Friday, March 30, 2007

I can't get no...vacation.

Or, how to be a neuro nurse, even when you're not.

Today Bonnie the Drama Dachshund got out of the fence somehow and ran to the local high school. It was raining and thundering and lightninging, so it was a scared and dripping Bonnie that I picked up after the nice lady from the attendance office at the school called me.

I took her home and let her wander around the back yard (it had stopped storming) while I walked the fenceline, looking for holes.

Suddenly, she stiffened up, put her head out in that getting-ready-to-barf way that dogs do, lengthening her neck, and seized.


It wasn't a major tonic-clonic seizure--no paddling paws or foaming at the mouth--but her muscles did go completely rigid and she bent into sort of a C-shape. I thought for a moment that she'd been poisoned until I saw the odd position of one of her paws, then realized that she was having a seizure.

So I scooped her up, called Chef Boy (she lives with him) as I ran her into the house and did the Doggie Heimlich for good measure, swaddled her in a towel, and drove her to the vet.

By which time she was fine. A little odd and post-ictal, but fine. The vet agreed with me after hearing my description of what happened; he said that dogs will often have their first (usually only) seizure after periods of extreme mental or physical stress. He worked hard to reassure me that this was likely a one-time thing, that she would be fine, that she wouldn't be damaged by the incident, and stopped short when I said, "Oh. A seizure? Cool; that's no big deal."

He and the vet tech looked at me blankly until I told them what I do for a living.

Dachsies, as it turns out, are near the top of the list of dogs that are most likely to have epilepsy or epileptiform seizures. Aside from management with phenobarbital if it happens frequently, there's not a lot we can do. Luckily, Bonnie is small enough to be no problem to restrain...unlike some of my other patients.

Now I have a neurologically-impaired cat, a dog that might have a seizure disorder, and a floor full of patients to deal with when I go back to work.


A quick poll:

Hypothetical situation:

If an employee at your hospital, not a nurse, but a patient care aide or a lab tech or a radiology tech, fell asleep on the night shift and slept through most of that shift, would he still have a job 24 hours later?

Monday, March 26, 2007

Walk the Line

About a million years ago, during the last semester of nursing school, we had to watch a video on ethics. The video was all about the tragic, fictionalized story of Judy, a pert, red-haired nurse with a turned-up nose, who got too chummy with a teenaged patient in the psych ward where she worked. After discharge, said patient showed up in her living room, having let himself into her house through the back window with a brick, and offered to take her away from her lousy life. We watched breathless as Judy got rid of Scary Teenaged Stalker-Boy, appeared before The Stone-Faced Commission Of Nursing, and finally Learned A Valuable Lesson about crossing ethical lines.

If only it were that easy. Truth is, there are moments in every work week when you wonder (unless you work, say, in the ER or a vent unit) if maybe a patient isn't getting a little too close for comfort.

Luckily, before you or a patient crosses a big line, there are lots of little lines. Keeping scary stalkers off your couch is a matter of figuring out how to redirect or contain weirdness early, before it gets out of control. Likewise, not every personal question or inappropriate remark is necessarily an ethical or privacy violation.

For example: If a little old lady tells me I'm pretty and I ought to meet her grandson, that's not something that's going to flip me out. For the same reason, a patient with a huge tumor in his frontal lobe can say nearly anything he wants without my throwing up walls. The converse of this is the neurologically-intact guy of about my own age who, while I'm starting an IV, asks if I have a boyfriend. *That* sort of thing, given who it's coming from and the situation, makes the alarm bells on a German submarine pale in comparison to what's going on in my head.

On the flip side, there's the problem of how personal to get with a patient. If I have a person who's dealing with sticky emotional issues in addition to a brain tumor, I might give them a very small detail about a similar situation in my own life and how I handled it. I *might*. It depends, again, on the person and on my gut feelings about them.

I have only a few hard-and-fast rules about personal relationships at work. One is that I don't date patients, doctors, or other people I work with. Another is that I won't allow inappropriate comments or questions to slide when they come from the neuro intact patients. The final and most important one is this: I always listen to my gut when it comes to those little lines.

I've only been wrong with the gut reaction once. My gut overreacted and the person it overreacted to was okay. Still, I'd rather overreact in a quiet, careful fashion to protect myself than end up with a friend I don't want.

