return rate is fantastic. Return rates normally run around 30%, with the majority of those surveys returned from people who have strong feelings--usually negative--about the subject being surveyed. Don't ask me why this is; I don't remember.

Anyway, if you cut the folks who can no longer read and write out of the survey pool, and remove a percentage of the families from that pool because they're taking care of Auntie Mae, you've smallified your return pool to those folks who were a) very sick at the time they came in, b) still have some memory of it, and c) care enough to return a 30-question form after rating things from 1 to 5.

Unfortunately for us, several of the people who returned their questionnaires have one or another type of dementia. One survey came back with three pages of single-spaced ranting attached; another had hand-written complaints about attempted kidnappings and abuse in the margins. There were others not as dramatic.

Those kind of affect the CS scores.

The amusing thing is that every member of Manglement with whom we nurses deal, from the lowliest charge to the uppermost uppity, has forgotten that crazy people skew results. Rather than throwing out three pages of paranoid rantings, they're basing practice changes on them.

Which basically boils down to "Keep your head down and give 'em whatever they want."

The floor nurses have given the new posters, training manuals, and inspiring speeches a collective shoulder shrug and are keeping on keeping on. If you have a patient who's convinced that the guys from the OR are going to kidnap her and sell her to white-slave traders, there's not a lot you can do (outside of, say, Haldol) to improve her Customer Service Experience.