Hi-ho, the derry-o

So I'm at home, organizing stuff with Wigstock: The Movie playing in the background. I've never seen it before and I do like talented drag queens, but still I'm barely paying attention. Near the end of the movie I look up during Crystal Waters drag king performance and say to myself, "Is that Michael K. Williams, better known as Omar on the best TV show ever The Wire, as a back-up dancer?!" Through the magic of Tivo (and a quick Google to confirm that he was a dancer for Waters), it is confirmed. Michael K. Williams, pre-scar, is in Wigstock: The Movie furiously workin' it.

Couldn't find a online clip of it so I just took pictures off the TV screen.

What a difference a day, or a weekend, makes

Today was much, much better. My preceptor apologized for how crazy it got last week and I admitted that I was somewhat demoralized by the experience. She said I did okay and that run-of-the-mill cases were never like that. I offered that other nurses came up to me while I was finishing up paperwork to see if I was okay and had my preceptor left me and gone home?! It was just paperwork and the oncoming shift had already taken over, but it was nice to see that they cared. We laughed about her now getting a reputation for being a harsh, cruel bitch who tosses her preceptees into the deep end of the pool. And then releases the sharks with lasers on their frickin' heads.

We again took two empty beds, but my preceptor (I've got to think of a decent pseudonym for her so I can quit typing "my preceptor") promised that she'd get me something more entry-level. It was another pump case, what we call it when the patient has been on a heart-lung bypass machine during surgery, but a much more stable one. In addition to getting the workflow down that much better, I learned that shivering unrelieved by warming blankets is likely due to a reaction to anesthesia and that Demerol treats it. Cool. I also learned not to throw away IV tubing from surgery even though you're not presently using it because you might need it later to infuse fluids. Noted.

Much better day. I absolutely can do this. Yay.

Brutal day

Thursday night I came home dejected. It was a brutal day at work and I thought, "Do I really what to do this? Can I do this?"

My preceptor has been fairly aggressive in pushing me to take on greater challenges during my orientation. Rather than follow a gentle curve of increasing difficulty—stable post-operation day 2, AV fistula, fem-pop bypass, and so on—we've been leapfrogging ahead as she feels I'm ready. Her assessment of my ability is inevitably higher than my own. She's not cruel or anything, just confident that I can handle it. She's always there when I drop the ball on details, which I do more than I like. I've been doing great with transfers out to less acute floors and stable patients so she wanted me to get more practice admitting patients fresh from surgery. On Thursday we took two empty beds and bided our time with a staff meeting and a discussion of medications.

Our first admitted patient had just undergone a carotid endarterectomy where the surgeon opens the carotid artery on one side of the neck and removes the plaque that is either narrowing the artery or is unstable and may rupture. I haven't seen it done myself, but I've been told it looks like they're scraping out chicken fat. So eat healthy and exercise! On the scale of things, it's not a big surgery. The patient had already been extubated (breathing tube removed) and was awake. I needed to assess her status, keep her blood pressure under control so she wouldn't blow the carotid sutures, and monitor her neurological status on the small chance she could have a stroke. There's other stuff too like talking to family and giving meds, but the first three are the big ones.

She's was doing well and then her urine output dropped. Almost all the patients out of surgery have a Foley catheter in that drains their bladder. It's important that we accurately record their output and after anesthesia it takes awhile for conscious control to return. We like to see at least 30 mL an hour out showing that the kidneys are being adequately supplied with blood to filter and that they are doing so. Less than that for two hours triggers a call to the doctor. In this case, doctor wanted a rapid infusion of fluid running in, what's called a bolus. Problem was that this patient's IVs were running into veins in her arms rather than a larger, central vein. Run the fluid too fast through her peripheral IV and the vein could blow. Which it did. Not really a big deal, saline running into the tissues is going to cause some localized swelling and maybe some soreness, but no serious effects. Luckily the patient had another working IV in her other arm so I switched it over and took out the blown one. These problems, low urine output then blown IV from the fluid bolus, are minor. You have to do something about them, but fairly easy to handle.

So she's mostly squared away when the next patient rolls out. This patient had multiple coronary artery bypasses and was coming out mechanically ventilates and unstable on multiple IV medications to maintain his blood pressure, heart rate, etc. I'll talk more about what a patient who's had open-heart surgery goes through in a future entry, but basically they've had their sternum cut open, heart stopped, bypasses sewn in, heart restarted, sternum closed with wire, and tubes inserted to drain fluid (or possibly air if a lung was collapsed for the surgery). Heavy duty stuff. This guy was quite unstable and had me running for hours trying to get everything done.

I don't have much experience titrating IV medications (increasing or decreasing rate of infusion to keep say, systolic blood pressure below a number set by the physician), in fact we weren't allowed to regulate them while I was in nursing school. I worry about that because while I understand what they do, all I know about dosing is "start low and go slow". The nurses at work tell me that I'll pick up what to start them at and by how much to bump them up or down. Can't come soon enough for me. Whenever this patient was starting to get out of range and my preceptor wasn't immediately available, I would be saying, "Uh, [fellow nurse] which one should I turn up and by how much or maybe I should just wait and see? Ack." Hard to detail what all happened but we had doctors seeing him about five more times for additional orders, procedures, and intense staring at monitors. Keep in mind that I still had that other patient who needed to be monitored, medications given, etc. At the end of the day, I stayed 30 minutes after just to finish all my charting—documenting my narrative of what happened and what I did about it.

Exhausted, I trudged home from the bus stop thinking, "Am I in over my head here? Maybe I should have just gone to a regular ICU."

Nurse humor

The other day I was listening to some nurses talk about patients having to go back to surgery because of excessive bleeding. "Yeah, sometimes they have a prolene deficiency, hypoprolenemia," said one to gales of laughter. I didn't so much get it. Later I discreetly asked my preceptor what I was missing. Prolene is a kind of suture material the cardiovascular surgeons use. Now that is funny.

Heh. Uh, so -emia means "concerning the blood" and hypo means "below normal" so the comical neologism hypoprolenemia means "the surgeon didn't put in enough stitches." See? Hilarious. Less so cause I had to explain the whole thing, but still funny. Well, maybe not to the surgeons.

Spoiled rotten

I forgot to mention this earlier, and this is hopelessly dorky, but the unit where I work has a stat lab to rapidly process our lab samples. Just a couple mLs of blood and I can get a CBC, BMP, and blood gases? With results in five minutes? Glory be.

What I do, Part I

I’ve held off describing my job because I wanted to get my head around it first. It’s going to take a good year before I’m comfortable in my role, but I think I’ve got the basics down enough to at least sketch in an outline. I work in the CVRR, cardiovascular recovery room. The purpose of the unit is to receive patients directly from the operating room where they’ve undergone surgery on their heart or vasculature, recover them from anesthesia, and stabilize them to the point where they can be transferred to an acute care floor or ICU.

Some of the common surgical procedures are carotid endarterectomy (removal of plaque to prevent further blockage), coronary artery bypass graft (CABG, or “cabbage”), heart valve repair or replacement, femoropopliteal bypass (fem-pop, should be a music genre), and arteriovenous graft creation for dialysis. We also get transplant patients - heart, lung, kidney, and I think liver – but that’s much higher level nursing than I’m capable of at this point. The workflow right out of surgery differs according the procedure done, but generally the receiving nurse sets up the bedside with monitoring (which displays EKG, blood pressure, heart rate, oxygen saturation, temperature), suction for oro-nasal and/or chest tubes, oxygen, and supplies like tubes for lab blood draws. When the patient wheels in the nurse hooks up the lines, takes report from the anesthesiologist, and does a rapid assessment of the patient.

Assessment is a huge part of a nurse's job, whatever area of care they're in. It means collecting data such as vital signs, the look and feel of a patient, the statements they make and documenting it to establish trends. It's also the first step of the nursing process known by the acronym ADPIE, assess, diagnose, plan, intervene, evaluate. The nursing process is how nurses organize their care. I'll go into more detail about patient assessment in a future entry.

Getting back to the fresh surgical patient, the goal is for the patient to remain stable in terms of blood pressure, heart rate, oxygenation, etc. This is often accomplished with medications given intravenously. Doctors will write an order like, "Titrate to keep SBP <150." This means the nurse will adjust the rate of infusion of the specified medication so that the systolic blood pressure, the top number representing peak pressure, is maintained below 150. Learning the medications used and why, the interactions between them, and the starting dose to the max dose are pieces I'm slowly acquiring.

Man. I just read over this and realized that I've left a lot out. By way of explanation I'll say this, there's a thing that happens to nursing school students about halfway through their first semester of upper-division classes. They're not civilians anymore. They have a hard time talking or even thinking like non-medical professionals. When they try to explain something, their speech is full of acronyms and jargon before they backtrack and start again, trying to translate effectively. The ability to summarize complex info and relate it on a developmentally appropriate level takes a while to catch up, if it ever does. All this is to say that I forget sometimes how much medical stuff is crammed in my head that I take for granted. So, if I vacillate between being overly simplistic and talking far above your heads, just let me know.

