Please don't feed the residents

Back at work with a bang. I knew that I would be called out first, because the last call period for my team I took some ETO time. That means I'm "fresh". I don't feel fresh...Laughing Baby, aka Skootch, has been sick since Christmas night. Even with LM staying up with her during the wee hours, I still feel like I haven't slept in a week. Last night was really bad, the poor wee one had a bad case of the snots and couldn't nurse and breathe at the same time, leading to much unhappiness. The 5am wake up call was very early. I knew I'd be out all day, so I did something I don't do much-I had a cup of coffee. A whole cup where normally I drink decaf. I'm still jittery. And yet, desperate for another cup.

I have a donor, middle aged woman who had a heart attack from a probably accidental overdose(I know, no such thing, you cynics). Her mom is so sweet, she's staying until we go to the OR, which is set at 0300. Please don't even get me started on the surgeon who really could have been here at midnight. The OR was hit with a bunch of level I cases and couldn't take us at midnight anyway, but I'm still sore about it. Do you have any idea how punchy I am at 3am? Even with a good night's sleep? I'm trying to think about my happy place and hope I don't get into a screaming match with him. Please pray for me.

On a happier note, I did inherit a very unstable pt this morning when I arrived. In 12 short( or long) hours, I have gotten her sodium down from 178 to 148, her chloride from 139 to 119, her pH from 7.19 to 7.38 and she is almost off the 800 pressors she was on this morning. Well, with help from the great nurses and my medical director. But, still. Happy, stable donor(knock wood), just like I like 'em.

Anyhoo, the punchiness is beginning, because I'm starting to fuck with the residents. No, seriously, I was waiting for the down elevator and this tall, handsome resident hits the up button. He smiles at me and nods and I think, "Holy, shit! I think he's checking me out" He says, "Hi, you medicine?" I look at him cooly and say, "No, transplant." I get on my elevator and leave him standing there. Ha. It's the second time today I've been mistaken for a doc, but I think that only means I look nerdy.

What I want for Solstice

I recently wrote this for a newsletter I write for monthly. I thought I'd include it here.

What I want for Solstice

My family

CD’s:
Beck-the new one
Sting-the new one
Hiromi(Japanese Jazz Pianist)-Brain

Tix to a Chorus Line on B’way

Ayun Halliday’s –Mamalamadingdong

Book on CD-anything by Wayne Dyer but especially The Power of Intention


This started out as a wish list. A new baby sling. The latest in organic, ecologically-sound, pesticide free woolen baby jammies made by indigenous orphans. That sort of thing. I start to berate myself. “Sure,” I tell myself, “you can wrap it up in an alternative package, but you’re still selling consumerism for the holidays.” That’s no way to celebrate. Especially when I really love this time of year. I like when it starts to get cold and you have to bundle under the covers again. I like Solstice. Having depression, the longest night of the year is very symbolic for me and I like to do a little Solstice magick. I even like Christmas Eve, lapsed Catholic that I am, because when I was little, Christmas Eve seemed like the one night when anything was possible. Improbably, that feeling has managed to stay with me.

Love Monkey and I discuss (read: argue) what, if any Christmas traditions we’ll follow and whether or not we’ll perpetuate the Santa myth. It gets heated at times. Meanwhile, the little one is agog at the displays that are going up. Late last night we made an emergency cranberry sauce and eggnog run. As I was busy rushing around the aisles and trying to avoid the other frantic shoppers, I noticed her looking up. On top of every aisle they had those enormous, lawn displays. You know, the big obnoxious ones that require a generator and a team of elves to set up. The whole horror show. She was delighted. I tried looking at them from her perspective. Bright, garish, full of movement and noise. She doesn’t know a reindeer from a rooftop, but she knows fun when she sees it. Suddenly, this tacky display turned into yet another amazing thing that the world has to offer. We walked around for awhile with our heads up in the air, taking in the sights and forgetting the cranberry sauce altogether. She made the other shoppers laugh and then I’d catch their eye and we’d smile at each other. A miracle of the season-holiday shoppers being nice to, instead of trampling, each other. All brought to you by a little child. Maybe those wise men were on to something.

So whatever you’re celebrating-have a happy Kwanzaa, a joyous Diwali, a bright Hanukah, a meaningful Eid-al-Adha, a merry Christmas, a jammin’ Junkanoo, a beautiful Bodhi day, a shining Solstice and most of all peace, love and happiness in the New Year.

Merry Christmas

I am off for 8 lovely days over the holidays. Last night, we went to Mom's for the Feast of the 7 Fishes. It's an Italian thing, but it's not really the same since my Grandma died 2 years ago. Tonight, we're cocooning and staying in. I'm playing domestic Goddess and cooking, which normally Love Monkey would do and does better than me. It's always "Alton, this" and "Alton, that". But I digress.

Christmas menu: Veggie platter with dip
Roast chicken with gravy
Yukon Gold mashed potatoes
Corn bread pudding
Artichokes
Various Christmas cookies

If you want to stop by, we've got plenty. But bring something to drink. Now I've gotta go make the gravy.

Happy Christmas and a Joyous New Year!

Why I hate email

I get a lot of chain email and I hate it. Even the nice ones. Even the ones that bring a tear to my eye. Here’s a recent email I received (in yellow):

The story goes that some time ago a mother punished her five year old daughter for wasting a roll of expensive gold wrapping paper. Money was tight and she became even more upset when the child used the gold paper to decorate a box to put under the Christmas tree.

I mean, how expensive was this paper? $3.99? $5.99? $10? $20? Was it made out of solid, freakin' gold? Even at twenty dollars, is it worth screaming at your kid? If times were so hard, why did the mom have this fancy-schmancy paper? Why didn’t she use the funny papers or plain paper that she stenciled or had her daughter draw on or something?

Nevertheless, the little girl brought the gift box to her mother the next morning and then said, "This is for you, Momma." The mother was embarrassed by her earlier over reaction, but her anger flared again when she opened the box and found it was empty. She spoke to her daughter in a harsh manner. "Don't you know, young lady, when you give someone a present there's supposed to be something inside the package?"

Again, is this worth your anger “flaring”? And if the little girl didn’t know that presents should contain something, well who did she learn that from? To berate her on Christmas morning, for God’s sake. Ok, maybe she had a good reason to be cranky. Maybe she’s a single mom, and she’s stressed from working nights and trying to keep it together for Christmas and daddy hasn’t paid the child support in 3 weeks and she was up all night putting toys together and she hasn’t had coffee yet. Maybe she had just explained for the three hundredth time that she doesn’t know what time Daddy’s showing up and that even if he could afford a pony, ponies can’t live in apartments. Hey, I’ve been there.

She had tears in her eyes and said, "Oh, Momma, it's not empty! I blew kisses into it until it was full."

Ok, here’s the payoff, the reason you read these sappy things and then wipe your eyes when no one’s looking. A lesson for us all.

The mother was crushed. She fell on her knees and put her arms around her little girl, and she begged her Forgiveness for her thoughtless anger.

Oh, don’t worry. The lesson’s not over yet.

An accident took the life of the child only a short time later, and it is told that the mother kept that gold box by her bed for all the years of her life. Whenever she was discouraged or faced difficult problems she would open the box and take out an imaginary kiss and remember the love of the child who had put it there.

See, why can’t we just have the box full of kisses? No, instead we have to be beaten over the head with the message-Cherish What You Have. Don’t Take Your Loved Ones For Granted. And, of course, Kisses are Worth More Than Gold. Do you notice that someone dies in a LOT of these stories? Maybe she died because her bad mother didn’t deserve her anyway. Or she had to pay off some of her mother’s karmic debt, which, frankly she’s been racking up by the bucket loads. But most of all, she died to teach us a lesson.

I get it already.

In a very real sense, each of us, as human beings, have been given a Golden box filled with unconditional love and kisses from our children, family, friends and GOD. There is no more precious possession anyone could hold.

Well, I don’t know about you, but the love I get, as well as the love I give, is pretty damn conditional. Because that’s what you get from other, imperfect humans. Maybe God gives unconditional love, but you wouldn’t know it from a lot of religions out there.

You now have two choices: 1. Pass this on to your friends, or2. Delete it and act like it didn't touch your heart. As you can see, I took choice No. 1. Friends are like angels who lift us to our feet, when our wings have trouble remembering how to fly. If you receive this more than once in return just know that your friends have also thought of you!

If you’ve read this far, you probably think I’m a total scrooge and maybe a cynical bitch, to boot. Here’s why I really hate these things. It’s because it gives us a false sense of closeness. I call it the “Aw, shucks” factor. We read something like this and it satisfies our need for several things: wisdom, easy answers to complicated questions and a feeling of closeness to others. But it’s the spiritual equivalent of a Snickers Bar. They’re nice once in a while, but your spiritual nutrition shouldn’t depend on them. And that’s just what so many people I know do: they’re feeding their soul with Snickers Bars and nothing else. They get their moment of “Aw, shucks” and then go back to being the same shallow, disconnected people they were 30 seconds ago. So, my secret’s out-I hate these things. I think they are worse than meaningless, I think they’re harmful to our psyches.

I like to read inspirational stuff, I really do. But I want the five-course meal, not a candy bar. Chew on this:

When God wants an important thing done in the world or a wrong righted, He goes about it in a very singular way. He doesn’t release thunderbolts or stir up earthquakes, God simply has a tiny baby born, perhaps to a very humble home, perhaps of a very humble mother. And God puts the idea or purpose into the mother’s heart. And she puts it into the baby’s heart, and then…God waits.

