Unexpected Findings

As some of you might have noticed, I'm NOT the world's best person at hand-holding...as the man friend would say "this is one of those times when you hug the person" The patient was 55ish. male. two pack a day smoker for...30 ish years. laid off a year ago. now he's got a cold foot- NOOOOO problem! we fix those in our sleep! except one thing... We did a pre-op x-ray to look for where all the clots were in his legs, pre op. Because it's important. We found out something important...but not what we were expecting- we found out that he has a 13 cm by 13 cm mass on his adrenal gland. So...differential is cancer, cancer or cancer. and it's on the adrenals. so this poor man, who worked HARD for 30 plus years, and got laid off through no fault of his own (economy, yanno) is without insurance, and now he has vascular issues AND CANCER. And at 13 cm, i dont know if we can save him. We should be doing better as a nation. Because otherwise we have guys like this- YES he smoked. YES he shouldn't have- but...would you doom him for that? would you tell him "no sorry...you're broke and laid off, and you need to DIE NOW"... I couldn't bear to tell him that...but we might not have a choice... THIS is when i'm so glad I have ManFriend- he's a biologist, and i can tell him ANYTHING about my work, and he'll just hug me, and remind me why i need to go back in again...if I didn't have him, i'd have quit. I dont practice in an urban area, but TRUST ME when I say our rural poverty can take your urban poverty hands down some days. We've got so many people without hot water, without electricity, without ANY kind of services. And they live in log cabins tucked into the woods, no access to public buildings for showers, or internet. There IS NO CHANCE for them to take advantage of public programs. They just...die

Whipple Chaos

A Whipple (or pancratacoduodenectomy) is a rather nasty surgery. They take out a piece (of a variable size) of the pancreas, and they take out your duodenum. Then they stick the NEXT part of your intestines (the jejeunum) to your stomach sort of like they would in a gastric bypass. They also attach your bile duct in there somewhere. Needless to say, when you go around stapling different body parts together that wildly, there tend to be...problems. Recently I took care of a whipple (ok, several whipples) with a Problem. You see, post-op they gave her a barium swallow, to make sure all those staples were holding. They were! (yay!) but that was on Monday. And now it was Friday, and...wait...NO bowel movements since then? Like...NONE? Ok...are they NPO? No? Cue sounds of impending doom. I spent the next TWO DAYS (on a five patient assignment) trying to fix this. Using Any Means Necessary. By day 2 we had dropped an NG tube, and there just wasn't...any...peristalsis. Wanna know how I knew this? The daily X-rays were showing the barium. From monday. In the SAME PLACE. So i'm spending the whole time saying to the team "guys, the enemas, the laxatives, the suppositories? THEY ARENT WORKING. Youre going to have to help me out here". And the attending is like "nono, just MAKE IT HAPPEN". and i'm like "...HOW?!?" So They want a CT scan, because by day 3, his mental status is going wonky, and he's getting tachy, and his white count is going from 11 to 20 over MY SHIFT. But here's the thing. Barium Swallow barium is 100% dense. CT contrast is 2% dense. The barium in his belly is basically acting as a shield that renders his whole belly opaque. And WHY can't I just "get it out of there"? BECAUSE I CANNOT TURN PERISTALSIS ON WITH A SWITCH!!! So instead, when his white count was getting ridiculous, his GCS had dropped from 15 to 13, and his vitals started to go off, we ran him over to the ICU. Maybe they'll have better luck explaining that i do not have a magic peristalsis wand. And they might want to fix that infection :-p

