Where am I?

Wow, I had my first two occasions to tell an injured person what happened to them after they wake up out of the drug-induced coma we put them in (in the first case) or the mini-coma they were in by themselves (in the second). I'm really going to have to work on my "Do you remember being in X accident? You're in the hospital - you have a tube helping you breathe, a lot of incisions and drains, a pain drip - are you in pain still? - and yes, you're still in one piece" speech.

You know what's weird? In both cases, their main point of perplexity, in the groggy haze as they began to point and mouth questions around the ventilator tube, was what the heck the things squeezing their legs were. They're sequential compression devices which we slap on everyone in the ICU to prevent blood clots. Nothing special. The first guy thought he was arrested and cuffed by the legs!

Stupid melatonin!

I've heard that you should be careful with taking melatonin as a sleep aid because it can make you irritable and depressed. Well, I took a melatonin tablet around 2 AM because I couldn't sleep, and now it's noon and boy do I feel irritated and depressed. Argh. I didn't even realize what was wrong with me until it occurred to me that I'm probably 1. sleep-deprived and 2. still riding on a megadose of hormone which is probably still trying to shut my body and brain down.

For the record, I took a 5 mg extended release tablet of melatonin. It also comes in a 3 mg short release variety which supposedly only lasts twenty minutes, so you have a short window in which to settle down and try to sleep. But I'm finding with the extended release, you'd better have an eight or ten hour block of time to not deal with being awake or being around rambunctious children.

Lockdown.

We put the unit on lockdown last night. That means the doors to the ICU are locked and a police officer gets posted outside the unit. I mean, all our security guards are off-duty cops anyway who wear vests that might be bulletproof and have very gun-looking things in holsters which I figure are probably tasers, but even I don't know for sure, so the visitors probably don't either. So on top of that we need a real cop with a gun.

This is all because we had one gangbanger who got shot up and sent to our unit around 3am, and thirty of his "cousins" and "sisters" came to visit along with his mom. Then a couple hours later, another guy was shot up, and was also being sent up to our unit, and the rumor was this was a retaliatory thing. So rather than have eight gang members in the room at once with the crashing patient and his irritated nurses, and then having the rival gang arriving to visit their guy, the whole unit got put on lockdown.

And I found out the hard way my badge doesn't scan to get me in the door.

All of this made me realize the young teen who got smashed by a hit-and-run driver should probably be in the pediatric ICU, where his mom will get to be around other parents with sick kids and not scary gangbangers.

"THEY" HAVE ARRIVED!

It's almost July, and the residents move to their new rotations. Which means all the new surgical residents with their new MD licenses arrived today. At 5 am. Scared out of their wits. And maybe I'm getting old, but they all seriously looked TEN YEARS OLD.

As they arrived, one of the nurses intoned "From this day forward, all of the patients will get increasingly safer." As in...today is the bottom, and it only goes up from here. Apparently there's even a study which showed that deaths, infection rates, medical errors, etc, at teaching hospitals all spike in July.  Someone else commented that today is not the day to have surgery!

I was forewarned of their approach: that they'd be lost, looking up blankly at the ceiling and lights vainly hoping for any signage to tell them where to go, and afraid to talk to the nurses or anybody else. And one, always one, will be wearing a backpack. All the nurses were disappointed when ten or so residents descended on (I mean, cowered their way onto) the unit with no backpacks. But then young guy with a backpack showed up late, and a few of the nurses discretely cheered.

I hate to say it, but if medical students worked as nurse's aides on the side, they wouldn't be so afraid of the hospital. It's like a prison: it's a different social world with its own rules, cliques, etc, and any familiarity would give you a leg up. Also, I'm pretty sure nursing school gives you 100 times more practical patient experience than medical school. I was not this scared right out the door!

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The Caffeine Dilemma

Drinking coffee seems paramount to surviving the night shift. The problem is I'm not really a coffee drinker. I think it tastes awful. And you're going to call me a whiner, coffee makes my stomach hurt and gives me palpitations. No, really. I'm pretty caffeine-naive. Even tea, my normal go-to stimulant, makes me have to pee like a racehorse sometimes, with its diuretic effect (suppressing ADH) that apparently you daily coffee drinkers are immune to.

