Why I Dread Taking My Kid to the ER

Haven't I used this subject line before?

I'm in the ER for a couple of days, following a nurse. A baby less than 30 days old was brought in with a sniffly nose and "vomiting x2". First of all, I don't think vomiting counts when it's a baby. Unless it has blood or green or black stuff in it, it's spitting up.

Besides that, the kid has nothing else wrong with it - no fever, no history of recent fevers, nothing. But the doctor wants IV access. No fluids or antibiotics yet - just access, just in case.

So for thirty minutes we get to hear little neonatal screaming that no one should ever have to hear for that long. It's awful. Toddlers scream because they know what pain is and they're afraid of it. But babies scream because they're in pain and have no idea what the heck is going on. They're abandoned and disoriented. It's the worst sound ever. All that fear and trauma and catecholamine activation can't be good for a baby, or their relationship with the parent, or their nursing relationship, and whatever else. The general rule should be to keep pain and suffering (and parental detachment) to an absolute minimum. At the very least they could've given up and tried again later, but ERs being ERs, you have to try to get stuff done now.

Then the doc decides the baby needs a sepsis workup. Apparently every kid under the age of 30 days who's sick needs a sepsis (blood infection) workup, since sepsis in a baby is pretty much the kiss of death. But this baby with no fever doesn't meet the criteria. So you know what that means: another round of stabbing the baby trying to get blood.

In the middle of Round Two of baby torment, a new doc comes on, wants to know why the heck we're working the kid up for sepsis, and says to CANCEL EVERYTHING.

I realize doctors have a right to want not to get sued, but I don't want to take my kid to the ER and have them treated like the avoidance of litigation and covering all our bases is the first priority of care.

image by addrox of addstudio

Holy Intestines, Batman!

So my baby swallowed a penny a couple of weeks ago.

A week goes by, and every day of that week my wife is asking me about what's going to happen: is she going to perforate her intestine and instantly die? Should we get an x-ray? I said I think she'll probably have a distended belly and be very unhappy in time for us to get to the hospital. And I don't think they just do x-rays on demand.

So then she was going to die of copper poisoning. I said I think they're made out of some kind of copper alloy now, because new pennies don't turn green like copper does. So she googled it and found that you can't get copper poisoning because the copper in a US penny is bound to zinc, which holds the copper in.

So then it was zinc poisoning. I forget what happens with zinc poisoning—nerve damage, hearing damage? I still say the alloy is pretty stable. I assume that's why they make coins out of alloys now: so they don't wear away by being decomposed by your sweat...or your baby's GI tract.

So the week passes. Now I'm starting to worry, too, but I still don't know what to do - go to the MD or ER and say "We think, but we're not sure, that my baby, who is in no distress at the moment, swallowed a small and metal something about a week ago?" (By the way, this is probably why RNs never go to the ER when they're having a heart attack—they wait for it to go away, and when it doesn't they feel too foolish to go and say they waited a week.) My wife in the meantime read stories from other parents talking about it taking up to two weeks to pass a coin.

After two and a half weeks, it comes out. But it wasn't a penny. It was a blue heart-shaped Miraculous Medal which nobody had ever seen before.

Of course, my mother-in-law has lots of used medals and other Catholic items, so she might've picked it up there. But it could've been a miracle.

I said we should sell it on e-bay. My wife wants to put it on a necklace and give it to her for her sixteenth birthday in front of her friends. And a friend of ours suggested putting higher denominations of money in to see if we get a first-class relic.

SIR! Metoprolol succinate, SIR!

One of the RNs said to me "Hey, you're a student nurse, you'll know this. Which is longer-acting, metoprolol succinate or metoprolol tartrate?" I said succinate. Another nurse said yeah, probably the sux. Then she went to a cardiology fellow (who I swear was younger than me) and asked him. He didn't know. Or he thought it was the tartrate, I forget. Anyway, they go back and forth about it, and I'm like...succinate! Succinate!

Hey, I'm in nursing school. I have to be able to answer snap questions this like I'm in boot camp!

ALMOST THERE!

My final* nursing care plan for all of nursing school is DONE.

Original patient: pH of 6.8, died before I could get to 'em!

Actual patient: ICU status post open heart surgery, lots of complications

Number of pages: 66

Number of words: 22,688

Number of words a friend said that nurses actually need when I boasted about my word count: two ("Yes, doctor")

Number of days spent writing: SIX

Number of sources: 10

Number of shifts worked during that time: a 12-hour in the ICU (what was I thinking??! Oh yeah, I was thinking "It's Sunday! I can do homework!" Of course all the poop hit the fan that day.)

