Last night I worked in another ICU at my hospital for the first time. The surgery schedule has been light with some surgeons on vacation, so my unit has been overstaffed with nurses. It's the way of hospitals, if one unit is overstaffed and another is under, then nurses float to even it out. Technically I'm not supposed to float until I've been off orientation for six months, but my home unit had to keep the experienced nurses to look after the complicated devices (continuous dialysis machines, intra-aortic balloon pumps, ventricular assist devices) which I cannot. Oh well, that's nursing for you.
It was great experience actually. The principle is that floated nurses shouldn't be given a difficult patient load because they're not in their regular environment. Doesn't always happen that way, but it did for me last night. My patients weren't confined to bed, had stable vital signs, and each had only one IV medication running. After assessing them, administering their meds, and performing one dressing change, I didn't have much to do for the rest of the shift aside from charting their vital signs and changing out their IV lines. Then one of my patients who had transfer orders to move to a lower level of care got a room at midnight. After I packed him up and moved him out, I only had one patient for the rest of the shift.
I was able to talk with the other nurses and get a feel for the unit which, though laid out much like the majority of ICUs at the hospital, is very different from my home unit in cardiovascular surgical recovery. With free time on my hands, I read my one patient's H&P (history and progress notes made by doctors) to get a better feel for the situation. Then I moved on to re-reading some hospital policies in an effort to A) know them better and B) stay alert. All in all, it was a nice break from the pace in CV Recovery.
Squeamish alert! Do not read on if discussion of open wounds gives you the willies.
A nursing classmate of mine told me a wonderfully vile story. The patient she was caring for was a woman whose hysterectomy incision had opened up. I don’t know the specific circumstances of the case, but even well-approximated incisions (the edges coming together nicely) can open up if the stitches or staples burst open due to a forceful cough or errant Valsalva maneuver.
Anyway, that’s just academic. The reality was that the patient was quite obese and the wound was a foot deep. Yep, from the skin all the way down to where her uterus used to be was a solid 12”. Care for such a wound involves cleaning the bed of the wound to minimize the risk of infection and promote healing. It took two people bracing themselves on either side to pull back the sides of the wound enough so that another nurse could get all the way down in there with a sponge.
If, when you ask if I have a sense of humor, you mean laughing when you say, "Now that I've got better blood flow, maybe I can do something with it," while I'm cleaning your catheterized penis, or joining you in denigrating your female relative's job as a way of complimenting mine, then no, I don't have a sense of humor.
Also, refrain from automatically assuming that male staff are doctors. Despite us referring to ourselves as "your nurse," you continually called the day shift nurse and I doctors. The women in the white coat with her name clearly printed on the pocket? She's the surgical resident who scrubbed in on your operation, not as you assumed, the charge nurse.
I am being a little hard on the guy. He was anxious, feeling out of control and his coping mechanism of choice was joking around. It's a much more positive mechanism than regression or somatization. It's why I gave him some slack, kept quiet, and ignored his attempts at humor. And yet, even though he "comes from a different era", you have to know that making sexual comments about the female staff is big fat no-no. By the morning, I was weary of it.
When I leave at the end of my shift, if my patients are awake and likely to be transferred out to a lower level of care that day, I sincerely wish them well. This guy, I just said, "Feel better," without eye contact. Petty, I know, but man he was grating.
While my love of science fiction began in high school, it truly flowered in college thanks to books loaned and recommended to me by a couple of friends (thanks M & E). Many college bullshitting sessions were spent discussing the implications and questions arising from the works of Le Guin, Varley, Brin, etc. Above them all though, was Orson Scott Card. How we adored him. He's descended into almost total suckage over the last decade or so, but still, Ender's Game, Speaker for the Dead, The Worthing Saga? Masterful.
Well, now he's done it. Sure I always knew he was a devout, Elder-kiss-up Mormon, but now he's calling for violent revolution against the U.S. government if gay marriage becomes common. No need for me to rant on as Michael Swaim (who knew Cracked.com had such astute writers?) has laid out the arguments beautifully. Warms the heart really.
Unlike Swaim and others I've seen, I'm not tossing the Card books I treasure. I won't buy another copy new, but good stories are good stories even if they're told by a greedy, bigoted asshole who I nonetheless will endeavor to consider a person deserving of love. And I don't even claim to be a Christian.
A few weeks ago at work the patient care techs were busy and my patients were tucked away so I answered a spate of phone calls to the unit. One call was from the lab, "Patient X? The sample in the green top [test tube of blood] is hemolyzed [red blood cells are ruptured]. We need another one sent."
I walked down the hall to convey the message to the patient's nurse, "Lab called. That sample's hemolyzed. Can you send another one?"
"Well no," she said, looking at me curiously, "The patient's dead."
I looked over at the bed and monitor for the first time. Sure enough.
This week I was talking with a couple of women at work and the conversation turned to diets and losing weight. We’re all nurses so we know about the physiological processes involved and how some diets (i.e. Atkins, South Beach) initially show quick response because they result in mostly water loss.
That reminded one nurse of the time she found Lasix among her deceased grandmother’s things. Lasix prevents the kidneys from reabsorbing sodium and where sodium goes, so goes water due to osmosis and all that. No sodium reabsorption means peeing out a lot of fluid. Water weighs 2.2 pounds per liter (or the metrically more sensible 1 L = 1 kg), so that can add up to tidy weight loss. Along with all that water, important electrolytes are also peed out, particularly potassium, a dearth of which can cause life-threatening heart arrhythmias.
With all that in mind (I know, it’s a lot to keep in mind), the nurse explained her logic thusly,
“I found Lasix pills in my grandmother’s medicine cabinet and I was thinking about fitting into pants better, but I had no way to monitor my potassium levels and I don’t like bananas so…”
“Aside from the ethical implications of a health professional taking medications not prescribed for her,” I responded, ”You could have just eaten avocadoes.”
“Avocadoes?!” she exclaimed, “The whole point was to make my butt smaller.”
Every couple of months the class of new nurses with whom I started meets for continuing education. The day’s agenda always includes time to talk about the challenges of the job. Essentially it’s a good-natured bitch session. Last time we met, someone brought up calling residents for orders and getting a less-than-confident or lackadaisical answer. Residents are still training as doctors and don’t know everything so nurses often coach them along. A common response from the docs is, “What do you usually do?” or “What do you want to do?”
I prefer the first question because it falls back on the routines of the attending physicians. They’re usually asking because hospitals differ in their preferences, not because they are clueless. At Hospital A, the typical orders for nausea are medication X at such-and-such dose and timing, while at Hospital B it’s medication Z. The second question, “What do you want to do?” is more annoying to me, because, you know, they’re the doctor with prescriptive authority. It’s putting the onus on the nurse with the doctor just agreeing or not with the suggestion. The worst though is when they obviously aren’t engaged. As one fellow nurse dramatized it:
Nurse: Doctor, Mr. Smith is getting increasingly hypertensive.
