Wednesday, October 31, 2007

Nursing Students: A Love Letter

It's that time of year again. We're getting three days a week of nursing students. Some are experienced, some are not. Some are sure of their vocation, some are not. Some look like they're going to vomit on my shoes, some...wait. They all look like they're going to vomit. Or pass out.

Nursing students, take heart: that nauseated, faint feeling does not last past the second year of nursing. At least, not consistently.

I love nursing students. The longer I'm out of school, the more I love them. I love that they're willing to put up with two to four years of unmitigated hell in order to enter a profession that is, mostly, rarely-mitigated hell.

I love that they think they know nothing, when in reality, they know quite a lot. The students who overcome their terror long enough to open their mouths always end up asking some interesting, baffling questions. The ones who advance theories are more often right than wrong, and even the wrong theories are logical.

I love how hard they work. With one exception in five years, every class of students we've had has kicked ass on the floor. They come early and stay late, even after a night of doing care plans. Nothing is too dirty, too boring, or not-nursey enough for them to do. They know their theoretical stuff backwards and pick up on the real-world stuff fast.

I love how they keep me on my toes. When I have two or three (or more; word's gotten around) students following me, I am extra-careful to explain everything, both to them and to the patient. I triple-check rather than just double-checking. I wash my hands longer.

I love that they're enthusiastic. We have very few nurses working at Big Bob's Brain Barn that don't love what they do, but we do have a few. Working with them is poison to the soul. Working with a nursing student is the antidote: everything is new and fun and exciting.

I love that they make me see the patients in a whole new way. You get so used to people who've had horrible disfiguring things happen that you often don't think of how little things could make their lives harder or easier. Case in point: One of my patients last week was a dwarf (not horrible or disfiguring, but wait...). I hadn't thought of how, without a step-stool, the guy couldn't adjust the shower head to hit him and would therefore be bathing in backsplash. The nursing student shadowing me picked up on that right away and fixed the problem before it became a problem.

I love how they make me see the profession in a new light. Some nurses get ground down and start referring to themselves as waiters. The students I encounter are more often than not active in student nurse associations, volunteer work, and political stuff. They see the profession of nursing as not just a service profession, but also as a scientific and activist calling. I am heartened and impressed by how much thought they've put into their choice of careers.

Thanks, guys. You can round with me any time.

PS: Don't steal my pen.

What Not To Do, Part Eleventy-Seven.

1. 55 in the left lane. Never a good idea.

2. Disconnecting yourself from your insulin drip.

3. Disconnecting yourself from your D-10 drip after you've come in with a blood sugar of 17. Yes, seventeen.

4. Saying to the patient's family member, after said family member has suggested that a chest X-ray might be a good idea, as patient is choking on his own lung goop, "You're not a doctor! *I'm* the doctor here!" (Which led family member to retort, "Really? Gosh. Learn somethin' new every day, I guess.")

5. Suggesting, because *you* can't add, that *I* have made an error in recording the ingo and outpee of a patient with a continuous bladder irrigation. Or, rather, suggesting that loudly and abusively in the middle of the nurses' station. (See: Never a Good Idea.)

What To Do, Always and Forever:

1. If you are a nursing student, ask questions. I had three sets of students in three weeks, all of whom asked really intelligent questions. One woman asked me a question (this happens at least once a semester) that made me say, "Uh...buh...uh...I dunno..." which leads to many fun hours spent with books and Google and the unit educator. I love that.

2. Let me know if you're taking your family member off-unit in a wheelchair. That way I won't alert security when I can't find or reach any of you. Boy, were our collective faces red.

3. Bring an extra set of scrubs to work. I learned that lesson the hard way--for only about the fourth time--last week.

4. If you're a patient or a family member, ask questions. I don't care if they have nothing to do with the subject at hand; just ask. It is what I am here for.

5. Please check with me before you get out of bed. This holds true especially if you've just had a femoral artery puncture and are supposed to stay flat for six hours. That way, I won't be so surprised when I walk into the bathroom to find you sitting on the john, spurting blood like a fountain from your puncture site. (See #3 above; also see What Not To Do At Shift Change.)

Sunday, October 21, 2007

What I wish I'd said.

The woman waved me down as I was heading to the hardware store. She was pushing one of those brightly-colored plastic toy cars and had a Chihuahua following her, so I figured she was looking for the dog's owner.

