Sunday, September 30, 2007

So, um? If you're in Central Texas? And you're not doing anything at the moment?

Could you please, please come over and get this enormous wolf spider out of my Everything Room?

We set up the washer and dryer today (it involved taking down a wall, which is what took so damn long) and while we were doing that, I saw something move out of the corner of my eye.

Now, I am a big spider fan. I love spiders. They fascinate and charm me.

But this spider? She's bigger than my palm.

I wear a size 7 surgical glove.

She is so large that the jelly-jar pint glasses I use for water won't go over her legs.

She moves quickly. Like a hairy Cuisinart. Disturbing.

I know, at least, that I won't have any palmetto bugs or roaches in that room. I might not have any Texas Red frogs or geckos, either.

Or a cat. I think she could take Max on and give him a run for his money.

Is there anybody out there with a really big clear-glass bowl or jar they'd be willing to bring over?

I'll just be hiding in bed, several feet off the floor. Wide-awake. Watchful.

Friday, September 28, 2007

Today has been a good day.

I had one patient go south about ten o'clock. I had another call late in the day because of a prescription screwup. I got three admissions in an hour.

But when I got home, Max leapt up from his spot behind the fence and greeted me at the back door. We spent half an hour on the floor of the kitchen discussing our days. He put his enormous paw over my hand (his paw, toe-tip to dewclaw, is as long as my hand from fingertip to wrist) and gazed at me soulfully, making subterranean rrowling noises when I got to the good parts. Then he told me about his day, via snifflings and snufflings and lots of grooming my arms.

We traded ear-scratches and belly-rubs and chin-licks, and then I checked my email. I found a reply to a piece of fanmail I sent another blogger. It was funny and kind and encouraging. I was a total fangirl before, but now I'm a double-total fangirl.

The cat is being reasonable. Given that she takes disapproval of everything to a whole new level, this is a good thing.

It has been a good day.

Monday, September 24, 2007

These big clumps of hair? Oh, they're nothing.

Take a tetraplegic. (That's the Medical Term for "quadriplegic", now fallen out of vogue because everybody knows what it means.) Give that tetraplegic person a rollicking urinary tract infection, dehydrate them significantly, add some weird heartbeats to the mix, and give her something called autonomic dysreflexia, which means "Nothing works right after you break your neck."

Admit that person to my floor with a blood pressure of 60 over 20. For those of you non-medical types, 100 over 70 or so is considered normal. 60/20 is a sign that something is wrong. Make sure her oxygen saturation level is somewhere in the high 70's (again, not good in a big way), and see that she's running a fever of 104.9 F.

Did I mention she's not producing urine? At all?

All the time I was running my twelve liters of fluid into her, to bring her to a grand total of nineteen liters of fluid, I was fighting with the attending who'd admitted her to our floor. She should've gone to the ICU straight off.

*** *** *** *** ***

Take a person with a significant medical history, including multiple cardiac catheterizations, liver problems, and several heart attacks. Put them through a very minor--as in out-fucking-patient, for God's sake--surgery. Make sure they lose something like 3 liters of blood during that surgery. (No, I'm not exaggerating. You can't make shit like this up.) Lose her once during the surgery and bring her back to life.

Send her to the post-op unit for four hours while you run five liters of blood into her. Make sure you're running huge amounts of IV fluid at the same time. Warm her up, dose her on fast-acting narcotic pain medication, and send her up to my floor.

The whole time she was there, from the time she arrived until I sent her to the ICU after she coded (too much fluid, most of it going to the lungs), I was fighting with the attending who sent her to us. She should've gone to the unit straight off.

*** *** *** *** ***

Here's a nice little old man who's recovering from a nasty bout of pneumonia. He's not dehydrated, his electrolytes are fine, and he's not feverish. But for some reason, he keeps throwing these bizarre heart rhythms on the monitor. They don't look good, and they're starting to look worse.

For eight hours, from the time he showed up to us until he coded and was pronounced dead, one of my coworkers fought the attending who sent him to us. He should've...but you get the idea.

*** *** *** *** ***

This is why I love the neurosurgeons I work with. If I say, "Hey. Something is Not Right here," they'll snap to and take a look at the patient, even if all I have to go on is a gut instinct.

And it's also why I hate every other service pretty much all of the time. The first patient had been admitted the night before, and all three nurses who had worked with him had agitated to send him to the unit. There's such a thing as having too much going on to be well cared-for by a nurse who has five or six other patients to manage.

The second patient was transferred to us over the objections of the manager of the post-op unit. The third came in okay, but should've been sent to the unit the minute he started manifesting tombstone T's. There are drips we can't run and tricks we can't pull on the floor that they can in the ICU.