Doc: Uhh. Hydralazine 10 mg, or whatever. I don’t care.
In class I wistfully offered how great it would be if we could write out the order and fax it to the pharmacy just like that.
8/23/08 1935 Hydralazine 10 mg, or whatever. I don’t care. TORB (telephone order read back) Dr. Apathy/St. Murse, RN
I found this taped to a bus stop. "Beware LADIES HE Will Come and SEX you at Night" and by HE, the author means SATAN.
My favorite part is "Stupid Idiot Daft Punk." Sure they might be harder, better, faster, and stronger, but apparently they are also stupider, idiotic, and somehow involved with Satan.
In an August 9th New York Times op-ed piece, Olivia Judson writes about rat studies which show that mothers who consume large amounts of junk food (as opposed to balanced rat chow) while pregnant give birth to babies with a hankering for junk food. Human studies are less definite but,
"...the results of several studies suggest that the very fact of a woman being obese during pregnancy may predispose her children to obesity. For example, one study found that children born to women who have lost weight after radical anti-obesity surgery are less likely to be obese than siblings born before their mother lost weight. Another study looked at women who gained weight between pregnancies; the results showed that babies born after their mothers put on weight tended to be heavier at birth than siblings born beforehand. Since the mother’s genes haven’t changed, the “fat” environment seems likely to be responsible for the effect."
Speaking as a health care professional who routinely cares for obese people, uh, yikes. This could result in a nasty geometric progression of obesity and related disease (diabetes, hypertension, heart and vascular disease, stroke, cancer, sleep apnea) in the next generation. Not to mention the increased incidence of lower back problems in the nurses who have to move such patients. Body mechanics of moving patients was one of the first things I learned in nursing school skills class and rightly so.
As I've said many times before, I don't miss having a car. I really can get to almost everything I need on the bus with advanced planning. Or even spur of the moment. After reading several enthusiastic reviews last night, I immediately wanted to see The Dark Knight. One series-of-tubes search later and I had a ticket to the Angelika downtown. After one bus and a few minutes walk, I was ensconced in a nice seat in an only half-full theater. Hooray for working nights and therefore seeing movies at 9:15 on a Sunday when few jerkwads clog the theater with talking or rampant cell phone use!
Anyway, the movie was great, really pushes out the boundaries of superhero movies. I recommend it. Be prepared though, it's long (2.5 hours) and densely plotted. There's enough plot for two films really, which actually detracts from the last 30 minutes as it introduces a new element, though anyone with a basic knowledge of Batman lore will see it coming. Let me also jump on the pile-on of praise for Heath Ledger's performance. Astoundingly, creepily awesome. I went in with high expectations and he blew me out of the water. Multiple times I audibly, involuntarily horror-giggled.
Though I was prepared for this via a review, it was still remarkable how much of an ensemble film The Dark Knight is. Bruce Wayne/Batman is decidedly *not* foregrounded in either plot mechanics or screen time. I won't take away from the story by explaining further, you'll know what I mean when you see it. Also great is the degree to which the citizens of Gotham are involved in the story. Multiple, nameless Gothamites are essential to the theme of ordinary people taking responsibility for creating civility.
Some elements that distracted me:
- That goofy, scary-voice Bale employs as Batman.
- Why is Nestor Carbonell (the Mayor) wearing so much mascara and eyeliner? (Also, is his casting a fun nod to him playing Bat Manuel on The Tick?)
- A certain medical aspect of the last bit drove me up the wall. Can't say what it is without spoiling, but argh! No.
- Is the minor character Berg Ramirez (or as his nametag says, Ramirez, Berg) an obscure shout-out to UT Austin Film/Latin American Studies professor Charles Ramirez-Berg? Cause Berg is not really a first name.
For the first time since moving to Houston I made it back to Austin to play poker with my McJo's buddies. As was clear from my play, I really wasn't paying attention to the game. I'd build up a nice little stack then piss it away while I chatted with everyone, just happy to be surrounded by snarky, opinionated, politically-aware, ego-hammering, magnificent bastards. Regardless, I held on and finished third.
Slept well then had a late breakfast before Mick convinced me to make a specialty shoe purchase. Some other folks at work have Z-coil shoes (spring in the heel) and swear by them. Haven't broken mine in sufficiently to wear them to work for 12 hours and now I'm having a touch of buyer's remorse just from the price. I'm still in the refund window though. We'll see.
ABC has been airing a six-part miniseries documentary about the staff and patients at John Hopkins Hospital in Baltimore. Though it delves a little too much into the personal lives of the doctors (more medicine please!), the ballad-heavy soundtrack is egregious (apparently husky-voiced singer-songwriters = emotion depth), and more nurses should have been profiled (duh), I recommend it as an interesting look at medicine being practiced today.
Thankfully, the episodes are available to watch online.
Despite a couple missed opportunities that are too ridiculous to go into here, I've previously only seen The Cure once. As a way to get fired up for the show, I made up a dream setlist as I drive to Dallas. As the encore began, I was struck with gleeful awe when I realized that they had played every damn song I wanted to hear! This is what I love about The Cure's live shows. They have a extensive career and dedicated fans, so play long shows with songs across their whole discography.
When my friend Dan heard that they were coming to Austin, and to the relatively small Austin Music Hall we were committed to going along with other friends. Tragedy struck when computer problems (?) or something prevented Dan from getting tickets for everyone and the show sold out. After seeing the setlists from this tour, I knew I couldn't miss out and so paid premium for ticket off eBay (grumble, grumble).
As the carload of friends drove to the show, we engaged in the witty banter that's a mainstay of our group (how frickin' self-agrandizing can I be? Ass). We speculated on the intricate goth outfits that were sure to be on display and then we rounded a corner to the sight of miles of black cloth and fishnets. As Chad put it, "Ladies and Gentlemen, Exhibit A."
Austin Music Hall has been extensively refurbished with more seating upstairs, a fancier entryway, better sound, and much improved intimate feel. After some nosing about, we set up downstairs about 30 feet from the stage. After a bland, boring opening act The Cure took the stage and blew us all away. Disintegration and Wish are about tied for my favorite albums and so opening with, well "Open" and then going right into "Fascination St." made me extremely happy. The show continued with plenty of songs from both albums with others sprinkled from across their career. It wasn't until they ripped into it that I remembered how much I love "Push" from Head on the Door (I re-listened to that CD later and rediscovered how great it is). "Catch" resulted in a happy emotional meltdown for Karen which was great fun to witness. During the show Dan and I confirmed out loud what was obvious, it had vaulted into our top ten concerts of all time.
Push from elsewhere on the tour
In Between Days
Sure Robert's put on a lot of weight and looks a bit silly with the make-up and hair at his age. This was balanced out by Porl Thompson ripped physique (how nice to have him back in the fold after years away and just killing on lead guitar) and the fact that Simon has not aged in 25 years. Jason the drummer isn't as good as Boris but I'm not complaining. They were in fine form. One of the coolest thing about the show is that they had no keyboards. All the synth lines were played on guitar by either Porl or Robert. I think The Cure uses keyboards very well, but it was invigorating to hear the songs without them.