I stopped and rolled down the window. She came over. She was neatly and appropriately dressed and seemed friendly enough.

"Hi," she said, "I'm Sheri. I was wondering: do you live around here? Have you seen any unusual cars in the neighborhood, cruising?"

I allowed that, having lived in the neighborhood for only a few weeks, I hadn't noticed which cars were usual and which weren't.

"Oh. Okay." She looked over her shoulder. "I've been noticing a lot of strange cars lately, and I was wondering where they were from."

Crack houses and meth houses have a way of springing up here and there in this town, but I hadn't noticed any weird smells or late-night activity, and said so.

"I didn't mean that," she said, "I think it's the FBI looking for me."


"I'm a paranoid schizophrenic, but I've been on my meds, and my symptoms are controlled, and I really think the FBI is following me. See that Audi? That car doesn't belong in this neighborhood. I think it's FBI."

I did not point out that with the volume of college students in the neighborhood, at least one would come from a family capable of affording an Audi.

"See, I've been working on this research on diseases, and I think the FBI knows about it. Al Gore and I are working on visceral leishmaniasis. I picked up some larvae in my back yard, and I kept them in a petri dish--except it wasn't a petri dish, it was an old pitcher--and they turned into black flies. I'm trying to get the university entomologists to take a look at them, but I can never get through. Anyway, I'm losing the sight in this one eye, and I think it's connected. And then there's that respiratory infection that's been going around--I think there's more to that, too. I'm giving a talk on it next Saturday at the library. It's invitation-only. It's for the children, you know, this awareness of coming plagues."


Just then, a car drove around us and honked. She flipped them off casually and, turning back to me, said with a laugh, "You don't want to mess with me. I'm a direct descendant of Genghis Khan."

I made some noncommittal remark.

She asked then, "What do you do for a living?"

I told the truth.

I wish I'd said "I work for the government."

Saturday, October 20, 2007

Why, yes, it *is* 2:15. Funny you should mention that.

I am awake at 2:plus because of Max, the best dog ever.

Max had a lump on his foot. I took him to the vet today because the lump, which had stayed the same for two years, had suddenly changed. Dr. Vet Guy decided to put Max under right then and take the thing off, along with a teeth cleaning and nail-trimming. Max came home a few hours later shy one lump and with pearly whites and a vet-special pedicure.

The Greyhound I used to have got flipped out by anesthetic and would wander, tachypneic and tachycardic, in circles until you gave him Valium and he fell over. This is apparently a Greyhound thing. Max, on the other hand, stared fixedly into the middle distance for a few minutes when he got home, drank a whole bunch of water and peed (carefully, being drunk), and then laid down and went to sleep. I slept on the couch, wanting to be nearby in case he needed me in the middle of the night.

Which it is now, and he doesn't. He's fine. I, on the other hand, am sore from being crunched up on what could be described as a couch only with the greatest charity. I woke up from a dream in which I was helping redecorate Hogwarts, pointing my wand at things and yelling "Accio 'Sixties!", attempting to remove all the bad mid-century design from the place. When the huge chandelier in my dream started to swing toward me, I said "Wait. Not you." Then I woke up.

Pathology on the lump should be back about the time Max needs his stitches out. The vet hazarded that it looked like a pericytoma, something humans don't get (as far as I know). Pericytomas are benign but locally invasive, rather like Max himself, and can regrow if not removed with clean margins. Near as I can tell from the shape of the Coban covering Max's foot, they managed to save the toe the thing was growing on. We'll see later on when I take off the bandage.

So here I am. Wide awake. At 2:plus a.m. At least I don't have to work today. And at least I'm not really responsible for decorating Hogwarts.

Tuesday, October 16, 2007

It's all about the Ow.

Flu shot, 24 hours later: Ow.

Hiccups that won't go away (a reaction to anesthetic): Ow.

Hiccups that won't go away (symptom of brain tumor): Ow.

MCL strain: Ow.

Thoraco-lumbar reconstruction to alleviate "flat back" syndrome: Ow.

Urological reconstruction to correct multiple fistulae between bladder and outside world: Ow.

Getting hit by a bus: Ow.

Getting hit by a bus outside a hospital and watching several dozen people pass by without reaction: Ow, ow.

Baby delivered in breezeway between hospitals: Ow.