The great events of the world are not battles and elections and earthquakes and thunderbolts. The great events are babies, for each child comes with the message that God is not yet discouraged with humanity, but is still expecting goodwill to become incarnate in each human life.

McEdmond Donald

At least the email isn’t extorting me to pass it on to 10 people in 10 seconds or risk certain death. For that, I’m thankful.

I am IS's worst nightmare

My job gives me a laptop(an IBM thinkpad, which I love), a pager and a blackberry. I am not completely computer illiterate, but it's close. I'm also hard on shoes, if you know what I mean. Really, I'm hard on everything, which is why we have no nice glasses in my house. Needless to say, I really should not be entrusted with a thousand dollars worth of technical equipment. When they asked what type of new laptops we should buy, I immediately thought of this. You know, for my busy lifestyle. My busy, klutzy, lifestyle. Florence King had a word for women like me, a slew foot. As near as I can figure, it's a sort of female Mr. Magoo.

Anyway, now whenever the IS guy sees me, he gives me that look. The look that says, "So, what have you broken today." And here's the thing, I had broken something. Or maybe my daughter did, but that's still my responsibility and now I have to 'fess up. My power cord won't fit snuggly into the damn laptop and it won't charge unless I hold the cord in an awkward position and then stay like that for 8 hours until it recharges. All right, that's not too bad, you say. Except that it's now the second time this has happened with two different computers and I try and tell him that I don't pull on it and I generally treat the cord nicely, and now he's giving me that look again.

I am on my second laptop because I learned the hard way that diaper bags are not meant to hold computers. I went to swing it onto my shoulder, the top was secured(I mean, it just closes with a little tab of velcro, sheesh) and as my bag hit apogee the laptop came flying, nay, soaring out of the bag. In slow motion, it seemed, it flew in an arc. I thought I could hear the sound effects from the Six Million Dollar Man when he used to throw something really far. "Nnnuuun, na, na, na." Then it hit the driveway like a ton of bricks. A small shower of black pieces flew up and it might have left a crater, but I was too afraid to look. Now, here's the amazing thing...it still worked. It didn't look great. But I was happy with it. However, when Mr. IS saw it, he said he had another he could give me and now, here I am with a NEW laptop and a power cord that won't fit in the little hole and recharge. Really, I think they should just give me safety scissors and fat crayons to play with. Sigh.

Why won't they say yes?

I just got finished reading this post at The Wait and the Wonder. (Spoiler alert at the end.) And I'm already fried from 36 hours on triage and a grueling holiday call period last week. I think it really started 2 weeks ago, when I had to deal with some serious crazy family dynamics. Think: lovely, peripheral family, divorced spouse, over protective big brother and a crazy daughter. Now, I almost never say that someone's grief is dysfuntional. Get angry, scream at me, fall out on the floor and pull your hair out, whatever-I understand. But this girl was UPSET. She spent most of the 12 hours I was onsite IN BED with her mother. In the hospital bed with the patient, her mother, who was brain dead and intubated. I can only imagine what the funeral was like. Anyway, she did not consent, even though her mother had indicated on her license that she wanted to be an organ donor. And in my state, that's first person consent, all legal-like, if we chose to pursue, which we did not. She said, "if my mother knew how it would upset me, she would have changed her mind." Mmmm. I think that when you finally meet your mom in heaven, you might have some 'splainin' to do.

Did a case on Turkey Day. Which went great, except that I'm still craving a real Thanksgiving Dinner and if anyone wants to come and cook me a belated one, I'm all for it. Love Monkey and the Teenager did make a to-die-for corn bread pudding with cranberry sauce a la Alton Brown that was amazing. And sweet potatoe pie. But I'm still craving some turkey and gravy. Oh, well, at least I'm off for Christmas, so I'll quit bitching.

This weekend I get to be the person sending the coordinators hither and yon. I was all psyched, thinking that I'd still get to go to the office party, all cool-like, what with wearing my Bluetooth and all, and just triage while boogying down. Unfortunately, the case that was in progress hit several snags, not the least of which was a) no one at the hospital wanted to do the actual pronouncement and b) I had no recovering surgeon. While we did manage to cross those bridges, by the time I got done with all the phone tag it was too late and I was too pooped to party. I heard the food was mediocre and the booze watered down, but still.

Two more no consents this weekend. One woman who died actually had a mom who was an organ donor and told her husband that she never wanted that done to her. So, wishes known, no consent. A young girl also died today, her mom didn't want her cut up, no consent.

I feel like I may be becoming too desensitized to dead people. We were watching CSI Thursday night, the one where the dead people talk, and Grissom is teaching a class of(I guess) new CSI's and I realized that I have been around a lot of dead people. I asked Love Monkey, (also a nurse) "How many dead people have you been around?" He thought for a moment. "I don't know, several dozen." Take my word for it, when you start hanging around with corpses, you realize that they have as much to do with the living person as a tin can has to its contents.

So, (and here's the spoiler) I read about Jackson's death from biliary atresia and I just think: why don't people donate? I just want to say to people, look-your body is going to turn into a puddle of goop whether you like it or not. Embalmed-still goop, just later rather than sooner. I realize it's a gruesome thought no one wants to think about, but it's still true. So please, please donate your organs. Don't let the gift go to the grave.

Happy Turkey Day

I'm a sad turkey. Yesterday, I was out for a few hours than went home because the patient wasn't brain dead and the family just wanted to extubate. And no, he wasn't a DCD candidate, if you're keeping score at home. Then I thought I was going to be releaving my orientee(who got her first consent yesterday-yeah!)and doing just an OR this morning, leaving me free to enjoy my Thanksgiving. Not to be. I got called out to a hospital and drove for an hour only to find the patient they had called me on had coded and was pronounced. No worries, they had another patient in the CCU who was brain dead. Wife had already brought up brain death to the staff and here we are, me and another orientee(yes, I train everyone) staying through the night and keeping this guy going until the OR Friday morning.

It's a nice case. No rushing. 3 organs to share. All night to do it. A few management issues, but he seems to have weathered them. Now, I just got a call saying he's Hep B core positive. I'm waiting for the hard copy before I wake my surgeon. This could put a crimp in my plan. His recipients aren't Hep B positive and I don't if he any of his patients are. So we may have to begin sharing again. We'll see. Right now it's the wee hours and my head feels fuzzy and I miss my family and my baby who I haven't seen in 15 hours.

On a positive note, we did have lumpia and ponsit, two of my very favorite Filipino foods. Especially the lumpia, yum. And apparently there's sweet potato pie waiting at home, when I get there.

9-0

Yeeeeeee
eeeeeeeeee
eeeeeeeeeeee
eeeeee
eeeeeessssssssssssssssss!!!!!!!!!!

It's a Cinderella story

All right Kim, I have to throw down the gauntlet. Because I've read a lot of your posts about Notre Dame, but today baby, is Scarlet Knight Day!

Even my dear, old Dad, who is Irish-Catholic down to his last corpuscle, is rooting for the Red!

Go check out your weather.com and you'll see that central Jersey is unseasonably warm today, blue and sunny skies. Perfect to kick some Louisville butt!

HOORAH! HOORAH! RUTGERS RAH!

RED TEAM, UPSTREAM, UPSTREAM, RED TEAM, RAH, RAH, RAH!

Change of Shift

Disappearing John does a great job of Change of Shift today. Stop by and get his behind the scenes tour of a hospital.

3 cheers for PICU!!!

I would like to extol the virtues of the Pediatric ICU and all who staff them. Why? Because in PICU, your patients aren't combative, they're cranky. Because in PICU, turning and positioning requires 2 hands, not a team of people. Because body fluids are kind of cute when they come out of little behinds, or noses, or whereever.

I've been in this PICU for, hmmm, let us see, 18.25 hours now. My patient is a teen who made the bad mistake of mixing booze, driving and bad weather to her permanent and everlasting sorrow. And the sorrow of her mom, siblings, cousin and young baby. It's been a slog, and I'm emotionally drained. I felt so bad for her mom, then when I found out she had a little baby-home, crying for Mama, I thought I was going to lose it. They chose to donate so that someday, this little one will at least know that his Mama saved 7 other lives. That all sounds so trite to me right now, because I'm exhausted and all I can think about is my little, wee one growing up without me. We(by we I mean the nurses) were sitting around, catching our breath for a few minutes and we started telling each other about "our worst" stories-the worst dead child story, etc. It was getting to be the wee hours and I was too creeped out for that shit. Finally, somebody told a story about her son's toilet training adventures and we were laughing again and THAT is why I like PICU-because nothing will get you out of your own shit like a good poop story.

About Face

As some of you may know, France did the first successful partial face transplant last year. Now, an English surgeon has received the go-ahead from the NHS. The ever thorough BBC has everything you need to know and more about face transplants here, including a link that shows what the journalist would look like with the surgeon's face, if you're really interested.

I was thinking that donating my face would be very, well, icky. Believe me, I'd donate any part of me after death(except my eggs, but that's another matter). But when I read the article and thought about having to go through life with terrible facial burns, or no nose or lips, I changed my mind. Let me know what you think.


Grand Rounds 3.5 is up at Health Care Law Blog. And if you have to catch up on your reading, like I do, Grand Rounds 3.4, check out Emergiblog. Happy Reading!

