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!