So far, so good. I've not had any teenaged stalkers show up on my couch, and I've made one or two valuable friends out of past patients or family members. I've had to have the rare come-to-Jesus meeting with the rare pushy male, but that's only been two or three times in five years.

I still wonder about little fictionalized Judy. I mean, how dumb do you have to be to give a teenaged boy in a psych ward enough information about yourself so that he can find you later? Shouldn't the nursing board have cut her loose to be Darwinized by another patient down the line?

Saturday, March 24, 2007

This post was meant to be

A review of "Coyote Ugly." I missed "Grey's Annoyances" this week (I had rabies; sorry, just recovered) and planned to watch substitute bad TV and paint my toenails.

Unfortunately, I only got through the first ten minutes of "Coyote Ugly". My head exploded before the second commercial break, and I've spent the last twenty minutes picking bits of skull out of the carpet.

Thursday, March 22, 2007

I just gotta get this off, chest.

There's a post in this week's Change of Shift about the S.P.P.

"S.P.P" is a nice way of saying "Stinky Poontang Problem." You know, genital odor, most often encountered in women. The three-day-dead fish stink.

The post on the subject was funny, yes. The author gave fantastic ways of dealing with the situation. But I gotta, *gotta* get this off my chest:

Stinky Pink Bits Are Not Normal.

(hauling out feminist-health soapbox) We've been conditioned through years of fish jokes and horrible comments on shock-jock radio to think that women stink naturally. They don't. An offensive vaginal or vulval odor is caused by one of three things:

1. Poor hygiene. 'Nuff said. We can fix that, at least temporarily, in the hospital.

2. A major pelvic infection or sexually transmitted infection that's gone untreated.

3. Overgrowths of normal bacteria or yeast in the vaginal canal.

Of the three, numbers one and three are the ones we most often see, and number three is the one that is most likely to lead to a case of unrelenting stink. And we, as nurses, can do something about that.

The first thing I do when a patient comes in as an admit is start an IV. The second thing I do is catch a urine specimen (after changing the Foley, if it's there). The third thing I do is a thorough interrogation of my patient, which includes questions about their sexual and genitourinary health.

I'm programmed that way. Years of women's health clinics haven't worn off yet. And it's useful, though you might not think it, in a neuroscience setting. Often the first symptom of a brain problem is incontinence. No, really.

If I get a positive response on the "does it hurt when you pee" question, well, I've got a UA already and can start appropriate antibiotics according to protocol. If I get a mention of persistent vaginal odor, I can get a wet swab (it's not hard, honest) and send it off to the lab. A little metronidazole is all it takes (800 milligrams in a single dose will knock out most cases of bacterial vaginosis, or BV) and my patient is a tiny bit healthier than when she came in.

For those folks who can't speak (like one of my current patients with a bad case of S.P.P.), I corner the doctor and *tell* him or her (not ask, *tell*) that the I suspect a case of BV and would like X amount of metro for X number of days. Nine times out of ten the residents cave; they don't want to deal with anything but brains. (I should mention here that I have both an NP and a PA backing me up here; it's not like I'm dashing off on my own with a speculum and an attitude. Although that would be a great basis for a superhero.)

Here's another good reason for a neuro nurse to deal with the bits on the opposite end of the body. Sit back, it's a story:

We had a patient come in once with encephalopathy. Normally when that happens the neuro guys get all up in my grill with requests for various blood tests and lumbar punctures and so on.

I was the *one* nurse to do a thorough exam on my patient. During that exam, and during the question-and-answer period with her husband that followed, I learned that the patient had had six or seven really severe herpes outbreaks in the last year.

That one simple question, "Have you been concerned about any changes or noticed anything new in the sexual health department?" made it possible for us to start from a position of knowledge in the patient's care. Sure enough, she had herpes encephalopathy. It's most common in newborns who are infected by their mothers, but it can happen in adults, too.

So, people, empower your patients. I don't care if you're in the ED, the postpartum wing, on the neuro unit, or dealing with postsurgical patients in the plastics ward: let the patient know that here they have a safe space to talk about *anything*, and you might end up solving a problem they didn't even know they had.

Change of Shift...

You'll never guess what I typed that I had to go back and correct.



Sunday, March 18, 2007

I'm just sayin'....