This just in...

So, I was talking to this nurse today over the phone, trying to get some information on a patient we're following. So I ask her, "Is he on any pressors?"

She answers, "Well, he's on lopressor." And she's serious.

If you think that's funny, you may have been a nurse too long.

Play this!

UK Transplant has this great game about allocating organs. It's addictive. I so need to practice...because, uh, my patients didn't do very well. Also, NATCO, The North American Tranplant Coordinators Organization, has a patient simulation for various professionals: transplant coordinator, hospital development, etc. which is very useful, educational and fun, if you're into that sort of thing. I am.

Better Late, If Ever...

And who reads ANYTHING on a Tuesday? Oh, guess what, Grand Rounds v3.3 is up at Unbounded Medicine, which is a funky site. Go there today and see a neat pic of someone who has there arm, well....just go and check it out. In the spirit of full disclosure, and because I'm a selfish Bee-otch, I only bring up the GR because I'm in it. And I'm listed under the Physician Stories...so please, it's Dr. TC from now on, thank you.

You think you can handle this?

Sometimes, this is my job:

"We do more before breakfast than most people do all day."

And sometimes, it feels like this:

"Faster than a speeding bullet, more powerful than a locomotive, able to leap tall buildings in a single bound. Look, up in the sky, it's...

Yet other times, it feels like this:

Recently, though, it feels like this:

"The hell you will. He's got a two day head start on you, which is more than he needs. Brody's got friends in every town and village from here to the Sudan, he speaks a dozen languages, knows every local custom, he'll blend in, disappear, you'll never see him again. With any luck, he's got the grail already. "

But in reality, I often feel like this:

"Hello?...Hello?...Does anyone here speak English?"

Recently, someone in the comments section asked me what it takes to be a transplant coordinator. Of course, I didn't read my comments, or surf the web at all, for like a month. So, I thought I make it into a post. Sometimes, it does seem like an army of one. Depending what hospital you're at, you're either surrounded my friendlies or behind enemy lines, but I'll take that analogy no further. Sometimes you do feel like Superman, you hit your groove, you haven't slept for 24 hours and you're going on pure adrenalin. And yes, occassionally I DO feel like the Grim Reaper, waiting around the bedside of a dying person. Although I want to be more like Indiana Jones (I even majored in Archaeology, a long, long, time ago), I usually feel more like bumbling Marcus Brody.

I don't want to be too snarky. It is a good job with a good purpose and I still like it. I will say this-my co-workers and I are an eclectic bunch. We're all idiosyncratic. We spend many hours alone in hospitals where we don't know the staff, don't know the doctors and don't know how the system works and yet, within a short period of time, we've got to get the system working and differing parties collaborating toward a single goal.

An ability to stay awake for long hours helps. It's very common to get a call at 5 or 6am saying that you have to be at a certain hospital in an hour. I've arrived onsite to find that the clinicals are already in progress and sometimes the family is ready to be approached. You spend the day managing the patient clinically, sharing the organs, coordinating the teams to come in. Inevitably, the OR is never at a sane hour. So by the time you get in the OR at 3am, you're fried and wondering if maybe a job in food service is the way to go.

Strong clinical skills are a definite requirement. Every donor is different. Some are hemodynamically unstable from the get go. Think a gun shot wound to the head or some other massive head trauma. They're in DIC, or DI. They're hypotensive from blood loss. Other donors are brain dead from anoxia, like a status post cardiac arrest. They may take a week to become brain dead and then you have all the problems of someone who's been immobile and on a vent for a week. Pneumonia, electrolyte imbalances, blood clots. Another challenge is the 180 degree turn in clinical objectives: from a head injury to an organ donor. With a neuro patient, you're trying to keep the ICP down, so you're minimizing fluids and maybe using 3% saline. You're clustering care and not moving the patient so much. After brain death, the patient becomes hypotensive from vasodilation and you're pouring fluids into them. To keep the Na low, or to lower it if it's already high, they're put on 1/2 NS. Suddenly you're asking for chest PT and frequent turning and suctioning. Inevitably, someone will ask, "why are we doing all this on a dead guy?" The best answer I've heard is that when you're taking care of an organ donor, you no longer have one patient, you have up to 8-one for every recipient who's going to benefit from these organs.

And that leads to the important skill:tact. You have to be a diplomat. Some hospitals do one donor a year, maybe. Some hospitals call you every week. Some now what they're doing, some don't have a clue. Some are very excited when they get a donor and are eager to work with you and some...well, not so much. In any event, you can't really go in their like gang busters and start telling everybody what to do. Well, you can. And some have. But it won't make you very popular and you'll make the next transplant coordinator's job that much harder the next time. Not that I'm bitter or anything, I'm just saying.

Add a large dose of compassion. And a good sense of humor. And don't take things personally. So, are you ready to see new places, experience new things and meet new people? And then take their organs? This job's for you.

blogging from the smackberry

The powers that be told me that surfing teh internets is free on our plan. I can only hope that's true or I'm going to have a $5000 phone bill.

Blackberry Hell

It doesn’t pay to get out of bed, some mornings. I was trying to get out of the house and to the hospital early. Well, early-ish, if you get my drift. Laughing Baby was just finishing up her breakfast nosh and was falling back to sleep. I was snuggled up next to her, tapping my toes and checking my email on my brandy new technical device that rhymes with “Smackberry”, waiting for her fall completely asleep so I could sneak out of the room and get ready. Next thing you know, I drop the Smackberry on her head. Oh! Howls of agony! Oh! Great Gobs of Mommy Guilt! Upon further inspection, I think they were more howls of indignation that actual pain and suffering, but not matter-everyone in the house was now awake and I wasn’t going anywhere in a hurry.

Speaking of the Smackberry: this thing is causing entirely too much aggida (Agida? Adgida? Ajjida? Any Italians out there know how to spell the damn thing?) Anyway, after much intestinal distress, I’m starting to like the thing but it is a pain in the ass. I’ve dropped more times than I should admit to. I set the ringer on high and it wakes everybody up in the middle of the night. I set it on low and no one hears it, including me. Yesterday, I was called 12 TIMES and they were ready to send out the bloodhounds to find me when I woke up, checked the phone and said, “Holy Shit!” and wound up having to apologize to all the people who lives I disrupted. Sigh. I am not a techie. I’ll figure out that it does this or that and the family just roles their eyes at me, like, what took you so long? As in, “Hey, this text messaging is great! Do you guys know how to do this?” Sigh.

And it’s turning my coworkers into people I’d rather not spend to much time around. They’re all like, “How come my email doesn’t work?” and “We need a class for this. How can they give us a Smackberry and not give us a training class?” Excuse me, but the last time I got a cell phone, it didn’t come with a class, it came with a Spanish instructor. His name-Manuel.

Every meeting is a flurry of chirps and beeps and bells and rings as people scramble to figure out if they just got a phone call, an email or a message from God himself. I’ve heard that when they elect a new Pope, white smoke will come out of the goddamn thing.

And while I’m kvetching, my house is a disaster. There are ants on the kitchen counter because Love Monkey made some cinnamon toast for the baby and it rained sugar on the counter. “I don’t know,” LM shrugs, “they must be special ants, the kind that only eat sugar.” What? So there it is, an ant parade, in my kitchen. Hopefully, they’ll stay there, because the LM also doesn’t believe in using the high chair, but lets the baby graze throughout the house, like a little goat and so soon the “special” ants are likely to follow said “kid” and her trail of crumbs. Also, blocks are everywhere, Little Einstein CD packs are scattered around and many, many cups and glasses line the bookshelves and cabinets, high up out of baby reach. But don’t worry! Lives are being saved, (including those belonging to ants) and I’m hard at work, living out of my car and eating fast food. I had a professor in nursing school who said she threw a pile of dirt in the corner and when it started to sprout, she knew it was time to clean. Words to live by. Now excuse me, I’ve either got a cricket in my house or the phone is ringing.

Vacation Ramblings

Or How I Went Nowhere On My Summer Vacation

(Disclaimer: the following has nothing to do with donation, you've been warned)

I can't think of anything that excites a greater sense of childlike wonder than to be in a country where you are ignorant of almost everything. Suddenly you are five years old again. You can't read anything, you have only the most rudimentary sense of how things work, you can't even reliably cross a street without endangering your life. Your whole existence becomes a series of interesting guesses.
Bill Bryson
Neither Here Nor There

This is the first year in a long time that we haven't gone anywhere. I mean, I go a lot of places. It's just that there all intensive care units. The locals don't have much to say, being mostly intubated and all. I felt a real longing yesterday while watching Rudy Maxa in Australia. I'm not a big fan of Rudy, who's sort of a Rick Steves for staid, conservative types. For instance, Rudy went to the Gold Coast and watched people surfing. But did he surf? No, Rudy laughed at the very idea. But Steve, he totally would have surfed, even if he looked like a total dork. I'm a big Rick Steves fan.

A big G'Day to all you Down Undah

So it made me long for Australis. I went to Oz several years ago and it made a big impression on me. I stayed a week in North Sydney and woke up every morning to a gorgeous view of the opera house, the harbour bridge and Luna Park's smiling, lunatic face. If you've never been, Sydney is like San Fransicso meets the Bahamas. The people are friendly, like Americans, but nicer, tanner and better looking, with cute accents. I can't really say enough about it. Except it's hard to find decent coffee. We did all the touristy things:the Opera House, Syndey Zoo. We took a tour of the Blue Mountains and saw kangaroos hopping around like deer in our parks. We had billy tea and wellingtons. I ate crocodile, which really does taste like chicken. Oh, how I want to go back. Except that I could put a down payment on a house for what it would cost 4 people to fly there. It's really far. So far, that when it's today in Australia, it's still yesterday back home.

