1016 Center Street....our Victorian house we fixed up in Hannibal, MO. This has nothing to do with the undead or nursing, but I wanted a picture of it on the internet somewhere. There's a lot of Victorian house images out there and I think this house deserves one. Even better, there were never any ventilators or monitors inside!

Random Blog Thought

If you read this blog backwards it makes more sense.
(i.e., most recent entry I realized is a bit confusing if you didn't read the one before)
I also can't figure out WHY it won't let me indent my paragraphs. I honestly indent them when I write it; and when I preview it they're indented, and when I publish it THEY AREN'T. This bothers me. It will also randome go into weird fonts or change colors. Who knows?
we'll see what excitement awaits this weekend.

Doctors Cluck, Doogie, Toddler, Linder and the Blanketrol of Death.

Sunday night in the MSICU (Med-Surg ICU)



I have two patients. One has an excellent night. Obviously, we won't talk about him.
Patient number Two is a lady who is what we call a train wreck. She's a two pack a day smoker who developed pneumonia bilaterally, rapidly progressed to ARDS (very bad lung condition) and is now on the ventilator doing even worse with her oxygenation than the Misfortunate Fellow in Trauma. She also has a clot in her lower leg (Smoking also causes blood to clot easier. Just Say No) and her right foot is rotting off. I could put it more clinically, but that's what's happening here.
She does have a super weak pulse you can hear if you use a doppler, (a handheld device that amplifies sound)put your ear against her ankle, stand upside down, do a backflip, say a prayer, close your eyes, count to ten, and strain with every ounce of your being. Said pulse is no longer audible three hours later.
This is very bad, for several reasons. 1) I am hungry, and I would like to heat up my sphaghetti and meatballs. 2) Cluck and Doogie will have to be notified- the lady's under Internal Medicine 3)the neurovascular intern/resident/retard-of-the-night will have to be notified and 4) I will have to actually speak with the aforementioned people.
If you think I'm heartless for not listing that the lady's going to lose her foot, that was a done deal long before the pulse disappeared. The foot is purple, mottled, and cold; and has been for two days.
Doogie and Cluck respond to their summons with all due haste-making the usual beeline for the chart and managing to trip over the cord to the blanket warmer and pull it out of the wall.
Cluck: Damn it Doogie! Watch out!
Doogie (sullenly): I didn't do it. You did it.
(Neither of them plugs it back in.)
Cluck (frantically surveying my nurse's notes): It says RIGHT HERE this patient had an audible pulse at the beginning of the shift!
Me (patiently): I know. I'm the one who wrote that.
Doogie: (accusingly, while clutchin his lab coat in despair) Did you TRY THE DOPPLER?
I do not respond to this. (The doppler is lying on the bed next to the patient's foot.)
Cluck (attempts intimidating stare): Well? WELL? DID YOU?
Me: I'm going to go heat up my sphaghetti. You two might look at the patient while I'm gone and see if you can find the answer.
(I go heat up the sphaghetti and return with it in a tupperware bowl)
Cluck (triumphantly) We SEE the doppler IN THE BED! THERE IT IS!
Me(chewing on sphaghetti) Great. You guys make me proud.
Doogie(who is too young to appreciate sarcasm) beams.
Neurovascular appears now, in the form of an intern who is a skinny, bespectacled fellow with wild hair and a petulant expression.
Let's call him Toddler. You'll see why.
Toddler (petulantly) Why wasn't I called FIRST?
Glares at Doogie and Cluck, who glare back. He's just an intern too)
Me (bored voice) You were. They got here first.
I'll give Doogie and Cluck props for promptness. You've got to find the positive in people.
Doogie and Cluck give him smugly satisfied looks that clearly state they are much better doctors than he is.
Toddler (irritably) You can't dopple a pulse? You can't dopple a pulse?
(Apparently there's an echo in the room)
Me: (finishing off spaghetti) Nope.
Toddler snatches up the Doppler with a determined expression. Toddler (angrily): We'll see about THAT. GET ME some JELLY!
This is what you put on the skin before using the probe)
Me (politely) I'm so sorry. I don't think I heard you say please.
Toddler (stomps foot, face turns red) I said GET ME SOME JELLY, DAMNIT!
Me (deciding it is definitely time for a diet Coke) Get it yourself.
(I leave the room.)
Doogie, Cluck, and Toddler all begin frantically searching the room for said jelly (which is on the bedside table right at Toddler's elbow) and when I peer back in, they're all yelling at each other; and Doogie's tripped over the Blanketol (warmer) cord again, since they never bothered to plug it back in.
Doogie (desperately): She's gonna die! She's gonna die!
Cluck: (sternly, to Toddler- he's a First Year Resident, you know, and Toddler's just an Intern) That foot has to come off! You've got to get it off tonight.
Toddler (outraged) We're not taking HER TO SURGERY! Are you CRAZY? She'd DIE ON THE TABLE!
(He's right about that)
Doogie: (apparently this woman's his long lost mother, or something) She's gonna die if you don't! She's gonna die! She's gonna die!
Doogie flings himself on the floor and bursts into tears.
(okay, I made that part up- but he looked as if he wanted to)
Cluck (to Doogie, in a tone of utmost gloom): Will you SHUT UP? We KNOW THAT. We're gonna have to call Linder.
Despair etches their countenances. Apparently this Linder is a quite frightening fellow indeed.
Toddler (nastily) That's right. I'm putting in my note this patient is too unstable for surgery. You can consult us again when she's stable.
(which will occur precisely at midnight on the Twelfth of Never)

