My Son vs. His Toe

This story might be gross. Just warning you.

My son broke his big toe. Yes, it was that son, the four-year-old who's always hurting himself, the one who's always getting into things, the one who got attacked by poison sumac with a vengeance. He flipped off a bench he was crouching on top of, and the bench slammed down on his toe on our tile floor. Ouch. What's worse is that we had just come home, it was 9 o'clock at night, and we were busy putting things away and sorting children and trying to get ready to get ready for bed (an arduous process around here), and I didn't really pay attention when he hurt himself--he's always doing it, right? So he actually had to hobble over to me before I noticed that he was crying a little more than usual and there was blood all over the floor. That's probably when I earned my dad of the year award.

I carried him to the bathroom and realized we probably had to go the emergency room. The nail was loose and already reddish-black, he had a big laceration down the front of the toe, and he was crying so hard he was almost dry-heaving. I felt so bad for him. I tried to gently wrap it and put ice on it. We arranged for a "babysitter" (my wife's brother...in other words, just an adult body to remain in the house, and most likely the kids would be up eating candy and watching movies all night) and I carried him to the van. He stopped crying so much and became more concerned why we were going to see a doctor about it. Poor guy. Then we drive to the hospital with a crying baby and a crying kid with a bleeding toe.

Luckily the hospital is so close. I carry him into the emergency room and he stops crying. The registration person at the desk asked me his name and birthdate. I can never remember his birth year. This happened a while back with my insurance company, too. She tried to calculate it with me -- let's see, he's four, this is 2011, his birthday is X, so...  Then my wife walks in after parking the car. It turns out, ironically, that our registration lady is the same person who registered us at a different hospital's emergency department a few years ago (with the same kid, I believe) and once or twice over the years has seen us at church. So she recognized my wife! Which is nice, though it doesn't seem like a generally good thing for ER registration people to start recognizing you. At any rate, she and my wife are discussing on our new family events (new births, etc) while I'm wheeling him down the hall to triage.

The triage nurse unwraps his foot and his toe is still bleeding pretty hard and looks awful. She asks him how it feels and he, trying to look unconcerned, says "It's fine."

She gave him some ibuprofen and sent us for an x-ray of the toe, which I figured was just a formality. I assumed he just needed some sutures.

Eventually we get to a room in the pediatric ED, and we wait. And wait. Eventually we're seen and the doctor informs us that the distal phalanx was fractured. He doesn't know if this will require pinning or not so he'll send us for a consult first thing in the morning for a plastic surgeon or a podiatrist (it's now 11pm or midnight). He shoots the toe with some lidocaine and sends the ED tech in to irrigate and clean the toe.

Do you see it?

The tech was very nice but very busy with lots of kids, being the only tech in the pediatric wing of the ED. At that point I felt like telling them I'm a nurse and volunteering to do whatever they need done--I had the impression the doc could work on the toe now, but had to wait for the irrigation to be done, so he had moved on to other kids.

During the clean-up the hard-working tech told me all about how he was a single dad of a few kids, since his kids had flatly insisted on staying with him after the divorce. He pulled a lot of hours as a paramedic and ER tech to put them through school and now college, spent the rest of his free time with them being a dad, and said he was going to vomit if another woman told him what a nice guy he was (since he's developed the theory that women say they like nice guys but really they like total scumbags.) I hope he didn't mind me as a fellow hard-working dad telling him what a nice guy he was. Readers--high-five that guy.

Anyway, back to the toe. After another long wait the doctor wants to suture the toe and see what he can do about the nail. The nurse has the foresight to have me hold a towel up so my boy doesn't have to watch it (why don't physicians ever think of these things?). But it's still not numb. Apparently big toes (and thumbs) are hard to anesthetize. He has to inject and re-inject the toe probably a dozen times to try to get to the nerve root. And this is what really hurt him the most, after the initial injury. He was crying but he tried so hard to hold still, and when the towel I held up slipped a bit he grabbed it and threw it over his own head. Still, as much as he squirmed, he held that leg totally still.

The doctor left to wait for the toe to numb up. My son tells me "I wish I was made out of metal."

The toe was sutured up but the nail was a loss. Removing the nail took forever. My son fell asleep during it (thank God for lidocaine). My wife had to leave the room to avoid passing out. I was a little grossed out myself. That's the irony of blood and guts, by the way. If I was in charge of the toe, I would've been fine. As it was I still had a job to do, so I was okay watching it but a little queasy. If I just had to stand around watching it, or if I had to hear about it, I'd want to barf. (Yeah, I know. I'm making you hear about it. Sorry!)