I do not know what to do. In both the cases that were my patients, I worked my way up the chain of command, finally culminating in repeated phone discussions with the attending physicians. I kept everybody updated, shoved my other patients off on other nurses and the charge nurse, and chewed new assholes right and left for every resident I could reach. Every nurse I spoke with about those two patients, from the clinical manager to the ICU charge nurse, asked the same question right off: "Why is this patient not in the unit?"

Yet the attendings, either through sheer laziness or disrespect for nurses (the first, I suspect, in the latter case; the second reason in the first case), ignored that my hair was on fire and their patient was tanking. The residents went along with the attendings, with the added joy of being snarky to boot.

I can handle almost anything within reason. Nearly losing two patients in two weeks is hard, especially since one of them will have a lifelong anoxic brain injury courtesy of her stupid surgeon. The nurse who cared for the poor, sweet little man who died is a wreck--she's two years out of school, technically excellent, and usually unflappable.

I do not know what to do. I have excellent working relationships with the attendings and all but one of the residents. The brain surgeons routinely ask that I take care of their patients, because they trust me to flip a lid if something goes wrong. Yet in two cases, *something* stopped two experienced physicians from taking me seriously enough to listen to me when I said a patient was more than we could handle and was *getting worse*.

The first woman was, thank God, fine. The second will be easily amused for the rest of her life. The third patient is dead.

I know it's not just me, since Other Nurse had the same issues with stonewalling...but still. What could I have done differently? How do doctors like to be presented with things like this? I gave 'em detailed, succinct reports on their patients, but that wasn't enough...

This has been keeping me up nights.

Thursday, September 20, 2007

"...While the other one won several prizes."

It was a normal day on the urology floor, meaning a highly abnormal day for Your Faithful Correspondent. I had gotten sent to Urology to make up a staffing shortage. There I was, schooled in the ways of the brain, trying to make do with rudimentary knowledge of the bladder, bowel, and kidneys. Continent ileostomy? Neobladder? What?

As luck would have it, I got an admission from the ER. The young man was reticent about his problem--he was a little younger than me, not willing to drop trou in front of a nurse in his peer group and come clean about his difficulty.

I finally got the guy to tell me what the heck the problem *was*. "One of my balls is huge," he said, "and really sore."

Well. Well. I had to assess it, so I did.

There's more room than you would expect in the average scrotum. I've seen 'em as large as small melons, but this one took the cake. One side of his scrotum was easily, and I kid you not, the size of my head.

The other was more-or-less normal. A little edematous, a little red, but pretty much what you'd expect.

Great leaping jiminy. What the hell do you do in that situation? Turns out you use ice packs and elevate the dadratted thing on a couple of rolled towels while you page the resident on call, stat, to come see your patient. A couple of milligrams of morphine calmed my patient; a couple of minutes of hyperventilation calmed his nurse.

The resident arrived and did his exam. Turns out the patient had had a little bit of an ingrown hair or zit or something, and had squeezed it, and the resulting infection had spread.

The patient went in that afternoon for an incision and drainage. Several days of intravenous antibiotics and some dressing changes fixed him right up, but I was reminded of the old limerick:

There was a young man from Devises
Whose balls were of two different sizes.
One ball was so small, it was no ball at all--
But the other one won several prizes.

Mom, in case you're wondering, I learned the limerick from James Herriot's books.

Wednesday, September 19, 2007

Sunday, September 16, 2007

Ah, lovely hydrocodone. Lovely, love....zzzznnnkkk

Yes, friends, I was a narcotic virgin.

I think I've had one Darvocet once in my life, back when I was a kid and Mom gave me one in desperation after I'd flown with a sinus infection. That was too long ago for me to recall what I felt like. Similarly, I think I might've had Vicodin at some point in the past, but I don't remember anything but getting mildly, then moderately, then severely queasy, then not taking it any more.

Now I have this cough syrup. It has 5 mg of hydrocodone per teaspoon, and I'm supposed to take two teaspoons at a time, which (let me tell you) makes for a party. It also has a decongestant and an antihistamine I've never heard of, so I'm sleeping really, really well.

It's become a hobby for me to look at these experiences through the lens of how my patients might feel in the same situation. When I had a migraine, I mentally cataloged everything that was happening to me, so I could relate better to people with migraines. Now I'm all about the side effects of hydrocodone. To wit:

1. You sleep like the dead, then wake up, *plink!* with no sensation that time has passed at all. This is nice, if a little disconcerting.