If I went back, I'd want to go all over too and make a big trip of it. I've always wanted to go to Perth, which, as Dame Edna says, is the nicest city 30 hours from everywhere. I go to Adelaide and Uluru and pretty much anywhere, but I'd really like to go to that place where the people live in caves dug in the ground.

And of course I'd want to visit New Zealand, cause, duh, there right next to each other. I mean, look at a map of the Pacific, right there in the lower left. See, they're right next to each other. My ER preceptor was from New Zealand, a snotty girl who all the guys were in love with because she was cute, perky and had the cute accent. Once we had to explain what a back-ho was to her. It was an interesting conversation. Really, all I know about the place is from an old boss of mine at a tool and dye shop I worked at during high school. The job was dead boring, but he used to tell me all about how New Zealand had the best trout fishing in the world and that the weather was in the 80's all year round. He was going to go there when he retired, I hope he made it. And, of course, the whole place is populated by hobbits. But you already knew that.

Tomorrow, if I'm done with cleaning out the basement, I intend to go to the beach. The shore, if you will. Whooopeee! It won't be the Gold Coast. But then, my chances of being eaten or stung by something deadly poisonous is much slimmer.

File under "WTF"

Medscape has an article that debunks an article from last year that says nurses shouldn't be paid well. The economist who did the study reasons, poorly, that if nurses receive low pay they'll do the job out of love and vocation and consequently the quality of nursing will stay high.

Medscape does a good job of showing why this is complete bunk. The first good point they make is that nursing is not just about caring for people, but is also a skilled profession. Think about this:could you imagine asking a doctor to take less pay to keep his motives for becoming a doctor pure? Why stop with healthcare? Can't this economist think of any other professions that shouldn't be motivated by (gasp) a paycheck? How about clergy? Not your average clergy, like my best friend's dad. I know he's not doing it for the money. I'm talking about those Tammy Faye/Jim Bakker types. Or how about keeping the pay down for lawyers? Surely they're not in it for the money? Or teachers? Or police?

One group of professionals that definetly needs a paycut are politicians. You want to be president? Fine, but you're going to make minimum wage. And only work 35 hours a week, so my tax dollars don't have to pay for your healthcare.

For me, what this study is really about is how nursing still labors under a stereotype. (Medscape also makes this point). Because the field is still dominated by women, people don't take it seriously. I remember working at a hospital where they wanted to cut back on our health benefits. A lot of the married women were like, "why should I care? I have my husbands policy to fall back on. " Forget all of us who weren't married and depended on our benefits. The point is that we deserve to get paid what we're worth(and that includes good benefits-how can a hospital rationalize bad health benefits?) We're not caretakers, we're health care professionals.

Also check out Medscapes article about nursing salaries around the country. I know it talks about the cost of living and how it varies to justify why nurses get paid so little in some parts of the country. I realize that a $400,000 house in my neck of the woods might be half that somewhere else. And car insurance is high here, too. But the price of a car is the same no matter where you go. Groceries aren't any cheaper in the South, neither are clothes. So why are some nurses still making $16 dollars an hour? It boggles my mind.

I'm all for the office of the national nurse, but I also think it's time for a national nurse's union.

Here's a thought

I got a lot of comments recently about the lack of support at a small, community hospital. And an offer for an 8 year old to come speak to them(thanks, Katie's Aunt), which would probably help more than anyone. It got me thinking. If this hospital had ONE organ donor a year, they could save up to 7 lives with that donor. Over a decade, that would be 70 people receiving organs and off the waiting list from just one hospital.

Catching Up

Because Sunday is the new Thursday. No, actually because I finally have 5 minutes to sit and surf....check out Change of Shift, this week at Intelinurse2b. Some really good posts, I must read them all some day.....

Auntie, as in, What's wrong with Auntie? was in the hospital last week with a nasty pneumonia. I went to visit her to make sure she wasn't scared and make sure the staff knew that she was delayed and also couldn't read, so she'd need help with instructions and menus, etc. I brought her a magazine to look at and hard candy and Love Monkey talked me into buying her a BIG box of chocolates-which she loves. Then the next day Mom tells me she diagnosed with diabetes. Great. The guilt, the guilt.

Action after review happened Friday. For this case. In case your keeping score at home. The manager of the unit allowed that the referral was late and that next time they'll call us sooner. And they're going to look at their policies and update them as needed. Hospital services told her that they really need a donor counsel at the hospital, because more than 2 people are needed to make significant changes at the hospital. She suggested the director of nursing and the VP of patient services. Her reply? They're too busy and aren't interested in donation. Which I find hard to believe. Because, bottom line, hospitals now need to show their conversion rate(possible donors/consented donors) in order to get accredited by JCAHO. So I think they'd be interested.

And I'm on VACATION!!!! Two weeks off work. Not going anywhere and I'll be cleaning out the basement, but I couldn't care less. Time for surfing the net, playing with the baby, maybe even going on a date with LM. Oh, glorious!

Grand Rounds

Grand Rounds is from South of the Border this week at Mexico Medical Student. Now excuse me while I pluck the baby out of the dog's dish.

All riled up

I don't even know if I spelled "riled" correctly and now I'm under pressure to be grammatically correct, after the last post. I was really mad last week. I'm better now, but still feel the need to SHARE MY WRATH with the blogging world. And I'd better type fast, cause the Little Einstein videos only last 30 minutes, and I've already spent 10 minutes yapping on the phone. BTW, I think biscotti from the local coffee joint are totally acceptable teething biscuits, albeit expensive ones.

Anyhoo. Last week I got called out for an organ donor referral to a teeny tiny little community hospital with a not-so-great reputation. Although, in all fairness, once when I was younger I smashed my finger at work and they did a top notch job of taking my finger nail off and stitching a little laceration I had. The finger nail never grew back in the right way, but I guess that's not their fault. Anything larger than fingers, though, I'd be afraid. That's all I'm saying.

The patient was a middle aged man who had minor surgery the day previous, went home with a headache and had an enormous bleed. He came in after midnight. It's now the following afternoon. His blood pressure has been 60/30 for 10 hours. He's not on any meds to keep his pressure up, just IV fluids. He also has a lot of medical problems, but his liver numbers are good, so we proceed. The hospital called 45 minutes the first clinical was done. He's not going to make it long with his blood pressure in the toilet, so I will have to ask the family pretty quick.

I get there and the patient is in nuclear, getting a cerebral blood flow (with a pressure of 60, you're taking him off the floor? Nothing like a code in radiology, I always say). I have already introduced myself to the family practice resident who's handling the ICU. There are no intensivists, no hospitalists. Any orders needed, the attending(s) have to be called. Another WTF, as Kim would say, but whatever. When the patient returns, she says she's going to speak with the radiologist and talk with the family. I ask her if I can be present. She says no, it's a conflict of interest. I ask her if, after she's done talking with the family, could she introduce me. No, that's also a conflict of interest. Really, cause at the other hospitals I go to it's called a "collaborative approach". Apparently she can't even be SEEN in the same room with me or it may imply that "I only want his organs" to the family.

All right, let's review:

1. They do nothing for the patient for 10 hours except scan his brain and give him IVF's.
2. They call us late. We should get the referral when the patient has a Glasgow Coma Scale score of 5 or less, not 45 minutes after the first doc says he brain dead.
3. Working together to ask a family to consent for donation is not unethical. Being pro-donation is not unethical. Possibly being a medical person and hindering the donation process may be unethical, but more on that later.

Finally, I ask the nurse to introduce us and to come in with me when I speak with the family, since she's been working with this patient all day and knows the family as well as anyone. I bring them into a conference room. There's the wife and two daughters. First, I assess their understanding of brain death and they get it. They know he's gone, they just don't want him to suffer. Understandable. Then I say to them, "Because of the way he died, (the patient) has an opportunity to save someone else's life through organ donation." The first daughter immediately says yes. Mom is unsure, but she defers to the daughter. The first daughter and the nurse both say how it would be a great thing for him to save another life and then the daughter says that he won't need his organs in heaven. The second daughter is distraught. We comfort her as best we can and she says it's okay with her. They all want to go back to the bedside and I tell them that in a little bit I'll have paperwork to go over with them, when they're ready. I give them an idea of the timeline and assure them that he will be able to have an open casket.

I go back to the nurse's station and start making phone calls. By now, a colleague of mine has arrived to help me out. We both note that the first clinical is not completed correctly. It has no time on it and it doesn't note if the patient is spontaneously breathing or not. She calls the neurologist back to see if he'll come and correct it or if we can fax it to him. I should note that the hospital system that this hospital belongs to uses a check list for brain death, for comformity and clarity, since many docs don't do this often and aren't familiar with the process. This one hospital doesn't use it, they have kept their own brain death policy. So it's just written in the progress notes. She gets a hold of him and he refuses to come back or have it faxed to him. He'll be in the next day, he says. She tells him the organs won' t be viable by then. He says that's not his problem.