Whew. This post really just flew off the cohesion rails. Oh well. I'll get the train back on track tomorrow.

I think the word I'm looking for is awkward

Today one of my patients was doing well after her surgery and so her doctor wrote orders for her to be moved out of ICU to a telemetry floor where she would be monitored constantly for cardiac problems via wireless EKG. I went through the normal process of a transfer, faxing a written description of her status to her new floor, calling a verbal report to the receiving nurse, disconnecting the IV lines she didn't need anymore, getting her into a rolling chair for the trip, all that. I called the waiting room and asked that her family meet us in the hallway for the trip.

We chatted pleasantly as we rolled to the elevator. I got in first pulling the chair in after me backwards. This is so if there's an emergency, the patient is facing forward. The family filed in after us and we're off. Only we started going down, not up. Oh well, no big deal right? We'll just go down a floor or two and then right back up. At the second basement level, I heard and felt the back door opening. "Dang, please don't be what I think this is going to be."

A quick look back confirmed that yes, the back door was opening because a few undertakers were bringing a body out from the morgue. Oh joy. It was covered of course and dead people don't really bother me, but I was acutely aware that the family of a rather recently critically ill heart patient were staring right at the guys in dark suits and a body bag on a gurney. Thankfully the patient was facing the other way. We all avoided looking at each other and the undertakers stepped back to let the door close. But it wouldn't.

Sure it would start, but then it just popped back open as if to say, "Are you sure you don't want to get off? Really? I mean the morgue is right here." The nervous chuckles stopped after the third time. Finally, dinging and shaking, the door ker-rawled closed on the fifth attempt amid the clearing of throats and intense floor-staring. All I could think was, "I've got to say something. What's the right way to transition from a very real, non-metaphorical confrontation with death?" I went with a far-too-effusive description of her new, private hospital room.

Missing Austin mightily

I've got the profound homesickies.

I miss my friends and the bats and the tower lit orange and a friendly, laid-back populace and the (only slightly smug) awareness that I'm in the oasis that is the political desert of Texas and thinking of how great the park system is every time I drive along Lamar between 15th and 29th and wandering around Emo's waiting for the music to start and fairly-good-to-very-bad art on the walls of every damn coffee shop and cafe and seeing the stalwarts at the SXSW volunteer call and flipping through the new used records at End of an Ear and breakfast tacos on the morning of tests and sitting in the balcony at the Paramount and waiting forever for my burger at Casino El Camino and and and.

Being away from them, I appreciate how wonderful it truly is to have so many long-time friends. Back in Austin I regularly hung out with people I've known for 8, 12, 15 years. That depth of shared time and experience is...I don't know what I'd be without them. It's a downer to have to start over some place else. Frankly sucks is what it does. I'm determined not to wallow though.

Now, can someone tell me where the cool people with knowledge and reason who like making and appreciating all manner of art congregate in Houston?

My favorite moment from SXSW 2007

Standing next to my friend when he was so overcome with joy at Bob Mould's solo acoustic set that he ended up in tears. It was very touching to see a friend's love of music just spill over like that. Yay music! Yay friends!

And you thought getting body checked was rough

Hockey player Richard Zednik is in stable condition at an ICU after having his carotid artery sliced by a skate blade while playing last weekend. I'm not big on hockey, but I am a huge fan of carotid arteries. Especially keeping them intact and patent. The video is not explicit, they wisely avoid showing a lot of blood. Watch the end to see the freak accident that caused it. I hope he recovers without permanent neurological damage.

The squirrel who looks like a tail-less cat

While going through stuff I've had stored away, I came across what I can only guess is the first story I ever wrote back in 1st grade.



The text reads,

"Wans I took a bike ride. I saw a tree and a hill and a filld of flowrs. Well at that minit a squirrel jumped out of a tree. And landid on my bike I rod my bike home and cap the squirrel for a pet and I howp I have anothr avichr."

My spelling has vastly improved (what's with all the missing "e"s?), but sadly my illustration skills have not.

A bit of advice I picked up recently

If you ever find yourself reading a book that, judging from its cover against common wisdom, is full of sardonic observations meant to produce mirth but regards a subject with which you are currently struggling so that instead of laughing out loud or even wryly smirking you are forlornly gazing out a window at an overcast sky or even quietly sobbing, then put that book aside until some distance is achieved. It'll be funny in a year.

Lentil soup

While listening to a bunch of songs last night, I prepped the ingredients for lentil soup. Here's all the ingredients ready to go into the crock pot.


Not pictured is the bouquet garni, the little bag of seasonings that makes the difference between a bland bowl of sustenance and delicious tummy-so-happy time. I don't pretend to understand spices. Aside from dill and rosemary, I have no idea what most of them do to influence the taste of a dish. I just trust recipes and throw in the bay leaves, tarragon, whatever.

I got up in the morning, threw everything in the pot and went off to work. After a about 9 hours of cooking, here's the messy blending part.


Here's the soup. Sure it looks like undifferentiated brown slop, but damn it's tasty with parmesan cheese and a hunk of crusty bread.

Weekend back in Austin

Went back to Austin this weekend to visit friends, pick up some leftover items from my old house, and do some shopping. Friday night was an art opening at End of an Ear where I bought a bunch of music. Then it was off to El Azteca for dinner. Their tamales are far below my gold standard (Curra's), but previously I've loved their mole and the salsa is always incredible. Next door was a hideously excessive Valentine's Day display in a flower shop. This shrimp appears to be allergic to itself, check out those lips. And what the hell do shrimp have to do with VD anyway? Not a shmoopy animal like bears and kittens. The night ended back at Mybloody's where we just sat around and goofed off.

Saturday was all about the acquisition of material objects. A good, steady paycheck will do that I've ascertained. At least I was buying books, music, movies, and furniture. Except for that last thing, I was very happy to be spending money at Austin businesses. Yay for shopping locally. The furniture was from IKEA. Yeah I know. I just needed to something cheap and decent looking. I only need it to last a few years.

Mybloody was all faux-exasperated that I hadn't ever been before, so he showed me how it worked. Thanks buddy! And of course at IKEA we gays run into other gays Mybloody knows. How embarrassingly cliche. Saturday night was a sedate one at Joolie & (name withheld cause I don't remember if he's amenable to being publicly identified)'s. I had to leave early to go to sleep as A) I'm on that sort of schedule what with the getting up at 5 AM for work and B) I had to get the rental car back to Houston.

After a nice, sedate ride back to my new apartment on Sunday, I did laundry and assembled furniture. All-in-all it was a fun, productive weekend though far too brief.

Where I do the nursing thing

Thursday was my first day taking on the total care of a patient on my unit. I wasn't that nervous as my preceptor was three feet away and this patient wasn't as high acuity as others I taken care of in the past. What was different was that I didn't have to ask the primary nurse to get medications for me or print the paperwork for blood draws for the lab. I was the primary nurse. I talked to the family on the phone, discussed the patient's status with the doctors, and endeared myself to at least one nurse on the night shift by bathing the patient before shift change. A good day.

I haven't really talked about the unit where I work. It's called CVRR, cardiovascular recovery room. We get patients right out of surgery for coronary artery bypass grafts, heart valve repairs or replacements, dialysis fistulas, heart transplants, anything to do with the heart or vasculature. The idea is for the patients to be on our unit for a limited amount of time, around a day, before they move on to a regular intensive care unit (ICU) or a monitored floor (called telemetry or just tele). Right out of surgery, the primary concern is keep them hemodynamically stable (heart rate, cardiac output, blood pressure, etc. interacting well to maintain the patient) while they recover from the anesthesia. As soon as possible, we want them off the mechanical ventilator and moving about. There's a lot more to it than that but I'll save some for future posts and for a time when I actually understand it better!

The closest I get to a poop joke

When I was studying for my nursing license exam a few weeks ago I came across a diagnostic test that was new to me. It's called a defecography. Here's what my book says:

Defecography
- Measures anorectal function.
- Thick barium is instilled into the rectum, fluoroscopy is performed, and the
function of the rectum and anal sphincter is visualized while the client attempts to pass the barium.
- No preparation is required.

I disagree. Plenty of mental (and possibly emotional) preparation is necessary to receive a barium enema that you must then crap out while being judged on your ability to do so by medical professionals. They probably videotape it too. Realizing this is a terrible image with which to leave you, I thought of an alternate definition.

defecography /def·e·cog·ra·phy/ (def-e-kog´rah-fē)
n.
The collected musical output of the band Def Leppard: "Photograph" is the best song in all of the Defecography.

