Thursday, April 30, 2009

In which Head Nurse turns back into a nursing blog, at least temporarily....

I'm back at work. That means I'm too tired to blog at the moment, but trust me: big things are coming.

And it won't just be about siding, windows, doors, bedroom paint, my choice of Roman shades for the new windows, and deck building. It'll be sexy, exciting posts about OMG GONNA KILL US ALL HOLY SHIT WHADDA WE DO RUN RUN RUN AWAY SWINE FLU FROM MEXICO!!

More later. I promise. Meanwhile, keep washing your hands, and keep tuned to this channel. Here at HN we're more committed to the truth than, say, Lou Dobbs.

PS: Cover your nose when you sneeze.

Sunday, April 26, 2009

Can we all please just take a deep breath through our masks?

As some of you might have gathered through careful perusal of this blog, I live in Texas. I live, in fact, not too terribly far from San Antonio, where several cases of THE MOST HORRIBLE PANDEMIC AWFUL ZOMG FLU EVER SEEN were discovered.

And yet, I am not locking myself in my house and refusing to go out. (Well, actually, I am, but that's for reasons totally unrelated to swine flu. It's more like that's my normal routine.) I am not panicking or avoiding large public spaces like the grocery store. I am not dousing myself in bleach or drinking whole pots of green tea. I am not stocking up on ammo or bottled water. I am, in short, while not sanguine, not freaking out.

How come?

Because epidemics *happen*. Once one gets started--and there's ample evidence that this particular flu bug has been moving around both Mexico and the U.S. all season, quietly infecting people--there's not a whole lot you can do besides quarantining the infected and washing your hands. Even before one gets started, there's not much you can do to stay away from viruses on a daily basis besides avoiding sick people and washing your hands.

Given that I can't exactly avoid sick people unless I want to move into a cardboard box, I'm washing my hands. I'm brushing up on the management of cytokine storm (for you non-medical types out there, that's an immune reaction that goes overboard and overloads your organs and kills you) and reviewing what I know about things like respiratory and droplet isolation. I'm gonna put an extra set of scrubs in the car today, since it's likely that at some point, if this dadratted bug continues to spread, I'll be killin' time at the hospital rather than at home.

I'm more worried about the level of ignorance in the general public about viral infections and the transmission of the flu than I am about the flu itself. I'm seeing comments on public message boards from people who want to stock up on antibiotics or just start taking Tamiflu as a preventive measure (neither will work). I'm seeing evidence that most people don't really understand the difference between viruses and bacteria and how their infections differ. I'm hearing talk from people here Deep In The Heart about moving off to Wisconsin and building a hideout.

If there's going to be fallout from this bug, it'll be because people are kinda dumb, not because they fall over dead.

Unless the Gubmint reports that this particular strain of swine flu turns people into zombies, I will continue simply to wash my hands and cover my mouth when I sneeze. I ask you all to please do the same. 

And maybe next time there's a scary epidemic, it can happen *during* the  Nationally Recognized Music Festival, so NRMF will get closed down and I can finally find some parking near the bar. That would be nice.

Saturday, April 25, 2009

In Which Jo Explains Why She's All About The Teeth

Teeth, my friends, are a big deal. When they work properly and are relatively sound, they don't inspire much thought beyond whitening and straightening. When they're not sound, all sorts of nasty things can happen.

First of all, they can fall out. Let's take as read the nutritional problems and aesthetic considerations of having no teeth: I'm more interested in the second possibility: they can rot. That hurts. It looks bad, smells bad, keeps you from eating nice crunchy things like vegetables, keeps you from smiling as widely as you otherwise might. It can also leave you with what's known in the medical biz as a flaming clusterfuck of problems. To wit:

Let's say you're a sixteen-year-old girl who's had minimal access to medical care and no access to fluoridated water all your life. You come to me with a history of a heart valve replacement, complaining now of constant severe headaches and dizziness. What do these two things have in common?

Believe it or not, rotten teeth.