From previous shows, we knew there would be at least two encores, but we still clapped and called for more. "M", "Play for Today" (and yes I sang the keyboard chorus melody), and "A Forest" just killed. Away to the wings, more clapping, and then back out for the highly anticipated run of seven songs from their 1st album. Even though I knew it was going to happen, it was still wonderful.
Jumping Someone Else's Train & Grinding Halt
After a 90 minute nap, I drove back to Austin tired but exhilirated for work the next morning. Absolutely worth the lack of sleep and jacked-up ticket price.
One last thing, coming so soon on the heels of the REM show in Berkeley it was inevitable that I'd compare the two. Both started off as "college" bands and broke into the mainstream before settling into the rock canon. Their best work is behind them but they both still write some good songs and play well. My estimation of these shows however is miles apart. REM played a good set to a rather flaccid audience who couldn't care less for older material. The Cure played a fantastic, almost three-hour show for a energetic audience filled with big fans. Blame it on the difference between Berkeley and Austin or the intimacy of the TX show to the outdoor venue in CA, or maybe the band themselves. Whatever reason, it certainly bumped up The Cure in my estimation.
The full setlist:
open, fascination street, alt.end, torture, the end of the world, lovesong, the big hand, pictures of you, lullaby, catch, the perfect boy, from the edge of the deep green sea, the figurehead, a strange day, sleep when i'm dead, push, doing the unstuck, inbetween days, just like heaven, primary, the only one, signal to noise, the hanging garden, one hundred years, end
E1: at night, m, play for today, a forest E2: three imaginary boys, fire in cairo, boys don't cry, jumping someone else's train, grinding halt, 10:15 saturday night, killing an arab
The timing of my trip to SF was dictated by REM's tour stop in Berkeley. They weren't/aren't coming anywhere close to Texas and I always said my first trip after graduating from school would be to visit MidSav and Rob in SF, so the timing worked out well.
I've been an REM fan for a long time, but back in the late '80s I was deemed too young to attend the Dallas stop on their Green tour. After that they didn't tour for years. So I've only seen them three times, Monster tour, Up tour, and at ACL during a tour promoting a Best Of. All good shows, though the ACL one wins out because A) I was so close, B) I was surrounded by great fans, and C) they played plenty of old stuff (setlists from that tour). The one-two punch of "Finest Worksong" and "Begin the Begin" made me wish yet again that concert joy could be bottled to enjoy later. Still, I was bummed when I saw the setlist from Houston. Maps & Legends?!
REM's new album, Accelerate, has been hailed as a return to form which really just means that there are some loud rock songs and it's not so wan like that last couple records. That sounds like damning with faint praise, but I really do like it for the most part. Anyway, I was excited to see them again and especially at the Greek Theatre on the University of California, Berkeley campus. It's a open-air, tiered venue so everyone can hear and see well. I'd bought my ticket early but since I'd let my fan club membership lapse missed the prime seats right up front.
MidSav & Rob dropped me off outside and I hurried in as The National had already started playing. They were good, but really belong inside a dark club. Next up was Modest Mouse, a band with several songs I like and many I find tedious and uninspired. The show was OK. The best part was (finally!) seeing Johnny Marr play guitar. Even when I closed my eyes I could pick out his lines. That Smiths reunion will never happen but if it ever did, I'd get there some way. Marr stills play beautifully and Morrissey can still belt it out.
Then REM hit the stage to huge cheers. The three actual members (Peter, Mike, Michael) were supplemented by usual tour guitarist/keyboardistScott McCaughey and new-to-the-fold drummer Bill Rieflin. Rieflin's a great drummer and I wondered if anyone else in the audience knew that he used to play drums for a long line of industrial bands like Ministry and KMFDM.
They kicked things off with a new song "Horse To Water" to a muted reception considering. Next song was "Little America" and I was all excited, "Yay old stuff!" and then I looked around and slowly realized that though a big chunk of the crowd was the right age to have been fans of REM when during their mid-80's IRS years, they didn't know this song. Third song was "What's The Frequency, Kenneth?" and the crowd roared its approval.
This sad pattern continued through the rest of the set and severely impacted my enjoyment of the show. Song on the radio? Big cheers. Not on the radio? Boredom and tepid response. Me all ranty in my head, "C'mon people, "West of the Fields"? "Wolves, Lower"?! They haven't pulled that out for almost a decade. But oh you'll finally start moving around when "The One I Love" starts up." Grumble, grumble, gnashing of teeth.
Best part of the show (aside from the lovely old chestnuts) was their reworking of "Let Me In" into a gorgeous acoustic-guitars-and-organ version. Even Rieflin came down off the drum riser to play guitar. Here's a recording from a different show:
With this wonderful version arrangement and the subject matter, I got all teary (wouldn't be an REM concert if I didn't at some point). The main set ended with "I'm Gonna DJ" which grates because it indulges Stipe's penchant for twangy hollering. Encore proceeded as per usual (when did encores for headlining acts become customary? The '70s? When did bands start intentionally putting popular songs in the encore rather than deep cuts or unpolished covers? A topic for another post) kicking off with the best song on the new album, "Supernatural Superserious". After another new one they started up "Driver 8" which sparked at least a little recognition in the audience before tearing into "Life And How To Live It"! I danced up a storm and focused on the band and the little group of superfans up front. Show closed as it often does with "Man On The Moon" which I've grown tired of, especially Stipe's silly hollerin' version.
La la la, get back to MidSav & Rob's place, talk about the lame-o audience, still enjoyed the show, go to bed.
Well, a little more to the story. REM sold out the Greek Theatre so fast that after I bought my ticket they added a second night. At the time I had thought about buying for that night (for which I was sure to get a better seat) and just selling my first night ticket, but I didn't. Sigh. After I got home from SF I pulled up the setlist for the 2nd night and was crushed. Leading up to my trip I'd been listening to a lot of REM, particularly my favorite album Lifes Rich Pageant. Four songs on that album I love particularly and are among my favorite in their whole career. The 2nd night in Berkeley they played three of them, "Begin the Begin", "These Days", and "Fall on Me". Oh the disappointment. Full setlists for the whole tour here.
The lesson I learned from this is that I will go see REM whenever feasible for back-to-back shows and I will do my best to be right up front with the superfans who love the old stuff too.
UPDATE: I found a note I'd jotted down during the show. After they played "West of the Fields," Stipe talked about the lyrics and how early REM songs were fairly impressionistic and didn't always make a lot of sense. It's well-known now that he doesn't have a great memory, even for his own lyrics and that's especially true for the early songs. When they started playing them more often live, he went online to find out what the fans thought they were. He was amused to see what many lyric websites had posted for "West of the Fields".
Stipe: Now, I wrote some bad lyrics when I was 21 and did drugs back then. But I never wrote, "The animals are strange, try to put it in."
Mills: What are the words?