Toddler stomps out of the room and I flip him off behind his back. Childish, yet satisfying. And it makes Doogie stop looking tearful and laugh.
Doogie and I exchange a conspiratorial smile as Cluck trips over the Blanketrol cord. We may possibly become friends.
Cluck (irritably): This cord is a SAFETY HAZARD!
Me (sighing) I know.
(Said cord is stretched from bed to wall, where it is plugged into outlet. Everyone has been tripping over it. I get some duct tape and tape it down to the floor.
Cluck and Doogie, who apparently are so terrified of calling this Linder fellow they're going to pee their pants, both rush for the bathroom at the same time.

After pacing nervously at the desk for a few minutes, Cluck boldly snatches up the phone and punches in Linder's pager number.
(Shouting is heard from the other end of the phone)
Me (mildly) Gosh, he doesn't sound too happy, does he?
Cluck (sulkily) Yeah, well, he's gonna yell at you too.
Me (clutching my chest melodramatically): Oh NO. What ever shall I do?
I start charting; and Doogie and Cluck drop to their knees and crawl under the bed.
(once again, I added that last part; but that's what they wanted to do)
The door to the unit opens with a bang;and here's Linder.
Seriously, this guy has white-blond curly hair, is about five feet tall, and is yapping like an angry little poodle. Doogie and Cluck look like they're about to pass out with fright; so he turns on me.
Linder: What? WHAT? What HAPPENED HERE?
(Gives the three of us accusing looks)
Me (sighing): This lady's foot is dead but she's too unstable for surgery.
Linder: (to Doogie and Cluck) HOW DID THIS HAPPEN?
Doogie (desperately to me, trying to distract Linder) Did you TRY THE DOPPLER?
(I put my head in my hands and pray for patience. Linder snatches up the Doppler; stands on his head, does various mamba-routines, but cannot hear a pulse)
Linder: (yelling) THERE'S NO PULSE!
Me (quickly losing patience with this yapping idiot) WE ALL KNOW THAT. That's why I CALLED THEM in the first place. That's why they CALLED YOU. Tell us something WE DON'T KNOW.
Linder storms out of the room.
Doogie and Cluck: What's he doing? Where's he going? Is he coming back? When's he coming? What's he doing? Where's he going?
Me: Who cares?
(I get up and start doing all the hourly checks of the lines, drips, tubes, etc., repositioning the patient, etc) Cluck paces around nervously, unsure if he should leave or stay. Doogie has discovered Saved by the Bell on the lady's TV.
Doogie (happily) I love this show!
Doogie sits on the Blanketrol and starts watching the show.
Cluck finally gives up in despair and charges out of the room; but Doogie hangs around and chats about his favorite TV shows, his new Ipod, his super cool cell phone, his totally awesome shiny new glow in the dark backpack; and his mom's new boyfriend that he doesn't really like.

