Wednesday, February 28, 2007

As seen on TV. But not really.

Every week on network TV, there's at least one medical show that shows a code blue. At least that's what it seems like; codes make for drama and give the actors an opportunity to pretend to place ET tubes and shout a lot.

It's not like that in a real code. For one thing, everybody is impeccably polite. For another, nobody can keep track of what's going on. For a third, there are a whole bunch of people in the way--students, extra residents, extra nurses, respiratory therapists, you name it.

Here's what a code is like: (Note that I've not attributed dialogue to different people, simply because you can't figure out who's saying what. You just act on what they say.)

"I need the crash cart! Call a code!"

Three nurses rush in to the room to help the first nurse turn the patient, place defibrillator pads on her, and place a backboard. Somebody grabs an Ambu-Bag and tosses it through the open door, then calls the code hotline.

"Start compressions. Do we have suction?"
"Suction's right here."
"Who's starting extra IVs?"
"I'm recording. Code commenced 1722."
"You guys need me? Anesthesia resident."
"IV left AC infiltrated."
"I've got fluids running free on the right forearm."
"Could you remove the headboard, please? Thank you."
"Could I have suction? Thanks. I've got an airway."
"One amp epi, please."
"IV's infiltrated, I think. I can't push this."
"I've got an 18-gauge down here." (Usually on the foot or lower leg.)
"One amp epi, then."
"Mike, you need a relief?" (This to the person who started compressions.)
"How long since that first amp?"
"Four minutes." (This coming from the recorder, who's trying to see what's going on through the throngs of folks standing around, watching.)
"One amp epi. Do we have a blood pressure?"
"Stop compressions. Do we have a rhythm?"
"Damn. Start compressions."
"Ninety-four year old female, CHF, ESRD, compression fracture of thoracic vertebrae following MVA. Found down, no witnesses to arrest. Estimated time before coding 5 minutes." (This to the attending, who's just shown up.)
"How long since that last epi?"
"Two minutes."
"Do we have vasopressin?"
"One amp vasopressin here."
"Push it."
"Do we have a blood pressure?"
"Damn IV infiltrated again."
"Frankie, I have another one over here. Gimme that line."
"Al, I'll take over and push." (The guys on the chest switch places.)
"Suction, please. Jesus, she's got a lot of secretions."
"Do we have a pressure? No pressure? Stop compressions. No rhythm?"
"Continue compressions."
"She's 94, multiple medical problems, was anoxic for a minimum of five minutes prior to code. I say we call it." (This from the attending.) "Are there any objections?"
"Any objections?"
"Anybody?" (Looking around at all ten people surrounding the bed.)
We all shake our heads and the code stops.

There's a feeling of failure among the doctors, not so much for the nurses. We've known her for a week, taken her to dialysis, helped suction her. She hadn't responded to anything but pain for a day and a half. She had very little chance, given her age and condition, of getting out of the hospital alive. This is a bad ending to the day, but she's had a good long run.

So we disconnect the IV lines and the oxygen, remove the pads, and leave all the tubes and cannulas in place. We go out in a group to give our names and titles to the recorder. Somebody stays behind to find the sharps left in the bed. The patient is yellowish, waxy, slightly collapsed, with an endotracheal tube taped to her cheek. The chief resident calls the medical examiner and arranges for an autopsy; the secretary calls the ambulance service. Someone's already called the family, right after the code began.

Then three or four of us sit and do paperwork.

On the way home, I realize I started two large-bore IVs on somebody who was already dead.

Friday, February 23, 2007

Thursday, February 22, 2007

Sweet Dreams...

Calamari, anyone?

Wednesday, February 21, 2007

A quick answer for Anne

Anne, in a comment on the post below, linked to a blog I hadn't seen before. It's written by a guy who calls himself "Switchblade Doctor" and contains some frankly misogynist and anti-nurse crap.

Anne wanted to know if that attitude is common among doctors.

It's not. Not by a long shot.

I probably work with at least one real jerk; the kind of guy I would cross the street if I saw him coming. I probably work with at least one doctor who believes nurses/advanced practice clinicians/doulas/midwives are full of shit. I probably work with at least one misogynist.

