If you have a patient who's been a heavy drinker and heavy smoker (like five 40-ouncers and a couple packs a day) since their teens, and they're now in their 60's, and they live with family members who are unlikely to stop smoking and drinking just to keep them healthy, and they also live in a food desert and have multiple comorbidities and things generally suck, it is not a dereliction of duty not to suggest that they get their carotid arteries Roto-Rooted in order to restore blood flow to their brain after a minor stroke.
Especially since no amount of improved blood flow is going to repair the damage caused by forty years of vascular dementia. You could've driven a truck through this guy's sulci. I mean, seriously. There was so little working brain tissue in his skull it would've been a crime to reperfuse it.
So we sent him home on blood pressure medicine that he won't take, and aspirin that he won't take, and comforted ourselves with the knowledge that, had we done everything in our power to make him better, he would've been nickel-and-dimed to death with tiny strokes. This way, what with the drinking and smoking and high-fat food, he'll likely have one huge stroke and that'll be it.
*sigh*
In response to a question below in the comments on the last post: Where I come from, "CCU" means "Critical Care Unit." It's the same as an ICU. NCCU, therefore, is Neurological Critical Care, whereas NSCCU is NeuroSurgical Critical Care. There is no difference, just as there is no difference between an LVN and an LPN--they're both skilled nurses who aren't allowed to hang blood in this state. The difference in terminology is a conceit of the facility, nothing more.
And with that I'm going to go eat junk food and fall down for a couple of days.
Kamis, 30 Januari 2014
Kamis, 16 Januari 2014
You know how, sometimes, things get brown and ucky and dull?
That's the way things have been around here, lately. Every couple of years I kind of brown-out--not burn out--on work, and blogging, and people and nursing generally.
Then I get better.
That is what happened this last couple of months: I browned out and then got better.
A lot of it had to do with work. You guys might've heard that the flu season has started. We have a thirty-bed medical CCU, and sixteen of those beds are filled by people under the age of 50 on ventilators or ECMO (a way of oxygenating blood by taking it out of your body, zapping it with O2 through a membrane, and returning it--sort of like lung dialysis) because of the flu. These are previously-healthy people, too. The old and sick ones are just flat-out dying.
Plus, there seems to be a sale on myesthenia gravis these days. I hear that if you have six patients with MG in your NCCU at once, you'll get an eggroll. I need our eggrolls to be delivered, please.
Meanwhile, as the plague is sweeping the state (and our staff), we were preparing for a couple of really hugely fucking important surveys. One was a TDH (Department of Health) thing that happens occasionally, just to make sure we're not all licking our hands clean between patients. Another was a certification survey, which was a very, very big deal, given that the surveyors would be coming to our unit, primarily, and going through charts and asking tough questions and so on.
Joint Commission surveys are generally held to be bullshit. They go like this: everything gets repainted, stuff gets put in storage rather than left out in the halls, the bathrooms finally get fixed in the locker rooms, and you get multiple nastygrams from chart auditors in the weeks leading up. Then the JC shows up, does whatever it is they do (pity the poor souls, though it's probably better than whoring), and things go back to normal.
This was not a JC survey. It was actually, you know, hard: thorough and comprehensive. Two very nice people showed up without much warning one morning and started asking me questions about neuroanatomy. One of them stuck around until the afternoon, watching us care for patients (there are certain things you do differently for neuro patients, and differently if they're, say, stroke patients versus neurosurgery), sitting in on patient education, and generally making me and my coworkers nervous. The two of them were critical care specialists, too, which made it even more fraught.
We passed. We passed perfectly, with no demerits. First time out, spandy-new NCCU, and we fucking aced it. Nobody else in the country has ever done that on this survey. So we got that going for us, which is nice.
Our manager, for whom I would take a bullet, bought us a huge lunch to celebrate. Our manager's manager, another woman I'd step into the line of fire for, came up the next day and was so overcome she was actually teary-eyed. The director of medical services and the critical-care big boss came up and congratulated us. So did the president of the entire Consolidated Research and Medical Care Gargantuan Whingnut, of which Sunnydale General is a part.
And the new nursing officer? The individual Der Alter Jo and I nicknamed The Dalek? Said nothing. No acknowledgement whatsoever.