Stipe: (mock testily) I don't know what the fuckin' words are. What were you doing in 1981 Mike?
After working 12 hours, with a 2 hour nap under my belt, I left the apartment for my trip to San Francisco. I was glad that I found a bus route that goes to the airport, less enthused when I realized how many stops it made on it's way there. Oh well.
The flight was uneventful with a layover in Arizona only noteworthy for this odd, planes-circling-a-vortex carpet pattern in the terminal. Thankfully, SF/Oakland has a great metro system of trains and buses. I easily navigated from the Oakland airport to the Mission district where I met up with Middle Savagery and Rob. Though quite tired, their sparkling conversation and enthusiasm perked me up and we had a great time eating dosas at Dosa.
Eating round, flat things would turn into an unintentional theme for the weekend. Thursday dosas, Friday pupusas, Saturday pizza. I don't think Sunday's meal, Mission burritos, held true but MidSav argued that they were round and flat before being rolled up so they counted. Though all the meals were yummy, the pizza from The Cheese Board was phenomenal. Also a standout was the Bug Juice Ale at Triple Rock, a brew pub in Berkeley.
Most of my time in SF & Berkeley was spent eating, reading graphic novels late at night, walking, and window shopping. SF is stuffed with little shops selling cute things. I think we went into at least four stores along the line of Giant Robot, which we also visited. The best window display goes to DoublePunch. Despite all the browsing, I didn't buy much. A few things from Little Otsu and a pile of CDs from Amoeba Records Berkeley branch. I went into the main Amoeba records too, but after a few minutes I was just too overwhelmed to focus. I'll go with a specific list next time.
Saturday night I went to see REM, but I'll cover that in the next post.
On Sunday we hit the Castro generally so I could see the gay(er) part of SF, but specifically so we could see the new Indiana Jones movie at the historic Castro theater. See, MidSav is an archeology grad student and so we just had to see the movie. The theater itself was grand and it was great to have the curtain part and the movie start. No ads, no trailers. I went in with low expectations, yet was hooked in the first five minutes by Spielberg's fantastic use of mirrors and shadows. And then the George Lucas crap came in and those low expectations came rushing back. Best action sequence of the film? The motorcycle chase, which un-coincidentally had no (or at least subtle) CGI effects. Anyway, we laughed walking out.
The two best things I saw in the Castro was the sex toy shop, Does Your Mother Know? because I love inappropriate ABBA references, and the guys in pink bunny suits giving out free hugs and roses. On the way to eat, we passed an alley covered in impressive graffiti. Turns out it's the well-known Clarion Alley.
After burritos, we returned to find the vehicle gone. Towed. Suck-o. Well, we weren't parked legally, just had followed others illegal lead. Between the three of us we worked out who to call and where to go to get it back. Sorry about that budget buster friends!
Monday I had some time to kill before my flight out so I rushed to the city and hit the SF Museum of Modern Art. I wrote some notes about the work that impressed me most, but I seemed to have misplaced it. I'm sure I'll come across it and then I'll just edit this entry.
Oh yeah, we also went out to the beach, ate at a diner overlooking the ruins of the Sutro Baths, walked through Chinatown, drove through the Presidio, and got offered "nuggets" while walking through Golden Gate Park. MidSav, according to the DEA, love nuggets are marijuana, so now you know. At this point, I'm kinda tired of writing, so the activities of this paragraph shall not be expanded upon.
I wasn't with my usual night preceptor one night, though I don't think the events of the night would have gone differently if I was. Night.
One of my patients had gotten out of surgery earlier that evening and was to remain intubated and on the ventilator all night. Usually we try to wean patients off the ventilator and get the tube out as soon as the anesthesia has worn off sufficiently. Though I don't remember the one time I was on one, it's clear that people mostly do not care for ventilators. Instead of gently sucking in air as usual, patients now have a tube down their throat that blows air into their lungs. Unnatural, uncomfortable, and often anxiety-producing.
This young man was prescribed medication to decrease his anxiety and surgical pain. They weren't really keeping up despite a couple calls to doctors for increased dose and over the course of the night he was getting increasingly agitated. His hands were tied down with soft wrist restraints as we usually do with intubated patients who are not yet calm and rational enough to not grab for their tubes and IV lines. This guy was clearly not with it mentally, yet had the presence of mind to try wiggling down in bed so he could get hold of something to pull on. Several times an hour I had to readjust his position because he was close to grabbing his Foley catheter or airway suction line. Through rubbing it against the mattress, he managed to slightly dislodge the line going into his radial artery (the wrist) that measures blood pressure continuously. While I was trying to re-tape it, he yanked back and it came out. Great. I bandaged the site and got an order to follow cuff blood pressures instead.
With all this, and upon the advice of my temporary preceptor, I called a doctor to get the patient started on a sedation protocol where we could adjust a continuous drip of medication to the desired effect, calm and not fighting the restraints. Unfortunately, the middle of the night is not the best time to request the needed medication pumps as the supply staff is only a skeleton and take forever to deliver items.
At one point, I had to reach across this guy and hold his arm down because he was grasping at his chest tubes. These are tubes that are inserted between ribs or under the sternum to drain blood and other fluid from the chest after surgery. They also help reinflate lungs that have been deflated either for surgery or because of a pneumothorax (good picture of deflated lung and chest tube there). I couldn't go around the other side of the bed to readjust and retie his restraint because I was worried that during transit, he'd grab and pull his tubes out. I said, "Sir, I cannot let you pull your chest tubes out." He looked right at me and vigorously nodded as if to say, "Oh we'll see about that!" The other nurse in my pod had gone to the supply room and my preceptor had stepped away for a moment. So there I was leaned over the patient, holding his wrist, craning my head around toward the hallway waiting for someone to walk by. It was kinda funny. Kinda. After only a couple minutes, another nurse walked by and quickly came over to help.
Around 4:30 I started to give him his bath. My temp preceptor, who is a large, strong guy, held the restraints while I washed down the patient. Despite doses of medication before the bath, the patient was still agitated. The medication pump had arrived, but we hadn't titrated the medication up enough yet to have the desired effect. At one point while we were concentrating on his upper body, he managed to get his Foley catheter tubing between his toes and yanked on it. Um, dude. There is a balloon inflated in your bladder to anchor that catheter. You do NOT want to be yanking on that. Can you say traumatized urethra? Well, not with that tube down your throat.
Toward the end of the bath he settled down though. I was just finishing up redressing his surgical incision when the patient jerked suddenly and I looked up to see a look of shock on my preceptor's face. The patient, moving quickly, had grabbed a chest tube and yanked it out. My preceptor covered the hole with his glove and called for help, I ran to the supply room for some gauze impregnated with vaseline which is used to cover the hole so air doesn't leak in.