The point is that I don't know it. The doctors I work with are acutely aware, as are the rest of the people in the hospital, that we are part of a healthcare team. Ain't nothin' gonna get done on time or done well unless everybody puts their personal egos and soapboxes by the wayside and busts ass.

I don't much want to go in to what SBD wrote on his blog: I don't much care. That sort of thing provokes a handwave and a bored "wev" from me. Everybody's allowed to vent, rage, be an asshole, or even make up an entirely new identity in order to get frustrations out. (How, exactly, do you know *I'm* not a sixty-five-year-old guy in overalls?) The issue for me is how this guy acts at work: if he's a jerk to me in the work environment, I feel perfectly at home using both official and unofficial tactics to get him not to be.

Work is work. Blog is blog. As long as you're professional and courteous and we treat each other with respect, I'm not real concerned with what political or social views you espouse. And, thankfully, the men and women I work with are smart enough and self-aware enough to understand that, regardless of their feelings toward "Nursing" or "Nurses" as a whole, they gotta work with *this* nurse, and work well with her.

We all get along pretty well. We know each other well enough by now to point out errors or missteps without anybody getting a bent nose, and there are several docs and other nurses I count on to curb my asshole tendencies. (Mostly by saying, "Jo, don't be an asshole.") Everybody is there to do a job; nobody's there to prostelytize or convert or ruminate.

So, Anne, don't be afraid. Besides, if you *do* run into somebody who's actively anti-nurse, remember: you will know where all the really big catheters are.

Thursday, February 15, 2007

*sigh* I give up. Let's do this right.

A Grey's Anatomy Episode Review: Many Waters Will Not Drown Love, etc.

Meredith goes into the water, with voiceover.

Nobody notices. Except me. I'm on the couch, drinking Dogfish Indian Brown Ale and cheering. Oh, and Dr. Yang notices, but nobody's listening to her, because she's a tempermental tense bitch.

Smoke. Fire. Helicopters. Slightly sinister child with a vacant stare.

Izzy (is it "Izzy"? I always think "Ozzy".) is busy with a guy who's busy herniating and seizing and so on all at once. I'm not going to bust anybody's dream up by telling you that she saves his life with four alcohol swabs, a Dewalt cordless driver with what looks like a Phillips bit on it, and some dude's box of Kleenex. And a voiceover from Chief Whatshisname and Dr. McStitchy.

Smoke. Fire. McDreamy and Slightly Sinister Child.

George is looking for a kid. That muscular young dude who's either about to sleep with Addison or who's already slept with Addison is looking for knocked-up women, dead or alive. You'd think he'd want the un-knocked-up sort so he could get in first, as it were.

Annoying Emotional Support Woman has a few lines. Also, a few surgery scenes.

Wups! McDreamy has figured out where Meredith is (namely, under about twelvty-zinty feet of 50* Puget Sound water; I went swimming there in July once when I was fourteen, fully clothed in a light blue shirt and jeans, I have the picture somewhere, but Jeebus Grits is it ever cold, let me tell you) oops. Yes. Meredith. Under water. McDreamy has a Revelation.

Izzy's saving that guy's life. Dr. Yang and Dr. Burke have a totally ridiculous conversation in a storeroom. Are you sure you want to get married, dudes? All your relationship moments take place in the clean utility room.

Meredith out of the water, with a fine, fine makeup job and a slightly better outfit than Ellen Pompeo wore to the Golden Globes. Sinister Child gets carried off to the hospital.

Many people, none of them EM physicians, are now working on Meredith. George finds his kid. Izzy makes a speech about what she believes in, having unaccountably left a neurosurgery for the privilege. McDreamy and McStitchy have a bondy kinda moment as that young buff guy Addison might or might not already have slept with learns humanity and humility. George and Izzy bond. Meredith stays blue.

The Slightly Sinister Child gets reclaimed by her mother without doing any weird shit with telekinesis or psychic power. I'm disappointed about that.

Meredith is still blue. If they'd brought some real ER physicians in instead of those guys the residents are always sleeping with, I'm sure she'd be fine. But then I'd have to deal with the rest of the season of "Grey's Anatomy".