If four of your cousins died from Huntington's disease, make sure somebody other than you in your family knows that when you come in with nonspecific neurological complaints.

If nobody in your family died from Huntington's, please don't leave the recitation of your medical history up to the one person in your family who will obsessively Google things until he thinks he's found something that matches what's going on.

If you're going to present with one-sided paralysis, please make sure it's consistent. Remember that if the left side of your brain is affected, the right side of your body will be, while the left side of your face will be.

If you're going to yell at a nurse for setting up suction wrong--and I can't believe we're going over this again, Doctor--please make sure you know how to set suction up yourself. Next time you holler at me for something that's actually right, I'll bite a chunk out of your skull.

Speaking of biting chunks out of your skull, it's probably not a good idea to rough-house with a pit-bull/Rottweiler cross with whom you're not really well acquainted.

Don't go swimming in stagnant water in Nigeria. Just don't. And if you do, don't come staggering to me six months later when things start to go badly for you.

Take your malaria pills. Please.

Scrubbing at your lumbar incision in the shower with a hairbrush is not the best way to keep it clean.

Shooting yourself or others in the head is actually a tricky operation. Please research the best angles and ammunition caliber to use to accomplish your goals prior to doing so. Otherwise, you'll end up missing a frontal lobe and I will want to strangle you.

Demonic posession does not cause seizures. Really and truly. Ativan will help seizures, but only if you let go of the patient long enough that I can reach his IV line.

Pica is nothing to be ashamed of. Plenty of people have it; in fact, there are whole families around here in which the women make weekly trips to their favorite sources of soil. Just let me know if you have it, and if your particular type of pica leads you to crave paint chips.

Wear a fucking helmet. I don't know how many times I'll have to say this. Especially wear a helmet if you're going to pull a wheelie while you're going 120 mph on a rough road.

Doctor, Doctor, please: write the orders for tests prior to doing the lumbar puncture. CSF doesn't stay good forever. I don't want to have to pull you away from whatever fascinating thing you're doing three blocks away to get you to come back and write cytology orders.

Know your facility's policy for chemotherapy administration. This is especially important if you're an oncology attending who's worked here for twenty years. If I can't hang it, I can't write it.

In slightly funnier news, a patient's wife told me this story the other day:

It was the late 1940's, and she had just learned to fly a plane. On a trip back from her in-laws' house, she was pulled over for speeding. The cop said, "Lady, the only way you can go that fast around here is if you have a pilot's license."

She pulled out her spandy-new pilot's license and showed it to him.

She did not get a ticket.

Friday, March 16, 2007


(UPDATE: Chef Boy's mom is home now and doing fine. They never did find anything obviously wrong with her; I'm thinking she had a TIA or was simply dehydrated. Thanks for your prayers and thoughts.)

There is such a thing in nursing as Having Seen Too Much of a particular syndrome, disease, or situation. I realized that I had Seen Too Much of Creutzfeld-Jakob disease (CJD) the other day when Footer started his report with "Well, he's a typical CJD-er" and I knew exactly what he meant.

CJD is *not* "mad-cow" disease. That's variant CJD, or vCJD to those who sling the lingo. Creutzfeld-Jakob, non-cow type, is a steadily and usually rapidly progressive neurological disorder that essentially turns your brain into mush. We're not sure what starts it off. If I were to oversimplify the cause and process, I'd say this:

There's a type of protein called a prion that lives in your brain. As long as this prion is happy, everybody's happy...but sometimes, the prion will flip over into its mirror-image (molecularly speaking) and become its own evil twin. This causes your brain to stop working in a particularly nasty way.

It starts with balance problems, memory loss, and speech difficulties. Within a few weeks to months, you're stuck in bed, with your arms and legs at unpleasant cattywampus angles and your hands all clenched. Your eyes don't track, you don't sleep, you can't eat, and you make weird meowing noises almost constantly. You can't control your movements or your bowels, nothing much medicinally helps your contractures or weird choreic motions, and eventually you die from pneumonia, since you can't clear the crap out of your lungs.

Given a choice of ways to die, I recommend not going with what's behind the door labelled "prion diseases".