Unintential dramaturgy on public transportation

For a fleeting moment, I thought, "Maybe this is one of those theater in public spaces-type troupes." But no, the drama unfolding across the aisle was real.

Cast of Characters

YOUNG MAN, tattooed and deliberately scruffy with fake animal claw earrings
SELF-STYLED HUSTLER, 40, red-faced and somewhat grimy from being outdoors all day

The play takes place on a half-full city bus in Houston on a Saturday afternoon.

At RISE:

(YOUNG MAN sits at the front of a clearly identified Houston bus. He is engrossed, reading Douglas Adams' Dirk Gently's Holistic Detective Agency [great book BTW]. As the unseen driver opens the door at a stop, SELF-STYLED HUSTLER enters right carrying a beat-up plastic shopping bag. He has an unzipped jacket on, but no shirt underneath. His pants and shoes have seen better days. He looks around and, despite plenty of empty seats, sits right next to YOUNG MAN.)

SELF-STYLED HUSTLER

Hey man. You got a computer?

YOUNG MAN

(annoyed)

What?

SELF-STYLED HUSTLER

I said, you got a computer?

YOUNG MAN

Yes.

SELF-STYLED HUSTLER

I'll tell you what then. You can buy this computer stuff off me.

YOUNG MAN

No.

SELF-STYLED HUSTLER

C'mon! Buy my computer shit.

YOUNG MAN

Leave me alone.

SELF-STYLED HUSTLER

Damn! I always said Texas people were rude. Why you gotta be so rude?

(Unseen bus driver, clearly perturbed, makes announcement off stage)

Will the gentlemen who just got on please pay at the front. (beat) Now.

(SELF-STYLED HUSTLER lurches up and goes right to pay fare, leaving bag on floor in front of seat. He fumbles with a wallet before finally extracting a dollar and feeding it into the fare box. YOUNG MAN meanwhile shifts over to take up both his and HUSTLER's seat, then kicks HUSTLER's bag downstage. SELF-STYLED HUSTLER returns and pulls up short when he sees the situation.)

SELF-STYLED HUSTLER

Hey man --

YOUNG MAN
(Barely suppressing rage.)

You're not sitting here. Stop talking to me and go sit somewhere else.

(SELF-STYLED HUSTLER grabs bag and stands right facing away from YOUNG MAN, but clearly still addressing him and the rest of the bus.)

SELF-STYLED HUSTLER

I hate people from Texas. They're either dumb or pretending to be smart.

(As the bus pulls up to next stop, SELF-STYLED HUSTLER exits, yelling over his shoulder)

Dork!

(YOUNG MAN scowls as he reads his book. Curtain.)

I'm not sure what to call it. The Worst Salesman Ever sums it up nicely, but it's rather plain. Yelling and Insulting Your Way to An Almost Violent Non-Sale is a little too on the nose. Ideas?

A damn fine book

A couple days ago I finished reading one of my favorite books again, The Perks of Being a Wallflower. Even on this, the fourth go round, it astounds me how perfectly the author Stephen Chbosky captures how it is to be an awkward teenager who's just figuring himself out and finding The Smiths, Catcher in the Rye, and audience participation at The Rocky Horror Picture Show through new, "weird" friends and a perceptive teacher. The book is just amazing and it makes my insides smile to know that it's also widely read. I'd go into more detail, but I love it too much not to let you experience it fully for yourself. Just to give you an idea though, here's a sample of the way Charlie, the protagonist, thinks. He's just finished making his first mixtape for a friend.

"I had an amazing feeling when I finally held the tape in my hand. I just thought to myself that in the palm of my hand, there was this one tape that had all of these memories and feelings and great joy and sadness. Right there in the palm of my hand. And I thought about how many people have loved those songs. And how many people got through a lot of bad times because of those songs. And how many people enjoyed good times with those songs. And how much those songs really mean. I think it would be great to have written one of those songs. I bet if I wrote one of them, I would be very proud. I hope the people who wrote those songs are happy. I hope that they feel it's enough. I really do because they've made me happy. And I'm only one person."

Ach, nailed it. Really, find it and read it. I've never been in a bookstore that didn't have it (some put it in young adult, some in regular fiction) and I see it pop up in used bookstores regularly. Also, praise and glory to Carole for giving me the book in the first place. Whoo.

Role confusion r/t gender stereotyping, pride, and an unfortunate shade of blue-green

For the first time since moving here, I had this exchange while riding the bus:

Person looking at my scrubs: "Are you a doctor?"
Me: "No, I'm a nurse."

This was a frequent occurrence in Austin. Mostly when I was wearing a lab coat, though sometimes when I was just in scrubs at a hospital or grocery store. I'm never defensive about it because, well, I'm not defensive about being a guy who's a nurse. In anything, I'm ridiculously proud of it as should be clear by the name of this here blog and the pic up there. Plus I really am a Registered Nurse now so it makes me happy inside to say so.

Turns out the person on the bus was about to start surgical tech school and wants to work at a hospital. She knew where I worked based on the color of my scrubs, which brings me to another point. In an attempt to cut down on patient confusion, many hospitals are requiring staff to wear color-coded scrubs. Nurses wear this color, respiratory therapists wear that one, housekeeping this one over here. Nurses at my hospital have to wear teal. Like this:


Couldn't it have been navy blue? ER nurses get to wear black. Damn their oily hides. The really bothersome thing is that my favorite style of scrub pants (made by Cherokee with cargo pockets on both legs, slit pockets, and a fly with a zipper) don't come in teal. Based the various offerings from multiple scrub makers, teal is considered a lady color. Sure they have "unisex" scrubs, but it's not the same. Not to put too fine a point on it, humans with penises need pants with flys.

Thankfully, I was clued in to a shop here in town which will custom-make scrubs with pockets and genitalia access points wherever you want. I'm going to take them the pants I like (in navy blue, sigh) and say, "Make me three pairs in teal that look just like this." Maybe they'll disassemble them and make a pattern a la Project Runway. At least no one has to wear this medical mistake:



There's no way you could actually do the work of a hospital nurse in that thing.

Yes but what are the side E-ffects?

There's a new medication on the market to treat GERD (gastroesophageal reflux disease). It's called AcipHex. Pronounced "Ass Affects." Who named this drug?! On the page you can see what they were going for with the acid and the pH, but as said out loud it's only natural to infer that the drug has an influence on your ass. Did they test market the name? Cause I'm thinking that the majority of interactions went like this:

Marketer: "What do you think of when you hear AcipHex?"

Consumer: (fearfully) "It's going to do something to my butt."

Terrible, terrible name.

Ugly day, better now

Work was fine, more computer training modules, but leaving the hospital I walked into a downpour. Getting home by bus is great, until you have to run blocks in the rain. I ducked into a dessert shop for a hot drink and to wait out the heavy rain. After a chai latte and a slice of green tomato pie, the rain had dwindled to a light drizzle. Now I'm home, in pajamas, about to watch The Wire. Much better.

The limits of providing patient comfort

Lots of necessary, yet often tedious information today in orientation. Small moment of amusement when one PowerPoint indicated some definition of nursing at the hospital as something like outstanding care with a personal touch. So of course I whispered to my friends, "But not, you know, too personal."

Which reminds me of a story a nurse told me. I won't go into the details, but the moral is even if the patient is alert, oriented, and quite handsome, do not assent to his request for a "massage" with full release. Also, don't giggle about it with co-workers the next morning cause you will all get fired for being highly unethical and really stupid in addition to cheap and tawdry. I can't recall an Aesop fable that covers this lesson so perhaps I should write one substituing otters or squirrels for the people. Wombats? Ooh, I can illustrate it with tasteful linocut prints!

¡Átame! or Atase, I don't know Spanish that well

Today was the second day of orientation at my new job. I now have health insurance, a 403(b)—like a 401(k) for non-profits—, and no vacation/sick days for three months. Oh, and an understanding of the standards of nursing practice. The important stuff is what I'm saying. We also practiced putting restraints like these on and tying quick-release knots.




Depending on your sense of humor or kink factor, these might seem mean/sad, adorable (that second one is called a mitten), or stimulating. Well you're all wrong. Hee. Restraints are necessary equipment to prevent patients from doing dangerous things like pulling out tubes and wires. Being ill or injured in the hospital can be disorienting and things sticking into your arms, chest, nose, mouth, etc. tends to be uncomfortable at best. When a patient is not all there and some bit of medical equipment is bothering them, they often pull at them.

I was caring for a patient once that grabbed his Foley catheter (that's the tube that drains the bladder) and pulled so that the tube sheared off where it was taped to his leg. He was lucky. Foleys stay in place because there's a balloon at the end that's inflated with saline to anchor it in the bladder. If the tubing hadn't sheared, he might have managed to pull the balloon THROUGH HIS URETHRA. Yeah. It's happened. The penis maybe doesn't work so well after that kind of trauma.

