When I Get Struck By a Car

It's starting to get weird working at a high-level trauma center. I've lived in its general area for a while now, so I've always heard ambulances and helicopters, but now I'm starting to realize: those are people going to where I work. I hear stories in the morning on the news radio about people getting shot or hit by cars, and by the night I'm hearing about the patients. I mean, people at work don't really gossip about patients—no, really, they don't—it's just once or twice I've heard things that matched up to what I heard in the news. (Don't worry, I would never post about those cases.) Anyway, I live in the area serviced by this hospital, and I go to work on foot, crossing some pretty busy city streets in the process. So that means if I get hit by a car, or mugged, or have a heart attack, or a meteorite falls on me, I'll be going to work in an ambulance—not just to my hospital, but possibly, after being patched up in the ER and surgery, to my unit! I wonder who'll be on that day. I wonder if that question will go through my head.



Of course, with my luck, when I get struck by a bus my hospital will be on bypass, and I'll have to go who knows where.

Nurse Needs Food...Badly.

It completely makes my day when people bring snacks for us at work. Especially when it's not the typical donuts, bagels, or muffins
(ass-expanders, as one nurse calls 'em). I'm talking chips and salsa, crackers and cheese, homemade Filipino noodles (pictured), chile relleno somebody's mom made, guacamole, shrimp rings, etc. Don't get me wrong, when patient's family member or a doctor brings in Dunkin Donuts, everyone eats them...but I think nurses working a twelve-hour shift need good snacks so they can pop into the breakroom periodically to maintain consistent levels of protein and carbs. Otherwise they often end up scarfing down large amounts of processed simple carbs and sodium in the hospital cafeteria (why are they often the unhealthiest places to eat in the world?) in two short 'meal' sittings, and using high maintenance doses of caffeine to get through the carb-induced post-meal insulin slumps.

Sometimes I take it upon myself to bring these snacks in, so today I brought cashews, almonds, and these soft German lemon cookies (okay, so they'll probably expand your gluteal area as much as a donut will). But if you're ever a family member of a patient in the hospital, and you want to bring something in for the staff, consider a party-style shrimp ring instead of a dozen donuts.

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The newest edition of nursing's blog round-up, Change of Shift, is up at RehabRN. There's some pretty cool stuff, including a fisherman who sutures himself, and an analysis of how even though everything in the workplace is computerized, we still write stuff on paper 'on the fly' so we can enter it into the computer later. Of course the new nurse shows get mentioned, since anytime nurses are more than just minor characters, they're burnt-out drug-abusing adultresses.

Next Change of Shift will be on emergiblog. Feel free to submit an entry even if you're not an RN. And mark your calendars—I'll be hosting Change of Shift on August 6th!

Posted during an extremely slow work day...4 patients in the ICU.
Pansit palabok photo credit: bingbing
Subject line credit: Atari multiplayer arcade game "Gauntlet" and also another Five Iron Frenzy song!

Give Breech A Chance: Canada Reverses C-Section Policy

Back in the nineties there was a ska band (ska? what's ska?) named Five Iron Frenzy who wrote a song singing Canada's praises—that William Shatner was born there, that you can be arrested by Mounties, that people there say "eh" instead of "what" or "duh", and that you have to go there if you want milk in a bag. Well, now you can go there if you want to give your breech baby a chance to deliver normally. Canada's Society of Obstetricians & Gynecologists reversed their prior recommendation that breech babies can safely be born only by c-section. Now they're recommending that obstetricians once again be taught how to help deliver breech babies. (One of the main problems you see with breech deliveries is even if a practitioner is okay with delivering a breech baby vaginally, they've never been taught how).

Unnecesarean made the entertaining picture above; Stand and Deliver posted the original story I saw and then posted several interesting links about SOGC's decision and the physicians behind it. If you want to dig into the nuts and bolts of how this happened, check out Flip Flop: How we (or at least Canada) went to routine cesarean for breech and back again in the era of evidence-based medicine.