A couple other nurses came over to help and I paged the resident on-call to come reinsert the tube or suture the hole closed. Woken up in the sleep room, the resident was groggy when he called back and at first didn't really get what I was saying. "Just come down here now please," I said as nicely but firmly as I could. The patient wasn't putting out much fluid through the tube and had another one on the same side so when the resident showed up fully awake, he just sutured it closed. While he was working, early morning visiting time had come and I tried to head off the family before they came on the unit. I caught the mom in the hallway and explained the situation, worried she was going to panic. Nope. "I thought something like this might happen," she said looking apologetic, "He's a pretty anxious person usually. I sorry he's giving you so much trouble." Oookay, then.
From there, we switched to a different, more powerful sedation med which worked well. The pulmonary doctor showed up soon after, thinking she was going to be extubating him. "What's going on here?" she asked innocently. I told her the whole story and she sympathized. I paused the sedation med so she could see his behavior (it gets out of the system quickly) and within five minutes he was back to pulling and wiggling. By this time we were at shift change so I reported off to the next shift nurse and went home to well-deserved sleep.
A couple days later I walked by the same pod and saw the pulmonary doc. She beckoned me over saying, "Look here." I rounded the curtain and there was my guy, sitting in a chair eating dinner. Thanks to the amnesiac qualities of the sedation meds, he didn't remember a thing.
I've been working nights for a couple weeks now and it's going well. My night preceptor is great and I've learned a lot from her. It was up in the air how long I'd be with her before I'm off orientation and working solo. At the end of last week, we both agreed that I needed more practice caring for unstable patients needing interventions such as vasoactive drip titration (regulating the dose of constantly delivered IV meds to keep heart rate and blood pressure within certain parameters) along with a second stable, but still critical patient. Managing both while still making and receiving calls, delivering scheduled medications, completing paperwork, and drawing labs, all within the alloted time, is a skill I've yet to completely master. Then of course I also have to be using critical thinking to work out what's needed when.
I laid down for a little cat nap tonight and unintentionally fell into a deep sleep where I had an incredible dream. It was late at night and a big group of my friends ringed a microphone set up in Mybloody's front lawn. We were playing a gorgeous song. Some had acoustic instruments: guitar, orchestra bells, viola, banjo, shakers, wood blocks; everyone was singing. It was a gentle, sweet song cut with a fair bit of longing and even though the words were sad, we kept looking at each other and smiling as we played on and on and on.
When I woke up to the roar of the A/C fan, I laid in bed stunned by how wonderful it all was. Then I scrabbled for a tape recorder, trying to hold on to the melody. Like many dreams though, it faded away and didn't make much sense when I tried to get it down on tape. I admit I teared up a little, both for the idea that my friends and I had made something so beautiful and out of frustration that I'd lost it.
I'm not convinced that dreams are a window into the subconscious, but this dream integrated two things I love very much, music and my friends, in a way I wouldn't have in my waking life. So friends, pick up an instrument today or just sing and try to catch a moment of joy or fear or sadness. I'll do the same.
After a work shift on Saturday 5/3, my preceptor dropped me off at the University of Houston so that I could see The Art Guys' show Nothing To It: An Evening of Itty Bitty Witty Ditties. Despite the trying-too-hard-to-be-humorously-obnoxious name, it was a lot of fun. The Art Guys are a Houston institution. I won't recount their biography, you can read that here. In brief, they are performance artists with an emphasis on the fun and funny rather than the dull and ponderous.
This show was a retrospective of their work performed in front of an audience that was clearly heavy on their friends, family, and ardent supporters. The first work sounded like a good idea, but in practice only partially worked. Called Future Music [In Three Movements], a projector displayed instructions that each audience member should, at a random time during the rest of the show, shout out one word. As soon as the description was up, people started calling out. The words were almost exclusively nouns like asparagus or chicken, you know "funny" words. And once the children got started, oh man was that annoying. Again, good idea for a piece, but when the audience is full of wannabe comedians and hyperactive, bored children, it don't work no good.
I won't go through every piece, just hit the highlights. A great work that worked was Kiss Piece where the two Art Guys applied lipstick and kissed every member of the audience. It was funny and sweet. Good friends and (I think) family got kissed on the lips, bald guys got kissed on the head, shy little girls on the hand. I can imagine that for a different audience it could be uncomfortable or even hostile (which would also be interesting), but for this hometown crowd it went smoothly. Kiss Piece was immediately followed by Guzzle A Beer - At Any Time - (For Tom Marioni). It's exactly what it sounds like. For the rest of the night, the director would intermittently flash up the title on the projection screen and the guys would crack open beers and guzzle them. Near the end they handed them out to some of the other back-up performers and even one guy in the audience. Seeing as the guys aren't really party animals, it was more to be endured than enjoyed, at least after the first round.
Inverted Karaoke was great. Jack, who cannot play, sat at a piano and attempted to perform "Bridge Over Troubled Waters" while listening to it on headphones that blocked out all other sound. Michael, equally horrible, "sang" along while also listening to headphones. It was cacaphonous and hilarious. Another mostly auditory work was Wrap Piece where the guys pulled out giant rolls of industrial-strength plastic wrap and proceeded to stretch it around rows of seats and handrails, working to express all the squeals and thrums they could. Plywood was a visual spectacle with dancers and chorus singing the praises of plywood. While fun to look at, this elevation of a mundane object to glory went on too long.
The last piece was also the most serious. Entitled For Martin, Jimmy and Bill, it consisted of Michael breathing audibly into a microphone while Jack slowly turned a rain stick. Sounds kind of lame, but in the near-dark, as a meditation on breath and the end of life, for someone like me that cares for people on ventilators every work day, it was beautiful and moving.
The whole show was filmed and will air on the Houston PBS station at some point. There are photos from the show on their website as well as clips from other performances.
During a brief moment of live TV, where as I'm usually watching something recorded by my Tivo, the weekend weather guy for the Houston CW affiliate was doing his thing. I was a bit dumbfounded by his name, Casanova Nurse. Really and truly, that's his name. Unfortunately his bio does not reveal the provenance of such a unique moniker. I like that he (most likely) does NOT live the life that his name could have dictated, skillfully wooing then abandoning patients in an endless string of medically-based conquests.
On that note, last week I was advised that I should make sure a female nurse or patient care tech was present whenever I examine female patients and to leave bed baths to the female staff as precautions against allegations of impropriety, which have ticked up recently. With the pain, lack of natural light (and therefore cues to the time of day), dearth of quality sleep, medications for pain and anxiety, or just idiosyncrasies, patients who've been in an ICU for days can become confused and somewhat paranoid. For instance, even in my short time working I've seen several patients who think that all staff discussions are about them, including gynecological surgeries for men and imminent childbirth for elderly women. Good thing I have a psych background, it's useful.
It's rather annoying that I have to be so cautious as I have no interest in molesting my clients and I can't really imagine a nurse getting in to this line of work with that intention. Still, better safe than sorry or as we often say, CYA.