Go, wanky guys the residents are sleeping with. Go!

I am Spartacus.


For those of you who wander the blogosphere and the links on the right, this will not be news. For those of you who don't, it might be.

The gist of the situation is this: Two bloggers, Amanda Marcotte and Melissa McEwan (of Pandagon and Shakespeare's Sister, respectively) were hired by John Edwards' presidential campaign to blog and do netroots support work.

Bill Donohue, the leader of the Catholic League, the largest conservative Catholic organization in the country, got his crinolines in an uproar about this. Reason being, Amanda and Melissa have blogged about the Catholic Church's opposition to women's rights, birth control, human rights movements in third-world countries, the use of condoms in preventing HIV transmission, and its opposition to equality for gays, lesbians, and transgendered folks.

Which would've been fine. I mean, it's Donohue's right to get peevish about things with which he disagrees just as much as it is Marcotte's and McEwan's right to get peevish.

Trouble is, Donohue called in some of his less-rational supporters. The result was, predictably, flame wars on both blogs, calls for the resignation of both Melissa and Amanda, and lots of right-wing pressure on Edwards.

And when I say right-wing, I mean *right-wing*. As in crazy right-wing.

Amanda and Melissa both resigned from Edwards' campaign. Amanda's visibility as a target was making it hard for the campaign to do anything but field hate mail; Melissa was dealing with escalating threats from nutjobs against her and her family.

Yes. Death threats.


The people who are threatening both bloggers aren't Catholics. They're not even Christians. They are, instead, people who are using a religious shield for their own brand of hate. Having been on the receiving end of this sort of thing myself--though not to the degree nor with the intensity that both Melissa and Amanda have--I feel the need to stand up and say this:

If I disagree with you publicly over tenets of your religion, I will accept that my right of free speech comes with the responsibility to listen to your rebuttal.

However, if you threaten me or my family, all bets are off.

Two very intelligent, thoughtful, capable young women got shafted and slammed, not necessarily because they were posting on the Catholic Church's policies, but because they dared to be intelligent, thoughtful, capable young women. This is evidenced by a number of comments and emails both have received: they don't contain refutations of claims; instead, they're full of rape threats and intimations that the bloggers are ugly or not real women.

This shit has got to stop. I call it when I see it in real life; I'll call it here on the blog.

Things Nobody Can Pronounce Week Is Here!

Every once in a while you get one: a week in which every second patient, it seems, has something nobody can pronounce. Or, at least, can't pronounce without practice and enough tries that some endocrinologist somewhere starts to snicker.

We don't have an emergency room. If a patient returns to us for some reason, they're usually triaged downstairs in the triage department, but sometimes they end up on one floor or another. (Keep in mind here that I'm not talking about people who, say, show up with one arm in a garbage bag or with a huge gaping hole where their head used to be.) We had somebody like that this week: she was in diabetic ketoacidosis, something I not only hadn't seen since nursing school, but stumbled over trying to pronounce.

And, since we're a research facility, we often get other hospitals' GOKs. GOK stands for God Only Knows, the sort of thing that's most often diagnosed on autopsy. In the past ten days, I've had a patient with olivopontine cerebellar ataxia (say that five times fast), one with gliomatosis cerebri (also known as infiltrative diffuse astrocytosis), and one poor schmuck who showed up with neurocysticercosis (worms in your brain). Oh, and the one with afibrinoginemia. (You don't clot. Dude.)

When people with unpronounceable diagnoses start showing up in droves, there's a corresponding rise in bizarre lab tests. Neurologists are particularly bad about ordering blood tests that can only be done with a reagent made from the fangs of Tibetan fruit bats. When the lab calls me with the news that the leptospiritus-santusomphalowaggle-L53 test can only be done during the dark of the moon on Thursdays, the conversation rapidly devolves into something like this:

Lab: "The doc ordered a 4,5-endopthalamucoid whingzap study on this patient's CSF. The 4,5-E-W test is obsolete. It's been replaced with the trigemisalamisofgame test with the Elisa ketohamonryenomustard confirmation, but we can only draw that on alternate Saturdays during April."

