Today's patient was all SORTS of dying. 70something years old, long time smoker, the inevitable lung cancer with scary bone metastases. He came to us from some nursing home because of a fever, but the REAL problem was Hypercalcemia of Malignancy. Which is pretty much the definition of "make this guy comfort-measures only"...except the family only got there today to make the decision. Essentially, once you HAVE Hypercalcemia of malignancy, your chances of making it a MONTH are 50/50. That is, if you also dont die of massive fluid loss from electrolyte imbalance, or one of the other nasty side effects.
The guy was more or less out of it, rousable only by a bit of shaking, a loud voice, or me, trying to give him his shots. He was unimpressed. Also, he had a lot of trouble swallowing, the result of an old brain aneurysm that ruptured, so getting him his medications required creativity. The hospitalist dropped in, to say that a PEG tube would be torture, and to call him when the patient's family got in, so that he could convince them that there was nothing more modern medicine could do but make him comfy-ish.
Once they pull the calcitonin shots, he'll maybe have 3 days to live. RIP, cancerdood.
Monday, March 9, 2009
Thursday, March 5, 2009
Northlands Update
It's chilly, windy, snowy, but the food's good.
My interview is on the 13th at 10 am. Woot!
My interview is on the 13th at 10 am. Woot!
Thursday, February 26, 2009
The Frozen Northlands
I leave today, after my second midterm for The Frozen Northlands. Sometimes there is internet access in the Northlands, sometimes not. But we do have snow. Lots and lots and LOTS of snow.
I won't be doing any nursing stuff for the next week or so though, so the chances of any interesting blog entries is somewhat lessened.
Happy "Spring" Break! (there are no leaves on trees, no green grass, no flowers, and at home there's 3 feet of snow. It's not spring.)
Just remember kids: YOU CAN'T SHOCK ASYSTOLE!!
I won't be doing any nursing stuff for the next week or so though, so the chances of any interesting blog entries is somewhat lessened.
Happy "Spring" Break! (there are no leaves on trees, no green grass, no flowers, and at home there's 3 feet of snow. It's not spring.)
Just remember kids: YOU CAN'T SHOCK ASYSTOLE!!
Wednesday, February 25, 2009
Nephro: An Introduction
Today's pt. was NOT cardiac, though he'd had the obligatory CABG some years ago. He has had prostate and bladder cancer, and a resected bowel, and god knows what else. He was on our floor because...well...I'm not really sure. Medical floor overflow I suppose. CHARMING man, he was really fantastic, great storyteller.
The Interesting Part: He had a nephrostomy. It LOOKS like a colostomy- pink stoma, bag attached, but instead of draining feces, it drains urine, directly from the ureter, because his bladder was obstructed by tumor, and removed. Two days ago they added a shunt to ANOTHER bag, draining his kidney directly because of an infection. Kind of painful looking, actually, and draining bloody, cloudy stuff. He didn't wince when I did the dressing changes, LOVED having a student, and regaled me with stories of the old WW2 comics he used to read, about brave army medics and pretty nurses. He agrees that the cape SHOULD make a comeback.
Also got to hang out with the telemetry techs again, and learned the finer points of paced rhythms, so I no longer look at them and say "uh oh! wide complexes! DANGER!!"
The Interesting Part: He had a nephrostomy. It LOOKS like a colostomy- pink stoma, bag attached, but instead of draining feces, it drains urine, directly from the ureter, because his bladder was obstructed by tumor, and removed. Two days ago they added a shunt to ANOTHER bag, draining his kidney directly because of an infection. Kind of painful looking, actually, and draining bloody, cloudy stuff. He didn't wince when I did the dressing changes, LOVED having a student, and regaled me with stories of the old WW2 comics he used to read, about brave army medics and pretty nurses. He agrees that the cape SHOULD make a comeback.
Also got to hang out with the telemetry techs again, and learned the finer points of paced rhythms, so I no longer look at them and say "uh oh! wide complexes! DANGER!!"
Tuesday, February 24, 2009
I am NOT poison control!
But nevertheless, a friend from college just called to ask if swallowing a bottle of codeine syrup would kill/ seriously maim you. Some chick she knows just did it.
Me:"Call the ER, and ask them if they want you to bring her in, or just give her ipecac"
Her, 5 minutes later: "Ok. ER says ipecac. And I dont even LIKE this chick!"
Better her than me...I wouldn't have gone over there when she called to say she'd taken it, I'd have just sent 911 over there to haul her to the psych ward.
Me:"Call the ER, and ask them if they want you to bring her in, or just give her ipecac"
Her, 5 minutes later: "Ok. ER says ipecac. And I dont even LIKE this chick!"
Better her than me...I wouldn't have gone over there when she called to say she'd taken it, I'd have just sent 911 over there to haul her to the psych ward.
Monday, February 23, 2009
I Spied Three Things
Three things I've never seen before while doing an observation day with the Wound Care Nurse, all of them vaguely horrifying.