The next thing I know, Dr. It's-not-ethical comes out of the patient's room and says, "They changed their mind." I'm suspicious. I go over to the daughter. She says that she wants to, but the rest of the family, the extended family who are now filling the room, don't want to. "And I can't go against the whole family." I talk to her for a bit, without being obnoxious about it, to see if there's anything I can do to change her mind. She's says she'll call if anything changes, but with a systolic blood pressure of 50 he won't last much longer. My colleague and I start packing up. I hear the resident and her attending going over the brain death policy. I offer to clear up anything for them. They just look at me. Then I mention that if this had stayed a consented case, we really would have needed a time on that first clinical for it to be accepted by the transplant surgeons. For it to be LEGAL. They go back to talking and ignore me. We leave.

Several days later my colleague gets an email from the nurse manager of the unit. I'm too flabbergasted to editorialize, so I'll just post it in full.

I also need to let you know that there were multiple complaints about the last referral in ICU by both the resident and the primary nurse with regards to the person who approached the family. They felt that she was placing the burden of approaching the family on them because she was not comfortable doing so. The resident tells me that she was placed in an uncomfortable position by your rep. In addition, when she finally did approach the family - the both stated that she was not assertive and they were not at alll surprised that the family refused. This is feedback that I am getting from my staff and physicians that I thought you should know (signed, the nurse manager)

Do I even need to say that this is complete bullshit? And hello-I did get consent. And then got it rescinded due to extended family pressure. Listen, it's hard enough to get a transplant. Why make it harder? And for the resident who's so concerned about ethics, think about this: you took an oath to preserve life. When your patient has an unsurvivable injury and you have stopped treating them in any meaningful way, the onus is now to preserve the lives of the prospective recipients. You are no longer saving one life, you're saving up to 8 lives and if you fuck it up you're potentially harming 8 lives. So put that in your Hippocratic Oath and smoke it.

Pet peeves, et al

There is a word that has made its way into the nursing vernacular. I refer, of course, to dilitate. Please, believe me, nothing dilitates. Your pupils, your cervix, your pores all DILATE. Look it up yourself. Go to dictionary.com and look up dilitate, and you will find this. See, I told you.

This naturally begets the second peeve: orientate. As in, I orientated her to the unit. Listen, I am not Protector of the English Language. I've even been known to use "good" when I should say "well". But I beg you, please stop, you're making making my ears bleed.

So, anyway, I'm orienting someone. And she's quitting, quitting for God's sake. I've taught her everything I know, some things I'm sketchy on and few things, quite frankly, I've just made up. No, seriously, she even knows to bring her preceptor a Gatorade. Brilliant is she. A natural. Oh and she's really good at the job, too. But her heart is in the ER and brother, I've been there, so what can I say?

I even told her about the blog. It's like she's seen under the Lone Ranger's mask(no Tonto/Kemosabe jokes, please). She wanted to know why I haven't written about any of our coworkers. Good question, 'cause that would be some entertaining shit. I guess I'm afraid that the transplant community is too small, that people would recognize who I was talking about. Or that when "Donorcycle:The Movie" comes out, everyone will be mad at the unflattering portrayals. So you won't be hearing about my boss, Mr. Keaton. Or Sister James Margeret. Or Stiffy and Scratch. Sorry, I just won't do it. And now, Tonto, you know too much. I must kill you. Death by dilitation.

Change of Shift

A day late and a dollar short....that's me. In case you didn't know, Kim at Emergiblog is doing a nursing blog carnival. Check out last week's, it's very good. A few of my favorites:

I swear I didn't steal her idea when I wrote my last post! Nurse Ratched and I are on the same wavelength.

But I have to point out these two to everyone I know. Get out the tissues....

Thank God for good nurses everywhere
and
why I, and every other TC, do what we do.

Check them out.

What I should have told my sister

I have inherited the title of "Family Nurse". My mother had it before me. When my grandfather would have chest pain or shortness of breath, instead of calling 911, he'd call my mother. Now, the next generation looks to me, apparently, for such sage advice as, "Don't call me, call an ambulance!"

Seriously, my sister calls me up the other night, she thinks she has a broken toe. She really banged it and now it's all black and blue. Now, for you gentle readers who have never worked in and emergency room, don't fear: I gave sound advice. Put ice on it, elevate your foot and buddy tape it to the next toe. And wear shoes with a firm sole for a couple of days. Take motrin or tylenol for the pain. All good. Good for her, she's doesn't have to wait for hours in the ER, no bill and the local ER has one less body in the waiting room.

Now, for you not-so-gentle readers who have worked in the ER, I realize I should have given her some different advice. Something like this: wait til 2 or 3 am, when the wait is shorter. Tell the staff that you banged your toe 2 or 3 days ago, but have been toughing it out and you thought 2am was a good time to come in. This will impress them and get you seen right away. For pain, have a couple of stiff drinks. Right before you show up, so if they start moving your toe around it won't hurt so much. And don't forget, keep asking repeatedly, "Is this going to take long?"

I know, I'm evil.

Good for her

Doctor, my eyes
Cannot see the sky
Is this the prize for having learned how not to cry


I got called out this evening to see a patient who was obtunded and vented, according to the report. I get there, only to see a gaggle of nurses giving report to each other. Then I hear one nurse say, "oh well, good for her." They part for me, and the nurse sitting at the nurses' station says, "Oh, (my OPO's name) is here. Listen, when I called she had nothing. I swear." I look in the patient's room and she's kicking her legs lustily. Apparently, in the interim, she woke up from whatever she OD'd on and is now kicking and fighting the vent, the staff and the restraints they've put on her. So, she's not dead. Good for her.

I sit down to write a brief progress note and call my office to tell them I'm leaving. Something from the front of the chart catches my eye. It's a suicide note. I tell the person on the other end of the phone and they make the typical, ER comment, "Well, let's hope next time she gets it right." I cringed.

Now, I've had my share of whiny, puking, usually teenaged suicide attempts. There may be some half-hearted scratches on the wrists. Or maybe they took some pill they found. Very often there is charcoal to be administered, then puked up, then administered again until you both look like you work in a coal mine. And the drama. Always the drama. I understand why health care workers have this jaundiced view of near suicides. Once I had a young woman with cystic fibrosis who was trying to live until her 30th birthday. In the next bed was a 20 something drama, who felt she would show her boyfriend by taking 5 tylenol and calling it a suicide attempt and was now generally being a pain in the ass. You just wanted to strangle her, or at least show her the woman in the next bed who would give anything to live to grow old.

When I hear that someone has tried to commit suicide I think of two patients, both women, who really touched me. The first was Patricia. Spanish-Pah tree see ah, not Pa trish ah. Patricia was how I learned that rat poison is basically coumadin, cause she felt the pain of living, made herself a rat poison shake and drank it down. She was basically okay but had to be watched for bleeding and given Vit K to help her blood clot for a few days. Don't ask me why, maybe because she had some things in common with me, but she struck a nerve. With my little Spanish and her little English, we talked about what happened. She was glad she didn't die and she wanted to get help. She was the first person I took care of in the ER that I ever visited upstairs. We couldn't really talk, but we communicated and she was glad I came to see her.

I can't remember the name of the second woman. Zoe? Zelda? She was also my age. She had been fired from her job and was driving back to live with her sister. While passing through my state, she pulled her car to the side of the highway, slit her wrists and jumped off a bridge. Some fisherman were in the water and pulled her out. She managed to escape serious injury. I remember being in xray with her while they cleared her C-spine. Her sister was in the waiting room. I asked her if she wanted to see her. She said, "do I have a choice?" I said, "you always have a choice." We locked eyes for a minute and she was crying and I started to tear up. She was the second patient I went upstairs to visit. Her mother was with her, high powered and full of money, taking charge and ordering the staff around. She demanded to know who I was. I looked at Zoe(?) and she looked just like a butterfly that's about to be pinned to a board. So scared and fragile.

How can you judge someone who wants to end their life? I wanted to take these women and hold them close and tell them that someday life will be worth living again. That they don't want to die, they just want the pain to stop. I don't think my coworkers, then or now, are cruel as much as they're in denial. Who hasn't had a dark thought, a secret urge to hit the reset button? I think they're whistling past the graveyard. By being cynical, they can convince themselves, "I'm normal and they're not." And if you haven't ever had that thought, then good for you. And my now awake patient, she doesn't need me hovering at her bedside, so good for her. I hope she wakes up and gets the help she needs.

I'm fried

Well, I have to say that doing Grand Rounds might have been the easiest thing I've done all week. And that's saying a lot, cause I thought GR was frustrating as all get out, what with the blogger and the mixed up links and the staying up all night fretting about it.

My laptop's broke. I was out for two days straight, trying to get 7 organs from a poor teenager who crashed his car. The last 24 hours on the case the RN and I were working our butts off, trying to turn around a crashing donor. In the OR, everything that could go wrong, did go wrong and I've spent the past 2 days second guessing myself, my boss and my career. Maybe I should work as a recipient coordinator. Maybe I should go back to the PICU. I'm confused. Then, today, when I still haven't really gotten any sleep all week, I get called out at 8am. And I'm the backup person. I shouldn't get called out unless everyone else is on downtime or out on a case. This led to harsh words exchanged between the Love Monkey and I and us missing a jazz fest we had planned for several months ago. We're better now, but it's my own damn fault. I need a vacation.