While thinking about all this it struck me that this sort of defines our "birth culture" here in North America. Formerly, the way our culture treated birth was in a very manipulative, non-family-friendly manner. Whether it was not allowing husbands in the birthing room, or not allowing mothers to be with their new babies, or tying women down and loading them up with scopalamine, or sedating them for days at a time, birth in this country was completely owned by the hospital and physician. The woman, let alone her family, had nothing to do with the process. This attitude is what defined birth care.

Nowadays the woman is more involved in her own care (though I think most women still resort to being passive patients, because that's what's polite in our society), and practices are becoming more woman- and baby-friendly (and husband-friendly, thankfully!). But now, birth care seems defined by precautionary measures. From the moment you check into the hospital, things are done just as precautions: an IV line is established, you're not allowed to eat, you get put on a monitor, you're supposed to be in bed. None of this may be relevant to your case, but it happens nonetheless. Even after the baby is born, your care is dictated not by what's applicable to you but to general hospital-wide precautions: you're not allowed to walk with your baby, it has to sleep in the bassinet, it'll get phototherapy for elevated bilirubin levels regardless of whether there are any symptoms of jaundice. I'm not against taking precautions. But most of these precautions in the majority of women are pointless, and some are dangerous. Nowhere is this more illustrated than in prophylactically doing cesarean sections for high birth weight, "post-maturity" (greater than 40 weeks gestation), or breech presentation. I already spoke about one mother who nearly died from a scheduled, precautionary section. This is serious stuff.

Now, as I've said before, birthing a breech baby carries risks to the baby, particularly a prolapsed cord. But a c-section involves risks to the mother and the baby. At the very least, mothers should be allowed to choose this alternative risk, especially since it involves more risk to their own body. But in the US, they're not. This decision is being made for women by societies of physicians, hospital administrations, and in all likelihood, insurance companies.

I believe you can "trust birth", as the slogan goes. But I also sympathize with healthcare professionals, because it would be impossible to trust like that in a factory-style hospital environment with so many patient variables. I think the model of birth care in America, even if it doesn't leave the hospital, needs to change before things will improve. It has to become centered on the woman, her baby, and her practitioner. Right now it is modeled after the medically ill patient: you're a patient, not a client, and your physician has put you in the care of the hospital staff. Therefore you and your practitioner have less of a say in your care than the hospital's policies and the staff's clinical decisions.


Other posts on breeches and c-sections:
Breech Babies (scheduled for a breech section, baby turned, sectioned anyway)
Obstetrics: Causing A Problem And Then Fixing It
Nearly Bleeding to Death From a Cesarean Section

New Lease on Life

I remember this friendly older woman I met once on the regular medical floor. She had various respiratory ailments like COPD that unfortunately progressed into respiratory failure. She coded like three times during her stay with us, including twice in the ICU, which is never good. If you have multiple full arrests in the ICU, they're probably already throwing everything at you that they can: mechanical ventilation, cardiac meds, etc. And multiple codes usually starve your brain of oxygen despite all the effort. Eventually she had to have a tracheostomy and feeding tube (trached and pegged, as we say) and was sent to a long-term acute care hospital. I didn't know what her awareness level was, but I thought she was pretty much gone. I was really surprised she survived to discharge.

There's a system in place to try to rehabilitate people like her; facilities for people who need lots of rehabilitation—not just physical therapy but mental/cognitive rebuilding, respiratory therapy, occupational therapy to return to daily life. But because I work in ICU, where these kinds of patients are sent out as soon as they're stable enough to go, I don't know much about this kind of rehab. I expected that she would spend the remainder of her days in a nursing home bed, possibly never recovering consciousness.

She came back to the hospital like a year later for a relatively minor case of pneumonia, and I couldn't believe my eyes. She was back to her normal self, sitting in the chair reading a magazine! She never got to close her tracheostomy, so she had to put a valve on in order to speak. But speak she could, and she seemed to have no cognitive deficit, no brain impairment. I was staggered. I mean, you could say she's not back to "normal"...she's been in and out of hospitals for a year, which irritates her, and she's got a trach, but heck. I'd take that if I were in her shoes.