1. The fattest man I have ever seen. I'm not prejudiced against large people, but this guy weighed in, on admission yesterday, at 904 pounds. Yes, NINE HUNDRED AND FOUR. He is scheduled to have some sort of pannus-removal surgery. The docs are pretty sure he has a heart condition, but he's too big for ANY nuclear medicine studies (the tables aren't big enough, and he wouldn't fit inside the machine, and too big for the cath table, the OR table, and pretty much everywhere else. They're planning to do the surgery IN HIS HOSPITAL BED because they can't move him. It took 7 of us to roll him to assess his skin integrity.
2. Somebody's tendon. No, not in surgery, he had a pressure ulcer from where another hospital put pressure ulcer preventing (o irony) boots on him. The inside of said boots were hard plastic, so the skin over his achilles tendon broke down. Voila! Tendon! He was really out of it, and on a vent, but it was still horrifying. I mean, insides are supposed to be on the INSIDE. Also, his big toe was BLACK and about to fall off. I don't think he'll be walking again.
On the other hand, I doubt he's going to be CONSCIOUS ever again either. Sad, either way. He just took really lousy care of himself (smoker, alcoholic, morbidly obese, no exercise, diabetic, dialated cardiomyopathy, cardiogenic shock, etc.)
3. A wound-vac. They're gross. I'm sorry, but I don't know how the floor nurses can deal with that. I mean draining normal stuff like blood or serum? Fine. This was draining...infectious goo. NOT fine. Gross.
And she had the inevitable NON EXISTANT pain tolerance. She screamed when the nurse POINTED at her, and demanded more "mo'phine", because we were "torturing" her. Without touching her. When she said she was comfortable when we walked into the room. Oy.
1. The fattest man I have ever seen. I'm not prejudiced against large people, but this guy weighed in, on admission yesterday, at 904 pounds. Yes, NINE HUNDRED AND FOUR. He is scheduled to have some sort of pannus-removal surgery. The docs are pretty sure he has a heart condition, but he's too big for ANY nuclear medicine studies (the tables aren't big enough, and he wouldn't fit inside the machine, and too big for the cath table, the OR table, and pretty much everywhere else. They're planning to do the surgery IN HIS HOSPITAL BED because they can't move him. It took 7 of us to roll him to assess his skin integrity.
2. Somebody's tendon. No, not in surgery, he had a pressure ulcer from where another hospital put pressure ulcer preventing (o irony) boots on him. The inside of said boots were hard plastic, so the skin over his achilles tendon broke down. Voila! Tendon! He was really out of it, and on a vent, but it was still horrifying. I mean, insides are supposed to be on the INSIDE. Also, his big toe was BLACK and about to fall off. I don't think he'll be walking again.
On the other hand, I doubt he's going to be CONSCIOUS ever again either. Sad, either way. He just took really lousy care of himself (smoker, alcoholic, morbidly obese, no exercise, diabetic, dialated cardiomyopathy, cardiogenic shock, etc.)
3. A wound-vac. They're gross. I'm sorry, but I don't know how the floor nurses can deal with that. I mean draining normal stuff like blood or serum? Fine. This was draining...infectious goo. NOT fine. Gross.
And she had the inevitable NON EXISTANT pain tolerance. She screamed when the nurse POINTED at her, and demanded more "mo'phine", because we were "torturing" her. Without touching her. When she said she was comfortable when we walked into the room. Oy.
Sunday, February 22, 2009
Care plans suck
They really do. It takes me forever to write it all out, and I can rattle it off verbally in about a minute and a half.
Fortunately, my clinical instructor thinks they're annoying too. She MAKES us do verbal care plans on every patient every day. Which is BRILLIANT. She has a formula for it too: First start with all the assessments you need to make, then all the labs you would check, then all the interventions you can do WITHOUT calling ANYBODY, then the interventions you can do WITH other services (pt, ot, nutrition, et cet) THEN the medications, THEN things you have to call the docs for.
She says that this way we'll get into the habit of always looking for our independent actions FIRST, and in many cases we won't HAVE to wake a doctor up, which will make EVERYONE happier.
Have I mentioned that my clinical instructor rocks? She still works PRN on the floor where she teaches, and knows EVERYONE. This floor is awesome, and the aides kick some major ass.
Fortunately, my clinical instructor thinks they're annoying too. She MAKES us do verbal care plans on every patient every day. Which is BRILLIANT. She has a formula for it too: First start with all the assessments you need to make, then all the labs you would check, then all the interventions you can do WITHOUT calling ANYBODY, then the interventions you can do WITH other services (pt, ot, nutrition, et cet) THEN the medications, THEN things you have to call the docs for.
She says that this way we'll get into the habit of always looking for our independent actions FIRST, and in many cases we won't HAVE to wake a doctor up, which will make EVERYONE happier.
Have I mentioned that my clinical instructor rocks? She still works PRN on the floor where she teaches, and knows EVERYONE. This floor is awesome, and the aides kick some major ass.
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