See, if you have really, *really* bad teeth, you're setting yourself up for bacterial infections that can lodge in your heart valves. If the infection in your heart gets bad enough, you'll end up having to have one or more valves replaced because they'll be so damaged that they won't work correctly. *That* means you'll have to be on warfarin, a blood thinner, for the rest of your life so that you don't get clots in the new valves that could travel to your brain and cause you to stroke.

The trouble is, if you don't have access to comprehensive medical care, the original problem (teeth) won't be taken care of. That'll lead to bacterial infections that travel to other places. One of those places might be one or more of the arteries that feed your brain. That, my friends, is known as a mycotic aneurysm, and it is no fun at all. 

Further, since you're already on blood thinners to take care of the clotting possibility, that aneurysm (which is nothing more than a stretched-out, thin spot in an artery) will probably leak blood now and then, damaging your brain.

Oh, and you're four months pregnant.

So let's review the bidding: no medical care, no dental care (to speak of), rotten teeth. Rotten teeth lead to an infection lodging in a heart valve that goes undiagnosed and untreated until the damage is so extensive that the valve has to be replaced. Blood thinners to reduce the risk of clotting from the new heart valve, but (again, poor medical care) the levels of drug in your bloodstream aren't monitored, so your blood gets too thin. Meanwhile, another infection has lodged in your brain and stretched out an artery, which then bleeds a bit now and then and makes you miserable. And warfarin and early pregnancy do not, in the least little bit, mix.

And you're sixteen.

I have never, in all the years I've been at Sunnydale General, seen as many consults on one patient as I saw on this one. We had dental, OB, cardiology, internal med, neurosurgery, neurology, pediatrics...and those were just the medical consults. Her chart was overflowing and she hadn't even been there a week.

The end result was this: we took her off warfarin and put her on a heparin drip. Later, when she was ready for surgery, we took her *off* the heparin and fixed her aneurysm. She miscarried her pregnancy and had to be followed carefully by OB so that she didn't bleed out. Mom and Dad and I sat down for a long, long talk about how on earth to get her teeth fixed and get her on some sort of contraceptive so this didn't happen again. I was gobsmacked by the difficulties they faced just getting her to the hospital in the first place.

I thank the gods who on my birth have smiled. If I lived like she does--and, not to put too fine a point on it, but it's in a house that isn't square and is about six hours away from the nearest clinic, where the weather reports are all in a language that was used as code in World War II--I would be dead by now.

She's lucky she's not. She's lucky one of her parents can read. She's lucky the U.S. Government, in its unending wisdom, decided that several million dollars spent fixing her various problems was a better investment than a couple hundred spent preventing them in the first place.


Fluoride, people. Regular dental visits. If you can afford 'em, do 'em. If you can't, well, you might be lucky enough to find a clinic or university nearby that can do basic care for cheap. If you find yourself flush, you might help a friend get a cleaning.

And floss.

Friday, April 24, 2009

What makes a tough day

Somebody younger than me with a projected survival time of three months (we can do better with glioblastoma; renal cell carcinoma is "not responsive to treatment" once it's spread).

Somebody my age with an aggressive, bizarre, rare form of multiple-sclerosis-like neuromuscular disorder that takes your sight first, then your speech, but leaves your motor skills intact.

Somebody older than me with a family that treats her like a leper because she has MRSA.

Deciding, once and for all, to hold my tongue.

Tuesday, April 21, 2009

Kitten Update

This is why Max is sleeping on the dining room floor rather than on his bed:

Because, really, who could go against this extreme gutulousness?

...and little brother is catching up:

Getting rid of dead wood

Or, In Which Head Nurse Turns Into A Remodeling Blog. Temporarily. Again.

The 75-foot-tall, 60-year-old maple in the back yard has been reduced to a very large pile of extremely massy logs. The lean-to that sat off the kitchen and blocked the view of the window, and which I hated with everything including my toenails, has been reduced to a very large pile of trash and siding.

A whole bunch of different guys came and invaded my back yard this morning. Half of 'em were your typical tree crew, with ropes and great big chainsaws and leather straps hither and yon and one very tough woman who was roping off with the rest of 'em. The other half were the cheerful, dreadlocked hippies from across the street, who'd agreed to take down the shed in exchange for all the wood from the maple and a small consideration. By ten they were all hard at work; by one-thirty the entire character of the back yard had changed.