I guess I'm pretty gullible. Critical care nurses and physicians can be pretty cynical about people who've suffered severe medical catastrophes that have the potential to destroy your brain. I don't mean cynical about their care (they're usually extremely good at their care), but about the long-term rehabilitation efforts I mentioned above. And when they talk like that, I believe them. But I guess rehab really can work.


EDIT: I left this open on my computer in draft mode! Apparently one of my sons found it and managed to publish it, but not before giving it the title "Q1**1*1q*!*!*!**!*!1111". :-) Sorry if you saw that!

Comparing Hospital Morgues

The hospital morgue I usually frequent (with deceased patients, of course; I don't just hang out there) is a big tiled room behind an unmarked metal door in the basement. It has an rarely-used autopsy table (a metal table with drains) on one end, and a wall of refridgerated vaults on the other. You lift the body up with a mechanical crane or lift, slide a tray out of the vault, lower the body onto it, slide it back in, and shut the door. There the deceased waits for the funeral home to come pick them up. Occasionally rain leaks into the bottom of the vault, which doesn't seem like a good thing, but other than that it seems tidy and neat.

So I was surprised when I saw the morgue at a larger hospital. It's literally a small refridgerated room, with no vaults. The dead lay, in their white plastic bags, on the carts they're brought down on. There's a shelf to one side labeled "Fetuses and premies", "Newborns and pediatrics", which was fortunately empty. A shelf on the other side, high up toward the ceiling, is full of white plastic containers, like ice cream tubs. Written on the side of each container, in different handwriting, in black Sharpie marker, was "BRAIN". What do you do with tubs of brains? I honestly don't know. Autopsies? I'm intrigued. And for just the visual look of it, I wish I had been able to take a picture of that shelf.

Incidentally, both the morgues are located next to their respective hospital's kitchens. One morgue even has a large "Food Services" sign over it. Soylent green, anyone?

"Brains" photo by Curious Expeditions

Father's Day

Happy Pop's Day to you dads. I got the day off, the wife & kids got me chocolate and kitchen gadgets (a garlic press and a scary-looking herb slicer-dicer), we're having strawberry shortcakes and whipped cream for breakfast, and the weather's hot but mostly pleasant. Looks to be a great day.

My preceptor and I, both bungling males, had to wash hair dye out of a patient's hair. She collapsed in the midst of dying her hair at home. She went through CPR and intubation, ambulance ride, the ER, the cath lab, and then up to our floor with the brown dye still in her hair. Someone had covered it with a surgical cap, but it was still was staining everything with reddish-brown streaks and freaking out every doctor and nurse who came into the room. Once she was stabilized we washed it out, aided by a daughter, and didn't make too much of a mess. Never know what you'll have to do in a day's work...

I've been keeping up with events, particularly AMA's conference and Obama's speech here in Chicago, and Canada's ob/gyns giving breech babies a chance; but I haven't had a chance to write about them yet. Stay tuned.

I Did NOT Go To Medical School To Play Nurse In The Bedroom!

My wife was laughing the other day because she remembered this time she saw a female medical student or resident physician writing about having casual sex with a male resident who wanted to role-play a nurse/doctor fantasy with her. The female physician, of course, would have to play the nurse. I can just imagine the outrage. You slog through medical school and residency and yet, at the end of the day, your male colleague just wants you to wear a cheap sexy nurse costume.

I don't see why he couldn't have been the nurse. I guess there isn't much of a market for the sexy male nurse. Granted, I'm not sure what he'd even wear. I don't know what the masculine equivalent of the little white dress is; seems like you'd still have to wear scrubs. Of course, for realism you could have your belly protruding, your chest hair showing out of the top of your scrubs, and maybe mismatch your top and bottom.