Six a.m.- Actual Real Doctor comes to doorway and states in officious tone, "The patient has no pulse in her foot."
Me: No, it doesn't seem that she does.
Actual Real Doctor looks irritably at the Blanketrol.
A.R.D.(more irritably) what's the point of this? Wrapping her foot up in a warm blanket? Who thinks that's going to save this gangrenous foot? This is stupid. Who ordered this?
Me: Not me. I guess the Vascular guys thought they had to order something.
A.R.D.: (apparently the Blanketrol has offended him greatly) Well DISCONTINUE IT! WRITE IT AS AN ORDER! GET THE DAMN THING OUT OF HERE!
He stops and glares at the floor.
A.R.D.: And WHAT IN THE HELL IS THIS DUCT TAPE FOR?
Me: Would you rather trip over the cord?
A.R.D. (practically screaming) CORD? CORD? I told you to GET THIS THING OUT OF HERE! THERE SHOULDN'T BE A CORD IN HERE!
Me (losing all patience- it's reeeeally time to go home and go to sleep) Well, I seem to have lost my powers over the Time-Space Continuum. Since you told me that approximately thirty seconds ago, I haven't had time to unplug, detape, disconnect, and remove the loathsome Blanketrol from the room. Perhaps you could come back in five minutes and it'll be gone.
A. R. D. (menacingly) My TIME is worth MONEY.
Me: (stomping over and ripping the duct-taped cord off the floor) Not my money.
A.R.D. storms out of the room.

Happy Note of the Morning- at seven a.m., actual real vascular surgeon appears. He asks politely if he can sit in my chair. He smiles and tells me good morning. (I am staring at him in shock)

He reads the nurse's notes and EXAMINES THE PATIENT. Shakes head sorrowfully and appears Genuinely Concerned. States, "This is a shame." Adds nicely to me, "Thank you for taking such excellent care of this patient."

He leaves the room, and I trip over the Blanketrol that I have sitting outside the door. Actual Real Vascular Surgeon hurries to help me to my feet.

So, you see, Good Guys do exist. Blanketrols and cords can be hazardous to your health. Smoking really is bad for you. Three heads are not necessarily better than one. And Doogie's got a shiny new backpack. Things could be worse.