The doc asked me if I want to save the toenail. I was surprised but he said they could possibly clean it up and try to suture it back on. That sounded like more of a hassle (trying to keep it from getting caught on things, trying to keep it clean). It got forgotten about and tossed with the trash, however, so it's a moot point.

The tech redresses the toe. The physician assumed I'd see a doctor first thing, so he thought one dressing was enough, but the tech had the foresight to stuff a bag full of dressing changing supplies. Which was great, because we couldn't see somebody first thing.

We go home around 1AM, go to sleep, and call the consultant in the morning. It's Monday morning at 8:30 and I'm calling the office as soon as it opens. It turns out he's a hand plastic surgeon, and doesn't do feet. His secretary also said this was the second injured toe call they had since they opened, and somebody in the ER needs to stop referring toes to him. I call back to the pediatric emergency department and talk to a nurse who gives me the number of their pediatric orthopedic surgeons' group. With this unofficial (yet obviously accurate) referral, I went there the following day.

We waited in the waiting room forever. We watched Phineas & Ferb for the first time, which is a grand show. Finally we see the physicians--the orthopedist, his resident, and a pediatric resident--and they say there's no surgery to be done, keep it clean, he can walk on it all he wants, but--get this--try not to let him run or jump on it too much. Ha. Ha. Ha.

For the next week we keep him from jumping on the trampoline and riding his bike. Which was sort of like trying to tell him not to eat and breathe.

We're supposed to follow up with an appointment with the orthopods, not for an x-ray or anything about the bone, but so they can look at the nailbed. The nailbed is healing great and, for a gross-looking ex-toenail, is looking fine. So of course, me being a nurse, and a nurse with a high deductible health plan, I haven't bothered to set that appointment yet. I probably still should. Especially since he's gotten in fights with his siblings, kicked things, and had his toe stepped on I don't know how many times.

Do I sign my kid's birth certificate? Do you know any lawyers?

In the past, I've signed my children's birth certificates as the "attendant". This is not something I really ever planned to do. I think it originally just sorta happened. You go downtown and find the vital statistics people in the basement of the courthouse where they create these arcane documents, and when you say that you didn't have a licensed medical attendant, and there's an empty line to be signed, somehow you end up signing as the father and as the attendant.

I also vaguely recollect a midwife claimed once that whoever cuts the cord (this being, she also claimed, the only 'medical' act that occurs in many home births) is the attendant. But that's probably false—on both counts. It still probably reinforced my mental justification for signing.

Now I'm not sure that's a wise thing to do. It might have been fine when I was an unlicensed nobody, but now that I'm subject to the Nurse Practice Act I'm afraid I could be accused of practicing nursing outside of a licensed facility. Or practicing medicine, that old standby. it just seems I shouldn't have my name on a public record in the capacity of a birth attendent. I've never had a felony. I've heard those things stay on your permanent record.

This could be a viable alternative.

But wouldn't family be exempt? I would assume it would keep me exempt just like before. Assuming I was ever exempt. Did I say I signed anything? I meant hypothetically. My, uh, friend signed it.

I'm just not sure what the alternative is. Would my wife sign as attendant? Should it just be left blank?

IT A GRIL

Go to Cakewrecks. It's funny.

We totally had a baby yesterday. It went like this. A couple days of false labors starting and stopping. Then yesterday morning she's going into what seems like real labor, in the bathroom, while I'm going about the house cleaning up and getting the kids ready to go off with Grandma. Then the midwife arrives and I pop into the bathroom to see how the wife is doing. I'm sorta surprised to see that she's having these really long powerful contractions pretty close together! Glad I was paying attention.

The next few hours develop as labor tends to do, getting harder and stronger and more intense. This one seemed more painful than the rest. The baby was originally posterior and we weren't sure if she had turned. (Posterior labor = badness.) At one point she had my hand in a death grip, crunching my finger bones against my ring. It's just kinda funny because it's not like I can complain, right? Another time she had her face on my knee while I was sitting next to her, and I thought...I don't know what I'm going to do if she bites me.

At one point the midwife said there was a 'lip', where the cervix or some other woman innard gets caught under the descending head, so my wife had to stop pushing. She almost couldn't handle that, and I thought we were in for a day of misery. But after a bit the midwife determined she could start pushing again. And then things started moving fast. Really fast.

I don't know if you're squeamish, but at some point after that the midwife calls my attention to the posterior region. The baby's head is already totally out—but still in the bag of waters. Imagine a baby's head in a water balloon, sticking out of somebody. A WATER BALLOON.  Despite four other home births I've never seen that before. In fact, we had one other baby 'in the caul' before, but that midwife broke those waters before I saw. The midwife didn't have to break these; her arm was half-up and in a show of baby might she shoved it out of the bag herself.