I started working nights this week. My schedule in general is:
- Wake up at 5 PM - On the bus to work at 6:05 PM - Work 6:45 PM to 7:15 AM - Home by 8:00 AM - In bed by 9:30 AM
Soooo much better than waking up at 5 AM. On my days off I'll wake up and hit the gym, do laundry, and grocery shop before those places close at midnight, then enjoy the peace and quiet of the night. At first I'm sure I'll do a lot of reading and movie-watching, but I do plan to go on some photo excursions around my neighborhood and finally get out to the music clubs to see some bands. A social life would be nice as well.
I was going to advise my friends to avoid calling me during the day, but I accidentally left my phone on yesterday and didn't wake up despite three separate calls. Yay for the air conditioner/white noise generator in my bedroom.
Started the day with two patients, both of whom were ready to transfer out of our unit. After getting the requisite doctor sign-outs and orders for Patient #1, I started packing up the his things when the monitor for Patient #2 alarms. I look over and see no blood pressure on the monitor, then flick my eyes over to the patient who is calmly sitting up in her chair, then to the blood on her wrist. Dang, the arterial line has come out. I ask another nurse to grab a blood pressure cuff while I get some clean gloves and gauze to hold pressure on the site of bleeding. Cuff goes on, site stops bleeding, secure it with tape, then toss the bled-on pillow.
Call report on Patient #1 (the one who didn't bleed) and move him upstairs. Back to the unit and my open spot is already assigned for a patient currently in surgery. Call housekeeping for a stat clean and start setting up for the admit. Intersperse setting up suction cannisters, tubing, monitor cables, etc. with prepping Patient #2 to transfer upstairs. Call report on her then hand off to my preceptor cause here comes the admit, a "pump case" - cardio-pulmonary bypass pump during cardiac surgery - who will be on a ventilator while recovering from anesthesia. These guys can be quite unstable and this one is initially very hypertensive. Treat that, have family back for a quick visit and status update, and then catch up on charting.
Now as Patient #3 warms up (they're chilled during surgery to reduce metabolic demand), he's vasodilating and dropping his blood pressure. Calls to doctors for fluid orders. Hang multiple bottles of albumin (yes the protein in egg whites and shampoos, though this version is human albumin) as an intravascular volume expander. Success! He's stable, which is good because now it's time to set up for another admit in the bed formally occupied by Bleeding Wrist Lady. It's not part of some cruel hazing, just happens to be the only spot open for an admit.
My preceptor helps me set up the spot while I keep one eye on still-intubated dude. Patient #4 rolls out and we're off again with stabilization, family update, and charting. While fetching a medication my preceptor says in passing, "Don't worry about the bloody sheet behind [Patient #3]'s head. It's all good. Just wanted to warn you so you don't look over and panic." I appreciate the heads up.
90 minutes later it's time to report off to the oncoming shift. Whew. Four patients in one day with two of them pump case admits is unusually heavy. Of course I had lots of help from the other nurses in my section as everyone pitches in during new admissions and nobody's going to let you (and the patient!) drown. I was most proud when a co-worker said, "I like that I didn't hear any crying over here."
Another nice weekend in Austin. This time I came up to visit with my wonderful (but slightly misanthropic), adorable (yet occasionally menacing) friend and former roommate Carole and her sister. Both now reside elsewhere and it had been a while since they'd been back to Austin. I didn't join them for the requisite trip to Toy Joy and Momoko, but I did attend the night swim at Barton Springs. Sure the water is 68 degrees but if you just start swimming, the exertion keeps you warm. Getting out is mildly uncomfortable, though I find that vigorous towelling and thoughts of perhaps going to Kirby or Magnolia for pancakes soon resolves the shivering and goosebumps.
Lots of eating out including meatloaf at Hyde Park, Thai pizza from Flying Tomato, breakfast tacos at Tamale House, and a strawberry cheescake snowball from Casey's where we heard but did not directly witness a two-car collision. Thankfully everyone was OK and I didn't have to spring into action. It makes me nervous that I might be called upon to render medical aid outside my job and volunteer activities. Of course I'll do it as needed, I'd just rather not have the "opportunity".
Oh hey, I just realized that Carole, her sister, and I failed to convene a meeting of the organization we founded many years ago. BOTA, or Bring On The Asteroids, is dedicated to periodically becoming so frustrated by the general suckiness of people that we throw up our hands and welcome an asteroid bombardment that will wipe out humans and allow the rise of a new sapient race. Hopefully the bonobos who are generally groovy and prefer sex over violence.
So I was watching an episode of a TV drama and there occurred a medical emergency which played out so poorly, I shrieked, "WHAT?!" at the TV. A very fit young man is in the hospital after being beaten up. One minute he's talking, then suddenly the EKG monitor (which an assault victim with no history of cardiac problems would not have) alarms and IMMEDIATELY a doctor comes running in saying "He's crashing. Get me O2 and an ambu bag." The monitor completely flatlines (wrong) and a couple more staff members (nurses, possibly) run in. The MD starts totally ineffective, fake-ass chest compressions with the patient still up at a 30 degree angle in the bed. The nurse with the ambu bag gives a few breaths, then caresses the patient's chin. Huh?
Oh it was so bad. I'm sure police and lawyers get riled by horribly inaccurate portrayals of their professions too. A guy asked me once which TV shows were the most medically accurate. The best one is Trauma: Life in the ER but that's a documentary show so it really doesn't count. I haven't watched it in a while, but ER was pretty decent in that the actors had practiced doing fake intubations, chest compressions, and other procedures. I recall as well that the treatments they rattled off by and large were accurate for the patient's condition. Of course, like all medical shows, the doctors did tons of stuff that really nurses do.
Scrubs is rather bad, both in the wildly inaccurate depiction of medicine and in severely dropping off in quality after the third season. Don't even get me started on House.
And then there's my favorite quack doctor. No not Dr. Nick of The Simpsons. I'm speaking of Dr. Spacemen (SPA-CHE-MEN) on 30 Rock. A couple episodes back Dr. Spacemen (wonderfully played by Chris Parnell) rushes in to see an unconscious man who he instantly and correctly identifies as being in a diabetic coma. After some ineffectual bungling, Alec Baldwin's character says, "Couldn't you just, you know, inject something right into his heart?"
Dr. Spacemen, with a look of concern and pity, responds, "I'd love to, but we have no way of knowing where the heart is. You see, every human is different."
BWAHAHAHA! Thank goodness for Tivo so I can pause and rewind because they weren't done. Spacemen grabs the phone and says, "Is it 411 or 911? [pause] New York. Uh, diabetes repair I guess?"
I didn't make it to the dramatic presentation. I transposed two theaters when I was looking at directions originally and when I realized the mix-up it was too late to make the show. Oh well, there will be other opportunities. I'll just have to stay on top of what's playing and plan ahead. What I like about Houston is that classic and contemporary, much-lauded works get mounted here. Quite different from Austin.