Restraints are also necessary for even calm, oriented patients if they are intubated (tube down the throat to maintain airway), with or without a mechanical ventilator attached. Cause everything can be fine and dandy, they're writing messages for you, participating in their own care, and then they get a little irritation, start to cough, and the first thing they do is grab the thing sticking down their throat and pull it out. Since the endotrachial tube has a cuff that's inflated to hold it in place below the vocal cords, pulling it out damages the cords badly. So possibly no more talking. And then there's the problem of the patient no longer having a patent airway. Bad stuff.

In conclusion, restraints are often necessary and very much therapeutic despite the initial image of tying a patient down against their will. I realize now that this isn't the cheeriest of topics, though to be it's just part of the job. Uh, just be happy I didn't link to a video of a Foley catheter insertion? Unicorn chaser?

RN. W00t!

I passed. Now I'm a real murse now. Well, actually not until my official letter comes from the state Board of Nurse Examiners in four weeks letting me know that I now meet the minimum standards to be qualified as a nurse. They don't give you a score on the NCLEX. It's just pass or fail. Kinda like that joke, "What do you call the guy that graduated last in his class from medical school? Doctor."

I guess a celebratory glass of wine is in order. Good thing I have a vacuum stopper or I'd have to drink the whole bottle.


UPDATE: Red wine, pizza, and HBO are nice when celebrating. Wheeee!

Lazing around

In an attempt to
1) temporarily distract myself from worrying about my NCLEX results
2) avoid unpacking moving boxes
3) better myself as a human
4) get caught up for the new season

I sat around all day today watching the fourth season of The Wire, the best TV show and/or film ever made to this point IMHO. I'm sure it would amused some of you greatly (ahem) to see me gleefully sniggering or captivated with jaw slackitude. Dear lord I love that show. And in a couple more days I can start watching Season 5!

The final test

This morning I took the final test to determine whether I'm licensed as a registered nurse (RN). The NCLEX, as it's known, determines whether the candidate possesses the entry-level knowledge so as to "provide safe and effective nursing care." It's a computer adaptive test, which means that each succeeding question is determined by how the test-taker is performing. At the beginning of the NCLEX, the computer program gives you a medium difficulty-level question. If you get it right, the next question is more difficult. If you get it wrong, the next question is easier. The idea is to maintain your performance above a line of competency. It's okay to dip below it occasionally, but then the candidate has to answer more questions correctly to rise above the line again.

In addition to level-of-difficulty, questions are categorized by Client Needs category. Candidates have to demonstrate competency in Management of Care, Safety and Infection Control, Health Promotion and Maintenance, Psychosocial Integrity, and Physiological Integrity. You can't crap out in one category and then make it up in another either.

Practically, the computer adaptive format means you can't skip questions and come back to them, a favorite tactic of mine. Really though, the format is not that bad. You are presented a scenario and usually have to choose between four answers. Sometimes you have to fill in the blank, but that's usually a medication calculation question with a numerical answer. The beastly questions are the ones where you must select all that apply with five options. Get one wrong and the whole question is wrong.

Here's an example of a question from a test prep book with my explanation of terms in brackets or a link to a picture:

A nurse is caring for a client with a T5 spinal cord injury. The client complains of a severe headache and is feeling anxious. The nurse notes the client is sweating, is experiencing bradycardia [pulse below 50 beats per minute], and is hypertensive [high blood pressure, exact number is situation- and client-dependent]. Which nursing intervention is most appropriate initially?

1) Notify the physician
2) Medicate with an analgesic [pain-relief]
3) Check for bladder distention
4) Discuss the client's feeling of anxiety

The correct answer is 3. To answer this question you have to know such spinal cord injuries put the patient at risk for autonomic dysreflexia, the symptoms of that condition, the likely cause, and that assessing for a distended bladder is the INITIAL action of the nurse.

This question is at the analysis level in that you have to know some facts and then apply them to the scenario. This is actually a pretty easy question for someone right out of nursing school. It's common knowledge that notifiying a doctor is almost never the right answer (there's always something to do first), and discussing feelings is always a low priority - physiologic concerns first, psychosocial later. So even if you don't remember autonomic dysreflexia, you're down to 50/50 anyway. Getting it down to two answers happens all the time. Often, two or three answers are right and it's just a question of which is more right. It's difficult at first, but nursing school tests are usually written this way so students have plenty of practice with the format.

The minimum number of questions on the NCLEX is 75 of which 15 are unscored because they're just being tried out. After 75 questions, the program reviews your performance and decides that either that you are competent, not competent, or that further assessment is necessary. If the latter, the program keeps giving you questions until the answer is decisive. The maximum number of questions is 265, though few candidates get that many. You have six hours to take the test and again, few take that long.

The first-time pass rate for students from my nursing school hovers aroung 98-100% so I wasn't too worried. Still, it was nerve-wracking to take a test that determines whether I'm allowed to practice what I've been working toward for three-and-a-half years. The general wisdom is that if the questions are somewhat confusing and nebulous, and you walk out not really knowing what the hell you were doing, you performed well. If the questions start to look like:

The brain is

1) protected by the skull
2) insane in the membrane
3) solely for mucus production
4) wait, you mean the one in my head or Big Steve downstairs?

you're in trouble. I took 80 minutes to answer 75 questions of which I definitely, no doubt about it KNEW the answers of about 10. So, good sign! I'll find out the unofficial results Monday or Tuesday. Oh and my diploma came in the mail today, so that's nice.

The highs and lows of moving

So here I am again. I graduated from nursing school in December and moved to Houston a couple days ago. Friday I take the Registered Nurse licensing exam and Monday I start my new job. Just got the series of tubes hooked up to my new apartment so I thought I'd finally post again.

Since arriving in Houston I've been hit my small bursts of excitement prompted by things like moving books and CDs from boxes to shelves, the nice grocery store a 10 minute walk away, a new bed, coffee, finally having time for DVDs again, and anticipation of my new job. Those bursts of excitement have been interspersed with moments of trepidation prompted by things like studying for the licensing exam, realizing that most of my friends are hours away, pondering life in Houston sans car, and anticipation of my new job.

To sum up, life in Houston so far has followed a pattern: unpack, JOY, study, FEAR, shop for groceries, JOY, figure out bus routes, FEAR, ponder my new life, JOY/FEAR. JEAR? FOY?

St. Murse

PS I pledge to post regularly going forward. Sorry about the delay. You know how it is. Or maybe you don't. Anyway, I'll be back-filling posts summarizing school and such from now back to April. Check back in the archives for those posts as I write them.

Delay in posting

Yeah, I know. I've been remiss, again. I'm busy, but also I'm so focused on the future (applying for internships, registering for my last semester, graduation, finding a job, etc.) that I find it hard to concentrate on relating my present life in school. Sorry.

I'll do better in the next week. Or so.

St. Dennis of Bindlestick

Weeks ago I paid $10 to artist Adam Koford for naming rights to a hobo for his Hobotopia series. Here's what he made of the name:



Frickin' awesome. I've got the original artwork on a postcard. Koford posted a nice photo of St. Dennis on his Flickr set.

SXSW Music 2007

Don't really have time to give an exhaustive review of bands and performers I saw/heard, so this is mainly a record for me.

Wednesday
The Pipettes - cute, but the backing band was bored and it showed
[The walk to and from this show netted for free: vitamin water, ice cream, a custom button, poster, and condoms]
Imperial Teen - fun, not as good as a couple years ago
Beirut - packed, loud audience almost overwhelmed band, good not great
The Early Years - interesting, I'd like to hear their recordings
The Mountain Goats - great, though I was tired and therefore not as involved in the show

Thursday
Emmylou Harris - an interview with songs scattered through; funny, sweet, just an amazing person; I heard her perform "Love Hurts", "Green Pastures", and "Boulder to Birmingham"; missed her doing "Orphan Girl" dagnabbit
Martha Wainwright - I see a lot of her family in her
Bob Mould - raging on solo acoustic
Tosca String Quartet + Lambchop - gorgeous, I'm bummed I couldn't see the whole performance
The Octopus Project - good as (almost) always
Golden Arm Trio - just caught a few songs; I used to see them all the time and I really should make a point of seeing them again sometime soon

Friday
Comedy on the Music Circuit panel - hilarious, but could it not have been with Zach Galifianakis and David Cross on the panel? Henry Owings, John Wurster, and some other guy too. Best part was Cross talking about a terribly misguided attempt to open for GBV (I think) after which someone in the audience actually peed on him from behind, whereupon Zach quickly offered a insincere apology.