Boy, is it gonna be hot in here come summer. I hadn't realized how much shade the tree was providing. That, combined with the fact that it held two different species of woodpecker and a group of bushtits (BUSHTIT! BUSHTIT! Hi, Mom!) and a whole colony of squirrels, made it hard to get rid of. When the one-armed tree guy showed up, though, and looked doubtfully at it before saying, "Ma'am, thar ain't no way we can make this here tree safe," I knew it had to come down. The next big storm would've sent it onto the house, probably killing me and possibly killing Max.

The cheerful hippies uncovered a nest of baby rats at one point. Mama sped away as soon as that part of the wall came down, so I lifted up the babies on a shovel (their eyes weren't even open yet) and put them down in a protected place. Mama had gotten them within about fifteen minutes. I'll deal with that later; I didn't have the heart to kill little baby *anythings* whose eyes weren't yet open and who crawled around squeaking pathetically.

I don't have the heart for much, lately. Chef Boy and I are dunzo after five years. The only respectful way to put it is that we had irreconcilable differences and leave it at that. Part of all the chopping down and clearing away the dead, dying, and rotted stuff is so that I can see my way clear to what I have to do with the house. I'm sure there's a juicy metaphor there, but right now I'm not going to examine it.

Anyway, the whole damn shebang of tree and shed was accomplished without too much blood loss and no maiming. Only one person stepped on a nail, and only one person ended up under a falling wall. Luckily, it was a very light, poorly constructed falling wall.

When the tree guys had topped the tree (which was the really dangerous part; past a certain point, it was so rotten they couldn't climb it and had to work overhead) there was, for about ten minutes, a huge solid mass of trunk standing in the yard. All the branches had been cut off, and I could see the shape of the trunk, how it had twisted with the prevailing winds for years, where the critters had built nests, all of its history right there. 

Then all of the tree crew and all of the hippies grabbed the end of a rope and held the top of the trunk steady as one person chainsawed through the bottom of the trunk. You'd think it would take forever to get a tree like that down, but it pulled down surprisingly easily. One big cut, and the whole thing was on the ground. Turns out the trunk was rotten clear through and it never showed.

I'm sure there's some juicy metaphor there, but right now I'm not going to examine that one either.

Monday, April 20, 2009

Product Reviews: Paired X Chromosomes Edition!

It's product review time again, kids! This one is more gender-specific than usual. Boys are welcome to read, but are unlikely to come away with any useful information.

Girly, Foofy Product Review Number One: 1000 Hours Eyelash and Brow Tint

Yeah, I tinted my eyelashes yesterday. Before anybody gets all het up about blindness and skin reactions and so on, let me say that I had no trouble at all with this stuff--no eye irritation, no skin irritation, no nothing. It didn't even stain my skin when I accidentally glopped it all over.

1000 Hours is an Australian product that you can get online. I bought it because I've got white-rabbit eyelashes; they're totally invisible unless I'm wearing tons of mascara. I've been considering dyeing my eyelashes now for a few years, but had been scared off by stories of people getting horrible corneal scarring from the dyes available in the States. After doing some research online and talking to various beauty mavens I know, I went ahead and dropped $25 on the 1000 Hours black/brown tint and tried it out.

The verdict? It rocks. My eyelashes are now visible, but not artificial-looking. The application was easy and fast, and there was no horrible dye smell. I'm keeping this one.

Girly, Foofy Product Review Number Two: Boden dresses

Whoever designs dresses for Boden really likes women. Like, really a lot. I have three dresses from there, and they're all different, and they're all bangin'.

The first is a clingy jersey number with a deep V-neck that gives me a waist. The second is a more structured cotton dress with a U-neck and a full skirt that doesn't make me look like a munchkin. The third, which I just purchased with an eye toward one-hundred degree, one-hundred percent humidity days, is a lightweight crinkle cotton thing with an empire waist that doesn't make me look pregnant.

The verdict? Spendy, but totally worth it. Plus, if these dresses hold up the way other stuff I've gotten from Boden does, I'll be wearing them for years. 