Yesterday work was a study in contrasts. When I started the day, I took two patients with the plan being that I'd give them up at 9 AM to another nurse so that I could get more practice admitting difficult cases. Two hours to assess the patients, document, give medications, while also managing phone calls from family, updating doctors on condition, and providing comfort care isn't much time. I didn't quite make it and by 9:30 just ended up fetching one patient's meds for the relieving nurse to give. Dang. Then I found out that the surgery schedule started late because resident interviews had begun that morning. We wouldn't be getting the kinds of patients I needed till much later in the day. I kept myself busy helping others and studying a little till my manager called me up for my 90 day review. I'm doing well apparently and get a small raise. Yay.
At 3 PM (or 1500 as medicine uses military time) I took back one of my original patients and prepared for a fresh post-op case. He came out at 1700 and the race was on to do as much as I could get done before the next shift showed up at 1845 while also, you know, taking care of the patient. As I was saying to Mybloody last night, I once started to write a post about post-operative care of patients who required heart bypass during surgery but when it took three paragraphs just to establish the basics of hemodynamics, I deleted it. Too complicated and therefore boring for anyone that doesn't want to actually do it I think.
Anyway, I again didn't quite make it in the time allotted. Between assessment, calls and conferences with doctors, warming the patient, managing blood pressure, giving meds, and documenting I didn't get to some paperwork and a few of the less important medical orders. I was and am disappointed that, though improving, I'm still slow. My preceptor said, "You did fine. Are your patients still alive? OK then." To which I replied, "That is *not* the standard I'm shooting for at this point." I'll get there eventually but I'm not one to be patient with my own progress, grumble grumble.
Oh Houston, I'm trying to like you but you're making it difficult. Last week I got excited because I found out about the Westheimer Block Party. Lots of bands and artists, free, and just a 20 minute walk away. It started at noon, but after a long week at work I slept in, read a bit with Muriel's Wedding on in the background, went to the gym, and ate a leisurely early dinner before heading down to the Party. Three hours later I was walking back home rather disappointed. Here are some notes I jotted down:
- This band would like to be the Strokes. Now they're playing Tom Petty's "American Girl". Huh.
- Bandana. Why?
- The painter of stylized rotund people is here.
- Shitty drummer for a jazz band. Saxomophones.
- Screw is still a going concern in Houston. [Reading the Wikipedia entry, it's still a going concern everywhere. Shows what I know.]
- Between song time > song time = no good + me moving on
I really should stop comparing Houston to Austin, but it's hard when the city you love to pieces is not the one you're in and the one you're in jabs you in the ear with mediocre to poor music.
Tomorrow I get my first taste of Houston theater. My cultural hopes are elevated yet wary.
Very busy at work this week, particularly today. My preceptor has almost completely stepped back, leaving me to handle things on my own unless I specifically ask her input on my plans or for a hand in boosting in patients in bed and the like. It's stressful doing the job without her help, but she and I agree that I'm ready and I best get as much practice handling the work solo because I'll be switching to night shift soon enough. After a couple weeks with a preceptor to get the hang of the work flow at night, I'll be on my own. Of course I can still ask the other nurses for help or input, but the responsibility will be mine with all the little mental freak-outs that come with shouldering it.
As I said, today was busy. I started the morning with one patient, admitted a fresh surgical patient, transferred the first one to the floor, admitted a third patient, transferred the second one out, then managed the third until shift change. Despite it being so busy, I had time to fall in love with my first two patients. Though their quite different backgrounds played a big part in why I was so taken with them, for confidentiality reasons I can't go into detail and changing the details to hide their identities just defeats the point. I can say that their motivation was a joy. Too often post-surgical patients just want to lie still in bed. These patients wanted to get better and followed the medical plan of care to achieve that. More than once I told one of them, "I wish I could shoot a video of you to show other patients how it's done!" I'll have to remember them both when I have the inevitable bad day.
A little Tex-Mex place near my apartment has a drink on the menu called Vampiro. It's a combination of orange, carrot, and beat juice [sic]. In rapid succession I thought of the following definitions for that last ingredient:
beat juice
1. the combination of blood and saliva that flies or leaks from the mouth whilst being pummeled: After he provoked those bikers, they extracted at least a pint of beat juice.
2. reputation for DJing skill: He's got massive beat juice.
3. semen: After holding off for 18 days, the masturbation session resulted in massive beat juice. At least a pint.
Beyond adding a deep red color and therefore justifying the name Vampiro, beet juice just doesn't sound all that appealing. Still, it's preferable to making a drink with definitions 1 and 3.
Though reports vary, it appears that there is a world-wide shortage of heparin. Heparin is an injected medication that prevents clot formation and extension. Where I work it's used to keep IV pressure lines and dialysis catheters from clotting off, to reduce clot formation until longer-term anticoagulation therapy kicks in as well as for the prevention of thrombosis formation in patients who have reduced mobility, i.e. lying in bed all the time. We got word that the normal supply was disrupted and so for single doses would have to use syringes that Pharmacy is preparing and distributing.
After some reading of wire reports, I think I got a handle on the shortage. Starting at the end of last year, there were reports of patients experiencing allergic symptoms such as difficulty breathing, rapid drops in blood pressure, nausea, and vomiting after single doses of heparin. In February, Baxter Healthcare Corp. issued a recall of heparin after many more reports of reactions including some deaths. Later Baxter announced they were suspending manufacturing. A couple weeks ago B. Braun Medical Inc. and American Health Packaging issue a voluntary recall as well.
Turns out that some of the ingredients were originally produced in China. In early March, the FDA found that the Baxter heparin had a substance called chondroitin sulfate in it that had been chemically changed so that it had a similar effect as heparin. Chondritin sulfate is much cheaper - shades of lead-based paint on toys huh? At first, the Chinese government said that quality control on the manufacturing of heparin should be carried out by the importers. They about-faced several weeks ago and issued new guidelines for stepped up testing and registering of suppliers. Between this lax control on manufacturing and the Tibet crackdown, I'm a little peeved at China.
The Federal Drug Administration (FDA) publicly stated that there was no heparin shortage because of the recalls but, uh, when you've got three of five manufactures recalling it and hospitals practically rationing supplies, that's a problem.
Yesterday I went to the St. Arnold's Brewery here in Houston with some friends. The brewery conducts a tour and tasting every Saturday afternoon. It was packed so the "tour" consisted of an employee with a mic explaining a few things about the brewery, which maybe 25% of the audience cared about. Then he explained the way the tasting worked, which I guess about 75% of the audience cared about (the other 25% were clearly veterans who knew quite well how it worked).
$5 gets you the speech, a souvenir St. Arnold's half-pint glass, and four tokens you redeem for drinks. Even the kids or teetotaling friends can join in as St. Arnold's has a root beer. If your kids are bugging the hell out of you I guess you could go half root and half real beer so they'll become sedated, or possibly belligerent. I kid of course, alcohol for children is a no-no.
I had two Lawnmowers and an Amber. By the time the final call came, I was too full from lunch and beer to use my last token. Next time I'll be more diligent. Click the above pic to go to Flickr for more photos, if you're into that sort of thing.