Kid Koala - His live, heavily manipulated "Moon River" was astounding
Daniel Johnston - Uh, somebody tell him not to do Nazi jokes
Thurston Moore Instrumental
Nethers
Hoodoo Gurus - Dang, they were great
Tullycraft - I though I was too tired to dance and then they just got me on my feet, bravo Tullycraft

Saturday
The Buzzcocks - still tear it up
Bill Calahan - beautiful
Tilly and the Wall - a lot of fun with an enthusiastic crowd
The Octopus Project/Black Moth Super Rainbow - lovely, trippy
Donnie Davies - Heh, Donnie just lipsynced to a guy hidden behind the PA speakers
Kid Koala - again great
Amon Tobin - Good, but not as fresh as he used to be
Junior Senior - Whooo, great way to end the week, lots of sweaty dancing

School health clinical

As part of our half-semester of pediatric nursing, my fellow nursing students and I spent a couple weeks with a school nurse. Before going, I was unenthusiastic. I was sure that spending more time in the hospital would be a better use of our limited time. Turns out, school nursing was of higher value to me. My school nurse had been an ER nurse, which is common. If you think about it, it makes sense. School nurses need to have superior assessment skills and experience triaging patients. As someone who wants to work in an ER, it was great experience and lots of it.

I remember my elementary school nurse as being someone who put on band-aids and let you lie down in her office when you had a stomachache. While we did those things, it's a small part of the job. During my four days there I gave out prescription medications, fed a kid through his gastric tube, washed sand out of eyes, bandaged hands and feet, iced potential sprains, conducted vision and hearing tests, checked temps and throats a hundred times, and on and on. It was busy with a steep learning curve.

For many of these kids, the school nurse is their major source of healthcare. They don't have insurance of any kind and can't even afford to go to outpatient clinics. It's a lot of responsibility for the nurse. On a regular basis, she has to accompany families to appointments to ensure that they go and often to translate as well. Every year she works with the PTA to raise money for eye appointments so kids who need glasses can get them. I see now that school nursing requires quick-thinking, resourcefulness, and huge amount of dedication.

Again, I don't want to go into this kind of nursing, but it was valuable experience and something I will draw upon in the future.

Pediatric clinical

I didn’t write much about my experience in pediatrics. My time for blogging is scant it seems. It was great overall, though slight in patient interaction in the hospital. Because one or both parents are there all the time and they usually like to provide as much personal care as possible, we as students didn’t do much beyond taking vital signs, performing the nursing assessment, and administering medications. Often my cohort could be found in the hall, hungry for something to do.

One day though, I had an infant and mother who’d had a rough night. The primary nurse and I encouraged the mother to take a break, visit the cafeteria, whatever she needed to do while we took care of the baby. While she was gone, we gave the baby her medications, removed her Foley catheter, and saline-locked her IV (basically kept the IV access while discontinuing the continuous infusion). Then I got to hold the baby.

Whoo! Baby-holding. Growing up, my Mom took care of kids in our house so I had lots of experience taking care of them. I forgot how nice it is to hold a little baby, especially if they’re not screaming. It was short-lived as the mom came back soon after. It was nice while it lasted.

My favorite part of this rotation was the observation experiences I did in the pediatric ER and ICU, and not only because I didn't have to complete a lot of paperwork for them. I'd worked in the ER before as a registration clerk and so I knew the layout, but it was such a different experience being there as a nursing student. I found myself focused on patient assessment: what they look and sound like, the history, how the family was interacting. I felt quite nurse-y.

The pediatric ICU was a great too. My instructors couldn't fit me in during the regular schedule, so I volunteered to come in on a Saturday morning so I could have the experience. It was worth the loss of sleep and down time. I lucked out and ended up paired with a great nurse who's also a grad student at my school. She encouraged me to help out with patient care and challenged me with questions throughout the shift. Her two patients (ICU ratio is at least one nurse for every two patient) were toddlers with tracheostomies. They were cute kids, and it was sad that they had to be hospitalized. Worse, because they were trached, when they cried there was no sound. Trust me, a little kid with a tears, a scrunched up face, and no sound is heartbreaking.

Despite enjoying the experience, I'm still drawn toward critical care of adults. I like kids and do well with them, I just think my talents are better used elsewhere.

SXSW 2007: "Famous" people

These are people with whom I interacted, not just saw:

Gilberto Gil - passing in a hallway I saw him, stopped and said I enjoyed his music

Peter Buck (REM) - brushed past me carrying his guitar, his jacket was velour

David Byrne - it seems like I help him every year

David Cross - patient with rabid fanboys which seem to cluster about him everywhere he goes*

Zach Galifianakis - sweet man, much less neurotic and volcanic than on stage

Jonathan Demme - I helped him check in and get his badge, very nice fellow

Dennis Miller - low-profile with cap pulled down low, checking in with his family, I'm really not a fan of him anymore due to his politics. Glad I no longer look like him.

Also, I gave Chris Gore (Film Threat) his SXSW badge. When I called out his name, someone down the hall shouted, "Chris Gore sucks!" and they were serious. Mr. Gore and I both laughed at the random hate.

This is sad, but I can't think of any "famous" women with whom I came in contact.

* Funny story. Several years ago I was working behind the registration desks when Carson Daly came through. After getting his badge, he continued to loiter in the area clearly wanting people to notice him. My fellow volunteers and I considered it haughty, then just pitiful when it became apparent that no one cared. Then David Cross came through and there was a visible and audible tumult. I didn't, but wanted to go up to Daly and say, "The only reason that no one is talking to you is that you are a giant tool."

My head at SXSW 2007

14
Originally uploaded by mybloodyself.

I almost forgot to post a picture for this year. Mybloody clippered the 14. It's how many years I've been volunteering. Not as cool as last year or the year before that, but I couldn't go too crazy what with having to go back to clinical sites this week.

The 14 is now gone and I've gone to a high and tight.

SXSW Film 2007, last two movies I saw

Zoo

The festival synopsis reads, “ZOO tells the story of a seemingly average businessman whose secret sexual life led to his shocking death.” The shocking death is bleeding caused by his colon being perforated by a giant horse cock. That is, an actual horse cock, not just a big human one. Yeah.

I was unconvinced about the desirability of seeing this film, but was assured by a staffer that it was “disturbing, but beautiful”. That description is entirely accurate. Showing influence from Errol Morris, Zoo features recorded interviews from people involved in the case (fellow horse “lovers”, an investigator) played over gorgeously-filmed reenacted scenes. The effect is meditative and far from exploitative. There’s only a tiny glimpse of actual explicit sex and many in the audience didn’t remember seeing it (and not because they’d gouged out their eyes and had tramautic amnesia). It really is a wonderful film; packed screening, audience rapt. Highly recommended.


Helvetica

A documentary about a typeface. I wanted to write this entry in Helvetica, but I don't know how to change the typeface for just one post. The doc is effective in showing how Helvetica was introduced and came to such dominance. The audience was absolutely in on the idea of this film so there was much enjoyment as various typeface experts give sloppy love, or vitriolic distaste, to Helvetica. Interspersed with the talking heads are numerous examples of Helvetica on signs everywhere. The film drags a little toward the end but all in all it's successful. Afterwards and for the next several days, Helvetica stood out like neon for me. Really quite amazing how ubiquitous it is. Recommended.

SXSW 2007 photos

I really need to go to sleep, but here's my photo set from SXSW 2007.

Donnie Davies at SXSW

I'll do a full SXSW wrap-up later, but I had to write about Donnie Davies' show. If you are not familiar with this internet phenomenon, Donnie purports to be an ex-gay Christian singer - he's not really any of those things. Read his thoughts here and be sure to watch the video for "The Bible Says."

A SXSW staffer told me that he'd shown the video to people in the office and one of the music guys was eager to book Donnie Davies. They slyly chose to put him on the same night as The Buzzcocks and Turbonegro, bands with more than a little homo-osity about them.



Donnie hit the stage to loud cheers and they immediately ripped into "Surrender" by Cheap Trip. On the "but don't give yourself away" line, Donnie would cover his crotch and shake his head. They actually pulled off the cover well and most of the audience was on board. Evening Service appeared to be the same band that's in "The Bible Says" video and the MTV interview, including bad wigs.



The next song served as proof that Donnie is totally not gay anymore, no sir. He grinded with the sexy lady dancers while performing a Timberlakian number.



At one point, Donnie asked the audience if there were any homosexuals among them who wanted to get saved. Having no desire to be saved, I nonetheless raised my hand as did several other people. Donnie pulled up a very obviously planted guy named Gary Bentler up on stage and had him demonstrate his limp wrist. In an attempt to "heal" him, Donnie lead us in the C.H.O.P.S. (Changing Homosexuals into Ordinary People) salute, while chanting "Heal Bentler." You can probably guess what the salute and chant devolved into.