Me: "But my patient has leptocryptosanguinofibrinogingliomaturia! And a midline shift! I've got to get this lab done! Can I draw it myself?"

Lab: "Yeah, sure. Just be sure that you use a 20-gauge needle and move diagonally, and only on the black squares. Oh, and don't get your patient wet after you draw it, and for God's sake, *don't* feed him after midnight."

I've developed a persistent twitch under my right eye. The internal medicine residents assure me that it's common, nothing to be concerned about, and should go away as soon as I stop my exposure to unpronounceable words.

Sunday, February 11, 2007

Wow. And advice.

So I was reading Twisty Faster today, because a pal of mine told me she'd linked this blog as an example of People Who Write About Lunch (and, ironically enough, I'd just finished a batch of mac & chee, which was the post Twisty had linked to), and I remembered that Bitch, PhD. is one of my all-time favorite blogs.

I read the comments on a post of hers about collective nouns and saw Head Nurse mentioned by somebody I'd never heard of before--the blogger who writes Battle Axe. It's a young blog, but Big Girl seems to have it *down*. I'll be watching that blog with interest.

No pressure, BG. Really.

There is nothing more exciting than seeing your blog mentioned in the third person by somebody you don't know.

Advice for People Who Use The Phone

1. Never, ever apologize for "bothering" a person who's on call. The correct thing to say is "thank you for returning my page." Saying, "I'm sorry to bother you, Doctor X..." makes whatever you're dealing with seem insignificant and belittles your role as a nurse/resident/whatever.

2. If it happens that you screwed up and phoned somebody who's not on call, the right thing to say is "Sorry", followed by a quick replacing of the handset on its cradle. At our hospital, this could also be a quick "My bad" or "Bad nurse, no donut." Either way, you apologize and get the hell off the line.

3. Have the chart in front of you. It took me *months* to learn that.

4. Ask the nearest nurse who's on call for the weekend. That'll save you from ever having to use #2.

5. If you're a resident, please, please, PLEASE identify yourself both by name and by specialty. "This is Barkejcwicz, Urology" is a lot faster than me having to ask "What specialty are you?" or "What the hell did you say?" This is especially important if you have a name like Chu or Young or Green or Smith or Amir. There are six Dr. Amirs in rotation just now; I may have paged both Urology Amir and ENT Amir, and I really don't want to get them mixed up.

Advice For Family Members

1. No matter how good an idea it seems at the time, don't give that pill.

2. The time to call me is as the patient is trying to discontinue his PICC line/NG tube/catheter, not after.

3. "Well, he's had them before, and I didn't think it was a big deal" is not what I want to hear when you tell me your brother had a seizure right as I left the room. Please call me back in.

4. If you're going to punch your son's girlfriend in the eye, make sure you do it off hospital grounds. And that she puts that baby down first.

5. Finally, and most important, *ask me*. If you have a question about something, ask. If something doesn't seem right to you, ask me what the heck is going on. If you're confused, ask me to explain. That is what I am here for. It's my job, my greatest pleasure, and a sure way to make certain your family member gets good care. Use me.

Advice for People In Nursing School

1. Don't panic. We're not all like your instructors.

2. That pink thong? Cute, but not good (oh, so not good) under the white scrub pants.

3. Ask us. If you need help, or you're confused, ask us. Some of us even dig working on care plans, and will rattle off interventions that will make your week. Just ask.

4. Act confident. Eventually you will be.

5. Do, or do not. There is no try. This goes especially for things like IVs and NG tubes. "I'm going to start an IV on you now" inspires more confidence in both patient and practitioner than "I'm going to try to get an IV on you."

Advice for People Who Blog

1. Go for wider columns instead of narrower. It's easier on aging eyes. Like mine.

2. Write it all down. You can always edit later.

3. The stuff you hate will be the stuff that strikes a chord with other people. I don't know why this is, but it's true: every time I write something that, in retrospect, I hate, other people find something in it to love.

4. Satire is hard. Parody is harder. Funny is usually pretty easy.

5. Spellcheck, I have learned the hard way, is your friend.

And that is all for now. The Cat is trying to convince me, through anguished meowings and paw-pats, that it's time for a nap.