She popped right out and was in mom's arms. After a little while she was nursing like a champ.

Right away I could tell she wasn't as big as the last baby (11 lb 6 oz). We guessed weights with the midwife, and we all agreed she was probably in the 9 to 10 pound range. Ironically I'm getting handy at gauging babies in the upper bodyweight divisions. Actually she looked small. And she still does. A pound makes an enormous difference in a baby. And despite the 'lip' and the pain, my wife said it was a much easier labor than last time—understandable right? Actual weight: 10 pounds 4 ounces.

She's a doll. She's cute and easy to please. Well, all babies kinda look like chubby old men, but as far as miniature chubby old men, she's cuter than most!

Uniform policy time.

Pregnancy update: which is that, um, we're still pregnant. We're past due day three now, I believe. This baby is low. Everyone applaud my wife for going to the gym yesterday! Everyone boo for that not instigating labor, however. Though I would've felt kinda bad for her class instructor if she went into labor then.

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There's a semi-confirmed rumor at work that we're going to adopt uniforms for nurses. This will be house-wide—every RN in the hospital will wear the same thing. The argument is that patients have complained that they don't know who the nurses are. I've heard this argument elsewhere, and I frankly don't believe it. If someone comes at you wearing a stethoscope and carrying a needle, you can kinda figure they're not the housekeeping staff. (If they're are, at least you'll be on the news.) It takes about three milliseconds for a nurse to introduce themselves and establish a professional rapport with the patient they'll be caring for over the next 8 to 12 hours. Do patients forget in that timeframe? Probably not.

I think in all truth it's the physicians who are complaining. We're a huge teaching hospital, so there are literally thousands of physicians. Outside the circle of residents and specialists you always see, I don't know most of these doctors from Adam (or Eve). And they're lost wherever they go, especially the poor primary care physicians trying to find their patients. I'm sure they've complained that they can't readily identify the nurse for their patient, standing at attention and waiting for orders. Heck, they usually can't even find or recognize their patients, but at least they have gowns on.

But on the other hand, I do have to agree that we nurses are a bit, shall we say, casual. At least where I work. The hospital and individual units have frequently issued t-shirts. They bear hospital or unit insignia with varying levels of discernability. They were made back when they were trying to achieve Magnet (big nursing award) status and instill unit pride and all that. Probably more than half of us wear them to work. But I have to admit that a t-shirt and scrub pants feels like working in pajamas.

In fact this was about to be my next scrub purchase. Including the pipe and slippers.

Half the time my stethoscope has been flung somewhere and my ID badge is flipped over or hanging off my waistline or hiding, so I can understand that you probably can't figure out who I am if you don't know me. Of course, like I said, my patients know me; but random physicians appearing at random times who are already frustrated at not being able to navigate the unit and find charts? Not so much.

To make matters worse, some people *shifty eyes* have gone on to just wearing plain t-shirts when they're running out of work shirts. Or we sometimes wear the hospital-issued green scrubs, so we look like residents.

So I know I'll feel more professional if I'm forced to actually wear scrubs. But in the meantime, I'm going to keep looking like I'm at a pajama party because that's what's allowed and it works for us. If I thought that patients were really misidentifying me, I'd worry about it. But you know what? People will still think I'm a doctor even if I'm wearing a white dress, white tights, and a red cross on my hat.

I HAVE NOT POSTED SINCE MARCH OMG.

What a busy couple of months. So we bought this foreclosure house which has occupied pretty much every waking hour aside from work. It's structurally sound but a combination of neglect and a former owner who thought he could DIY a lot of this stuff equaled a lot of work for us. We had to fix the plumbing, yank out old wiring and satellite cables, rewire a bedroom and a bathroom, repair the drywall in almost every room (and ceiling), paint every everlovin' surface of the house, play some more plumbing "where is this leak coming from?" games, clean out the gutters (organic sediment since 1994, probably disposed of some good fossils), rehabilitate the lawn and kill some grubs, install some appliances purchased on Craigslist, fix said appliances purchased on Craigslist, and I don't even remember what else. It culminated in having electricians discover exposed live wires (thx former owner) all over our attic. My favorite part was when my wife's aunt came over and, looking over the ladders and tarps and paint cans and dust, asked who was doing all this work for us - who our contractor was. I am my contractor. And I'm a pretty unsatisfyingly slow one.

It's been a learning experience for sure. I had no idea how to do 90% of these jobs, but thanks to the internet and a couple of how-to books—that sounds safe, right? :-) Makes ya want to live here. Anyway, I have tools for everything now. I'm mostly impressed by the fact that I can fix walls. Got a hole in a wall? I can make it disappear.