Interestingly, in addition to not being an ex-gay (or probably gay at all) or Christian (at least of the scary variety), Donnie's not even a singer. He just lip-syncs while this guy sings off-stage:



Donnie and Evening Service closed with "The Bible Says" which was a rousing success with the audience, at least half of whom had never heard it before. All-in-all a wonderful palate cleanser before I headed off to more music elsewhere.

UPDATE: Due to financial constraints, I have to sell the Donnie Davies t-shirt I bought at the show. I listed it on eBay at the price I paid, $20.

Sun. SXSW Film

Diggers

My first narrative film so far. I generally avoid them at festivals because they're often disappointing and I could be seeing a good documentary instead. I went for this because of the talent involved. Written by Ken Marino (ex-The State, Veronica Mars), exec. produced by David Wain (ex-The State, Stella, Wet Hot American Summer), and starring Paul Rudd among others. It was competent. Kinda cliche indie ensemble film with all the strengths and weaknesses that implies. Great visuals though shooting digital but keeping the 70s film look.


King Corn

If you anywhere close to a typical American or Canadian, your body is rife with corn. Something like 90% of the carbon in your body was corn at one time. King Corn is full of scary/interesting facts like these. Two college grads move to Iowa to farm one acres worth of corn and fill us in on how ubiquitous corn is in our diet. I was dubious that they could keep it compelling over a feature-length documentary, but they pulled it off. I thought I was well-informed on how pervasive high fructose corn syrup is and its probable role in declining health. It's scarier than I knew. As one interviewee put it, it's a good thing that cows are slaughtered when they are, because they'd be dead in six months anyway from the massive corn diet. Apparently eating mostly corn gives them stomach ulcers an makes them acidotic, a supabad condition in people for sure. Im going to suggest that my nursing school buddies see this. Highly recommended.


The Devil Came on Horseback

A brutal, necessary experience. This doc is told through the eyes of Brian Steidle, an ex-Marine officer who gets a job with the African union monitoring the cease-fire between Northern and Southern Sudan. While there taking photos and collecting interviews, he becomes aware of the genocidal massacres happening in the Darfur region. Helpless to avert the killings, rapes, and destruction, Steidle leaves Sudan to return to the U.S. and get the word out. So far, despite the U.N. and the U.S. labeling it as genocide - a label that legally requires intervention - there have only been stern reprimands.

As I said, a brutal, necessary experience. The world needs to know that 13 years after Rwanda, it's happening again and history will judge us harshly if we do not act. Steidle was at the screening encouraging the audience to contact their legislators and come to the Capitol on Monday to register in favor of a bill to divest Texas investment in Sudanese-involved companies. I was moved to do just that. Happily, I saw strong support in the Senate and House for the bill so unless it gets pushed down the agenda it looks likely to pass.

Brian Steidle was at the Capitol as well and I made sure to thank him for his work. There's a sense of sadness and resolve about him that is inspiring and also heartbreaking. It's probably the former Catholic in me talking, but I wanted forgiveness from him for what I haven't done.

Sat. SXSW Film

Cat Dancers

I had no intention of seeing this film because of the aforementioned poster. Then I met up with some film buddies and they convinced me. This would continue to be a theme of the day and I will hereafter bow to their film-picking wisdom.

This doc tells the story of the first exotic animal act in the U.S. Joy and Ron Holiday were internationally-acclaimed dancers who thought ahead to the natural decline of their physical prowess and so transitioned into a touring act that incorporated dance, magic, and exotic cats. When the act grew too large for them to comfortably manage, they added Chuck Lizza to become a trio in more ways than one. From there the movie takes an almost inevitable tragic turn, which of course I will not spoil.

The filmmakers did a smart thing in the opening minutes of Cat Dancers. Ron Holiday is a bit of a comical figure. So, the filmmakers jump in and get it out of the way. Here's this guy who wears wigs and eyeliner. He's more than a bit nelly. And then they move on with the story. I really enjoyed this film. It's mostly interview footage intercut with photos and old 8mm films in a rather traditional manner, and yet the subject and the way it's handled is compelling. I believe it was picked up by HBO so should be showing there soon. Recommended.

Election Day

Election day 2004 from the perspective of voters. Simple idea really, but coordinating crews in 16 different cities must have been quite an undertaking. No revelations or big lessons learned. Just the experience of people voting all over the country: long lines, officials somewhat ignorant of election rules, idealism, apathy, etc. Not a stunning movie, but interesting throughout and a good document for history.

Big Rig

Great film. As with Cat Dancers, I was wary and then goaded into it by friends. Because it's a doc about truckers right? What convinced me was that the director, Doug Pray, also did Scratch and Hype! Glad I succumbed because I loved Big Rig. Turns out truckers are fascinating people who know how to tell a story. Pray and two crewmembers essentially hitchhiked across the country catching rides with truckers while interviewing them. The stories are often personal, but also touch on the commonalities of life as a trucker; long hours, rising gas prices, separation from family. Highly recommended.

Fun with fluids

You make the call!



How did he get urine on top of the urinal?

A) Very tall
B) On purpose, jerk
C) Barely subsided erection
D) That's not urine

1st day of SXSW, and a little blood

It's the first day of SXSW and so far I'm pleased. We're up and ready to go in Registration and I've already seen an amazing example of velveeta-ness. To whit:



Also, the Blood and Tissue Center called me this morning and requested that I come in for a blood donation, not just because they're low on my blood type, but specifically for me. Like the red blood cells, platelets, and plasma I make in my bone marrow. I didn't know whether to be flattered or surveiled (is that a feeling? One of being monitored?). They need fresh drawn blood tomorrow for someone who's having surgery and apparently I match them well as far as antibodies, etc. The impression I got was that I'll donate tomorrow morning while a courier waits to whisk it away. I hope the surgery goes well or else they might hunt me down at the convention center for more.

How to make money with only slight dairy-related regrets

Yesterday after the convention convened for the day, we waited 90 minutes to check in to our hotel (fun!) and then I went to the gym of a different hotel. A short nap and a can of Sparks later, I went with my schoolmates to dinner at a decent seafood restaurant. The blackened redfish and crab bisque I had were delicious. What I ended the meal with, not so much.

As I posted on 2/22, I regularly bet friends money that they won’t do entertaining things. The bet last night was the rapid consumption of all the condiments that came with a baked potato: chives, a kind of Hollandaise sauce, sour cream. The person I bet wouldn't take it, but then the bet was turned back on me by others.

For $15, I did it.


Complete photo documentation can be found on my Flickr stream.

Nursing Student convention 2007

I’m at the Texas Nursing Student Association convention in Galveston for the next several days. The convention business itself is fairly dry, but it’s to fun go on a trip with my school friends where I’m only paying for food and entertainment. From the 2005 and 2006 conventions, I’ve developed a reputation for three things:

1. Taking unflattering photos of my schoolmates,
2. Offering money to my friends to do entertaining things,
3. Eviscerating poorly thought out, badly worded resolutions being considered by TNSA convention delegates

To illustrate:

1.


2. I have offered someone $10 to drink half a bottle of malt vinegar. For $20 plus costs, I encouraged a large guy to walk into Baby Gap and put something on forcibly overcoming the size issue.

3. I did not see it because I was walking up to the mic, but I’m told that whenever I did so, my schoolmates would freak a little because they were excited/concerned about the articulate smackdown coming. Seriously y’all, some of these resolutions were ridiculous and needed to be taken apart in an entirely rational manner. I have been accused of being mean by delegates from other schools, but that’s just an ad hominem attack because they had no counter-argument. So … shut up.

The common format for resolutions (sensible and otherwise) includes a
resolved statement stating that the resolution – if passed – be sent to a variety of different organizations. A sort of heads up on what we’re doing. I was thinking how great it would be if I wrote an absolutely serious, cogent resolution that then requested that it be sent to, multi-Olympic Gold medalist Bonnie Blair, Prince, and whoever turns out to be the father of Anna Nicole Smith’s daughter.*

*thanks to Matt, the co-writer of this thought

Into the bone

Last week in our pediatric lecture class, the instructor showed us the equipment used for intraosseous access. Everyone knows about intravenous (IV) access, but IO is so much cooler. Rather than using a vein to infuse fluids, a bone is used instead. It seems bizarre to jab a needle into a femur or sternum, but bone is highly vascularized and fluids infused by that route rapidly enter the bloodstream. Also, bone doesn’t collapse or roll like veins can, and studies show that there is no increased risk of infection. Right now, IO access is used in critical cases where immediate fluid resuscitation is required.



I’ve seen a child come into the ICU by helicopter transport with an IO line that was started by the flight nurse. It works pretty much like an IV. The needle with attached catheter is inserted and the metal guide known as a stylus is removed. The tubing is hooked up and it’s ready to go.