How do we diagnose it? Definitively, through brain biopsy or on autopsy. The trouble with those is this: prions can be inactivated only with extremely expensive and difficult sterilization processes. Normal autoclaving won't cut it; you can't burn the suckers up. So any time we start messing around with the brain of somebody who might have a prion disease, we have to toss all the stuff that touches their neural tissue. Reason being, prion diseases can be transmitted by one person ingesting or otherwise ending up with the prions from the infected person in their bodies.

However, there are pretty-close methods we use. The most reliable is known as the Tired Old Nurse test: if the most-experienced nurse on the floor sighs and says, "Dammit" upon sight of the patient, it's a near-sure thing it's CJD. We also do EEGs; there are particular brain waves that are diagnostic along with other clinical signs. And, of course, there are the rule-outs that get done early: poisons, drugs, weird encephalopathies caused by viruses or bacteria. It's basically a What Every Young Neurologist Should Know disease, in that you learn about everything else that's not causing it.

Nursing care for the patient with CJD focuses mainly on safety (I've had patients dance themselves out of bed before or hang up in their own restraints), clearing the airway of secretions, keeping the skin intact, and keeping the patient as comfortable as possible. We do a lot of stuff that doesn't seem like normal nursing care at first glance: for instance, nails can be a problem.

When a patient is in decorticate posturing (scrunched up), their hands many times will end up around their necks or in their armpits. Long nails mean dozens of tiny infected wounds in tender skin, especially in the groin when legs contract. So we keep their nails really short and blunt.

Another thing we do is lots and lots of aggressive mouth care. People with CJD tend to clench their teeth hard enough to grind off pieces of enamel, so you try to suction and scrub those bits out of their mouths before they swallow 'em. That is, if they can unclench. I often thank Frog for missing teeth in a CJD-er, so I can slide a small suction cath into the space.

And then there's the whole eye thing. If you're not really sleeping or blinking, you tend to get corneal ulcers, so we irrigate the CJD-er's eyes and lubricate them with oily goo several times a day.

The most important part of the nursing care of the CJD patient, to my mind, involves the unaffected family members. They've watched the person they love go from being a happy, normal, laughing person to something that's not quite human, often in the space of a couple of weeks. I encourage them to talk to the person. I look at the pictures they bring in and admire the grandkids. Most of all, I do what I have to do to the patient (most of it unpleasant) as gently as possible, explaining what I'm doing all along.

After all, I don't know if some part of that person can still hear and understand me. I doubt it, but if it were me, I would want to know what was going on outside my head, even if I couldn't control any of it.

Tuesday, March 13, 2007

A request for kharma

Chef Boy's mom is in trouble. She was visiting family out of state and had what sounds like a TIA, along with worrying back, groin, and abdominal pain.

It's hard for me to tell, since everything is very confused at the moment. She's in the hospital, zipping through CT scanners and getting lots of morphine.

Prayers, please? Thank you.

Monday, March 12, 2007


Nnng things:

Freddy Mercury is still dead.

Lyle Lovett is still married to somebody else. (She can't love you like I can, Lyle! Come to me! We have the same hair! We can share product!)

The dermatology resident who told me that all I needed was Cetaphil and a good mild moisturizer lied. Through her teeth. I now have almost as many zits as freckles.

We're still short two aides and several nurses. Note to Manglement: when the majority of the staff on a floor leaves within a couple of weeks, there's a problem.

Freddy Mercury. Still dead. As much as I keep hoping it'll all turn out to be a bad dream and he'll be ready to tour again tomorrow.

I took a spectacular tumble today during my workout with Attila the Cheerleader; so much so that she didn't even laugh. As I was hopping up onto that dog-damned step, sideways, the edge of my right foot caught the edge of the step and over I went like a sack of potatoes. I now have bruises all over my right side.

And I still don't write as well as Sid Schwab. may have five-dollar-off shipping, but they don't carry Chuck Taylors.

The Gap has stupid ads.

Jack Bauer is pretty cool with a belt and a switchblade, but I miss MacGyver's hair.

Freddy? Deaddy.

Speaking of dead, another one bit the dust this past week at work. We're having a run (actually, *we're* not having the run; *Carolita* is having the run. We suspect she's whispering "Go toward the liiiiiight" to them in Spanish) of that lately.

My cuticles are horrible.

I got bile all over my favorite scrub top. SHOUT stain remover does not remove bile.

My Google home page is all messed up.

The cat garked up a hairball into my clogs today.

Carolita apparently got hold of F. Mercury.