Landing on head after falling off drydock wall: Ow.

Slamming your head into the sharp corner of a metal cabinet: Oweeee.

Having two tonic-clonic seizures that land you, intubated, in the MICU: Ow, ow, ow, but not like you'd notice.

115-lb dog stepping on your foot in excitement when you come home at night: Ow, sort of.

Carotid artery dissection: Ow.

And my personal favorite: Laying your bike down on the road to avoid hitting a rabbit: Owie, owie, doh, ow.

Sunday, October 14, 2007

More chicken-stapling and a simple wish for Christmas

Santa, Baby, hurry to the unit tonight....

All I want for Christmas is total and complete immunity, starting now, from all derangements of the nervous system for myself, my family, and all my friends. That's all I want.

Because, frankly, when you say to a coworker "I've seen one too goddamn many cases of brain cancer this week", you have to stop and reconsider what you're doing for a living.

Sarcoma. Lymphoma. Glioma (high and low-grade both, inoperable and semi-operable both). More sarcoma. Metastases. Astrocytoma. Every-darn-thing-oma you can think of. And, of course, the worst cases were in the most pleasant and productive people. One of my favorite patients in a long time showed back up due to complications of his particular -oma, and he'd lost 40 pounds in two weeks.


So it was with relief that I took report on a patient who'd had the misfortune to catch some sort of weird necrotizing disease. It wasn't that flesh-eating bacteria, nor anything you can get from, say, a bug bite--it was something I'd never heard of and couldn't spell, and promptly forgot the name of as soon as the shift was over. At any rate, it was a nasty case of face-eating whatever.

You know the mask the Phantom wears in the Lloyd Webber musical? Imagine the lines of that mask, but including the entire nose, covering your face. Now imagine that everything inside the outlines of that mask is gone. Eyelid, nose, cheek, mouth--down to the bone, including muscle and fat. That's what happened to this dude. He'd gone on vacation to somewhere lovely and quiet (Belize, maybe?) and come home rested and tanned. Three weeks later, his face had rotted off.

So he came to us and we rebuilt him in a series of surgeries. I got him after the second-to-last one. He'd already had all the nasty infected stuff cut and scraped away, and his eyelid and cheek and lip rebuilt (and the surgeons did a hell of a job, I have to say). This last surgery was the basic structure of his nose, and used rib bone and grafts from various tender places like his thigh. (Query for those more experienced with flaps than I am: if you take a flap from the upper thigh and build a nose out of it, won't it...uh...grow hair like it would if it were on the leg?)

Here's the really shocking thing: Two weeks after his last surgery, the eyelid-and-mouth rebuilding one, his eyelid and mouth looked essentially normal. I mean, give him another month to heal up and you wouldn't know anything was ever wrong with the guy. Plastic surgeons don't get nearly enough credit for doing really good work.

In other news, the war sucks. So does the Gubmint.

Take a 23-year-old kid. Put him in a tank in Iraq. Hit that tank with a shoulder-launched rocket. Make sure that a piece of shrapnel takes out a chunk of his right temporal lobe and a bit of one of his frontal lobes.

Medivac him to the nearest mobile unit so they can save his life. Then send him off to Germany, where he will get comprehensive, high-quality care. Once he's stable, send him home without a plate in his head. They can always replace the plate at the VA, right?


And in so doing, they can totally fuck him up.

I'm not exaggerating when I say this: our local Veteran's Administration hospital is the sort of place you wouldn't send your worst enemy. One of the residents I trust implicitly came back from there with stories of dirty surgical instruments--packets of stuff for brain surgeries coming from Central Sterile with blood and Cheetos inside. Nurses I've worked with tell stories of coding patients who are cold and stiff. It's bad. There are rats in the bathrooms.

So Army Boy ended up there. And underwent a total of twenty-eight surgeries to clear infections that would never have happened had he gone to a facility that took basic pride in, you know, keeping wounds clean and administering antibiotics. Eventually, as it will, something bad happened: he ended up in septic crisis and stroked.

So now he's 25, permanently and severely disabled, addicted to Demerol (a pain medication that no sane person ever uses for neurosurgery patients, as it's neurotoxic in large doses), and is rated at 40% disabled by The Gubmint.

Which means, essentially, that he's going to be living on 40% of his already crappy private's pay for the rest of his (probably shortened) life.

