Thursday, November 10, 2005

Just because you can doesn't mean you should, and other lessons

If Mama is 87 years old, demented, obese, with long-standing heart troubles and CAD, a less-than-ideal immune system, and unable to make sense of what's going on, it might not be such a good idea to have her hip replaced.

Especially if the outcome--a six-day stay in the ICU, a raging infection, and general misery for all--is one you've been warned about beforehand.

I'm just sayin'. Mama is going to be lying in bed for the rest of her life anyhow, not knowing where she is, alternately screaming and cursing, Foley and O2 mask and rectal tube and permacath in place, regardless of what you do. Quality of life here is an issue. Would you rather Mama be in pain with a huge fever, in a strange place, with invasive things done to her, or in *controllable* pain in a familliar place, with less likelihood of dying in fear?

If anybody ever does that to me, I will make it a point to die on the table and then haunt them for the rest of their lousy lives.

What a Young Nurse Should Know

Strokes do not necessarily change a person's personality. If Papa is a racist now, after one of his frontal lobes got bludgeoned by a big ol' clot, it's likely that he always had those attitudes, but also had the socialization to keep them to himself.

Likewise, if Auntie is dreadfully unpleasant now that she's lost her right parietal lobe and part of her frontal lobes, it's very likely that deep down, waaaay hidden away, she was pretty unpleasant to begin with.

The trick is to accept the family's apology for Papa's or Auntie's behavior without pointing out to them that you took care of Papa or Auntie last year, prior to this stroke, and not much has really changed.

Nobody told me there'd be days like this...

It has been a hellishly long six days. The two days I've had off in the last eight, the 'Net was down here at Las Casas Del Nonrobust Connection, so I've not been able to blog. That's probably just as well, because any writing I'd be able to produce would sound a whole lot like a drunk running into a wall at 3 a.m.

There are days in nursing when everything goes smoothly, you get your charts opened by nine, you have a chance to eat and even maybe drink a mid-afternoon cup of coffee, and you feel good when you leave the floor. There are other days, when nothing specifically horrible happens, but everything gets all wadded up in a huge ball that takes you hours to untangle. The last six days have pretty much been the latter sort.

It's not that the work recently has been particularly demanding in a physical or mental sense. After all, I'm not the one who has to localize somebody's stroke on the basis of symptoms or read their EEG. There have been no six-hundred pound patients falling out of bed lately (thank God and knock wood). It's just that little, simple things, like accessing a Mediport, took on a new and complicated dimension this week.

The Mediport (a permanent, implanted catheter under the skin of the chest through which one can infuse medications and draw blood) would flush, but not draw. This necessitated my trying to unclog it with TPA and failing, then ordering a chest X-ray, as per hospital protocol. Meanwhile, the patient whose Mediport it was was getting itchier and itchier (liver failure will do that to you) and more and more anemic. All of the falderal about TPA and chest X-rays was necessary, as I didn't want to run a couple of pints of blood into somebody's chest wall unless I was ordered to do so.

Then the one respiratory isolation room on our floor got bolloxed up somehow, so that the exhaust wasn't going to the outside air, but instead to the floor in general. Which would not have been a big deal had somebody discovered it *before* we'd put a possible TB case in the room. Again, not a big deal from a health standpoint, since it'd take a person about a million years of overtime to catch TB from the diluted particles that were exhausted into the air, but a cluster-fuck from a logistics standpoint.

Then the post-op unit sent me the wrong patient. I was waiting for an angiogram and got a belly surgery. Oops. More Three Stooging ensued, with the patient going to another floor, everybody smiling in a rictus of horror and trying to make like we'd planned it that way, and my promising, in a tense whisper, to skin the PACU nurse who'd messed up.

It seems the Universe knew I'd bought a fresh bottle of Bruichladdich.

...Most peculiar, Mama.

The differential diagnosis crew will be hard at work for the rest of the week.

MS behaves differently in different people, that we know. Sometimes you see the characteristic plaques in the brain on MRIs, sometimes you don't. Sometimes there are exacerbations and remissions, sometimes there aren't.

But MS does not behave like this:

An eighteen-year-old male presents with a six-month history of pain in the legs and decreasing coordination, especially truncal control.

Fast forward a year, to the latest exacerbation of what's been diagnosed as MS, despite no clinical evidence: the patient shows a persistent left-going gaze, still complains of intolerable pain in his legs and arms, the use of one side of his body. He never got better, not for one single day, in the intervening year. His family is now reporting personality changes, aggression, fearfulness, and aphasia.

His MRI signal is abnormal in the hippocampus. His EEG is insane.

We're all being very quiet on the floor, waiting for the neurologists to take a brain biopsy (not very useful, as you'd have to get very lucky to get what you need in a single cut), get the results back from his lymph node biopsies, and make a diagnosis.

My Favorite Martian (aka one of the best, most pleasant, least weird neurologists on staff) looked at me with a very solemn expression the other day, after he left my patient's room. He said nothing. I said nothing. Then we went down to the station and, together, ordered all the biopsies and reserved all the ORs that he would need for the next week.

We think we know what it is, and we really hope we're wrong.

Ending on a hopefully-more-cheerful note

The fact of the matter is, I'm not dead. The flu shot I got might've caused me to be sore and grumpy for the last two days, but grumpy and sore are my usual personality traits, so nobody much cared.

I'm off for three days, on for one, then off for two. On the last day of my mini-vacation, I'll be attending a monstrously wonderful pre-Thanksgiving potluck for the third year straight. We get such marvels as biriani and tabbouleh, enchiladas and that weird corn/mayonnaise/chili powder/lime concoction so beloved in Mexico, spring rolls and squid and dried fish. Somebody always fries a turkey, as a concession to the Suthun way of doing Thanksgiving, but we can eat barbecue instead if we like.

(I'll be taking Chef Boy's rolls and my own Danish rice pudding, thanks.)

The New Car continues to be amazing. I fill it up once every couple of weeks, drive it around while I play with all the nifty automatic settings for this and that, and consider my $380 per month well spent.

They charged me the price of a ten-year Scotch the other night when I picked up the Bruich. It's actually a 14-year. And, because I am the original cheap drunk, I can expect that it'll last me at least three more months.


shrimplate said...

Are his gammaglobulins low?

Anonymous said...

I don't get it. What do you think the young man has?

Lioness said...

You can't do this, what do you think is wrong w him?? What? What? I'm beggging!