Archive for April, 2010

Northumberland County

Spent the day yesterday in Ontario’s granola belt. Some photos. Let me know if want to see more of this kind of thing, or should I stick exclusively to the nursey stuff?

Port Hope’s main street. For my American readers, it’s an old Loyalist (read Tory) town, settled just after the American revolution. They take historical conservation very seriously here.

Trilliums. Don’t remember ever seeing them in bloom so early.

Victoria Hall, Cobourg. Another Loyalist town.

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It’s The Egg That Makes It

I’m off to the country today. In the meantime, in my quest to bring you the best (worst) examples of North American culinary excess, I present the Lady’s Brunch Burger— and yes indeedy, that’s a glazed donut.

A back-of-the-envelope calculation of nutritional value shows an astonishing 1366 calories and 36g of fat — excluding condiments. I’m guessing anyone who finds this appetizing is already on metformin and a calcium channel blocker.

Or Homer Simpson:

[Homer gasping for air due to being so out of shape]

TV Announcer: We take eighteen ounces of sizzling ground beef, and soak it in rich, creamery butter, then we top it off with bacon, ham, and a fried egg. We call it “The Good Morning Burger”.

[Homer starts gurgling in ecstasy]

(The Simpsons “Bart’s Friend Falls in Love”, 1992)

Life imitating art, or what? Or reality catching up to satire?

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Rape Me All Over Again

Regular readers will know I am not much in the habit of commenting on politics, especially those of another country, but this is just plain ugly:

Transvaginal ultrasound transducer

Oklahoma lawmakers overrode their governor’s veto Tuesday to enact tough abortion laws that force women to undergo invasive ultrasounds and allow doctors to withhold test results showing fetal defects.

Even women who are victims of rape or incest will be required to listen to a detailed description of the fetus and view the ultrasound image prior to terminating a pregnancy.

They will also likely be required to undergo vaginal rather than abdominal ultrasounds as doctors are required to use the method that “would display the embryo or fetus more clearly.”

Transvaginal ultrasound anatomy

Patients and ultrasound techs have told me transvaginal ultrasounds are horribly invasive procedures. In essence, a long probe like the one above is inserted into the vagina up to the cervix. At my hospital they aren’t done routinely, and are only performed if absolutely necessary. Now imagine a 15 year-old incest victim or a 23 year-old rape victim being compelled to undergo this procedure in order to obtain an abortion.

Hey, let’s re-enact the crime! Let’s victimize the victim! Because evidently, in Oklahoma anyway, this is considered good heath care.

I’m not a fan of abortion, to be clear. But I am a nurse, and it seems to me to compel women to be symbolically raped to obtain health care is particularly evil. And unless you’re willing to have this procedure performed on yourself, or your raped daughter, please spare me any cant about the rights of the fetus.

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Triage Haiku 10

Creatinine High

Dead kidneys — wilted flowers

Sparse rain of urine

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Those Emergency Blues is, Like, So 2008

Just wanted to point out that you can now follow me and my musings, bemusings and confusings on Twitter. I’m not sure how or why this will work. Or what to do with it, exactly, or how this will make me a better/happier/healthier writer/blogger/person.  (I must be the unhippest person in the visible universe. Next to Stephen Harper.)

But it sure is exciting!

We welcome our new social media overlords!

In somewhat related news, I have upgraded my internet service from two tin cans and a string to an actual copper wire.

[UPDATE: For some reason a young woman whose avatar showed her holding her boobs in a leopard-skin bra was "following" me. This was creepy. It has been corrected.]

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Another Take on DNR

89 year-old, death not immediately imminent, but certainly on that road, septic, obtunded, dehydrated, atrial fibrillation, blood pressure in her boots, Levophed drip. Previous history of Altzheimer’s dementia, congestive heart failure, myocardial infraction, osteoarthritis, CVA, etc., etc.

She’s a full code, by which we mean that if her heart stops, we do the full monty.

Numerous family members do shiftwork at the bedside, all extraordinary dedicated. They watch the cardiac monitor, then scrutinize my reaction if it beeps or whirrs.

Will she get better? they ask. She was well up to a day ago, they tell me.

I find this hard to believe, given her long difficult medical  history. I tell them as gently as possible that she may not survive, she is too sick, that her kidneys have shut down and her heart is tired.

Dr. Sivampillai, the internist, comes in. He reads the chart, and looks  thoughtfully at he family members clustered about the patient.  He’s a lovely, conscientious man. He shakes his head and sighs.

“She’s a full code, no?,” he asks. “And on Levophed too.”

“We’ve all talked to them.”

“They need to get used to it,” he says. Sure. Conventional wisdom.

But then he says: “Give them time — they very soon will get tired of all this, this toing-and-froing, and jumping at every beep from the monitor and then we will see them make her a DNR.”

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Sock It to Me

In the Resus Room the other night, working my second-to-last night shift. EMS brings us a 24 year-old female — I’m going to call her Lovely Girl — who’s had a few beers, five or six shooters, and then progressed to vodka shots and maybe some extra-legal intoxicants as well.