I am not usually political on this blog, but I have to say this here: Of all the harebrained, poorly conceived, abysmally managed, and based-on-bullshit things I've ever seen in my life, this current war is the worst. It's competing neck-and-neck for disdain with the way the VA here treats its patients.

We do get veterans from time to time, usually with some problem that the VA can't fix. I had one guy early on in the Iraq war who'd had half his face blown off by an IED. I had a woman with a tricky trio of amputations that had to be revised--she'd gotten hit by enemy fire while serving in a "support" role. 'Cause women aren't allowed in combat, don't'cha know.

Every time I see one of these guys or girls, it breaks my heart. It's one thing to take care of a 70-year-old with CNS's another to care for a 19-year-old girl who's missing both legs and an arm, and to know that that condition arose from the lies and grandstanding of someone who never saw combat.

And now I will stop. Nurses believe in God, I think, primarily to have somebody to blame. All I can say is, when God and I meet up at the end of my life, we are gonna have one Hell of a Come-to-Jesus meeting.

Thursday, October 11, 2007

Things I love Thursday, with apologies to Gala Darling

Baby Giraffes.

Chefboy and I went to the State Fair yesterday. (That simple sentence fails to convey the driving....driving....driving we did.) The petting zoo had a baby giraffe, about ten feet high, who decided that *my* five-dollar cup of critter feed was the *best* five-dollar cup of critter feed. He lowered his head, stuck his insanely narrow muzzle into the cup, and licked up feed with his huge black tongue. I was totally smitten. I was also intimidated by the size of his feet.

Mosquito Barcoding

Wahoo! Look it up. It's cool.

TIGI Oatmeal Cookie body wash

I know I've written about this before, but I just snagged the last two bottles at the grocery store. It's like bathing in brown sugar without the stickies, but then it resolves to a deep, rich sandalwood.


My dog

He grumps and growls and barks and howls and raises his paw for belly-rubs. What could be better?

The new Wusthof knife Chefboy got for me

It makes insanely quick work of chopping. I didn't even feel it when I sliced my finger the other night (just a little slice; no worries).

Monday, October 08, 2007

Total Fangirl.

What do I do when I'm not working or blogging about work?

Well, when I'm done cleaning house, Furminating the animals, paying bills, grocery shopping, dancing on tables, scaling K2, and remodeling antique biplanes, I hop online and waste time at these non-medical sites:


Pop-culture snark for people with brains. Especially since Snarkywood went into hiatus, I love the comment section here.


The single best Web-only comic for the money. Someday Randall Munroe and I will run off to a tropical island with good connectivity. He'll draw his comics and post them while I crack coconuts and mop his feverish brow. Call me, Randall!

Gala Darling

She's young. She's from New Zealand. She lives in Melbourne. She has bright pink hair. She's the go-to girl for fashion, relationship, and life advice for the young-twenties set. I'm about *mmph* years older than the target demographic, but I love her beyond reason anyhow. How could you not, when somebody signs off "Super love and cupcakes"?

Modern Mechanix

I fell in love with this site when I saw a layout from Popular Mechanics (I think it was) on "A Kitchen Built To Fit Your Wife". Ironically, the same ideas the authors thought were good in 1952 were ones Martha Stewart incorporated into some recent kitchen design or other. Paleo Future is another good one for the tech-heads.

Manolo's Shoe Blog

Not *that* Manolo. Better.

And, of course....Dogblog.

'Nuff said.

Sunday, October 07, 2007

*mmmph* *rrr* *yawn* ...chickens...

Yeah. I don't know why I woke up a full hour early, either.

Spent yesterday on the Complex and Terrifying Incisions Unit, where it's par for the course to take care of two patients who've had their jaws recreated with bits of bone from their legs or ribcage, another with something in the middle of her belly you could put your head into, and a fourth with a series of flaps that go from shoulder to cheek, from collarbone to chin, and from cheek to nose. Some of those are flesh bridges, with the donor end still attached.

Maybe that's why I dreamed of stapling chickens to people overnight.