Girly, Foofy Product Review Number Three: OPI nail polish

I don't use anything else any more. I don't paint my fingernails--why bother, when they're short and being scrubbed constantly?--but I do paint my toenails in the spring and keep 'em done through the summer. After brief flirtations with Revlon and other, lesser brands, I'm sticking to OPI from here on out. The polish wears well, the color in the bottle is what you'll get on your nails, and it's easy to take off, no sanding required.

The verdict? Why use anything else? You can get bottles for cheap(er) at places like Sally or your local Drug Emporium.

Saturday, April 18, 2009


If you want your things, they're on the front step.

Friday, April 17, 2009

I finally watched WALL-E.

And it was the damn CG cockroach that got me.

You know? As the ship is taking off, and Wall-E is on it, and the cockroach is yelling, "Come back!"

It got me.


Cryin' over a damn CG cockroach. This has got to be 1) a new low in Head Nurse History, and 2) a sign I need a week off.

Thursday, April 16, 2009

Do Not Want: The brain edition.

Yeah, yeah, I know. I'm a lazy blogger, posting videos from YouTube and graphics from National Geographic. Tra friggin' la; I have the day off.

Which leads, of course, to what I've been doing recently. 

Which is dealing with encephalomalacia. 

Not my own, thankfully; the brain softening of other people.

See, your brain isn't supposed to be soft. It's kinda firm and resillient (in vivo, that is), with its own lovely network of venous sinuses and arteries and linings and ventricles. It's a thing of beauty, whether you're watching it live through a dissecting scope in the OR or on video.

Except when it gets soft. Then it's not so beautiful. Worse, though, than the aesthetic considerations is what encephalomalacia does to a person. Basically, it takes a productive, happy, loving member of society and turns them into a nonresponsive, snoring shell of a person who's getting fed through a tube.

And sometimes we simply don't know what causes it. We can take biopsies galore, we can run every single test on blood and CSF and urine and what-have-you that the most specialized specialists can think up, we can scan and X-ray and poke and prod...and we still don't know why you've all of a sudden become a lump in the bed.

It's frustrating. More than that, it enrages me. Bad enough that somebody that I grew to know a little and like a lot is dying; why on earth can't we figure out why?

The last time this happened, the diagnosis came back primary leptomeningeal melanoma. That happened years and years ago, when I was first starting out in neuroscience. That particular diagnosis was obtained on autopsy. This one probably will be, too.


This, my friends, is the bad thing about nursing: seeing somebody you thought was getting better suddenly get worse and having no hope of an explanation in time to fix them. The only bright spot is that, since we're hip-deep in researchers, maybe the *next* person won't be so badly off. If we can catch whatever-it-is in time. If they have the same thing. If we can figure out what this is in the first place.

Because it's been a while since poutine was mentioned on this blog...

Whatchoo lookin' at?

Sunday, April 12, 2009

Five by Five

It's been a while since I've done a meme, so here's one:

1. Five posts from the blog which I particularly like:

2. Five things of which I am proud:

a. That I work out three to four times a week and thus can lift heavy things
b. That I started the prerequisites for nursing school at 30, despite feeling quite old
c. That of all my colleagues at the hospital, I only really have problems personally with one
d. That my dog likes me
e. That I can get pretty much anything to grow--outside.

3. Five things I'm a bit ashamed of:

a. My temper
b. My foul mouth
c. That I'm a beer snob
d. That I have a terrible weakness for beauty products
e. That every present I wrap looks like a mentally-deficient orangutan went at it with a chop saw.

4. Five things you'll never find in my house:

a. Miracle Whip
b. Far-right periodicals
c. Coors Light
d. A non-dusty surface
e. Anything you can't touch, use, or sit on.

5. Five things you'll always find in my house:

a. Coffee
b. Toilet paper (I have a morbid fear of running out)
c. Brain drugs (ibid)
d. Lots of books
e. Dog and cat hair

What're yours?

Strange Surprise, Endless Science

One of the biggest parts of a nurse's job is education. You teach patients how to take care of themselves in the hospital and at home, you teach family members what to expect from a particular diagnosis, you teach doctors how to write orders for labs that have to be done just so.