New Students

Someone has decided that, since I've been at Frozen Northlands Regional for over a year, i can be trusted with shiny new nursing students. Well I'm not sure what it says about the REST of the nurses on our floor, but apparently they like working with me. This might be because my stock answer isn't "go away" it's "look it up, tell me what you THINK is causing him to be that odd shade of yellow, and we'll talk". But I dont know what this particular school is teaching them. Cause DAMN. First off, when I was at Very Catholic Nursing School, we were taught that YOU. DO. NOT. SIT. DOWN. not unless ALL the nurses are seated, AND there are seats left over. Because if your nurse isn't sitting, YOU SHOULD BE HELPING- not just on your patient either! How about checking if all the beds are made? Everyone is washed up? Anyone needing ambulation? I know these are all students in their FIRST med-surg clinical, so they're not allowed to do a lot of things without me or the instructor, but ALL OF THOSE THEY CAN DO. So when they leave at the end of their clinical day, and TWO of my patients havent had their beds changed? or been walked? PLEASE! THERE WERE TWO STUDENTS!!! I mean, I'll get to it when I can, but I was dealing with the FOUR ENEMAS I had to give to the wildly unstable post-Whipple in one room, whose bowels havent moved in a week, and who was becoming progressively less coherent...but that's its own post. Suffice it to say, he was practically a one-to-one patient, on a five patient assignment.

Racism

Well DAMN! Ive been woefully neglectful posting lately, due to a combination of us being 7 nurses *SEVEN* short on our floor, coupled with all sorts of random bull. So. I've been on the floor for over a year now, practicing All By Myself. Know what's been striking me lately, now that I have enough experience to look up and around me instead of STRAIGHT AHEAD TRYING DESPERATELY TO GET EVERYTHING DONE? There are a hell of a lot of racists here in the Frozen Northlands. Not my colleagues. They're pretty chill. We have nurses and docs from pretty much EVERYWHERE, since we're a Badass Teaching Hospital known for having some of the NICEST people in the universe working for us. It's the patients. We are a predominantly white area. REAAAAAALLY white. And a disturbing number of people get pissy when their nurse (or even their doc) isn't lily white as well. Case 1. A few weeks back, i had a patient go on at me for TEN MINUTES about how his night shift nurse (the fantastic Minh- seriously, this chick never misses a THING on assessment. She's a rockstar. I had her teach me about limb ischemia when i started, because she is SO FREAKING GOOD) "didn't smile enough, wasn't caring enough, and can't speak english- if she's in this country she should try to speak the language!" ...Minh speaks PERFECT english. She's university educated in two countries, and can do flawless medical translations in two languages (English AND Mandarin) and she's passably good in Cantonese. Not just SPEAKING THE LANGUAGE, but MEDICALLY LITERATE. Sure, she doesn't grin at her patients, but they're tucked in, with snacks, clean, cozy, warm blanketed, and they get checked for comfort HOURLY. With a five patient assignment. I asked the patient what he would LIKE in his care. He said "well girls like YOU- you know, local girls!" I was like "sir, i'm not from here. And that sounds a bit racist." Dead...stunned...silence. I learned this technique from my cousin-in-law Roberto. He's from Chile. He says the best way to deal with racists is to flat out tell them "youre being racist". People usually just blush, and try to ignore behavior like this, and then the jerks dont get called on bad habits. Case 2. One of our awesome new surgical interns, Olivia, is of chinese descent. She and another intern, Rajan (indian descent)were doing a dressing change, supervised by Erik, an Icelander...like...from Iceland. The patient called me into his room first (DIFFERENT PATIENT, SAME ATTITUDE): "who was that foreign doctor?" Me: "Dr Sigbjornnison? Oh he's a senior surgical resident. His name CAN be a little hard to understand when he speaks fast. " DPSA: "Nono! The colored one! the FOREIGNER! I need to know if he's any good- i mean, did he go to a REAL medical school? Here?" Me: "Dr Singh is from New Jersey, sir, and I believe he went to Syracuse" DPSA: "and the little oriental girl?" (said with a dismissive sneer) Me: "Dr Lee is from California. And she went to Princeton and Columbia. All of your doctors are incredibly well trained. If you have any concerns about their MEDICAL training, you can always ask your attending physician. Otherwise, please just let them do their jobs" As if these totally awesome people don't have enough crap to deal with as nurses and surgical interns...Its up to ALL of us not to let them suffer silently. If you hear someone making racist remarks about a colleague, CALL THEM ON IT. Politely, but firmly. After all- this is a team sport.