Number of my children who just about developed behavioral disorders and/or got sold to the gypsies because of how they acted while dad was busy for six days in a row: 3, maybe all 4 of 'em.

Number of my children who sorely missed me while I was working on this stuff: 4

Number of wives who probably almost forgot they had a husband: 1

Number of things learned: plenty! ABG interpretation, acid-base disorders, vent settings, cardiac dysrhythmias, electrolyte balance, and drips. That was nice for a change, compared to most care plans.


* Wouldn't be surprised if they sprung another one on us. Just for good measure.

If Nothing Else, I Learned Why Twinkies Never Freeze.

I've been looking to fetch this post from my Livejournal and republish it here. Now I finally am. I wrote this when I started working at my first hospital job as a nurse's aide, about four years ago. It's about an ornery but likeable old cuss who I still distinctly remember.

I work at a hospital now, and if the people there aren't always as strange as they were at the nursing home, at least they're more diverse conversationalists. A few days ago I escorted an old guy out to have a cigarette. He alarms everybody because he's somewhat forgetful, he refuses to wear a hospital gown, and to top it off his brother is a patient down the hall. So he looks like a visitor in his jeans, flannel shirt, and Teamsters hat, sitting in his brother's room. He wanders the hospital with a box of cigarettes and a heart monitor in his shirt pocket. It wasn't long into my shift that they called a missing patient alarm on him; turns out he was just getting some coffee.

He said he's sick of hospitals and doctors. His wife was taken in to a hospital for a UTI, and some damn Filipino nurse, in his words, gave her 32 shots of Demerol over a 72 hour period. She came home visibly worse and died a few weeks later. He's convinced that the painkiller did it. I have no idea what Demerol can do, or if it was really unnecessary; I have no idea if he's accurate about the number of shots. I've heard this sort of thing before, though, so I didn't think a whole lot about it. But then there's his dad. When he was young his father broke his ankle handling timber, and he was put in traction in a nursing/rehab home. This put so much pressure on his heel that it rotted off. That got my attention, because I've seen rotted heels. All my life I thought the term "bedsore" meant muscle stiffness, and even after learning about pressure ulcers in class didn't quite prepare me for seeing how nasty they can be on the floor. I can't imagine this average guy noticing this on his dad, never having seen one before. There's no excuse for bedsores, but I guess that realization is kind of new in the field of medicine, and I can almost imagine that the people at this home probably shrugged it off as common. So I think that's where his real mistrust came from; but being young, it probably didn't formalize into open rebellion until that thing with his wife.

Then he began talking about food preservatives, which he thinks give everybody cancer. This I've also think I've heard before, until he says he hauled the chemicals himself for thirty-five years. He could describe taking a chemical to one factory to be made into ethylene glycol—antifreeze—and the same chemical to another factory where after two more steps it was made into propylene glycol, a food preservative. He hauled chemicals which flavor cigarettes because they don't let them cure long enough. All very encouraging. Of course, he was smoking the whole time, but he said he avoids certain preservatives like the plague.

But aside from seeing antifreeze go into your Twinkies, it had to be crazy being a chemical hauler. Probably still is. He said "between your boss and the guy you're delivering to, nobody cares if you live or die." He hauled a chemical to one client who, because of recent construction, didn't have eyewash and a chemical shower ready next to the delivery pump. So he refused to pump. His boss and the client were furious, but he didn't back down. They sent him out again to the same client six months later; his boss said they should have everything set up by now. They didn't. They tried saying there was a sink 300 feet away. He said that if he called OSHA and they came out and stood right next to him, he would do it. His boss never sent him on that route again. The next guy who went was an inexperienced driver, and when he opened the huge stainless steel latch over the pipe, he didn't completely secure it. There's always some caustic soda around the rim of the pipe, and this latch slammed down and a drop popped up—right into his eye. He had to run the 300 feet, but by then his eye was gone. So get this: his boss signs an "agreement" with him that if he won't sue, he'll have an easy lifelong job in the yard at truck driver pay. The driver agreed to it...and a week later the boss fired him. So my friend convinced the kid to sue, and he got a quarter million out of the boss and another quarter out of the client. But he's only got one eye.


Note: a comment left to the original post gave me a now-defunct link that claimed that the cream filling of Twinkies never really do freeze.
photo by Larry D. Moore

Code Blue During Clinical...Almost

I always think about what might happen if one of my patients codes during clinical. What would I do? What am I allowed to do? Can I push epinephrine? Do CPR? Should I get out of the way? Is the code team going to look at me, in my absurd geeky white school uniform, and tell me to scram?

Well, I almost had my chance already.