It’s been quite the night for Lovely Girl: she’s well lit. She’s been kicking in plate-glass windows, has a few nasty lacs on her ankles; a fist fight happened somewhere along the way, her face is contused, so she’ll need a CT at some point to rule out cerebral bleeding.

Almost needless to say, Lovely Girl is in police custody, for public mischief and assault.

Lovely Girl is a piece of work.

She reeks of vomit and beer.

She’s cursing, spitting like a Bactrian camel, scratching, biting and flailing around on the ambulance gurney so hard she’s in danger of capsizing. We need to restrain her — and contrary to popular belief, we don’t restrain people willingly.

So we put her in four-point restraints, tying her down to the emerg stretcher. The police help to hold her down.

“I have to piss,” she wails.

Geez.

Fine, we tell her. We can’t get you up (or even get a bed pan under you) till you start to cooperate, because you’re a danger to us and yourself. Spitting in our faces is a fairly clear indication that you’re not ready to help us help you.

Do you want a foley? someone asks. (This is really inept. You don’t play the foley catheter card until you’re out of options.) And Lovely Girl’s evidently been down this road before. She doesn’t react well to this suggestion.

“No fuckin’ catheter!”

Without any further discussion or debate she urinates in the bed. Not a dribble, mind you, but a veritable of lake of straw-coloured urine, so voluminous it overflows the stretcher and drains to the floor. We stare amazed. What does she have, a basketball for a bladder?

It’s unfortunate, but we can’t leave Lovely Girl in her own urine. Theoretically and officially, this is a patient-comfort measure. A patient left laying in their own urine will suffer skin irritation and breakdown. Practically speaking, Lovely Girl is going to stink (worse) in very short order.

I sigh. I tell Lovely Girl we need to get her undressed. I tell her we’re going to be taking off her restraints, one at a time. I state as factually as possible that one false move will result in the restraints being replaced faster than you can say Jack Daniels. I tell her that if she so much as twitches  she can marinate in her own urine till she’s sober enough to leave.

She grunts understanding.

We banish the police to behind the curtain. One restraint off, then the other arm — Lovely Girl is oddly and suddenly docile and calm. We sit her up. We pull at her clothes, get her piss-soaked t-shirt off. I start to unhook her bra —

“You bitch!”

Lovely Girl plows me in the left lower jaw, and knocks me off my feet. I go sailing backwards into the Resus Room ventilator, and end up in a heap on the floor, stunned.

I actually see stars. Like a cartoon character.

All hell breaks loose. I really don’t remember a lot of it. Someone calls a Code White*. Suddenly a million people are in the Resus Room. I’m helped into a stretcher and taken to the Observation Room for assessment.

The police come in after I’m examined. They take a statement, promise Lovely Girl will be charged with assault. Later, they cart her off in her skanky, filthy clothes.

Call me jaded, but I don’t really believe them. To my knowledge, people who assault nurses are never actually charged, much less prosecuted. To much hassle and paperwork, I guess. And we’re just nurses, after all. All part of the job. But I’ll let you know if I can justify my cynicism.

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*See Glossary.

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An Ethical Question

So the other day we get this drunken, obtunded 22 year-old woman into the Resus Room, and maybe she’s overdosed on something-or-other and maybe she hasn’t — and then EMS gives us a present:

1) a large Ziplock bag chock-filled with hundreds of Percocet tablets and,

2) a smaller sandwich-sized Ziplock bag similarly filled containing Oxycontin 10 mg tablets.

So of course we gave her Narcan. This had no effect: she was just plain piss-drunk.

But what to do with her alternatively-acquired, non-pharmacy dispensed narcotics? Do we

a) give them to the police (who were actually attending, because Drunk Girl was found in a public place)?

b) pretend we didn’t see them, and leave them under the stretcher?

c) give the to her skeezy-looking “boyfriend”, who’s looking all anxious and nervous around the police?

d) throw them all away?

e) actually follow hospital policy (for once) and secure all home medications in the hospital pharmacy?

a) is very tempting, but ultimately must be rejected on two counts: first there is a huge patient confidentiality issue here, and somewhat related to this point, Emergency staff are definitely not an extension of law enforcement agencies.

b) might be a good option, except that everyone knows about them, so if they go missing, there’s going to be a lot of finger-pointing and recrimination and general nastiness. Besides, they figured in her treatment, so we can’t ignore them. Officially speaking, anyway.

c) has the same problems as b). No means of accounting for them to the patient, though skeezy-boyfriend, I’m guessing, has a financial interest in their disposition.

d) from a practical point of view, might be the best answer. No fuss, no muss, tell the patient they “got lost” somewhere. We know best after all, and someone carrying narcs in a plastic bags is obviously up to no good, right? But apart from the obvious dishonesty, there’s a more fundamental issue of patient autonomy. Bottom line, they’re her property, and we don’t know for a fact they were illegally acquired: we’re merely speculating on a strong suspicion.