One of the hardest parts of a nurse's job is education. You have to make sure that what you're saying is comprehensible and that you're not going too fast for somebody who's already overwhelmed and frightened. You have to be sure that the message is getting across; sometimes, just saying "Don't scrub your incision with a toothbrush" isn't as obvious as it sounds to you, because that person will then go home and scrub their incision with a hairbrush instead (true story). 

And one of the hardest things about educating people is that sometimes you come face-to-face with the maxim "A little learning is a dangerous thing". 

We all have horror stories about taking care of other nurses, or doctors, or people whose family members are nurses or doctors. The main reason those are horror stories is because people who know *something* about something automatically assume that they know more than they do about that thing. In other words, they try to apply what works for them in their own particular branch of medicine to the branch of medicine they're now dealing with. Sometimes it works. Mostly, it doesn't. It's kind of like trying to install plumbing in a new house when all you've done is fix kitchen sinks for twenty years.

So the education part of the nurse's job gets harder. Most of the time, you're starting with a blank slate in terms of teaching a patient. With people who are medical to start with, you have to correct misunderstandings and revise what they know already before you can get down to the basics. 

Nurses have a fun job when they're in this position. See, a doctor or other medical person who's not a nurse will get a totally different picture of what's going on with a patient than the nurse taking care of the patient will. Sometimes the difference is in the details; sometimes it's more overarching than that. Usually the conflict, if there is one, has to do with the nurse's care of the patient rather than, say, a difference of opinion with the doctors on the case. 

No, I'm not taking the catheter out. I understand your concerns about a UTI, and I share them, but right now my bigger concern is keeping accurate records of intake and output, because the person in the bed has a condition that causes trouble with their electrolytes. Yes, it is typical to use anticoagulants in addition to mechanical therapies to prevent DVTs, but in this case, anticoagulants could potentially cause harm, so we're going with mechanical therapies and frequent turning. Yes, I agree with you on the pulmonary toilet angle, and I'm going off right now to rewrite the respiratory therapy orders. 

It's hard to remember, when you're getting quizzed by the guy with the MD whose daughter is in the bed, that it's not about you. It's about the care that his daughter is getting, and you just happen to be the person in line for questions today. It's also hard not to simply say, "Look; you might know more about allergies/rheumatology/endocrinology/dermatology, but I know more about *nursing*" and leave it at that. It's hard to educate, explain, and clarify with someone who is just as frightened (or more so) and overwhelmed (ditto) than the average bear, yet still keeps jumping ahead of you or going off on tangents.

So what to do? Keep calm. Explain everything, and don't assume that because the person you're talking to is medically-inclined you can gloss over things or skip stuff. Respect their opinions. After all, this is a doctor/nurse/RT/PT/whatever you're talking to; there's a good chance that their knowledge of your patient combined with their knowledge of the sciences will show up things you've missed. Remember that they know more, so they're liable to be more aware of possible complications and Scary Stuff than a layperson. Be kind. It can't be easy to know what they know and be seeing what they see, especially when it's their Baby Daughter/Beloved Husband in the bed. Keep in mind that medical folks are people too and might sometimes forget to eat or sleep, or might just need to be sent home to relax for a while. 

And don't act too amused when they express surprise that you know so much about what's going on. 

Tuesday, April 07, 2009


Monday, April 06, 2009

North, northwest, the stones of Faroe*

Some days do not suck.

Those are the days when, against all odds, everything goes right. The meds you need are there on time, without you having to call the pharmacy four times. The equipment you need somehow magically appears on the shelf in the clean utility room, despite nobody having needed that particular machine in four months.

And those are the days when your demented patient, who has advanced Alzheimer's, remembers only one person, and remembers them well: the man she's been married to for sixty years.

For a few hours, as long as he's at her bedside, she's completely oriented and alert. She understands that she's in the hospital, that she's not well at the moment and that she needs the antibiotics you're putting into her PICC line, that she's not to pull out whatever lines and leads you have attached to her. She doesn't fight you, she doesn't try to get out of bed. She just stays in bed or up in the chair, talking to her husband, perfectly happy.