Patient comes in the day before in a hypertensive crisis - extreme high blood pressures. At the start of my clinical, I immediately gave blood pressure meds (for pressures 200/115+). Then I sent them off to a scan. Unbeknownst to me, the scanning people call the real RN and say the patient's unresponsive. She says don't call me, call the rapid response team!! So they call the rapid response and the location on the overhead loudspeakers, and my heart sinks. That's my patient. I knew it shouldn't be anything I did. I hit the patient with three strong meds, but they're sustained release and this patient has been taking them for a long time. But still - if you give somebody pills, and then they code, that's a great way to feel like your degree (or your license) is going up in smoke.

Anyway, the RN runs past me shouting something about her blood sugar. I had a brain freeze and couldn't remember it - what if she's low? I should've known! But then I remember it was 160+, high. She should be fine. I ask the instructor if I can go to the rapid response, and then I run.

When I get there, everyone is clustered around the transport cart. At first I hang back, but then I thought This is my patient and I push my way up to the front. That was good, because I could answer some questions nobody knew - labs, history, how long that central line has been in, etc. Blood pressure was normal. Heart rate, respirations were fine. Sugar was great. No temp. But the patient is moaning and minimally responsive. The residents start talking crazy stuff - oh, we know this patient, they come in all the time with a sickle cell crisis. Um, no they don't - they don't have sickle cell anemia! The hemoglobin is 15, abnormally high! Not exactly anemic. Looking at the patient, I thought it was something neuro. With high blood pressures there's a high risk for a brain hemorrhage. The initial CT scan was negative, but that doesn't mean there's no bleed now.

Once we were stable, the code team left and allowed the scan to continue, leaving only me, the scanning tech (who was extremely wary of having this patient!), and another nurse. During the scan I took the blood pressure again, and we were back up to 230s/120s. All I could think was that we need a head scan, need a nitro drip or something to get the pressure down, and we need to be in ICU. The scan is rapidly completed and we head up to ICU. Technically I'm not supposed to rotate to ICU yet, but I helped get her into the ICU bed, the receiving nurse had me do a quick neuro check, and then I took off and went back to my unit.

It was a great experience for me. I could've not gone. But this was my patient. I knew the labs, the history, and their clinical course since they were admitted. I knew, at a basic level, what the plan of action should be. My mind was racing through why the blood pressures were so high and why we were unresponsive - was it neuro? Renal? I wanted to see the outcome - did they do a head scan? What drips did they start? And I feel terrible for the patient; I watched them go from awake and cranky to almost coding. And a little part of me, as a (student) nurse taking care of a patient, is intensely relieved that it was not anything I did - or failed to do.

photo by brykmantra.

The Final Stretch?

Gosh, I've been gone for a while. Well, right before my final semester started in August, my wife and I packed up the four little ones and boarded a plane to see my family in Florida. Yes, that's right...four kids under six on a plane. Kinda like Snakes on a Plane but scarier. I've flown with one, two, even three kids, but four—when they outnumber the adults two to one, I start to question my decision not to make a road trip. But they all did quite well. The two older ones are troopers, having flown at least once a year all their lives. Busy airports, takeoffs, landings—they're fine. My third child, a two year old boy, kept saying things like That plane is gonna crash into us! (gleefully) on the runway and Ha ha! We're fallin'! during takeoff. I tried to inform him that other passengers probably don't want to hear these things. The baby thought it was a blast, with all the people around and not being locked into a carseat. So we might, if we brace ourselves, do it again.

I'm entering my final semester of nursing school, and let me tell you, the instructors have us shaking in our absurd white school uniforms. This is the last stop before we take our boards, become registered nurses, and start practicing on real live people by ourselves—and they have made it perfectly clear that they tolerate no excuses, no errors, no mistakes, no omissions, and no ignorance.

I go to what many people consider the toughest nursing school in the area, but I haven't flinched so far at what they've given me. I've made good grades and impressed my clinical instructors even while working full time and being a dad. But I was honestly scared the first two weeks of this class. There's a final-semester teacher who is legendary for being tough (many say mean) and failing people. She allegedly flunked four of the eight clinical people assigned to her last year. So guess who my clinical instructor is? This person! But as I've met her, and she's talked to us, I can see where she's coming from. You walk on a razor's edge with her, but that's because that's what you do in the real world. She doesn't tolerate mistakes because if you make an error or do something stupid in the real world, either by action or ignorance, somebody could die. And she's extremely knowledgeable and very good at sharing her knowledge. So as I've survived actual clinical days, I've become more confident: if I can make it through her, that means I can do this job. And I know this stuff. I know how to be a nurse, or if I don't know something I know how to find out. I just have to put it all together and apply it.

So wish me luck! I'll try to post when I can.