My wife suggested we could role-play a female doctor and male nurse, where she would order me to continue monitoring the patient and up the Pit while she goes to the cafeteria to stuff her face and frets about whether the patient will deliver before the ball game starts...but I don't know, it's just not doing anything for me.

EDIT: I am NOT the dude in the image! :)

Patient Privacy Rethink

You may have noticed that I've taken down some of my older posts. I've done this over, um, privacy concerns. Even apart from the possibility of violating HIPAA, I have real-life bosses and school instructors who might not see quasi-anonymous patient stories in the most kindly light. Some of the stories will probably return after some drastic editing, but in the future I'll try to shift away from talking about individual patients and talk more about general issues.

I was included in the newest Change of Shift over at Florence dot com, down under the "Procreate" heading (oh geez). I like the "nurse's dream list" article. I'd already thought of portable CT and automated, on-the-fly recording of IVs, assessments, etc (say, into an iPhone with voice recognition); I'd like to add wireless heart monitoring; I get tired of those wires and don't see why they haven't invented that yet. Dispersing Ativan gas into the hospital's ventilation system is a fantastic idea I hadn't thought of.

There's also a good analysis of mattresses and back pain which I should show my brother-in-law who doesn't believe his back pain has anything to do with the ancient straw mat he calls a mattress (I obviously also need to include more lolcatz in my posts).

So on to important things: some fun with flatulence last night.
4yo boy: walks into kitchen talking about something, stops midsentence to start waddling funny and letting out loud farts
2yo boy: doesn't look up from reading a book on the floor, says "Baby, dat's gross!"
baby: clueless, unable to defend herself
4yo boy: "That was just me, I was bein' silly and burpin' out of my butt!!"
5yo girl: peals of laughter

Pranks, or, Why I Can't Wait To Be a New Grad

I was warned by someone in the ICU that if my preceptor asks me for a cart and a portable heart monitor to take a deceased patient to the morgue, I shouldn't fall for it. Apparently he'll ask new people for a cart and a monitor, you know, "just in case something happens," and people have fallen for it.

He told me about all the pranks he helped play on new grads and other folks when he worked night shift. They would page overhead that there were muffins and coffee in the cafeteria for one hour only and then see if anyone showed up (particularly new residents). They zipped a nurse up in a body bag and called a transporter to take the 'patient' down to the morgue, so she could sit up when they were halfway down the hallway and scare him. They would send a new nurse to go pick up fast food for everybody, and while they were out, put their patient in another room, put the code cart outside the room, and call a code as soon as they came back. They'd use a cell phone to call a new nurse, and say (in an Indian accent) that they're an infectious disease doctor and they've discovered a contagious rash in the patient's left armpit which requires full isolation. They'd have the nurse go in the room in complete isolation garb to examine the rash while someone else held the phone, and when she didn't find one they'd have her check the other armpit, and so on.

So he says. Somehow I'm thinking that mischievous people should not be left alone around unconscious people.

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You might also like the 'best medical pranks and practical jokes' page on impactEDnurse. Forgot about that when I wrote this...may as well have posted this as a comment there!

First Day in the Neuro ICU

My first day as a student nurse in the neuro/trauma intensive care unit started off with a bang. Right after morning report, we had a code blue on a multiple gunshot wound victim. My preceptor nurse and I ran to the room, but when we got there she stood by like a porter and gestured me into the room. I wasn't expecting to jump right in on a code on my first day (first hour, really), but I'm glad she did that.

The general report sheet on all the patients on the unit has diagnoses scrawled on it for each patient, like GSW (gunshot wound), MVA or MCA (motor vehicle / motorcycle accident), and, to my surprise, 'pedestrian vs auto'. They've even had 'ped vs train'. Seems an ironic way to put it; somehow I think the pedestrians don't often triumph over the vehicles.