You see a lot of things as a nurse. I've seen people die, and seen people born, and seen people end up trapped somewhere between the two states, with no way of resolving the issue. I've seen people forget everything they were, and people come back from what we all thought were insurmountable injuries. The best thing ever? Was watching my confused, distressed, combative patient become the person she was before she was admitted--all due to the man she'd spent two-thirds of her life with.

Would to God we should all have somebody like that.

Sunday, April 05, 2009

Things They Don't Tell You In Nursing School, Part Four Hundred Seventy-Two:

Some days suck.

They're not the days with three codes and a couple near-misses. They're not the days when some idiot resident decides now is the time to scream at you in the nurses' station. They're not the days when big things go wrong; they're the days when a multitude of tiny things don't go quite right.

Mostly, it's because of people. Not patients--people. Patients are, though we tend to forget it, basically people just like we are; they just happen to feel like shit and need good drugs. 

There's the patient who has a dozen excuses for why he simply can't walk right now. There's the patient who is inexplicably rude to you, or the one who's offensively rude about you in front of a doctor or family member. There's the patient who, for some reason, you just can't do anything right for, no matter how hard you try. They're all people, and most of 'em aren't as big of assholes as they seem while they're in your hospital.

Some days it's easy to channel your inner Cherry Ames and just keep on plugging. Other days, the sorts of days I'm talking about, you get frustrated and have to stop yourself from running screaming out into the night (or dawn) as soon as your shift ends.

I once had a patient who had a big, nasty brain tumor in her frontal lobes. It turned her from a bearable, if brusque, person into the sort of alkaline bitch you wouldn't want your worst enemy to meet. For a week, I had no problems at all dealing with her, and could even sweeten her mood a bit--all while getting charts open on time and handling five other patients with varied (and more pressing) needs.

This has not been one of those weeks. When a patient was insulting about a resident to me, I snapped back, "Keep a civil tongue in your head" and handed her off to my (angelic) charge nurse without a backward glance. When a patient gave me yet another reason why she simply couldn't turn over in bed just now, I growled "You're turning, and that's final" and then hauled her over on her side before she could protest. When one other patient said to me, after I finished starting a particularly tricky IV, "I bet you don't have a boyfriend; it hurts to hold your hand," I had to get out of the room quickly in order to hide the ridiculous tears that started in my eyes.

That's what they don't tell you in nursing school: that dealing with people is hard. It's rewarding and satisfying, yes, but it's also really, really hard at times. You get lessons on how to handle the really difficult, insane people, but nobody prepares you for the exhausting, grinding, disillusioning work that makes up some days. 

What's worst about those days is how lonely you feel during and after them. It feels like, no matter how much your coworkers sympathize, you're the only person who's ever had a day this bad in the history of nursing. You feel inadequate, you wonder what the hell is wrong with you that you can't manage to take care of four or five sick people without nearly losing your mind by noon, you think seriously about applying at Starbucks. 

The good news is that those days, those weeks don't last forever. Eventually something turns around: the surgeon who's known as a stickler compliments you spontaneously, or the raving bitch in room 9 decides you hung the moon. Sometimes it's as simple as having all your meds and equipment there when you need them, and avoiding the running-around that characterizes so much of the average nurse's day.

So: If you're a new nurse, or a more experienced nurse, or an old, old, old nurse (and, believe me, after a week like the one I've had, you feel old-old-old), don't lose heart. Eventually the moon will move out of Klutz and things will stop sucking as much as they do now.

In the meantime, you still have the end of the shift to look forward to.

Saturday, April 04, 2009

The following communication will not be therapeutic.

If you have a patient-controlled pain relief pump that is giving you thirty micrograms of fentanyl every five minutes with an optional bolus of one hundred micrograms of the same drug every hour, and you've been taking advantage of that bolus every hour on the hour for the past twelve hours, and you've also been taking more than one hundred milligrams of baclofen and more than one hundred and twenty milligrams of oxycontin and various other milligrammage of narcotics twice or three times daily, please do not try to get me to believe that you are going into withdrawal because I have removed your fentanyl patch, which expired three days ago.

Because I will look at you and say, "Really?"

Then, when you do not respond, I will say, "Really?"