2. Everything takes forever to accomplish. I'm not taking this while I'm working, but it's still odd. It takes twenty minutes to shower and ten to make coffee, because I'm....moooving...iiiiin...sllloooowww...motion.

I'm moving like Mrs. Which talked in "A Wrinkle In Time."

3. Nothing much matters. Ten minutes to make coffee? No problem. I'm coughing up green crap? Doesn't worry me in the least. Wanna cut off my big toe and stick it in my ear? Go 'head, I'll just be over here, napping.

4. I itch. All over. No rash, so no allergy, but a common side effect.

5. I'm not coughing as much. When I *do* cough, I have to make an actual thoughtful effort to manage it, because my cough reflex seems to have taken a powder. (Ha.)

Chef Boy just brought me soup, toast ingredients, and a big bunch of purple tulips. The Cat is curled up at the foot of the bed, one eye barely open, watching to see when I decide to lie down. Max is in the hallway, one eye on me and one on the door, so he can get belly-rubs from any intruders that happen into the house. I have lemonade and limeade and fresh coffee, and a book on the couch that I've been wanting to read. All this, combined with a hydrocodone haze, makes this one of the most pleasant illnesses I've ever had.

Thursday, September 13, 2007

Lazy Post, with a good reason and an excuse...

I got a very nice email from a man who worked out an algorhythm to show the top 25 nursing blogs by hits on the InnerNewtTubes.

They are here.

I recommend, strongly, perusing all of 'em. I write one; most of the rest I read, and two on here were pleasant surprises to me.

Why am I doing a self-aggrandizing lazy post?

Because I just spent 2.5 hours at the doctor and came away with a diagnosis, not of allergies, but of pneumonia. Tra fricking la.

Don't worry; I don't feel bad. I just thought I had a bad cough.

Monday, September 10, 2007

No, I didn't fall through the bathroom floor.

She Came In Through The Bathroom Window

I'm moved in. I have one house, one cat, one dog (more on that in a minute), and one almost-bathroom. It needs to be grouted, but it looks *sharp*. It'll be totally usable tomorrow, after everything dries.

The moving guys who took care of the heavy stuff came in a trio. Their combined ages couldn't have been more than 65. All of them were cheerful, stringy, rangy guys who could pick up a fully-loaded cedar chest alone and haul it down three flights of stairs. I'm proud to say that five years of nursing and a year of heavy training left me able to keep up with them. I also let them punch holes in a wall (it's got to come down anyhow), much to their great delight.

Getting back to work was weird. You know how the strange people and strange cases seem to cluster? Well, we've had a couple of clustering weeks; I came back on the tail-end of the weirdness time. The census reads like the table of contents from a particularly nightmarish pathology book: worms in the brain? Got 'em. Basal cell carcinoma that ate into a sinus so that sinus and orbit had to be removed and replaced with a free muscle flap? Yep. Bizarre ventriculitis caused by God only knows what virus? Uh-huh. Autonomic dysreflexia, septic shock, dehydration, dementia, and meningitis? All in one bed, buddy.

In short, I was reminded that "Found down at the Kwik-E-Mart" is not an encouraging beginning to a history.

The Curious Incident of The Dog

Eons ago when I was still married, my then-husband found a dog in a vacant lot near our house. He (the dog, that is) looked determined to lay down and die, being nearly starved and looking like he'd been on the road a while. That, of course, is never gonna happen in *my* neighborhood, so off to the vet I went, with an 80-lb stranger in the back seat of my Civic.

Several months later, after he'd been fed well and exercised regularly, somebody at the vet's office mentioned that they thought he might be an Anatolian Shepherd mix. Anatolians, aka Kangals, are enormous livestock guard dogs native to Turkey. They're popular here and in Oklahoma because of their toughness and intelligence. I shrugged, figuring that Max wasn't big enough or furry enough to qualify.

Fast-forward four years. Ex-husband is moving, and needs somebody to take the doggo. I couldn't originally, because a large dog doesn't belong in a small apartment with somebody who works 16 hours a day. However, now I could, because I have the house and the yard and all. So I went last night to pick up Maximum Maxhound.

He must've been a half-grown puppy when we found him, is all I can say.

I now have a 115-lb monster taking up most of the kitchen floor.

The cat beat him up last night. She was unhappy with his being here and so attacked him in the living room, giving no quarter, and chased him through to the kitchen, where she cornered him by the back door and went to work on his hindquarters. He's now understandably nervous about coming back inside, so I wander out every few minutes to the yard to scratch his ears and tell him he's the best, sweetest boy ever.

And he is.

(Note: the picture above is not Max. It does, however, give you a good idea of his size.)