Which leaves us with d) as the correct answer.  So I call down to pharmacy, and get the persnickity pharmacist who insists on coming up to count all 834 Percocets and 213 Oxycontin tablets.

Heh.

Unfortunately I had to stand watching him count them out.

Oh, the price of being ethical.

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Landfill Clutter

Regular readers know I’m a bit of a handwashing, infection control freak. For good reason. As I’ve pointed out before, poor infection control practices account for a large percentage of sepsis within hospitals. But even I think this is a little over the top. Ladies and germs, I give you the hands-free soap dispenser:

NEW LYSOL® No-TouchTM/MC Hand Soap System

  • Automatically senses your hand
  • Helps prevent the spread of bacteria
  • Includes ingredients known to moisturize the skin
  • Okay, let’s reason this through a bit. The premise is that there are all sorts of nasty bacteria on the top of those squirt bottles, because you’re touching it with dirty hands. Fair enough. But you’re proceeding directly from touching that icky top to washing your hands. Which to my mind, makes the whole deal about those nasty bacteria moot.

    To recap:

    1. Squeeze down on top of soap dispenser.

    2. Wash hands.

    So do you really need one?

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    Meltdown

    When someone starts shouting in the Emergency Department, it’s never the happy shout of someone who’s, let’s say, just won the lottery or been happily reunited with a long lost relation. No, unfortunately, it’s usually a sign that a psych patient is about to launch himself into orbit. Or a patient has coded. Without thinking twice you run to the source of the noise, because one of your colleagues might be doing chest compressions and defibrillating while being pinned to the wall by the angry patient in the next bed whaling on a ventilator. You never know.

    So I’m doing up the staff assignments yesterday — a charge nurse task, I am learning, requiring the skill, tact and cunning of  a wedding planner arranging the seating at the rehearsal dinner — when suddenly I hear a lot of yelling coming from the Resus Room. Naturally, I drop my pencil and race in, brandishing my lame-ankle cane. Get out of my way! Nurse in trouble!

    It’s Beth, standing beside the patient in Bed 2. You’ve met her before. She’s tightly-wound at the best of times and she’s the one who’s all shouty. To no one in particular. “I’m so sick and tired of coming to do something,” she screams, “and nothing is ever set up properly, no one ever does this and never does that, and I’m the only one who actually makes sure everything is done and every else who works here is lazy and incompetent. . .”

    “What?”

    She turns and glares at me accusingly.

    “Don’t you ever check to make sure equipment is where it should be?”

    Beth, it seems, is having a wee moment. A postal moment.

    I’m gob-smacked. Speechless, for once. Even the patient is staring in astonishment.

    The trigger? The two Resus Room nurses were doing something or other with the patient in Bed 5, Beth wandered by and decided that Bed 2 had some upper airway secretions and needed a little suctioning. But the Yankauer suction handle was missing from the suction set up. Yes, before you ask, the Resus Room nurses are responsible for ensuring everything is in its place. But, one the other hand, it’s hardly a crisis: the patient’s airway is obviously not obstructed, I can plainly see another Yankauer on the suction set-up in the next bed, unused, and the supply cart is literally ten feet away from the patient.

    Overreaction? You think?

    Clearly there are other issues. But at the same time, it’s a nasty, busy day, Dr. Eagerpants is being a knob and pissing off both nurses in the Treatment rooms, two morphine 10 mg amps have gone AWOL, which will force me to do a lengthy search through old charts, and to whine just a little, my ankle hurts. I don’t have time to delve into the Tao of Beth. The best I can do is to is find a nurse to take Beth’s patients and send her off to break. My good friend Dianne peeks around Bed 5’s curtain, her rhinestone-edged reading glasses glinting. What the fuck?, she mouths. I shrug. Don’t know, and right now, don’t care.

    Later, on my way home, I think about this a little. Beth is my age — somewhere between forty and death — married, a couple of kids, house in the ‘burbs, middle-class respectable  and so on. I don’t know her well: she’s a bit too driven, a little too unhappy, I think, to be really likeable. She married fairly young, and I gather the wedding was driven by hormones as much as anything else. Twenty years on, she’s driving a minivan with a DVD player in the back seat for the kids, hockey bags in the back, and the guy she married, who was so hot and so cool at the same time  — and the momentum of sex can drive a marriage for a long time — is suddenly looking like every other guy in her subdivision, who’s turned forty and flabby and dull, and also leaves skid marks. She’s stays, yes , for the kids, but also, because she can’t imagine what else she might do.

    I think about what Beth said: “No one ever does this and never does that, and I’m the only one who actually makes sure everything is done.” I’m suddenly certain she’s said this to her husband. Repeatedly. I think of this, and I think of the elderly ladies who sometimes attend the demise of their husbands, and when their husbands finally die, their expression, after fifty or sixty years of marriage, is not one of grief, but of relief.

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