I was back home at 8pm. I got to see my little baby-boo sleeping all curled up. She's what keeps me going. I wish I could be home 24/7 with her. Aaaarrggghhh. And the thing is, I like my job and I'm good at it. But maybe it's not what I need to be doing right now.

Grand Rounds 2:42

Welcome to Grand Rounds 2:42 and welcome to donorcycle. . I’d like to thank everyone for their donations, er, submissions. So come in, grab and drink and peruse this week’s finest writing from the medical blogosphere.

Straight From the Heart: here are my favorites

1. Not only is this a well-researched and well-written piece, but you can get the t shirt! Seriously, the sweetest little baby I ever took care of had BA,
   and her life before and after transplant was like night and day. Thanks, Amanda, for this amazing post.
2. Navel Gazing Midwife goes out on a limb and shares her experiences with bipolar disorder.
3. Chronic Babe just has to vent…To sleep perchance to dream? Well, how ‘bout to teach, to shush or to punch?
4. A post from A Hearty Life about China's first heart transplant.
5. Aaah, look at all the lonely people. From Anxiety, Adiction and Depression Treatments.
6. And you thought HIPAA was scary? Here's a look at who's invading your privacy now. From Medical Connectivity.
7. Who doesn't love July 1st? I remember one July, they called a Code Red(fire), and all the new interns just heard "Code" and went running upstairs. Instead of laughing and pointing, like we did, About a Nurse exhorts us to act kindly towards these new docs.
8. Hey Fellas! Did you know childbirth is like baseball? Well, now you do. Thanks Milliner's Dream.
9. What do you do with a non-compliant patient? Go to their wedding, of course, like Doctor Anonymous.

The Brains of the Bunch

Do you know how many times I've heard, "my daughter's sister's cousin was brain dead, but she got better?" Jake, at Pure Pedantry, tells us the difference between a persistant vegetative state and a minimally conscious state. With charts and diagrams and not-so-large words.

Star-crossed lovers? Diabetes Mine has a different look at two up-and-coming diabetes drugs.

Health Business Blog and adaptive trials-coming to pharmaceutical company near you.

A cure for malaria? I'm interested.

A Nice Set of Lungs

Asthma vs. The Beaver. No really.

Breath Spa for Kids on pediatric ED visits. With a shout-out to the irrepressable Flea, who has something to say about time spent on the phone.

Sometimes we need a little medical management:

From The Doctor Is In, part of an ongoing series on medical reimbursement.

Make your own medical journal. From Clinical Cases and Images.

The Pharm Voice says we might one day be able to safe to visit Minnesota. Aetiology says it's okay, just don't drink the water.

Straight From the Doc offers an alternative to Cancer Commentary talks about Disease Proof thinks that just because you can sink a free throw, doesn't mean you know how to eat right.

Mental rumination can be a good thing. At Health Psych.

And while we're at it, The Happystance Project says that loneliness can be bad for your health.

The Bile Duct

What to do when the object of your lawsuit won't sit still. From Healthy Concerns wants you to Stop Blaming the Victim already. Nuff said.

Practice makes perfect. Unless you're My Life, My Pace, in which case practice makes for a whole lotta hurtin’.

Kim's in Ireland, but her heart's at Grand Rounds. And why is she talking about burnout when she's drinking Guinness?

Anikka's mom, from The Wait and The Wonder, on GI bleeds and mother guilt.

Urostream, with a Uro-rant.

I'm not sure about the analogies, but decide for yourself. Hippocratic Oaf and the coming "war".

No Bones About It

Dr. Jest and what keeps a widower happy.

Neonatal Doc, the HPV vaccine and the controversy it's creating.

Nick Jacobs, from Hospital Impact, on why it's better to be lucky than good.

Sorry surgeons, (but in my job, the OR's last and usually at 3am, but I digress.

Dr. Bard Parker with some required reading for young surgeons.

Barbados Butterfly, on what makes a good dog.

http://barbadosbutterfly.blogspot.com/2006/07/good-dog-rusty.html

And this youngster should have read Dr. Parker...

http://jaotte.wordpress.com/2006/06/27/my-first-day-in-surgery-part-iii-scrubbing-in-and-screwing-up/

Curse you blogger, for acting up again!

keep on blogging.

Well, I'm never doing that again. All right, maybe next year. The baby's up and I'm pooped.

Organ Donation Saves Lives!

I passed!!!

Hang on to your kidneys, I am now certified to procure organs! You may call me Queen of all Transplants, but since I am basically modest there's no need to kneel or genuflect or anything. As a treat, and because I'm a total dork, I'm thinking of getting a lab coat that A. has my name-T. Billie, RN CPTC and B. fits....because like Goldilocks, I have 2 lab coats. One is large and shapeless and the other is ridiculously small and won't button-from my svelte days in nursing school when stress and a diet of coffee, motrin and maalox kept me skinny. Aaaaah, nursing school.

mmmm, stylin'

Grand Rounds 2:41

This week, Grand Rounds are at RangelMD. Check it out.

Next week (gulp) Grand Rounds are here!

Send your submissions to donorcycle at hotmail dot com by midnight, 7/10/06

Also happening this week:

I sit for my certification exam

I have a meeting with the aforementioned crazy-ass neurologist.

And the baby is CRAWLING! And lightening fast, the little nipper.

And I'm on call for the 6th weekend in a row

So please......be gentle.

I hate my job, I love my job

Here's things I like about my job:

It's totally cool, No day is ever the same, I can teach, take care of patients, provide emotional support and spend a lot of time with families. I can wear scrubs or business clothes. My schedule is very flexible. My bosses are pretty approachable and listen to my concerns.

What I don't like:

Pay-not so good. I can be out for 24 hours at a time. I have to be tactful with people who I think are ignoramuses-not the people who may not know things about the donation process, but people who are really against donation and hinder the process(more on this). We are guests in the hospital and I have to play nice with everyone, usually easy for me, but I have limits. And the pay, did I mention I'm not getting rich doing this?

The last few weeks have been a whirlwind of personalities. I've been out a lot. I've done about a case a week for the last 7 weeks. That's 24 hours out, not to mention the referrals where I go and evaluate, but the person's not brain dead or not medically suitable or what have you. One weekend, I went out at 10am, got consent, finished by 7am THE NEXT DAY, went home and slept, woke up, went to another hospital, got consent and got home at 9am THE NEXT DAY(that's day 3, if you're keeping score at home). The family's like, "Who's that coming in and out all weekend? What's their name again?"

I have families that have been wonderful. Even in their grief, they wanted to give the gift of life. I've had families who were mad, threatening lawsuits and scaring the bejesus out of the hospital staff and they STILL wanted to help save a life through organ donation. I was screamed at-SCREAMED AT! by a crazy-ass neurologist (is that redundant?). I have spent 23 hours on site only to have the donation come to a screeching halt because the serologies came back positive. I had a nurse be very rude to me while I was giving an inservice on donation after cardiac death and then have the 'nads to say, "A non-heartbeating donor? WELL! You must be desperate for organs." And throughout it all, the family has been bitching like crazy totally supportive. And the baby! Did I mention that Laughing Baby is crawling! God in heaven. She's gone from completely immobile to a whirling dervish in like 3 weeks and I feel like I spend all her awake time picking her up and "refocusing" her energy on toys instead of, say, the electical cords. And she climbs like a monkey. I have NO idea where she got that from. All right, I'm done-before I wear out the caps key. (AM I SHOUTING!)

What to do when your patient's not dead

So here's my weekend. 72 hours on call and really, I shouldn't complain. I wasn't even out for a total of 12 hours. Friday, I went to a hospital close by, found out another coordinator was already there, so we both talked to a few people, got a few things done. We still hadn't actually seen the patient, cause there was a ton a family and we weren't ready to announce our presence. The neurologist had seen the patient and done the first clinical. So far, things going smoothly. Then we see the door open and a tech walk out. We look in at the patient... and she's moving. We sigh. Call that neurologist back, her patient's still alive(barely, but still).

Saturday, no calls. I slept like a cat. 8 hours of sleep, 1 hour for stretching, eating and using the litter box(eh hem). Then back to sleep. The family, bless them, left me alone.

Sunday, I'm back out to a hospital an hour away for a potential donor who "had nothing" ie they had no reflexes:no cough, no gag, no pupil response, no pain response and not breathing on their own. I get there and fortunately for me the respiratory therapist had put the patient on CPAP for a few minutes and she did indeed breathe on her own. Then I went into the room and noticed she was shivering. The nurse(who was very overworked, I admit) said, "her fever must be coming down too fast." Except, and here's the thing, dead people don't shiver. Not even brain dead as compared to your dead dead. Shivering, still alive. It's a fact. Look it up.

Just when I think my my weekend call is over, just when I said, "hey, this weekend wasn't so bad." What was I thinking? I get phoned at 1:30 in la manana to see another patient who's "got nothing, maybe a little breathing on her own, but not much". I head on out, luckily not terribly far away. I get there just as the patient is going up to the ICU from the ER. She's being bagged by respiratory. "Sure she's breathing on her own, see." and he stops bagging for a second. Deep inhale. They get her onto the bed and I take a look at her. Pupils equal, one sluggishly responsive, one brisk. I ask the doc to get a set of liver enzymes and call me in the morning. Well, later in the morning. And go back to bed.

So why do we go on site so early. Sometimes I feel like that scene from Monty Python's The Meaning of Life:

"I've come for your liver."
"But I'm still using it!"