Sunless exercise or Older folks are weird with the walking way early

It’s just a fact of nature I suppose that older people rise early and do things like go for walks. There are several such people in my neighborhood. Six in the awful, wicked, deplorable AM and they are out there with walking stick, golf club, or baseball bat (yes really, and no it’s not a crime-ridden area).

As I left for my Monday morning clinicals the past two semesters, I always saw at least one. I’d just wave and drive past, internally shaking my head at the folly of elders. To think they’ve lived this long and don’t yet know that one should be fast asleep in bed at 6 AM. Or at least slinking home after an ill-advised “sleepover”.

Weird wacky bunch all I said, until I saw the 5 AM walker. Yes, a small gentleman with a sweatband striding around the neighborhood at 5 AM happy as you please. A hearty “Good morning!” as I drove past on my way home (from work, not sex). Total mental case. Maybe military.

So then one night/morning I’m getting out of my car at 4:07 AM after an emergency trip to Whataburger, when I see it. A walker. I say “it” because no human could possibly be out getting some fresh air at 4 AM. Clearly this is an It. An It in the form an old man striding, striding I say, down the street. The only only only thing keeping me from running after him, I mean It, for a vigorous interrogation was my attire: non-descript grey shirt, pajama pants, bare feet. Perfectly fine when making an emergency trip for pancakes, distinctly unsuited for confronting a possible alien who – let’s face this gimmick is starting to get a bit thin – is really just an old guy walking around at an ridiculous time of night/morning.

I’ll post an update with more details when the stars align and I am up at 4 AM, outside my house, and reasonably dressed.

Live Earth

I want to go to the Live Earth concert in Antarctica. That would be cool right? Both literally and figuratively. Maybe a ice shelf would calve off at the climax of a particularly awesome song therefore highlighting the danger of global warming in a very pump-your-fist-and-shout-yeah kind of way.

Perusing the band list, it's obvious that Snow Patrol should play in Antarctica. Though I don't particularly care for them and I understand that it is often too cold to snow there.

Apples to Apples

I went to mybloodyself's house after work and joined in on a game of Apples to Apples. It's incredibly easy to learn and great fun, especially if you know your friends well.

I won a game and I'm most proud that I knew beyond a shadow of a doubt that Joolie would pick my card to match with Glamorous. Because really what's more glamorous than a Festering Wound?

And thank your lucky stars that I didn't post a picture, though if you insist, go here.

Little babies with tubes

Today was my first day of pediatric clinical. As in previous semesters, I'll spend a day or two of the week at a hospital caring for a patient. My first patient was a month-old baby with a probable obstructed bowel. Adorable, even with the distended belly and nasogastric tube suctioning green bile into a canister.

Mom was ever-present and sweet, which was just annoying. I mean come on, let someone else hold your cute baby for a change. I'm only there for a limited time lady, I want to cuddle the bundle of precious too. Or am I only good for taking vital signs with the tiny, coo-inducing neonatal blood pressure cuff?

(Roughly 6" x 1.5")

Some people. Hrumf.

Honestly, it was a nice day. Children just aren't as complicated as adults it seems. I had a fairly easy patient though. Other students' kids spit out their meds, I just had to make sure the acetaminophen suppository stayed in long enough to melt.

I'm back

I have no good reason for going so long without posting. For a long time it was procrastination. Then it was the accumulated weight of experience unblogged; heavy indeed. Finally, it was the wistful mockery of my friends who launched a parasite blog in the comments. The posts so amused me that I let another week go by.

Speaking of parasites, a friend gave me a wonderful present Parasite Rex, a book all about parasites and the vile things they do. Great bedtime reading, if you want to dream of things squirming around inside your body.

You might have seen this clip already, but it's so frickin' cool (UPDATE: new version of the same video)

Who are these other guys?

Aside from my dad, I wonder who these other guys are?

HowManyOfMe.com

There are: 15 people with my name in the U.S.A. How many have your name?

Beneficiary of kindness

Today started early. By 6:50 AM I stood waiting for a UT shuttle bus to take me to campus where I’d catch the Airport Flyer bus. A fellow male nursing student and I are attending the American Assembly of Men in Nursing 2006 Conference in Portland, OR. I was feeling a little stressed because the Cameron Road bus hadn’t arrived when a car pulled over. The driver rolled down the window asking, “Are you going to campus? Get in and I’ll drive you.”

Seeing as how she was an older woman, I wasn’t too worried about being kidnapped, robbed, and beaten. An offering of ribbon candy was possible, but as long as I demurred politely I figured I was safe. Throwing my bags in the back, I got in. Turns out she’s an English professor at UT and picks up students on her way to work all time. At roughly the same time every day, she drives along the Cameron Road route and offers a ride to whoever is waiting for a bus that early in the morning. Remarkable.

We chatted about my impending trip and she told me her great experience with the nurses that cared for her (several men among them) during a hospitalization. When we got close to campus, she asked me where I needed to go and I offered that she could drop me off where it was convenient for her. “I have a handicap permit dear, anything is convenient for me.” So I directed her to the bus stop. She wished me a good trip, I thanked her profusely, and that was that.

I’ve got to find a way to have her kindness recognized.

A great day as a nursing student

Yesterday afternoon I went to the hospital to pick my patient as I do every Sunday. This entails looking through patients' charts on the unit to which I'm assigned in search of one that would provide a good learning experience. I wanted this one patient I'll call Mr. B, but was told he'd be going to surgery in the morning and would be off the unit for hours. As my instructor would not appreciate me sitting on my ass for those hours, I moved on and picked another patient. I spent the requisite time recording all the patient's medications, abnormal labs, history, course of illness, etc into what we call a client database. It's a way of pulling information together in order to be ready to provide nursing care. Driving home, I was disappointed that I wasn't able to take Mr. B.

This morning I arrived to find that my patient had pulled his IV out of his hand the night before, refusing to allow a new one to be started, and was generally hostile to staff. Hmmm, maybe an opening here. I asked about Mr. B and found out that he hadn't gone down to surgery yet. I approached my instructor about switching patients and she was a little apprehensive in that I hadn't prepped to take care of him. In an effort to convince her, I quickly read through his chart, copied down his meds (most of which I knew), and made a case that Mr. B was a much better learning experience. I think it was probably my ebullience that won her over.

I quickly did a general assessment (listen to heart and lungs, take vitals, assess neuro status, etc.) right before transport came to take Mr. B down to surgery, with me in tow. We arrived in pre-op and the nurse started the pre-op questionnaire. When asked about allergies, Mr. B said he was allergic to some __________ drug he was on. The nurse went to answer the phone and I thought, "But he's not on a __________ med. I wonder if he means __________?" So I asked him and he said, "Yes, that's it." Then I did a little teaching about what that medication was used for and confirmed the reaction he experienced. When the nurse came back, I was able to show her in the chart where his negative reaction had been documented earlier. Whoo-hoo, mental hi-five.

There was still some question as to whether I could observe the actual surgery. The patient couldn't take food and drink orally, so the surgeon would place a tube through his abdomen into his stomach to allow for what's called enteral tube feeding. Then liquid nutrition could be regularly pushed through the tube using a syringe. The operating room circulating nurse came by and said I could observe. I put on a cap and mask and off we went to the operating room. The scrub nurse was already laying out the various clamps, cloths, retractors, needle and thread, etc. that would be needed. The anesthesiologist and nurse anesthetist started an IV and got the meds going. Within three minutes, Mr. B was under. The circulating nurse asked me if I'd like to insert the Foley. Absolutely (not ironic in the least)!

At this point I'd like to say that I've already seen more than a few lame Rep. Mark Foley/Foley catheter jokes, and will not propagate more. OK then.

I'd put in a Foley once before, so I wasn't too nervous. Plus A) the nurse was walking me through it and B) the patient was unconscious. That done, I stepped back so she could finish prepping him. A few minutes later the surgeon arrived and in less than 30 minutes:
- Sliced down the center of Mr. B's abdomen through the skin and subcutaneous fat
- Cauterized the small blood vessels (it doesn't smell bad at all really)
- Made an incision in Mr. B's stomach and introduced the tube
- Made an exit incision in Mr. B's left abdomen and pulled the tube through
- Stitched and stapled Mr. B closed

Totally routine, but tremendously cool.

They woke up Mr. B and then off we went to Recovery. The recovery room was bustling - lots of surgeries today - and the nurses were busy hooking patients up to EKGs and oxygen saturation monitors, recording their vital signs, and administering pain medication. I pointed out to Mr. B's nurse that he had an IV medication that had been sent along with him that needed to be started. She told me to find the doctor's order in the chart (always necessary). I did and she started the IV thanking me for catching it. Mental hi-five again. Mr. B was doing great and so we disconnected him from monitoring and back we went to his room. Later in the day, I got to deliver his crushed medications and liquid nutrition through the tube.

I'm sure five years from now all this will seem mundane, but today it was awesome.