For all this work we're getting a nice brick home on a beautiful lot that's double or triple the average lot around here in the city. The kids love it. It's close to family and my job. It's good.

Now we have to unpack and settle in.

In other news, baby number 5 is slated to emerge in August. My wife is feeling okay, taking a lot of naps. It's hard to schedule midwife appointments in with all the other work and house stuff going on.

In work news, I am forgoing the BSN program. I'm a bit busy, no? I am thinking about doing a little CCRN preparation. The coworkers were listening to the Laura Gasparis review CDs (well, mp3s these days) and she was hilarious.

Thanks for the well-wishes and the concerned comments and emails. We're doing well. Just really busy!

The Bachelor's of Nursing. Tell me again why I should get it.

Some days ago I was assigned a nursing student from a university to follow me in the care of one of my ICU patients and give certain meds under supervision. I've done this before and I'm always surprised at how easy they have it. The instructors, when they come by, are very nice, helpful, and never expect them to know anything. For instance, she was asked how many units of insulin the patient should get, and she hesitated a second and then seemed to venture a guess. The instructor teasingly called her out on it. A guess? In my day, if I hadn't been prepared with an answer, let alone tried to guess on a medication as important as insulin, I would've had my head stuck on a pike in front of my school as a warning to students forever.

Like 57% of nurses in the US, I was prepared by a community college and received an associate's degree in nursing. So tell me: do you think I will learn anything more about taking care of sick human beings by completing a bachelor's degree in nursing with her university? Because I could. The school is associated with my hospital and will get paid by my hospital if I go there.

No one in nursing acadème or nursing administration comes out and says that an associate's degree is not enough to be a nurse. But they do fixate on the idea that it's not enough to be considered a professional. Not enough to be considered independent or autonomous. Not enough, in other words, to compete with physicians. Going back at least to the 1980s, nurses have been trying to get out from under the paternalism of physician-led healthcare. The general public thinks we're just order-followers, med-passers, and scalpel-hander-overs, and we're still trying to shake that image. For some reason, we think the only way to shake it is with academics. So there are countless RN-to-BSN programs out there, and our hospital system will gladly pay for us to go through them—so I can't really complain that they want us to do it.

Okay, yes I can.

It's kind of silly. My degree is a two-year degree. The four years at a university school are typically divided between two years of general education and two years of formal nursing. In other words, it's a two year degree. But, they say, a university program also includes coursework on research, community health, ethics, and nursing theories. So did mine. So what's the formal difference? A formal degree. Something that academics and administrators can point to. But probably not anything that's going to help you in the care of sick human beings—in bedside care.

The irony is that at the same time we ADN nurses are encouraged to get our BSN, we're also told we don't need a BSN to be good nurses, and that the BSN program is not going to teach us very much we don't already know. They might as well say: it's basically pointless, or it only helps a little, but more importantly it achieves some ulterior goal aside from improving you as a nurse. Goals like being able to say you have more BSN-prepared nurses for your Magnet award application.

The reality is that a nurse doesn't need a higher-level liberal arts education in order to be a nurse. That doesn't make us unprofessional. There's a science to nursing, but there's also an art; there's a logic to nursing, but there's also a knack. We don't like to admit that we're basically like car mechanics, but we are. We know can interpret pulmonary measurements and blood gases, but we can also just eyeball a patient and have a good idea if they'll fly or crash when taken off the ventilator. How different is that from a mechanic who knows how a catalytic converter works but also knows whether a knocking sound is benign or bad? The idea that an academically-prepared professional must fix your body but mere 'skilled labor' can fix your car is absurd. The difference is the degree of knowledge, not the category. Whether you're a car mechanic, a nurse, or a neurosurgeon, you're basically exercising your knowledge as you do tasks. This includes physicians. Physicians are not artists or philosophers. They're task-oriented like everyone else.

What does this have to do with my BSN? Well, since physicians are in the same ballgame as the rest of us, and not an elite group of Ph.D.s, I don't see the need to compete with them academically as long as I can achieve my goals in patient care. I've never met a resident or physician who cares what degree I have. They care about my license and expertise.

But I'll go for it. I'm open to learning new things. It's a stepping-stone to advanced practice, and I don't have to pay for it. But I still kinda worry about the efficiency and efficacy of this: in five years, will it matter than I spent this much time and effort away from my family to do this? Will I think I wasted my time? Most likely there's no increase in pay or status. Am I just submitting to some outdated dream of nurses who abandoned patient care for academic politicizing? I don't know. I just hope this effort helps me more than it helps them.

That's no excuse!!

Sorry for the dearth of posts. We're trying to buy a house, for real this time.

Also...we are pregnant.

I'm not going to say how many kids this makes.