I don't know about where you live, but in my neck of the woods the hospital staff(nurse or doc) are supposed to call when the patient meets certain criteria:

1. Neurologically devestated-anoxic or an injury(bleed or trauma)
2. GCS of 5 or less
3. Loss of 2 or more cranial nerve reflexes

The idea being that the earlier we get on site, the better the outcome will be. Many times, like in the above scenarios, we just wait and see. If they get better, good for them(unlikely, though, as the prognosis for someone with a GCS >5 is pretty dismal. I mean, you get 3 points just for lying there). If they're not medically suitable ie multi-organ failure, HIV, cancer, then we say thank you for the referral and walk away. If they are medically suitable and brain death is imminent, we formulate a plan with the hospital staff about talking to the family, management and when, how and who is going to start the brain death protocol. So, yeah, I do feel like a vulture sometimes.

So nurses, (or docs) if you call us with a referral, here are some handy tips. Please give me about 5 minutes of your time. If you're too busy(and you frequently are) let me know when I can call you back. I need to know your assessment of the patient, their vital signs, their medical/social history, what drips they're on, their urine output and recent labs. If you don't know something, just say you don't know, you haven't gotten to it yet, whatever. I'll let you know when I'll be there and if there's anything that would help us, like maybe the doc will order LFT's or some other blood work to see if they're worth pursuing as a donor. It's a team effort.

Busy, Busy, Busy

May was a busy month. I was out overnight at least once every week. Driving all over God's creation, too. Not to mention cars breaking down, teenage drama and still unpacking the last of our boxes. And the Laughing Baby is starting to crawl, God help us. Since I can't crate train the little scamp, I'll guess we'll be buying a baby gate.

My last 3 cases were a little disappointing. In 2, the family said, "take whatever you can, they won't need it anymore," but for various reasons we were only able to recover a liver from one and kidneys from the other. Other organs no good and not suitable for tissue.

The 3rd case was a youngster, in the wrong place at the wrong time. Perfectly healthy, except for the bullet in his head. Mom would only donate kidneys, I don't know why. I should be glad that two more people are off the kidney list, but it's frustrating. His liver was perfect! (not to mention his heart and lungs.) I guess I can see why people say no, but why the stipulations? Maybe she knew someone who needed a kidney. I'll never know.

Anyway, back on call for 72 hours. I spent my days off getting reacquainted with the family, playing with the delicious baby and some chores. And I STILL have boxes to unpack. Ugh.

Two-fer Tuesday

Since I missed Grand Rounds last Tuesday(and actually missed Tuesday, last Tuesday, being out all night), I've included Dr. ibear's Grand Rounds here-which I'm still reading.

This week, check out Parallel Universe. Someone else is writing about donation for a change. I, meanwhile, am ranting about being a patient. Maybe that's why it's called Parallel Universe.

I hope Laughing Baby sleeps tonight, 'cause I've got a lot of catching up to do.

Calling all geeks!

Can someone with HTML skills (real skills, not my idiot savant skills) help me figure out why my sidebar is now my below bar? I have been trying to figure it out and I'm at a loss. Thanks!

Treat me like a child

Treat Me Like a Child


I noticed a few things while working as a pediatric nurse. Kids get treated differently. They get treated, well, like kids. They aren’t expected to behave, to sit still for shots or take nasty medicine without, at least, making a face. We give all kinds of consideration to young patients. We take our time with them. Treatment rooms are pretty standard, so painful procedures get done elsewhere and the patient’s room remains a safe place. Newer children’s hospitals put in diversions, like Play Stations and toys and books. They come in bright colors and have a Child Life Specialist to explain all the scary things and to see what makes the child happy and more secure during their hospital stay.

Recently, I visited a friend (a grown-up) on the oncology floor. I expected the treatment there to be a little more patient-friendly than the average floor because in many ways cancer patients get treated like children; they’re both considered “innocent victims” of disease. But my friend was considered “a good patient.” She was sick, but not too sick. She didn’t complain a lot. She tried to be upbeat and cheerful and helpful when called upon by nurses and doctors to do things that weren’t pleasant. She told me that she didn’t see her nurse a lot and when she did, it wasn’t for very long. “I guess she’s busy taking care of her sicker patients.” One doctor who promised to come in and check on her every day, came by once during her two-week stay. She found out different things from different staff as they paraded through her room each day. She was scared because there didn’t seem to be “a Plan.” It was like fitting together the pieces of a puzzle. She needed the advice of friends who were nurses and doctors to put it together for her, because the staff certainly didn’t. In the end, the things that satisfied her she got because she opened her mouth and complained until something was done. Why does it have to be that way?

So here is my patient manifest. A list of requests, (okay, demands) for my caregivers, should I find myself ill.

Don’t expect me act like a grown-up. Grown-ups get scared too, but don’t like to show it, so it may come out in different ways. They may have denial or anger, or they may be overly cheerful and helpful. Expect that underneath, I am scared. If I act like a grouch and snap and generally act hateful, don’t take it personally. Treat me gently. Certainly, you should give up on the idea of me being “the good patient.”

Think about where I am in my life. Erikson’s stages of development don’t stop when someone reaches the age of majority. When’s the last time you put down “Integrity vs. Despair” on a care plan? People have real, developmental needs throughout their life span and they shouldn’t be ignored by health care providers because they’re adults.

Explain things to me like a child. Not condescending-but simply. Avoid big words and ask me questions to see if “I got it.” Part of assessing the patient is to see how much they know about their condition and don’t take that for granted. Medicine and hospitals are foreign concepts to anyone who hasn’t been ill. Most people know more about how to maintain their cars than their bodies. Part of your job is to communicate. Please don’t tell me, “He’s a real jerk, but an excellent doctor.” I don’t care how well you diagnose, treat, cut, or cure. If you can’t communicate effectively, you’re not doing your job well.

If I’m well enough, give me something to keep me busy. We all know if you keep a child occupied, they’ll stay out of your hair for a while. And I don’t mean the TV. I hate walking into a hospital room and having that TV blaring 24/7. It’s not just a babysitter for kids anymore. What happened to daily rounds by a volunteer with a cart full of books, newspapers and other diversions? And God forbid if every hospital room doesn’t become private soon. Yes, roommates can be a bother, but it can also give you someone to talk to and commiserate with. I used to work on a floor that still had one four-bed room. More often than not, the four would become fast friends and you wouldn’t have to answer a call bell all day.

Let me have control over something, even if it’s little. I hate to feel like I’m just another number on the pill-dispensing assembly line. If I want to take my aspirin with lunch, let me take it with lunch. So what? If it’s something that can’t be changed, take the time to explain why to me (see #3).

Have a plan and let me, or my family, in on it. Floors should have walking rounds, with all the members of the healthcare team. Everyone knows what’s going on and everyone gets on the same page. Do it at the same time everyday so that I and my family can know when you’re coming and get the answers we need. I need to have my family or a close friend with me when you talk to me. Just like a child, I get overwhelmed with too much information and may need a second set of ears to hear what you’re saying.

Treat me like an “innocent victim” regardless of whether I’m in the hospital for cancer or a drug overdose. Many, many people are hospitalized due to their own action. Does it really matter if it’s because of too many beers or too many cheeseburgers? This is called compassion and it’s usually not thought of until it’s missing. You would think that some patients would be above judgment, but once I overheard a doctor say, “We’re going to harvest HIS organs? Why, so another drug addict can get a liver?” Give me a break.

It sounds simple enough, but it’s rarely seen. There are some good excuses, I suppose: managed care, high patient to nurse ratios, staff burn-out and many other issues that are better saved for another time. Even so, if I should ever find myself in a hospital, save a bed for me in PICU, I want to be treated like a child.

From around the world

Here's a story from Malaysia about how a 19 year old donor inspired others to come forward and sign up as organ donors. They have a neat time line of events, showing how it all went down with the recovery(or harvest, as they apparently still say in Malaysia). We stopped using the word harvest because I guess it sounded a little harsh for the donor families, like we're going to reap some beans or something. One surgeon I talked to like harvest better because he thought it sounded more natural. Anyhoo, enjoy.

Check her out!

Just got this site from Our Friend Kim at Emergiblog. In the Unit. Besides the fact that she can write, the page is awesome! Who do I have to sleep with to get a website that cool? And yes, the pull down menu is totally cool. (Do I sound like a teenager, because, um, like, I think I do).

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I did another 24 this week. This time with an orientee-Gosh, I can't believe they trust me to teach the new people(smirk). It was a great case for her, we did from soup to nuts(translation-ER to OR). And the unit we were on was very helpful. The staff did a great job of not just maintaining the patient, but also being supportive of this family. After consent they did everything we asked them-Aline, central line, meds, blood. It all went very smoothly.

The problem with being a TC is that it gets lonely. You're out there all by your own self and the staff not only doesn't know you, but they're busy and stuff. So you don' t really get that comraderie going. So, having another person around was great. Except that I felt like a new mom who hasn't been out of the house in a few weeks-I couldn't stop talking! "Ohyournewandwheredidyouworkbefore-andhowdoyoulikeithereandthisishowyoumanageadonor" Agh! Somebody stop me!

By the time we got to the OR in the wee hours of the morning, she had that deer in the headlights look. But she told me the next day that she thought it was a good first experience for her. She asked me how you get used to being up for 24+ hours in a row. I'm not really sure, but somehow I did. It's a long drive home in the morning though. Sometimes I pour cold water on my neck to stay awake. I'm pro donation, but not so much I want to actually want to cause my own head trauma.