South Park Studios, where you can watch any episode from the series, recently launched. Following the lead of other animated program websites, they have an avatar generator. This being South Park (with all that implies), you can chose from the basic body types of Female, Male, Canadian, 4th Grader, and Kindergartner. Skin tones offered are Hispanic, Caucasian, African, and Gay Tan. Yeah. I went with Male and Caucasian. The outfit is the closest I could get to scrubs, though the color is exactly right. Wish I had the Photoshop skills (and the actual program) to take out the "T" and add in a stethoscope and a pocket with pen, scissors, and hemostats. Still, fun! UPDATE: Mybloody made my wishes come true. Picture now updated with stethoscope, pen, and hemostat. Thanks Mybloody!
As I've written about before, patient assessment is a major part of being a nurse. Here's Part I of what I do within 30 minutes of getting a patient either when I'm coming on shift or they roll out from surgery. I was going to type up the whole thing in one post and then I realized how long it takes to write it all out versus just doing it. It's organized by body system and yes, we have a form to remind the nurse of all the things to check.
Neurological
Shine a flashlight in their eyes and watch for pupil constriction. Grade the size of the pupil (esitmated in centimeters) and the speed of constriction (brisk or sluggish). Grade their level of consciousness (alert, lethargic, obtunded, stuporous, or comatose). Grade their behavior (sedated, inappropriate, confused, agitated, or combative). Ask them their name, the day/date, where they are, and why they are there to judge how oriented they are. People who only know they're name are Ox1, if they know they're in a hospital and why and at least can get the month then they're Ox4. While they're speaking, grade their speech (clear, slurred, incomprehensible, or they have a breathing tube in and cannot speak). If they are aphasic, note whther they are having difficulty speaking (expressive aphasia), understanding what I'm saying (receptive aphasia), or both (global aphasia). Put two fingers in their hands and ask them to squeeze and release. Have them push against my hands with their feet and pull back their feet toward their knees. Grade their strength in these movements. Note if they have a drain or pressure monitor to their cerebral spinal fluid and if so the condition of the dressing over it, the level it's at, and the type of drainage (clear, serosanguinous, sanguinous).
Cardiovascular
Listen for heart sounds, note presence of S1 & S2 (the lub-dub sound) and any extra sounds. Check capillary refill at fingers and toes, grade brisk or sluggish (<>3 seconds). Note nailbed color (pink, pale, dusky, cyanotic). Grade the temporal, brachial, radial, dorsalis pedial, and posterior tibialis pulses (palpable, heard with Doppler, absent). Note chest tubes, their placement (pleural, mediastinal), suction applied if any, and what they're draining (clear, serosanguinous, sanguinous). Note pacemaker and/or internal cardiac debrillator and whether it is on. Note whether unused transcutaneous pacemaker wires are wrapped. Print a EKG strip and analyze it for the heart rhythm. Note or adjust the alarm settings for heart rate, blood pressure, and ST segment elevation or depression.
Note all IVs, their size and placement, when they were inserted, how the insertion sites look, and if the dressings over them are intact or due to be changed. If A-line (arterial line used for continuous blood pressure monitoring) and/or CVP (central venous pressure line used for monitoring that pressure as a measurement of right-side heart function and fluid status) present, calibrate the transducers and note how the monitor waveform looks and that the dressings over them are intact and up-to-date.
That's enough for now. I'll get to pulmonary, renal, etc. later. Is this boring? Should I spice it up with stories of things gone wrong?
Those that know me well know that I love the band The Magnetic Fields. I interviewed band leader Stephin Merritt a couple time while writing for the UT Austin newspaper. There was a time when I had the money and vacation time to justify flying across the country to Boston or New York mostly to see MF. And despite dropping out of all the other music-related listservs, I've kept up with the Stephinsongs listserv for 11 years. Yah, supa-devoted fan.
Mr. Merritt does not compose autobiographical lyrics despite the seemingly heart-felt pronouncements in many of his songs. Though a relatively modern element in popular music, the confessional, when-I-say-"I"-I-really-mean-me style of lyrics seems to be the default interpretation of critics and audiences. Nobody really thinks that Bob Marley actually shot the sheriff or that David Byrne was a psycho killer do they?
Recently Merritt was interviewed about the release of the new Magnetic Fields album Distortion and had this to say, “In the lyrics, there’s only so much intimate detail that heterosexual audiences can put up with. So even if I were autobiographically inclined, I don’t think I would go very far into details. Fortunately for me, I’m not at all autobiographically inclined, and when I put autobiography into my songs I’m generally joking.”*
So, if Stephin was autobiographically inclined and if he went into intimate details, then we'd have, what, More Songs About Butt-Fucking? Actually, that sounds like a pretty good idea. I'm officially claiming that title for my new queerpunk band Big Black Dildo. Or Cock. Is Big Black Cock better?**
*Stephin Merritt, Los Angeles Times, Jan. 27. ** I almost can't believe that I went this far for stupid Steve Albini joke. Almost.
4 hours of computer modules at work, gym, watched California Split
Wednesday
Work 6:45 AM - 7:15 PM Drive to Austin 8:30 PM - 11:00 PM Stuff badges for SXSW 11:15 PM - 11:50 AM
Thursday
Listen to REM from behind Stubb's 12:00 AM - 1:30 AM Sleep 2:30 AM - 10:30 AM See bands, wander 12:00 PM - Friday 1:30 AM
Friday
Drive back to Houston 2:00 AM - 5:00 AM Sleep 5:00 AM - 7:00 AM Classroom education at work 8:00 AM - 4:00 PM Watch TV, eat, sit around 4:45 PM - 6:30 PM Sleep 6:30 PM - Saturday 08:00 AM
Saturday
Drive to Austin 9:00 AM - 12:00 PM See bands, wander 12:00 PM - Sunday 2:00 AM Sleep 2:30 AM - Sunday 7:30 AM
Sunday
Drive back to Houston 8:15 AM - 11:00 AM Think of about how attached I am to Austin and SXSW 11:30 AM - 11:32 AM Nap, gym, laundry, grocery shopping, watch the original Funny Games 11:32 AM - 9:45 PM
So that's what I did last week. It wasn't a successful SXSW in that I didn't see too many things that impressed me and wasn't able to see any films. In fact the only band I really enjoyed whole-heartedly was The Raveonettes. A few were interesting, but nothing more than that. I'll chalk it up to my own fatigue and jadedness. The kids are alright, must have been me.
UPDATE: I forgot to write that Black Moth Super Rainbow were great Saturday night/Sunday morning. I really enjoyed their collaboration with Octopus Project last year at SXSW and they clearly came ready this time. They had confederates in the crowd who, at climatic moments, would throw out candy and confetti, spray fake snowflakes, and float (empty) piñatas through the very engaged audience. Every couple of songs, the guy in the band who was crouched on the floor playing keyboards or vocodering would stand up, look around, and seem amazed at the size and excitement of the crowd. Yay for them.
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.
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.
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."
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.
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.
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.
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.
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?
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!
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.
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.
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.
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.
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.
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!