Meat Purveyors R.I.P.

They didn't actually die, but Friday night the Meat Purveyors played their last show in Austin. Sigh. Man they are/were so very entertaining.

The night started with Mybloody and I going to End of an Ear so I could exchange some CDs. A store employee (via a scrawled note on a LP sleeve) dared me, so I bought a Juice Newton Japanese import record for $1. Then posed for a photo holding it with a smile that said either "I've been looking for this rare import version with the airbrushed cover forever and now, at long last, I'm holding it!" or "I'm a total douche who buys shit like this just because store employees dare me to." In my defense, it was $1. And her version of "Angel of the Morning" is pure cheezy goodness.

We left and drove over to Joolie's house to pick her up. She showed us some printing she'd been working on. I need a pack of her "Eat a dick" notecards, as do you. Then we headed to Continental Club for the show.

The Weary Boys were meh and we spent most of their set outside talking and going for a slice of pizza down the block. Then Meat Purveyors started and it was glorious. Mybloody had never seen them do their Madonna trilogy ("Lucky Star", "Burnin' Up", and "Like a Virgin" played at breakneck pace) so he was happy when they opened with it. Later they tore through their wonderful version of Ratt's "Round and Round." It's a testament to Ratt's songwriting and the Meat Purveyor's talent that the song sounds so good with twang vocals and mandolin. In between the band energetically zipped through a swath of their own great, punkish, bluegrass originals with at least a few from every album. I really should have gone to see them more often.

We ended the night happy to have seen them one last time and went home to put up our sore feet (mine were from dancing, not from being old).

My fat scar

Since a couple people commented on it, I guess I should explain. My scar is rather noticeable and so for years whenever someone asked me about it, I told them about it.

When I was in sixth grade, I sat next to a boy who'd already failed twice. He was much bigger than all the other boys and even had that wispy, teen moustache. I did well in school, he did not. Very soon after the school year started, he let me know that he would be cheating off of me and that I was to let him. If I didn't, or squealed to the teacher, I'd get pounded.

I didn't care for this, so I came up with a plan. For the next multiple choice test I would circle the wrong answers. He'd copy me, then I'd subtly change them to the right answers. I'm sure at the time I thought it was brilliant. Of course, I hadn't thought it through to the logical conclusion. We got our tests back; he got a 0, I got a 100. That afternoon he intercepted me as I walked home from school, pulled out a knife, and slashed me across the stomach.

Except none of that really happened. The kid was real, but he never cheated off me. I just loved telling people that story and seeing their eyes get big.

The real story is more complicated.

When I was ten I started having abdominal pains often. One night it was bad enough that my mom took me to the emergency room. An ultrasound revealed that I had a multitude of small gallstones. Gallstones, deposits of cholesterol or calcium in the gall bladder, are usually a problem in older folks. It's uncommon for kids to have a problem with them. I only had one of the common risk factors: female, fat (obesity), fair (Caucasian), forty (middle-aged), fertile (multiple children).

After various doctors conferred, the recommendation was removal of my gall bladder. It's not a secretory organ itself, it just stores bile produced by the liver. So you really don't need it; the liver will just dump bile directly into the duodenum (first section of the small intestine). The idea was that if I had lots of small ones when I was ten, it was going to be a problem sooner rather than later. I wonder if part of it was also that I was to be the youngest person at the time to have a cholecystectomy - a badge for the doctors.

My roommate at the hospital scared me a little. He'd been accidentally shot in the jaw while hunting which shattered it, and so couldn't speak distinctly. He also drooled a lot. I got to like him after a day though. I imagine some of my distaste for guns came from seeing what happened to him.

The surgery itself wasn't an issue, though I wasn't awake at the time. When the anesthesiologist started the meds, he had me count back from ten. I recall getting to sev...

Recovery was annoying because I couldn't walk well or eat much. I hobbled down the hallways clutching the handrails on the wall; it felt like my thighs was sewn to my chest. I'd get full after a cup of broth. I steadily improved and was happy to go home with a stitched incision. A couple days later I was eating a hamburger (often fatty foods after cholecystectomy cause upset, but I never noticed it) when somebody wanted to see my incision. I pulled up my shirt and everyone saw the small purplish bump on the incision. Not so good.

The sequence of events is hazy, but I ended up back at the hospital being examined by a very concerned doctor. It was an infection for sure. The doctor was worried enough that he started working on it right there in the exam room. No time for anesthesia to take effect so I got the topical cold spray. I was swabbed with some sort of antiseptic and then the doctor popped my stitches.

The next part explains why I have a high pain threshold. The doctor inserted his gloved fingers into the incision and starting pulling out what I recall as pockets of pus. I distinctly remember looking down and seeing his fingers inside me to the knuckle. A nurse - the one who wasn't holding me down - was talking into my ear trying to get me to visualize something more pleasant. She was talking me through getting a good hit in a baseball game. I remember being annoyed because, though I played, imagining a baseball game wasn't all that wonderful for me. But then how was she to know that I'd rather have her talk me through Greek mythology or the plot to The Westing Game?

Now, when I assess patients' pain level ("What would you rate your pain on a scale of 0-10 with 0 being no pain and 10 being the worst pain you can imagine?"), I always remember the intensity of my level 10 pain.

I can't remember much after the fingers-in-the-incision part. I didn't pass out, I just don't recall. The next vivid memory is being in a hospital room with an IV full of antibiotics and the incision packed with gauze. There wasn't room on the infectious unit, so I had been given a room on what I used to call the "terminal kids" ward. Several bald cancer kids and two cystic fibrosis kids were on the same unit. It totally weirded me out when one of the cystic fibrosis kids came to my room and gave me his toys "because I won't need them soon." His mom came by later to get them, apologizing profusely.

I stayed in the hospital for quite a while getting antibiotic therapy and wound care. The wound care consisted of taking off the cover dressing, pulling out the gauze packing (with yellow-green goo), pouring in hydrogen peroxide, gritting my teeth as it foamed up and stung mightily, twitching in pain as silver nitrate sticks were applied to cauterize the wound, then repacking. Twice a day for a long time. Even after I got out of the hospital, my mom picked me up from school to perform the wound care. Because of the infection, I couldn't just be sewn back up again.

So 20 years later I still have a thickened scar running across my abdomen on the right side rather than a thin, white line. Presently, the standard procedure is to perform cholecystectomies laparoscopically eliminating the need to open the belly. Patients now end up with three white dots where the camera and instruments are inserted. Damnit. At least I got a good story out of it.

Emesis assessment

Here's the text of the Powerpoint slide we just went over in class. Fun stuff.

Emesis [also known as vomit] -- Look at it!

Assessment
- preceded by nausea, precipitating or relieving factors, frequency, is it sudden, projectile, or persistent

-Note color and volume
Clear or greenish vomitus with undigested food-stomach
Bright yellow- bile or upper intestinal
Dark brown with feculent odor- prolonged bowel obstruction
“Coffee-ground” or BRB (bright red blood) - bleeding

The Pumpkin-ing of Yogurt

I just finished a container Lucerne Limited Edition Pumpkin Pie yogurt. As an avid consumer of pumpkin-flavored items (see very first first blog post), I was excited but wary. Turned out to be kinda gross. Oh well. Guess I'll be heading over to 7-11 sometime this weekend to see if they've got the Pumpkin Spice Latte back.

Update: In a pleasant turn of events, the Lucerne Limited Edition Cranberry Orange yogurt is wonderful.

Stoopid medical humor

Today in Skills lab we learned how to operate IV pumps. The instructor demonstrated at the front of the lab so we could all see, but since there wasn't a bed and a dummy right there she let the end of the IV hang down into the trash can. Immediately I thought/said, "This trashcan is hypovolemic. Hang a bag of saline before it gets shocky." See, this is what has happened to my sense of humor. Sad really.

Later, the instructor was explaining that it was important when learning how to use unfamiliar equipment to read the manufacturer instructions or watch the training video that is usually available. Relying on co-workers can result in a game of telephone where proper procedure is transmuted into bad habits through a steady accretion of errors or shortcuts. I turned to a friend and before I could even open my mouth he got there first, "Make sure the cartridge lever is pushed down. Purple monkey dishwasher."

Oh Simpsons, is there any situation for which you don't have a relevant quote?

Anatomical art

Mybloodyself hosted a craft night on Saturday. I'm not particularly crafty, but I do enjoy making shrinky-dinks. Here's a couple:



I just had a test about heart attacks on Friday (96%, whoo!) so it was fresh in my mind. The black part is dead tissue.




This is a salute to an organ I haven't had for more than a couple decades now. The sister of a school friend of mine had to have her's removed this weekend. She'll have three tiny white dots from the laparoscopic surgery while I have a fat 10 cm scar. Ahh medical progress.