My main patient was the victim of a lower brain clot who unfortunately deteriorated to having no reflexes (cough, gag, corneals) and unequal pupils. We spent all day managing his blood pressure, which varied wildly minute by minute depending on how we adjusted the vasopressors (from, say, 40/20 to 280/210), and working him up for brain death. We performed frequent neurological checks (watching those pupils), an apnea test, a cerebral bloodflow study, and the cold caloric test (filling his ear canal with ice water, which messes with the balance center in your ear—an awake person would probably become violently ill, but even a comatose but working brain will cause eye jerking). The apnea test was unclear—four breaths in twenty minutes. Most people either try to breathe or don't breathe at all. Nuclear medicine showed positive cerebral bloodflow. So he was not legally brain dead, but his prognosis is still extremely poor.

Incidentally, the trip to nuclear medicine was my first movie-style trip running with a patient on a small metal stretcher: the monitor beeping, the IV bags swinging, bagging him through his breathing tube while keeping one eye on the monitor and another eye on navigating through doorways and crowded halls. At my other hospital, we move ICU patients on their motorized hospital beds with portable ventilator machines, which is much more serene but not as exciting.

The man's wife spent most of the time crying and praying a novena to St. Joseph. I really felt for her. I can't imagine how it must feel to know death is probably imminent for your spouse, but they still have a pulse. For some reason I couldn't wrap my mind around letting go of that pulse. I know it's supported by strong IV drugs and it would drop away to nothing if they were discontinued...but I can see why people fight till the end.

Killer Botany: My Son versus the Poison Sumac

My two-year-old son got into poison sumac which was growing in the more abandoned portion of our backyard, and had the most hideous reaction on his hands. Poison sumac causes a reaction like poison ivy (they both contain urushiol oil) but is usually much more potent and toxic.

His hands swelled up and developed blisters like I've only seen on dying kidney failure patients. His hands looked burned. The blisters were all up and down the insides of his fingers, and the rest of his hands were red and inflamed.



Strangely, he wasn't itching them. For the first two or three days, he held his hands up in front of him and didn't pick up very many things. He would still pick up a fork to eat. Sometimes he would get crabby about them, especially if he knocked his hand against something, but really he was a trooper about it. He would show them to people and say "I got inta somethin!" or "My hands are yucky!" Doctor recommended lots of calomine lotion, which seemed to help dry or flatten out the blisters. He hated when we applied it, but I think that's because the brand we purchased (Ivyrest) has something like 10% benzyl alcohol, which probably burns. Also, between the half-flattened blisters and the weird Pepto-Bismol pink crust that calomine lotion dries into, his hands looked more horrific after the applications than before.

Needless to say I was almost ready to hospitalize the poor kid and await the obviously inevitable bilateral hand amputations! But my wife wasn't really bothered by this. Apparently her sister is somewhat allergy-prone and would develop bad blisters from poison ivy when she was a child. This must be why sexual reproduction is so exciting—you don't know what you're getting into. Each kid is a new opportunity to learn something new and perhaps disturbing about your partner's genotype.

It's been a few days, and he still has hideous leper hands, but he acts as if there isn't any problem at all. He still doesn't want any medicine or ointment on them. It's hard not to take him out in public. I took him and the baby out to the grocery store, and the cashiers were oohing and ahhing over the two of them, and didn't seem to notice...but I think our cashier noticed just as we were leaving, because she made an awful face and looked away. We also took him to my wife's family Memorial Day party, but his hands were just a good conversation piece. I don't think anybody was too grossed out by them, but several people didn't exactly want him touching them. Oh well.



We identified that it was poison sumac via the The Poison Ivy, Oak and Sumac Information Center. They have tons of plant photographs submitted by viewers, as well as photos of rashes and other reactions. It was kind of mind-boggling—I marched out into the backyard with a handful of printouts to try to identify plants, and a large bush of sumac was sitting right there, picture-perfect. (That's the image at the top of this post.) With gloves and garbage bags, we tore the sumac out of the backyard. The plants were big and well-established, and one had a larger roots than the plant, so these must have been in the backyard the whole time we've been here. Nobody had a reaction like this.