And when you tell me that you're feeling queasy and you want Phenergan, because ondansetron doesn't work for you, I will say, "Of course it doesn't."

It has been a long week.

Friday, April 03, 2009

This has been running through my head all day long... I dealt with five people who all had interesting, obscure things wrong.

Yes, I know there's nothing to look at. Just listen. 

Lyrics here.

I heard this song first on a Weekend Edition broadcast; Case said she'd often heard love referred to metaphorically as a force of nature, and wondered what would happen if an actual force of nature fell in love with a person.

It would make even *my* most Crazypants McStalkerson of boyfriends look sane, that's what.

Thursday, April 02, 2009

Random 0557 musings, or, how having kittens means never having to say...

"Honey, let's sleep in in the morning."

Kittens love to play at night. Kittens love to play in the morning. In fact, kittens (these kittens, at least) play all the time, with short breaks for naps and eating and using the litterbox. It's mostly playtime at all times, though. Which means, between kittens and Max waking me up ("It's four a.m.! C'mon! Time to get up!") I've gotten about....oh, nine hours of sleep in the last two days.

I got an email the other day from a patient's family member. Yes, I do occasionally--very occasionally--give out my email address when I've been taking care of somebody for a really long time and have gotten close to the patient or family. Anyway, the patient's brother wanted me to know that the patient had died.

Just like that. And it was somebody that we all had expected to get better.

Sometimes inexplicable things happen, and you're left holding the various bits of the story, wondering what the hell went wrong. It's hard when it's somebody you've cared for who's been really, really sick and nobody expects them to live, but it's not as shocking and kick-in-the-gut as it is when it's somebody who, two weeks ago, was doing relatively fine.

I mean, they come in sick as a dog, you pop 'em into the ICU, spend a month or so balancing electrolytes and stabilizing them to the point that they won't croak during surgery. Then you do the surgery, and it goes well, and you transfer 'em to acute care. And, in acute care, you spend a couple of weeks (or more) getting 'em up, making them eat on their own, rebalancing their electrolytes, making sure they pee, walking 'em around the hall...and finally discharge them to rehab.

Where they suddenly drop dead. Not the rehab's fault, by the way. Sometimes things happen.

It makes you really good at dealing with loss in a healthy way, I'll say that. If you don't figure out how to handle things well, you won't be working/alive very long. 

If you're me, you lift very heavy things and run in between sets until you're about ready to barf. Then you do lots of heavy yardwork. Then you have a nice dinner with your favorite chef and then play with kittens, and finally go to bed and hope to sleep. When you wake up, it might be three seconds before you remember why you've got that lump in your gut.

And then you pick up the bits and look them over again, wondering what the hell went wrong.

Sometimes people just decide to die. I've seen it happen--where a person makes a conscious decision to kick off, and a day or two later, they're dead. There's not enough time to get them into hospice or even transition to comfort care: they've made up their mind, and that's it. Maybe that's what happened here. Could be.

Wednesday, April 01, 2009

What to Expect When You're Expecting A Ventriculostomy!

Back to work, kids! Today, we'll learn about (cue music) Tubes In Your Brain!

(I really wish I could hire James Earl Jones to say "tubes in your brain". That would be cool.)

What's a ventriculostomy, anyway?

Simply put, a ventriculostomy is a tube that goes into a ventricle in your brain to drain off CSF.

Simply put into English, it's a tube that a surgeon runs through your skull and into one of the big, fluid-filled spaces on the inside of your brain (yes, your brain has big fluid-filled spaces on the inside) in order to drain off what's called cerebrospinal fluid. Cerebrospinal fluid surrounds your brain, penetrates it...oh, sorry. *ahem* It does surround your brain, though, and it cushions it and provides a number of different benefits.

So why the hell would I need a tube in my brain?

The reasons aren't good reasons. That is, you're obviously not doing all that well if we're needing to stick a tube in your brain.

The three big reasons to get a ventriculostomy (or "ventric", for those who sling the lingo) are head trauma, including brain bleeds; hydrocephalus that happens really fast, or an infection inside the brain itself that needs to be dosed directly with drugs. We also sometimes put them in during or before surgery, or use them for chemotherapy, though those are less common, at least that I've seen.