Big Girl, keep writing. And thanks for the props.

Friday, February 09, 2007

...and then there were three!

This is really, really cool.

There are three of us. Three of us named Jo. I didn't know that until tonight, when I was checking out Change of Shift. Jo from Coffee and Conversation I had already met online, but I hadn't seen Jo from Sinus Arrhythmia (and Ponies from Betelgeuse).

Once upon a time, I was the only Jo I knew about. Now I feel all warm and fuzzy, not only because the world of nurse blogging is getting bigger faster than I ever thought it could, but because there's more than one Jo out there. It's nice to have company.

And no, I'm not worried that anybody's going to get us confused with each other. If anybody needs to, you can think of us as the girls from Apartment 3-G. I'm the redhead.

Change of Shift!

A day late, but here.

Wednesday, February 07, 2007

Product Reviews, #493

The Hypochondriac's Guide To Life. And Death. by Gene Weingarten

This book, which Beloved Sister sent me as a birthday present and which I opened early, is....really good. I mean, really, really good. Buy a copy. Laugh hysterically and stomp on the floor, and make your downstairs neighbor file a complaint with the apartment complex management. It is that good.

Part of the reason I love this book so much is that it explains the neurological exam in layman's terms, much more funnily than I could.

Four Emus Sauv Blanc/Semillon white wine, $4.89 on special at the Mini Mart

A good table white. It has a screw top, which facilitates drinking bottle number three or four, if you go that way. It's also good for making cream sauce with plenty of garlic and lots of heavy cream. Not too sweet, with a pleasant lemony flavor.

Stone Pale Ale

Lemony. There's that word again. I can drink approximately four ounces of this before I have to crawl off to bed, but Chef Boy assures me it's a fine IPA. From the makers of Arrogant Bastard Ale.

TIGI Bed Head Uptight Heat-Activated Curl Maker

It works. If you have moderately curly hair, it'll make you Ringlet Girl or Boy. However, it is heat activated, so you'll have to blow-dry with a diffuser with the dryer set on 'hot'. Which necessitates Biolage Ultra-Hydrante conditioner. Which also works magic.

Since I have been using these two products (four days) I have had three people describe me as "beautiful." That's a better track record than even Dior DiorShow Mascara.

John Edwards

Avoid. He fired two liberal bloggers I adore, Amanda Marcotte and Melissa McEwan (or maybe not; check this space for updates) because reich-wing weirdos got their panties in an uproar. I'm going for Obama this year.

Monday, February 05, 2007

Best Collective Nouns

It was a dull stretch on Saturday, and we were coming up with collective nouns. You know, those words used to describe a group of something, like "a gaggle of geese" or "a murder of crows".

Here, then, are the three best we came up with:

Neurologists: A dither of neurologists.

Surgeons: A strut of cardiothoracic surgeons.

Nurses: A grumble of nurses.

As opposed to a group of nurses who are punching out at the end of a shift, in which case it would be "a yeehaw of nurses".

Thursday, February 01, 2007

My name is Jo, and I am a "Grey's Anatomy" fan.

There. I said it.

I suck.


Big ones.

You have to understand; I hate "Grey's Anatomy" with the burning of a thousand white-hot suns. I don't care about Meredith Grey's anatomy, her love life, or anything else. I don't care who's sleeping with whom, or who doesn't wear rings, or who watches pay-per-view in Vegas, or who's named Iphigenia. Although "Calliope Iphigenia" is the single best classics-themed name I've ever heard. Ever.

But tonight, when Meredith's mother had this sudden, never-before-documented return from amnesia? That brought me to tears. Not the bit where Meredith goes in to talk to her, only to realize that Mom has slipped back into Nowheresville; the bit before--where Mom learns that she's actually cukoo, and nothing will help.

Because I do occasionally see that at work. And then I go eat, like, six bags of Jack & Jill bar-b-Q potato chips. And some lichee nut jello. And a cheeseburger. And then I sit in the breakroom and burp and stare into space.

And frankly? If I had a patient so toxic that opening them up would knock out half the surgical staff? I have a list of people to go first. Bring 'em on.