So I've been drinking tea at night, and it's mostly worked to keep me awake. Sometimes I need a little something more, though, especially on that first night shift of the week after I've been on a normal day-waking schedule for a few days. I've been drinking more tea or double-steeping it (i.e. two bags), which works well if I don't mind how it strips the enamel off my teeth.

So I bought a bag of Guayaki traditional yerba mate at Trader Joe's. It's a South American drink which supposedly has more caffeine that tea but less than coffee. Also it doesn't taste as acrid as coffee or tea. Actually, it's really good with honey and milk. But I was intrigued by the claim on the side of the bag:

Of the six commonly used stimulants in the world--yerba mate, coffee, tea, kola nut, cocoa, and guarana--yerba mate is the healthiest.

Aside from the health claims, I hadn't thought about my caffeine options in terms of what the world's most popular natural caffeine sources. Typically when you think of caffeine you think of coffee, pop (soda for the Southerners), or energy drinks. So now I'm on a mission to scientifically test (read: try drinking) all the six stimulants. Three I already know, and three I don't:

• Chocolate hardly has a caffeine effect. However, it has theophylline and other chemicals that I imagine, maybe rightly, have a heart-protective effects.
• Tea is my baseline, perking me up a little or keeping me from needing a midmorning nap. However, it can paradoxically make me feel tired or cloud my thinking, especially on a lack of sleep. I don't know why this happens, but evidently tea reduces cerebal bloodflow? Or it could just not be strong enough to overcome the lack of sleep.
• Coffee wants to put me into v-tach. I feel that it's just straight-up hardcore caffeine.
• Yerba mate seems to give more energy than tea without tasting awful or trying to kill you or ulcerate your stomach like coffee does. Guayaki's website claims that "Yerba mate also provides sustainable energy due to its complex combination of xanthine alkaloids and caffeine...Clinical studies have shown that caffeine-sensitive individuals generally have very positive results and don’t experience the hard side effects (jitters, stomach discomfort, headache) commonly associated with caffeine." Seems to be true so far.
• And I've never tried guarana, but it seems to only come in corn-syrupy factory-produced energy drinks that also possess seizure-inducing levels of caffeine, so I'll never know what guarana does by itself. Is there a natural way to drink it? I also have no idea how to get kola nuts, except that they apparently used to be the source of the caffeine in Coca-Cola, but not anymore of course.

Any thoughts? What are your stimulants of choice? Or are you anti-stimulant?

Oxygen deprivation brain injury in term babies

I attended a nursing conference at our hospital where several departments where debuting their new practices or clinical trials. One new practice that interested me was therapeutic hypothermia for babies who suffer a hypoxic brain injury, presented by the NICU. They put these babies on cooling blankets and drop their temperature to around 86 degrees F (!!!) for about a day. This doesn't affect their death rates, but does seem to reduce the amount of brain damage, i.e. less cognitive and sensory deficits.

I thought this was a little weird—why would a baby who was living in a 98 to 101 degree womb (so I've heard) suddenly need to be in a chilled environment to avoid brain damage? The presenter's answer was that these are babies who are full term and were otherwise healthy, but suffered a hypoxic event before or during the birth—an event which deprived them of oxygen long enough to cause brain damage. These are often the kids who develop cerebral palsy, and this hypothermia therapy seems to lessen those symptoms.

I can't help feeling that many of our birth practices result in these brain-damaging events. Birthing on your back and artificial induction in particular. I mean, in nursing school they taught us how to deal with the fact that supine birthing drops the mother's pressure and the blood supply to the uterus. It's something I'm going to research more, though—who are these babies, and what factors predicts these events?

I also want to pose this question to any midwives out there: how many hypoxic events do you see in your practice? Because while in my L&D rotation and in speaking with L&D nurses, it seems this is a common risk of birth. But I've rarely heard midwives speak about it. And I realize that L&D units have a higher volume of cases, some of the midwives we've spoken with or used for our births saw a lot of births over many years. They'll speak about the occasional infant death due to birth defects, but not hypoxic brain injury due to the birth process itself.