Okay, great. What's in this for me?

Well, if you remember your anatomy, you'll remember that there's only room for your brain inside your skull. If you should add more stuff there, like extra CSF or extra blood, your brain gets squished. A ventric can help your brain not get squished by giving it more elbow room. Not that your brain has elbows, mind you.

If you stayed awake during the second hour of anatomy, you might remember that there's something called the blood-brain barrier. Normally, this nifty anatomical trick keeps your brain safe by filtering out all the harmful stuff that could get into your bloodstream, thus keeping it away from the delicate and mostly-defenseless brain. Unfortunately for us, the blood-brain barrier also keeps things like chemotherapy drugs and antibiotics out of the brain. We occasionally have to stick 'em into the brain directly to see an effect.

How do you get one of those ventriculowhatevers?

Sit down. You're gonna love this.

A neurosurgeon drills a hole in your skull at the crown of your head (roughly speaking) and sticks a tube in, aiming for your nose.

Best part? At our facility, it's done at the bedside. With a nurse holding your head and speaking soothing words of comfort (unless it's me, in which case the nurse is humming a little tune and trying to block out what's happening). It's done with a hand drill, usually, unless it's in the operating room, in which case it's done with a power drill. Oh, and lidocaine. Lots of lidocaine.

Yikes. What happens next?

Well, a ventriculostomy, unlike a lumbar drain, is open all the time. It's connected (as with a lumbar drain) to a sterile, closed system. It's also connected to a leveling apparatus that in some cases is kind of fancy and in others involves, like, an old radio antenna* and a marked pole. 

What happens next is "not a lot, really". In other words, if you're the recipient of a ventric, you should begin to feel better fairly quickly (if you're in a state to feel much of anything at all). You might have a dull headache for a while, given that somebody's punched a hole in your brainbox, but that's it. 

Your nurse will watch you like a hawk, making sure that the ventriculostomy drain stays at a particular level, ordered by the doctor, and that there's not too much or too little fluid draining out. If you need drugs administered through the ventric, you'll get those administered by a doctor, through a syringe connected to the tube setup.

What can go wrong?

The biggest threats are infection and overdraining.

See, whenever you penetrate into the brain, you're opening that box of troubles right up. Ventriculostomies are done in a sterile field, of course, and we're paranoid about making sure nothing horrible gets in to the hole. Sometimes, though, things can happen that mean you end up with an infection in the ventricle. In that case, we treat it with stuff instilled--you guessed it--through that ventric.

If your brain is overdrained of CSF, it sags. Sometimes it can herniate (bulge through) the hole in the bottom of your skull. This normally leads to death. That's why the nurse who'll be taking care of you is hopped up on caffeine and hovering over you like a hen with one chick: it's her responsibility to make sure nothing happens (like a sudden position change) that could cause you to overdrain CSF.

The whole infection threat is why she's drawing blood and constantly checking your temperature and asking if your neck is stiff, too. 

What happens when you guys are done with tubes in my brain?

Well, we take it out. The ventric tubing gets pulled out by a doctor, and that's it.

No, really. Sometimes you might get a stitch to close the hole in your scalp, but usually we just slap a piece of sterile gauze or a bandaid on there and let it be.

Holy shit! You're kidding, right?

Nope. Not in the least. The skull itself might take a while to heal, but your scalp heals really quickly--and your brain just sort of squooshes shut around where the tubing used to be. what?

Well, presumably, if we've taken out the tube, we've solved the problem.

If your problem is hydrocephalus, we've probably put a shunt in (more about that in a week or so) to help keep your CSF pressures normal. If the problem is an infection, we're done with instilling drugs into your brain. If the problem is a tumor in your brain, we've installed something called an Ommaya reservoir to pump little doses of chemo toward that tumor on a continuous basis. Whatever it is, we're done with tubes in your brain.

That's all, folks! Now you can be happy you've never had to have a ventriculostomy!

*No, really. I had a confused patient once who kept fiddling with and breaking off the leveling arms on his ventric setup, so I had to replace the leveling arm with an old radio antenna I scavenged from the surgeon's lounge. Just call me MacGyver.