A Simple "Thank You"

I had 5 very difficult male patients today: A. was a mildly confused ETOHer with acute pulmonary edema who desatted and got dizzy...and bradied down to the 30s...every time he tried to walk...which was often. B. was a vigorous 50something year old man whose little toes we had amputated...on both feet. He could manage to carry a cup of coffee AND a bottle of water in his bathrobe pockets without spilling anything. He's married to a nurse, you see, and wouldn't want to bother US for things "he can manage himself"...even at the risk of coffee burns C. was a man who was just...needy. His feet itched. a lot. he wanted them rubbed. Then massaged with lotion. then benedryl. then more lotion. Heaven forbid he should do these things...himself! nono! the NURSE should do these things for him! D. was the delightful 90 year old with soft blood pressures and a penchant for telling world war 2 tales...i could have listened to him ALL day...except that i had to somehow figure out how to get his massive seroma drained without tanking his vitals...which would be untenable...as he is so damn NICE! E...ah E...he didn't seem to like us much, me and my Lovely Assistant K...he grumbled, complained, didn't like us much. And then he surpassed all our expectations. He passed his PT eval, swallow study...everything. And then on his way out the door he grabbed my hand. "I want to tell you, before I forget". He said, like an old movie star- "I've been HORRIBLE to you all- short tempered, cranky, unkind...but I want you to know- you've been WONDERFUL to me!!! You treated me like you expected nothing LESS than my full recovery, and that made me work harder. You never took it out on me when i was mean to you. I wanted you to know, I am so very grateful to ALL of you- nurses and aides who took care of me. Please tell them for me" And then he left. But...that's why I do my job...for people like him...and for the people who never manage to tell me that what i do matters...but really? People like him make my day... Even though two hours later I got puked on and yelled at :-p

Clinic Admits

330 PM, and I've just discharged a patient. JUST discharged, as in I'm still stripping the room, and housekeeping hasn't made it up to clean yet. Phone rings.

Me: "Surgical Floor X, this is Alpine, can I help you?"
Ennui, RN: "Hi, this is Ennui, over in Vasc surgery clinic. I'm sending a patient. Can you take report?"
Me: "The room isn't clean yet. I just want to make that VERY CLEAR...but yes, I suppose I can take report."
Ennui, RN: "pt is a large-ish gentleman with an extensive vascular history. he has an infection. Needs IV antibiotics. Can I send him?"
Me: "wait a minute! what's the history?"
Ennui: "its in the chart"
Me: "indulge me?"
Ennui: "it's not in front of me. look it up when he gets there."
Me: "allergies?"
Ennui: "they're in the chart!"
Me (getting REALLY fed up): "Fine. Okay. Mental status? peripheral pulses? WHERE is the wound? Bowel sounds?"
Ennui: "didn't look at the leg...didn't listen to the lungs...didn't get bowel sounds...you can check the pulses, right?"
Me: "um...okaaaay"

What i was THINKING: "youre a NURSE??? What do you guys DO over there if you dont look at the wound, or do ANY assessment? You dont know this guys allergies? or history??? WHY ARE YOU CALLING TO GIVE ME REPORT IF YOU CANNOT TELL ME ABOUT THE PATIENT???"

I hear don't have to work nights, weekends, OR holidays...must be nice...

The Fifth Vital Sign

Pain is not the 5th vital sign. I know this might be an extremely contentious statement, but it's NOT THE FIFTH VITAL SIGN.

Here's why:

Signs are those things that are objectively observable and measureable. The definition of pain as "whatever the patient says it is, whenever they say they have it" is in direct opposition to this. If "i have 9/10 pain" doesn't mean the same thing to everyone, then it's NOT A SIGN. Blood pressure, respiratory rate, heart rate, temperature, and pulse oximetery are all SIGNS. If I take your blood pressure, with decent technique, and another clinician does the same, the results will be just about the same. Our evaluation of your PAIN however may differ wildly.

This is not to say that pain isn't an important thing to assess, or that it's invalid. it's just NOT A SIGN, and to call it one is, in my opinion, to devalue it, by putting it in the wrong classification.