SURVIVING NIGHT SHIFT!

I survived my first week of night shift, 7pm to 7am. It takes a little gettin' used to, watching the world get dark first, and then light toward the end of your shift. It definitely helped working the shifts in a block. In preparation for the transition, I stayed up until 3am or so, then tried to sleep in the daytime hours before my shift. I think this had mixed results—I was somewhat sleep-deprived, so I was ready to crash right at the start of my shift, but it did help me stay more awake in the middle of the night. Or maybe it was the strong black tea. Either way, I slept fairly well for a handful of hours the next day. Surprisingly my four little pirates didn't wake me up...or maybe having four kids is what enabled me to sleep through daytime noise. I was still tired that evening!

So this is me now, except more bleary-eyed and slumped over:



Actually, I feel pretty good, surprisingly. Last night's shift was the best of the three; I was the mosted accustomed to the hours. I even thought I might be too awake to go to bed when I got home, but I was fine. I slept until noon so I could try to get back to a night sleep schedule for my four-day weekend. As the night RNs told me, perfecting your sleep habits is an art form when you're three days on, four days off, and trying to have a regular life.

Sleeping aids? I used time-release melatonin. It felt like they knocked me out, but then again I was pretty exhausted! I didn't take one today so I could stay alert most of the day. Since melatonin is a hormone, I'm kinda wary of using it too much—I imagine it can make me tired and irritable when I don't want to be, or even backfire and make it hard to sleep.

The culture of night shift is so different from days. So many of the patients are awake, and if they're not awake we have to bother them every hour anyway. Which is probably why they always slept during my day shifts!

The physicians are usually laid-back but also seem more apt to growl and snap—and also not listen. I found myself reiterating a lot to get my point across. That's okay, I guess—I imagine they're covering too many patients on too little sleep. However, despite that, they rely so much more on your judgment and critical thinking. One of my post-surgical patients went bad on me, and the surgeon who I woke up on the phone simply asked "Do you think he needs to go back to the OR?" Just like that, a surgeon and a surgical team could assemble on my word alone. It's pretty daunting, but I think it'll be a good experience for me. And like I said, the same physicians who are busy and irritated on days can be much friendlier at night. One of the head trauma surgeons even helped me get a chest surgery patient out of bed and into the chair at the crack of dawn. And the residents? They must stick the younger and more inexperienced ones on night shift, because they never seem to know what they're doing. I had to help them a lot, but they tend to be so profusely appreciative (I guess because you're not biting their head off) that I didn't mind.

The nurses at night tend to be calmer than nurses on days. They're funny and play jokes on each other, laugh with the patients, etc. But I think they own their environment more than day nurses, who have so many more people in their rooms and on the unit—more family, therapists, MDs, etc. This makes them extremely intolerant of people "breaking the rules," having more than two visitors, pre-teen kids, flowers in the room, using cell phones. They get angry with day shift nurses who tolerate these transgressions...and I tend to be one of those! I mean, cell phones in the room? That's so old—can anyone name any equipment they interfere with? Oh well. I can't complain about them, though, because they are so helpful. If your patient crashes (which one of mine did two out of three nights), or you get an admission, you'll have at least three or four nurses teaming up to help you out.

The only thing that's going to make me cry about night shift is the lack of distinct lunchbreaks. The nurses eat at the desk for their lunchbreak, and (hygienically as possible) work or chart while they eat. On days, a nurse covers your patients and you go away to the breakroom, an inne sanctum which by unspoken nursing law can only be invaded by work-stuff if your patient is ACTIVELY CODING AND DYING. (As in, it takes a code or an Act of Congress to get one nurse to pull another nurse out of the breakroom.) I still feel I need that separation, a real break. But it's a little frowned-upon to expect another night nurse to watch your patient while you eat. They claim they're too busy, but I think it's just tradition that they eat at the desk. We manage it on days, which are always crazy-busy. Oh well...I'll get used to it, I suppose. Or I'll get gutsy and ask them to watch my patients anyway!