It's amazing what we can do with a few sutures and some extra meat. Since good ol' what's-his-name in 4th century Byzantium (Google sez: Oribasius!), we've been fixing facial and bodily defects with varying degrees of success. To wit:

Let's say you want to get a nice, cheap gastric bypass surgery. Let's say you decide to go to a surgeon who does business in a converted storage warehouse (oh, Frog, I wish I were making this up). Let's say said surgeon mis-connects something that leaves you with a sizeable necrotic area in your tummy. And let's say this necrotic area eats its way to the outside of your body over a period of months. Got a huge hole in your midsection? We can fix you up with less of a scar than a Star-Bellied Sneech has after his star-removal.

Or, to take another for instance, there was the patient with valid identification, no criminal record, enough money, and a poor understanding of ballistics. Note to those who would play Russian Roulette: If you're going to try to shoot yourself in the head, be sure, if you place the gun below your chin, that you angle up and *back*, rather than just up. Also, use a nice big bullet. Otherwise, you'll just end up with a fibula reconstruction of your jaw, several flaps rotated from your shoulders to fix your cheek, something weird connecting from your right chest to where your upper lip used to be, and a brand-new nose.

Or the guy who tried to take care of his skin cancer himself. The surgeons took out one eye, the sinus behind and below it, the bone around the eye, and a few other bits for good measure, and grafted a big chunk of meat on from his thigh.

On my usual unit, I nurse people who've gotten the crappy end of the stick from Fate. On this unit, I nursed people who had temporary and disastrous or extended and inexplicable lapses in good judgement. Either way, it's interesting and awful in equal proportion.

And it ends with me desperately trying, in my dreams, to staple frozen chickens to a bunch of people in an old-fashioned hospital ward.

Thursday, October 04, 2007

The Mental Health Day: A Guide For The Overworked

When To Do It

Use Mental Health Days sparingly. If you text-message your boss with the words, "Call me back or I'll jump" and you mean it, then that's the time to take one.

Don't plan them in advance. The best Mental Health Days are those arranged at 4 pm the previous day, when you feel like you'll have a stroke if you have to come in the next day.

Don't worry about how busy it is at work.

How To Manage It

Keep a mental list of those people you work with who've got either an ARM they're struggling to pay off or a taste for Stickley furniture. Those are the work whores who are always happy for some extra hours.

Call them at 3:50 pm and leave a message on their voice mail: "If you hurry, you can pick up some extra hours tomorrow!" Make it sound like a great opportunity.

When they call back three minutes later, act like they've gotten really lucky. Then call your boss back and tell her you've got coverage for the next day.

How To Do It

First, don't set your alarm. You'll wake up at your usual time anyhow, at which point you can either go back to sleep or make a larger pot of coffee than usual.

Second, don't shower right away. Save your shower for the afternoon or early evening, when no normal people would ever shower. You may, however, brush your teeth on your usual schedule. When you do shower, make it sudsy, hot, and take a long, long time.

Third, have a stash of good MHD stuff laid up. My stash includes at least one fashion magazine, some Filipino potato chips, and British chocolate. Ramen is good, as are eggs or frozen pizza. The trick is to have fairly caloric food easily available that doesn't take a lot of effort to prepare. (Note: things which alter your level of consciousness are entirely optional, but might not be a bad idea. There's something nice about ending a big Scottish breakfast with a small nip of Scotch or a half-pint of brown ale.)

Fourth, make a space on the couch. If, for your own sanity, you have to sweep and dust the room first, do that as soon as you get up. Then you can park yourself on the couch the rest of the day with no worries.

Fifth, do nothing that is not fun. If the recycling bins are overflowing, ignore them. If the cat needs to be flossed, put it off. Bills that arrive in the mail on your MHD should be filed immediately and not paid until the next day. If your idea of fun is going for a four-mile hike with the dogs, do it. If it's lying on the couch eating V-Cuts and Flake bars and reading Elle, then by all means, feel free.

How To Recover From It

There's nothing better than following an MHD with a day in which you get a lot done through other people's labor. Get your car washed. Get its oil changed or the inspection done. Get your hair cut. Take things to the dry cleaner's. At the end of the day, you can look at your neatly-checked-off list with a feeling of accomplishment totally unsullied by exhaustion.

In case you couldn't guess, yesterday was my Mental Health Day. I filed my nails, modeled a new pair of shoes for myself, then went out and had a steak. Today I had my oil changed, inspection done, and hair cut.

Now I think it's time for lunch and a nap.

The most important thing about MHDs is to ease yourself back into life slowly, of course.