Maggots and leeches and }}}shudder{{{, oh my!

If you are my sister, or if you are eating, skip this post.

I got a question the other day from a friend of mine about maggots and leeches. Specifically, she wanted to know what sorts of situations warrant the use of maggots or leeches, and how on earth maggot therapy or leech therapy actually works.

So I thought I'd put the answers up here. If you're a lay person or have never worked with leeches or maggots, or even if you have, you might find the following kind of icky.


Maggots are the larvae of flies. They hatch from eggs and spend their lives as larvae eating dead (and sometimes living) tissue, feces, dead plant material, what-have-you. Maggots are the obsessive-compulsive garbage men of the natural world. With the exception of a couple of species of beetle (one of which is kept specifically for cleaning the bones for display skeletons), no critter is better at eatin' dead stuff and gettin' it out of the way.

In certain situations tissue will die. Let's take the example of a diabetic person with a nasty wound on his foot: because the nerves in his foot have died off as a result of his diabetes, and because there isn't a lot of blood circulation there ditto, the wound has gotten truly horrible. As in, gangrenous, black, bits of infected crap hither and yon, eating into the deeper structure of the foot.

(Here I'm describing a wound I actually saw, though not the worst one. The worst diabetic foot I ever saw had four toes that came off in the bandages when I unwrapped them.)

Okay, so dude has a bad foot wound. Standard practice would normally be to do a "sharp debridement" of the wound--in English, that means snipping away the dead tissue (it doesn't hurt)--in order to let the underlying healthy stuff grow and heal the problem. Unfortunately, there are a number of situations in which sharp debridement isn't an option. If the wound is too big, or too deep, or the proportion of dead tissue is truly awful, or if the structures involved are really delicate, you don't want to get in there and just start scissoring away.

So we send in the maggots. ("Isn't it rich? Aren't we a pair? Me in a hole in his foot, you in his hair?")

Maggots do three really cool things: They eat dead tissue, they *don't* eat live tissue (if you have the correct species), and they sweat antibiotic goo out of their skins. So they're perfect for cleaning out really icky wounds.

Plus, since they're sterile (both ways, in that they're non-infective and won't turn into flies), they're easy to get *out* of the wound. You put 'em in, cover the area with a loose bandage, warn the patient not to soak the affected bit in water, and three weeks later, hey presto! Big fat maggots that fall out and have to be wrangled across the floor.

Which is the downside--collecting them all after they come out of the bandage. But it's worth it, to be able to look at a formerly-necrotic, stinking wound that would've otherwise necessitated amputation, and see healthy pink granulating tissue.


Don't disrespect the leech. It could be your best friend if you have the misfortune or poor judgement to, say, stick your head inside the business end of a combine and get your ear torn off. (Yes, another actual case.) (Or if you have, say, major facial trauma or limb trauma with a lot of bruising and hemorrhage under the skin.)

The patient, whom I'll call Albert E., had had his ear reattached but had developed a fairly common complication of tricky teeny-eeny plastic surgery: the reattached ear had gotten congested with blood. The swelling was such that it threatened to cut off blood supply to the ear and kill the tissue, so we stuck a couple of leeches on the worst-off parts of the ear and scalp.

Leeches are easy to work with. They don't talk politics and they don't take breaks. They also have both an anticoagulant and (if I'm remembering right) an anesthetic in their spit, so it doesn't hurt the person to have a couple of purply-black worms on their skin. The absolute worst thing that can happen with leech therapy is that a leech is yanked off before it's done feeding: in that case, the mouthparts might be left behind, causing an infection.

The second-worst thing that can happen is that a leech attaches itself to someone other than the patient, like the nurse. Which is why you always wear gloves and use forceps in handling the little guys.

Leeches are also a biohazard, in that they're full of human blood, so you can't just toss 'em in the trash. We dispose of ours in containers of rubbing alcohol (yikes eek ow yuck gar ick) and then in sharps containers after we've put that Sorb-O stuff in the alcohol.

There you have it: The two grossest things you're ever likely to see working as a nurse (or being a patient)--but with the redeeming quality that they're actually useful.