Ah, back amongst the Undead

It's good to be home.
Isn't it odd how something completely terrifying becomes routine over time, and then a Comfort Zone after about, say, fifteen years. I'm talking about the ICU. These patients are actually interesting. INTERESTING. As opposed to, let's say, triage in the ER- "It's 3 am and you have acne on your ass? Gosh, that IS an emergency. Wait, you wanna tell me about all your personal problems too? YAY."
It may be difficult for some who know me (or saw my pictures playing in the graveyard) to believe, but I actually like to use my brain. Anyhow, last weekend I worked MICU (Medical ICU) Neuro, and Trauma. The Trauma patient was an unfortunate and grieveously misunderstood fellow who was fleeing the police after beating up his girlfriend when he wrecked his car, leaving him in the VERY unfortunate position of brain dead, or as we like to say, Undead. You know, like a banshee.
Anyhow, the interesting part is trying to figure out what's going on when the patient starts crashing, because there's multisystem organ involvement and about 300 things to consider. Said patient is on a ventilator, intubated, paralyzed, and sedated. He has three vasoactive drips , an orogastric tube with a tube feeding, two chest tubes and a mediastinal tube (evacuates blood from the chest cavity); a foley catheter; a continuous EEG; a bolt in his brain; an arterial line to measure blood pressure, a PA catheter (which is floated into the chambers of the heart to give filling pressures) a ventricular drain, and a bolt in his head that looks like Frankenstein.
He also sports Nazi, White Supremacist, and Satanic symbol tattoos. Charming.
He's hooked up to a heart monitor, a blood pressure monitor, an arterial blood pressure monitor, a monitor for the PA catheter, the EEG machine, a BIS monitor to check sedation, and a pulse oximeter (to measure his oxygen levels)
So his oxygen levels, which weren't good to begin with, start dropping alarmingly for No Apparent Reason. We hate this. It's unexpected and awfully rude.
It also inspires panic in the heart of all first-year and most second-year residents, who are rounding at night; and really really really hate to bother their house officer (an advanced resident) and admit they haven't the teeniest, tiniest clue what's going on. So they decide to figure it out. This is quite frightening indeed. In fact, it is mortally terrifying; except for the fact that I can scare them into submission with just one of what my children call "Grandmarti looks".
Nurses are Patient Advocates. That means we keep people from killing you.
Oh, forgot to add the patient also has HIV; a nasty chest injury, a massive head injury, and fractures of his cervical spine. The C-spine fractures have been fixed (operated on and stabilized) but he's still in the collar and on Spinal Precautions, which means they have him lying flat.
First Year Resident and Intern (picture Doogie Howser and his younger brother) begin madly foaming at the mouth and flipping desperately through the chart. This is an easy way to tell a new doc from, say, a fourth or fifth year resident. They literally Run For The Chart as if their asses are on fire. They run so fast they almost trip over the cord to the ventilator and yank it out of the wall. They have GOTTA HAVE THAT CHART! And they need those nurse's notes, too, so they can scribble down the vital signs and read what the nurse has written. They don't actually EXAMINE the patient, for heaven's sake. Apparently this involves Advanced Assessment Skills far, far beyond the reach of mortal man. (of course the nurse does this continuously throught the night, but what do we know?)
So resident (we'll call him Dr. Cluck-see his ID photo here) and intern (we'll call him Doogie Jr.- see his ID photo here begin their panicked page-turning and frantic monkey babbling to one other.
Dr. Cluck: Yesterday he was okay! Today he was okay! WHY DOES THIS ALWAYS HAPPEN AT TWO A.M? If I call Linder he'll KILL ME! THIS F**ING SUCKS!
(Sits down on MY CHAIR and puts his head in his hands)
Me (ominously): If you spill my soda I'll kill you.
Doogie Jr: His chest Xray wasn't that bad! What's WRONG WITH HIM? His lab work's all normal except the low potassium!
(The two of them look accusingly at me, hoping to find a Responsible Party who isn't them)
Me: Well, it WAS. Before it was corrected by that electrolyte protocol we have on EVERY PATIENT, remember? He got 40 meq and a follow up that was within normal limits.
(Despair etches their countenances and Cluck grasps the bedside table like a lifeline)
Me: So, I asked RT (the respiratory therapist) to draw some blood gases and he's switching the vent mode from APRV to Assist Control and adding some PEEP.
Doogie and Cluck together: Yes, yes. Good, good. (Nod heads, as if they understand this)
They leap up and bumble out the door together to consult their medical books.
Twenty minutes later they return, attempting to look officious.
Dr. Cluck: Well? WHERE ARE THOSE BLOOD GASES?
As a new nurse, I was so scared of physicians I could hardly open my mouth. This wears off after, say, five years. After fifteen years, they're dead meat.
Me: They're in that chart you're clutching so desperately to your chest you're going to have a rib fracture. You might try looking there. It's amazing what they put in charts these days.
Cluck and Doogie furiously scan the blood gases, which, to put it rather rudely, Suck Ass.
Together: "THESE GASES ARE TERRIBLE!"
(They give me another accusing look. Apparently I have the power to decrease oxygenation with my mind)
Me: His sats were bad on 100%. (oxygen, that is. Room air is 21%, oxygen so, this is Very Very Bad) What were you expecting?
Cluck and Doogie look at each other desperately to see if either one knows What They Should Have Been Expecting.
Me: We need to sit him up.
An elevated patient always gets better oxygenation than one lying flat.
Cluck: This man is on SPINAL PRECAUTIONS! (Gives me a look of mortal offense and outrage) Has NEURO been here?
Me (getting irritated with them) Nope. They haven't been here all weekend. And his fractures have been repaired- he doesn't need spinal precautions. He needs to SIT UP.
Doogie (ignoring this): We could put in another chest tube!
(i.e., Doogie wants practice putting in chest tubes, or, more likely, wants to watch Cluck put one in)
Cluck (looks horrified; does not want to attempt chest tube on crashing patient- first smart move he's made all night) Yeah. Umm. Yeah. We'll run that by Whosit in the morning. We need to LOOK at that chest XRay!
(What a brilliant idea. Might I add, at no time have they gone near the patient)
Looking at XRay:
Cluck: It's an effusion. Yes, an effusion. (fluid collection in the lung)
Doogie: It's a pulmonary embolus. Yes, a pulmonary embolus.
Me (threateningly): It's a consolidation. HE HAS PNEUMONIA. (which presents as a consolidation on an XRay) He NEEDS TO SIT UP.
(Patient's Sat alarm has been dinging throughout this conversation, indicating Damn Near Dead guy is about to become Actual Dead Guy.)
Doogie: We can do a CAT SCAN! YAY! A CAT SCAN!
(Apparently he watches House)
Me: Well, that's a good idea. (It was) (Doogie beams, squeals, and jumps with delight- he's done something right!) But he's too unstable to go.
Cluck: Is he WORKING AGAINST THE VENT? PERHAPS IT'S AIR TRAPPING.
(Apparently he looked this up on line during the twenty minutes he was gone)
Me: Umm...he's paralyzed, remember? He's not working against anything.
(Except Cruel Fate, which has placed him in this situation- I'm really sure he was misunderstood as a child)
I look across the unit and see Unknown Doctor strolling leisurely into the room of a brand new trauma pt just off the helicopter. He stands in the doorway, looks unconcerned, strolls in, intubates the patient, and wanders out yawning. I know an experienced doctor when I see one.
Me (pointing): Why don't you get that dude to look at the XRay?
Doogie and Cluck: Yeah! YEAH! He's a FOURTH YEAR SURGERY RESIDENT! YEAH!
They break into a tap dance of delight, and then exchange frightened glances.
Doogie and Cluck, to me: You go ask him.
I ask said doc if he'd mind giving an opinion on a chest XRay (they LOVE to give their opinion)
Doc: "Sure." (Strolls over and glances at film for three seconds) "It's a right lower lobe consolidation. This guy's got pneumonia."
Doogie and Cluck (in desperation) His Sats are TERRIBLE! HIS GASES SUCK!
They fall on their knees and grovel for mercy at his feet; crying bitter tears of anguish.
(okay, not literally, but figuratively)
Super Doc actually LOOKS AT THE PATIENT. Wow. He also LISTENS TO THE PATIENT'S CHEST and CHECKS THE VENTILATOR SETTINGS. I'm completely impressed. An actual doctor.
Super Doc: "He needs to sit up."
Doogie and Cluck (screaming in despair) "HE'S ON SPINAL PRECAUTIONS!"
Super Doc: His fractures are fixed. Nobody wrote an order discontinuing the precautions because it's rather obvious they aren't needed now. (gives them a severe look)
Doogie and Cluck look so mortally ashamed I feel sorry for them.
Me (elevating head of patient's bead to 90 degrees) Well, that's what we were discussing. Neuro hasn't been in all weekend.
(i.e., they DO know something, I swear! Don't get them in trouble! and, let's blame Neuro cuz they're not here)
Patient's Sat goes from 83% to 95% upon elevation of patient. Super Doc strolls out yawning and Cluck and Doogie appear on the verge of embracing me. I back away quickly around the patient's bedside, because I know they aren't going anywhere near the scary scary patient.
Cluck: (officiously) Well, let's go CHECK OUT SI. (Surgical Intensive Care Unit) There's patients THERE we haven't killed yet.
(okay, so I added that last line)