The Real 24

All right, listen up. This is a seriously long post. So go to the bathroom, grab a snack, take the phone off the hook and tell the kids to be quiet. Don't say I didn't warn you.

24

Keifer Sutherland can kiss my butt. Last night I did a real 24, and I didn’t get to film it over a bazillion episodes, either. Here’s how it went: I got called out at 0615 to evaluate a potential donor who was unstable. 24 hours later I was leaving the hospital having completed a successful organ recovery. So what did I do in that time? Well, I don’t have fancy split-screen technology and multiple camera angles, but I think you’ll get the idea.

0615 Triage calls me to go see this patient. I have an hour to get on site, so I jump in the shower and get ready, only to find at

0700 My car won’t start. I left the lights on (Doh!!). I call triage back and let them know. Fortunately, another coworker is already en route to the hospital to help me out, so she’ll arrive first. I call the hospital and check on the patient’s condition. The nurse allows that he’ll keep the patient from coding ‘til I arrive.

0830 Finally arrive in Shoot’em Up City Medical Center. My patient has his brain injury the old-fashioned way, from a spontaneous bleed in the brain, but that’s rare in these parts. My coworker is already in the unit, watching the attending chew out a resident for not calling him in the middle of the night with a bad ABG result. This continues for some minutes. When the dust settles, we huddle and decide what the course of events is going to be the morning and how we’re going to manage the patient. I’m impressed with the doc right away-he really wants to help us keep organ function viable in this brain dead patient and do whatever he can to help us get consent. Ahhhh, when they don’t fight you at every turn. It makes my heart happy. Neurosurgery was in already and started the first brain death clinical

0915 Doc takes the family into the conference room to talk. When they can’t talk at the bedside, it’s usually bad. He comes back several minutes later and says that he told them the prognosis was brain death. They want to make the patient a DNR and remove the vent. If I’m going to ask them to make him an organ donor, it has to be now. Coworker and I head to the family room. They have already declined a priest or a counselor, so it will be just the two of us.

Conference Room-I introduce myself to the family as a nurse who works with families of patients with devastating head injuries. Sometimes I’ll have the doctor or nurse introduce me as part of the health care team, but today I just walk in for no other reason than my spidey senses tell me to. His parents are not English speaking, but a family member translates. I tell them that I know the doctor has given them some bad news and that I’m here to see if there’s anything they need and to help them make some end-of-life decisions. Mom says she knows he’s gone. They talk about having to make funeral arrangements and taking his body “home” (he’s From out of state). This is important. You can’t ask for organ donation is they think the patient is going to recover and walk out of the hospital some day. You can’t ask them the second you tell them about brain death-they need to absorb that information first and really process it and understand what it really means. If they’re saying, “well, the doctor says he has a one percent chance of making it,” or “will he be like that person on TV and be a vegetable for 15 years,” they’re not really understanding brain death and you need to do more teaching before you ask for organs. I mean, come on, it’s not brain surgery, and yet I’ve seen more than one brain surgeon say the stupidest things to family members. The family keeps talking back and forth in Spanish. All I pick up is “Corazon, something, something, corazon”. Finally, they say yes. They want other people to live, not that he’s gone. They just want the recovery done by tomorrow because they want the funeral arrangements made and to bring him home.

1030 I go over the consent with the family and the family member who speaks English does the medical-social history with me. It takes about 20-30 minutes, depending on how much history the person has. I like to tell people that it’s like the questionnaire you fill out when you donate blood. Some questions are very general, some are very intimate. I ask every family these questions, whether the donor was 5 or 95. So please don’t be offended. I’ll reiterate that right before we get to the question that asks if Grandpa ever had gay sex for money or drugs. Please don’t be offended. In more cases than you think, it’s actually an ice-breaker. People start laughing, “Oh, God, if he was only here, he’d be so mad!” or something like that.

1100 Everything’s being done at once. I draw blood for serologies and HLA testing. This takes about 8 hours to process, so we do it as soon as we can. I call triage, I call the office. Triage goes nuts because I promised this family that we’d do this by tonight. Never make a promise you can’t deliver. I’m not worried. We’ll get the second clinical at 1500-it’s already set up with the doctor who’s going to do it(the same one who was yelling at the residents, bless him). We’ll have serologies this evening and then go to the OR. I may even be home by 2am. That would be nice. I call home and tell LM the good news (or bad news, that I’ll be out all day). I’ll call later when I get a better idea what’s going on. LM wishes me luck. Coworker and I start working to get an echocardiogram done. Lungs will be out-he smoked 2 packs per day for 25 years and his PO2 is 75 on 100% FiO2. So, no good. Also, he’s starting to go into renal failure for no reason I immediately think of. His BUN/creatinine was 49 & 2.2 this morning. Now they’re 50 and 3.5. So I’ve got to try and reverse this. Or at least halt it.

1130-1430 I get the hospital to start a synthroid drip. The patient is on levophed and dopamine to keep his blood pressure up. The synthroid will make him more hemodynamically stable and hopefully we can come down off the other pressors and maybe save his kidneys. Meantime, the echo is done and lo and behold, a cardiac transplant surgeon is in this hospital seeing patients and reads it. Bad news, his hearts a mess. Left ventricular hypertrophy, pulmonary hypertension, right ventricular enlargement and an aortic valve stenosis. Finally, he has a small, pericardial effusion. Even I can tell his heart looks bad on the echo and I usually don’t see anything on a sonogram. We had the cath lab on standby but we call them and tell them it won’t be necessary. So, now we’re looking at recovering liver, pancreas, kidneys and tissue. He’s way ahead on fluid, so boluses aren’t really going to help. I ask them to give 5% albumin, 40mg lasix and another albumin to see if that helps his urine output. 2 hours later, still no pee.


1532 Patient is pronounced legally dead. The doctor goes out to tell the family in the waiting room. A large group of family comes in with their own priest and prays. Someone asks when they are going to take him off the machine. I had gone over this with the immediate family, telling them that he’ll be on the ventilator until we go to the OR, but now I’m wondering if maybe it got lost in the translation. So I get someone on staff to translate. They say they know, they’re just waiting for more family to arrive then they’re all going home. Meanwhile, I’m keeping up on my charting. We’ve called the OR to tell them we’ll be doing the recovery sometime tonight. The nurse manager stops by to see if we need anything. The attending comes over with the residents and tells me that if I need anything to just tell them. Then he tells them to listen to me. I like this guy.

1800 I’m making calls to transplant centers to share the organs. Serologies are back and they’re negative. Liver gets accepted right away by a local program. I keep making calls to find a backup in case they get to the OR and don’t like the way it looks. Someone actually is interested in the kidneys, despite the BUN/creatinine. OR says we can go at midnight, my recovering surgeon agrees. Woo hooo! I’m excited by the “early” OR. Usually we’re going at 0400. I start calling the tissue banks but because this guy had a history of drug use, no one wants his tissue-so no bones, heart valves, eyes, ligaments, skin.

2000 His urine output is still almost zero, despite my attempts to turn it around. I’ve talked to my medical director. We’re out of ideas. We’ll draw labs at 2100 and see what happens. I’m getting myself together, all the paperwork I’ll need for the OR. The recovery specialist has been called and will be here to help with the OR. My coworker goes home. I meet the night shift nurse and go over everything with him. So far, so good.

2130 Recovery surgeon calls. They have to move the OR back to 0200. Damn! OR says that’s fine with them. The anesthesiologist comes over and I give her our info sheet on what we need from her in the OR. I also have a pick list for the OR staff so they know what we need.

2215 Labs are back. BUN 52. Creatinine 4.5. Kidneys are out.

2330 I make sure everything is ready. My charting is done and ready to be copied and put in packs that go with the organs (organ, in this case). I grab something to eat. I ate once, earlier, about 1330, but I’m starving again. I try to not imbibe too much caffeine, it only backfires and makes me frazzled, so I’ve only had one cup of tea since this am. Do chocolates count? Cause I’ve had a few of those, too.

0030 Oh, the hour I should have been in the OR. I try and lay my head down and nap but I keep getting phone calls and pages.

0130 I run over to the OR to make sure they’re ready. They have a fresh pot of coffee, so I give in and have some. The nurse starts packing up the patient and we call respiratory for the ride over.

0230 Incision. The circulating nurse is, I actually believe, nuts. She’s certainly driving the scrub tech crazy. She asks a million questions, which is not so bad, but always at the wrong time. Then when I need her, she’s gone. My surgeon is cranky and so am I, having been up since 6am. We get the solutions set up for flushing and storing the liver.

0323 Cross clamp. This is always hairy. They cannulate the aorta to flush the organs with a special solution we use that preserves the cells. I open up the lines to start flushing. The surgeon fills the chest and abdomen with ice. It’s eerie to see the monitor go flatline, even when you know they’re dead.

0430 Liver is packed, paperwork is done. The surgeon is just finishing. I’m sitting on a cooler and nodding off. The OR nurse is STILL TALKING. God in heaven.

0600 I’ve helped the staff do post mortem care, cleaning the body and putting it in the body bag. Tags on. I grab my bags, thank everyone and leave. I stop at Burger King on the way home and have the grossest breakfast.

0700 I pass out. Ahhhh, sweet bed. Why do I do it? Because it feels so good when it’s over.