We submitted our pictures to that website to support the human war against urushiol plant terrorism (although I guess we humans are really invading into their territory). I'll be using that site when we buy a house to investigate the yard.



Two weeks later, his hands are halfway back to normal. Kids have amazing healing abilities.

Home Birth Bonanza

Apparently the hot subject for the last week was home birth, and I wasn't notified. First Stand and Deliver features a post about collaboration (or lack thereof) between midwives practicing in homes and obstetricians and hospital staff. She cites an Oregon State University study about physician and midwife attitudes during hospital transfers. A main problem seen is that OBs get the impression home births must be dangerous (because this one birth is being transfered, even though it may represent a low proportion of home births). Another problem is that midwives are reluctant to work with the physician because they are on the defensive, so patient handoffs can be abrupt or disruptive, which can only be bad for the birthing woman.

I can add that they may be reluctant in states where they are illegal. I spoke with one Illinois direct-entry midwife (the only legal midwives here are nurse midwives) who told me about a transfer: she took the woman to the ER and beautifully assisted the on-call obstetrician with the delivery, while the ER staff, typically and understandably, was afraid to get involved. The obstetrician was so impressed that he offered her a job on the spot. She said she'd consider it...and when he left the room, said quick congratulations to the woman and high-tailed it out of there. He assumed she was a legal midwife, a CNM. It doesn't matter that she's a great midwife; because legal recognition trumps skill, she can't officially collaborate with physicians on her clients. She can only bravely and quietly ride along to the ER and leave before anyone asks too many questions.

On the other end, Midwife with a Knife writes about how she surprises people by being an obstetrician who's not entirely against home births:

Sometimes, with these complications, there is no time to get to the hospital, and the baby and/or mom can die. And, to be honest, sometimes laboring in the room 10 feet from the operating room doesn't help with these either...
The other thing to remember is that these are rare events. Even in hospitals. Even in high risk populations they're uncommon. In fact, they're so uncommon that the statistics for perinatal death for homebirths are not any different (it's like if you have a 1/1000 perinatal mortality/morbidity rate and add to it a rare event, it doesn't increase the risk by very much. Even if you double the risk, that's not a big increase for rare events).
...a normal uncomplicated pregnant woman wants to give birth at home? Sure, go for it!

I told her, and KevinMD who also just wrote about the collaboration between midwifery and obstetrics, that it seems inefficient to train physicians for years to achieve a high level of emergency obstetric skill, in order to attend births which generally don't require any of those skills. I think this artificially raises the intervention rate on normal births (as a doc said the other day at work, when all you have is a hammer, everything looks like a nail), as well as ill side effects of those interventions. Thankfully MWAK agreed with me instead of telling me to bug off. :) Not only would it lower the intervention rate and probably make birth safer if we handed normal births over to midwives, but it would be a better division of labor and resources. Critical care physicians don't spent 95% of their time seeing healthy adult patients in a family practice clinic. Medicine has already divided critical care from family practice in order to become more efficient and provide more appropriate care. So I don't see why critically-skilled obstetricians devote their time to the 95% of births which are normal and uncomplicated. And no insurance company would pay for you to go see an intensivist if you're healthy and just have the common cold. If insurance companies weren't paying all women to get high-tech obstetric care, my insurance premiums would probably be lower.

Dividing labor (pun intended) between emergency/high-risk obstetrics and midwifery would also produce a better integration between the two, which would be better for those of us (like my wife) who do home birth. There's no reason on earth why most women can't birth at home. There's also no reason why women who choose to birth at home should be treated like second-class patients if they do require emergency obstetric skill. I'm sure if I ever have to transport my wife, even if it's to a hospital I work at, we'll be treated like we have three heads. It's a shame. But I don't think good, patient-friendly integration will ever happen if obstetricians (and their hospitals) are fighting with midwives for the same market.