If you find this frightening, keep in mind- 1) They can't do anything too invasive without asking their senior resident, who will tell them they are stupid 2)Nurses who work critical care, especially in large trauma centers, know what they're doing and will call retard doc's supervisor if they attempt to do anything stupid. Actually just threatening them with this works. 3)A more experienced resident will round on the patient later in the shift; or you can call him, if the retard quotient is just getting unbearable. 4) The patient has had the benefit of state of the art surgery, a Super Special Vent that can do fancy things other vents can't, and many specialties which will wander in during the day, with Actual Doctors- fellows, attendings, etc; and he would most definitely be dead if he weren't in a Level 1 Trauma Center. Even WITH Doogie and Cluck. It's much scarier at the outlying hospitals, believe me.
Here's hoping Doogie and Cluck did not encounter a new graduate nurse with an unstable patient in SI.

A Change of Venue

I don't know why (see all above posts) but after three years I've decided to take a break from the ER (and all the mandatory overtime, that has reduced me to a mere figment of my family's imagination)
Never fear, however- I am returning to work in the ICUs of a Level 1 Trauma Center; one of those great big old hospitals where the residents come to learn and play and you try to keep them from killing anybody. There's six ICUs here and I'll be working in all of them- Trauma, Neuro, Surgical ICU, Medical ICU, Cardiac ICU, and Cardiothoracic (i.e., cardiac surgery- open heart, etc) ICU. Plenty of opportunities for tragic death, gruesome descriptions, and a bit of fun.
This week I have orientation; which I doubt will give me Funny Material to blog about (one never knows when it comes to me, though- adventure generally lurks around the corner of the simplest task) but in a couple weeks I'll hopefully be able to post some new stories and let you get to know some new characters. Interns are always great for comic relief, believe me. Patients' families are pretty good too.
I can't say I'm missing the ER, although I would like to have seen Joe (the unicorn man) again. He was awfully cute, and so were his hats. Even if the people he took them from are buried in his backyard.