And I am going to bed. If I hold down the "reboot" button on my day long enough, tomorrow might be better.

Thursday, March 08, 2007

Change of Socks is up!


Not with a bang

We code them sometimes. Mostly, they have DNR orders, but sometimes they die too soon after being admitted, or there's a family member who simply won't accept the fact that, after Mama had blood filling the ventriculostomy burette, there's little likelihood she'll sit up and ask for a Coke. So we come in, all efficiency and organization: the RN from the ICU who's on the code team, the youngest residents to do compression, the chief to run the code, and somebody like me to do odds-and-ends stuff like record with one hand while starting IVs with the other.

That is not a way to die. You wouldn't know it from heroic stories in the news and touching scenes on That Popular Medical Drama, but we only get about a third of them back. Maybe forty percent, on a good day with the wind setting right.

It's not a good way to die, with two kids trading chances to compress your sternum and crack your ribs. It's not a good way to die, with a preternaturally calm voice calling out "one amp epi, eighteen-forty-two". And it's especially not a good way to die, with air blown into your lungs from a big bag escaping through lax vocal cords with a quiet "gk gk gk" as those aforementioned kids whang on your chest.

Do not ever code me. If I didn't hate wearing bangs, I'd have "DNR" tattooed on my forehead.

Instead, I'd like to die like this: all my kids are around the bed, along with the oldest of their children. I've made it perfectly clear from the get-go, since the stroke, that I have zero desire to be fed through a tube and rehydrated with catheters in my veins.

So the kids come in and take shifts, talking to me when I'm awake, sitting and talking among themselves when I'm not. At some point in the proceedings, they'll all come in at once, since it's obvious I won't last much longer.

And the kids will go out into the hall to catch the nurses that have taken care of me, to give them a chance to say goodbye.

Maybe, if I'm very lucky, my heart will simply stop beating after the last nurse comes in and wishes me a safe journey.

I've hung out with the dead and with the dying. Never before has somebody simply gone out like a candle when I was right there. It happened so quietly we didn't even know it had, and when I realized she was dead, I was filled with immense gratitude and happiness for her.

That is the way to die. If I get my choice, I want it to be with people who love me cheering me on to the next world, not with strangers trying to make me miss my train.

Saturday, March 03, 2007

Why yes, thank you. I am that dumb.

Thank Frogs February is a short month. Here is a partial list of the stupid things I did in the month of February. It is meant to give nursing students confidence, other nurses a feeling of community, and the doctors in the audience a good laugh.

1. Referring to a subarachnoid hemorrhage during rounds as a subarachnage hemorrhoid.

2. Tying a tourniquet around an arm, watching a nice juicy vein pop out, sticking an 18-gauge IV needle into said vein, and flushing it enthusiastically. Without first removing the tourniquet. Pop went the weasel.

3. Pulling the spike out of a bag of fluid while we were moving a patient. If it had been neuro juice (normal saline with 20 milliequivalents of potassium per liter) it would've been bad enough, but this was D5 1/2 NS. For the uninitiated, that's slightly salty sugar water. If the bag had been sitting on the bed, it would've been bad enough...but it was hanging up, higher than my head, on a pole.

4. Calling one of the rehab boys by his nickname, "Chuckles" (note: I was not the one that came up with that nickname for him) in front of his chairman. To be fair, I didn't know she was his chairman.

5. Don't even ask me about the guy with the bad gas and the colostomy bag. The less said about that day, the better.

6. Speaking of which, I ate undercooked beans and rice from the cafeteria shortly before the biggest bigwigs of them all were due to tour the floor.

7. Charting the fresh lower-limb amputation on the wrong patient. Twice.

8. Misplacing all of my nurse's notes for the entire day at 1750, and finding them only after I'd recharted everything on fresh new notes.

9. Running a sand bed over the toes of the sand-bed-distribution-company rep. Just so you know, they look like huge bathtubs and weigh as much as an old VW Beetle.

10. Doing my famous silent imitation of Mick Jagger doing "Brown Sugar" in the hallway for a couple of phlebotomists, and hitting the climactic strutting bit, complete with hip-shaking, just as God (our chief neurosurgeon) and all his minons came around the corner. They were nice enough to applaud.

Still, none of that is as bad as the time my scrub pants fell off in front of a group of prospective residents.