This is the person who's responsible for approving hiring and firing and wages and working conditions and safety and all that shit, and he has not said word one about a survey which, to be honest, focused less on medical care and more on nursing care.
I kind of expected that, to be honest. Still, it sucks that the person whose job it is to make sure that my colleagues and I have safe, sane, decently-provided working conditions, continuing ed, all that stuff, was absent from the hallelujah chorus.
It baffles me that somebody so tone-deaf could keep moving up through the ranks like he has. I wonder what photos he has in his posession.
Anyway, it's been a hard slog of a couple of months. I don't know if things are getting better, or if I'm just getting acclimated to being torn four different directions at once for twelve hours at a stretch. I gained all of the seventeen pounds I had so carefully lost, and slept worse and bitched more than is normal for me, but that all seems to be evening out now.
Anyway, I'm back. Mongo is a big, furry goofball. The cats are just fine as froghair. Boyfiend is doing something brewerish tonight. Sherlock is in his flat and all is right with the world.
Then I get better.
That is what happened this last couple of months: I browned out and then got better.
A lot of it had to do with work. You guys might've heard that the flu season has started. We have a thirty-bed medical CCU, and sixteen of those beds are filled by people under the age of 50 on ventilators or ECMO (a way of oxygenating blood by taking it out of your body, zapping it with O2 through a membrane, and returning it--sort of like lung dialysis) because of the flu. These are previously-healthy people, too. The old and sick ones are just flat-out dying.
Plus, there seems to be a sale on myesthenia gravis these days. I hear that if you have six patients with MG in your NCCU at once, you'll get an eggroll. I need our eggrolls to be delivered, please.
Meanwhile, as the plague is sweeping the state (and our staff), we were preparing for a couple of really hugely fucking important surveys. One was a TDH (Department of Health) thing that happens occasionally, just to make sure we're not all licking our hands clean between patients. Another was a certification survey, which was a very, very big deal, given that the surveyors would be coming to our unit, primarily, and going through charts and asking tough questions and so on.
Joint Commission surveys are generally held to be bullshit. They go like this: everything gets repainted, stuff gets put in storage rather than left out in the halls, the bathrooms finally get fixed in the locker rooms, and you get multiple nastygrams from chart auditors in the weeks leading up. Then the JC shows up, does whatever it is they do (pity the poor souls, though it's probably better than whoring), and things go back to normal.
This was not a JC survey. It was actually, you know, hard: thorough and comprehensive. Two very nice people showed up without much warning one morning and started asking me questions about neuroanatomy. One of them stuck around until the afternoon, watching us care for patients (there are certain things you do differently for neuro patients, and differently if they're, say, stroke patients versus neurosurgery), sitting in on patient education, and generally making me and my coworkers nervous. The two of them were critical care specialists, too, which made it even more fraught.
We passed. We passed perfectly, with no demerits. First time out, spandy-new NCCU, and we fucking aced it. Nobody else in the country has ever done that on this survey. So we got that going for us, which is nice.
Our manager, for whom I would take a bullet, bought us a huge lunch to celebrate. Our manager's manager, another woman I'd step into the line of fire for, came up the next day and was so overcome she was actually teary-eyed. The director of medical services and the critical-care big boss came up and congratulated us. So did the president of the entire Consolidated Research and Medical Care Gargantuan Whingnut, of which Sunnydale General is a part.
And the new nursing officer? The individual Der Alter Jo and I nicknamed The Dalek? Said nothing. No acknowledgement whatsoever.
This is the person who's responsible for approving hiring and firing and wages and working conditions and safety and all that shit, and he has not said word one about a survey which, to be honest, focused less on medical care and more on nursing care.
I kind of expected that, to be honest. Still, it sucks that the person whose job it is to make sure that my colleagues and I have safe, sane, decently-provided working conditions, continuing ed, all that stuff, was absent from the hallelujah chorus.
It baffles me that somebody so tone-deaf could keep moving up through the ranks like he has. I wonder what photos he has in his posession.
Anyway, it's been a hard slog of a couple of months. I don't know if things are getting better, or if I'm just getting acclimated to being torn four different directions at once for twelve hours at a stretch. I gained all of the seventeen pounds I had so carefully lost, and slept worse and bitched more than is normal for me, but that all seems to be evening out now.
Anyway, I'm back. Mongo is a big, furry goofball. The cats are just fine as froghair. Boyfiend is doing something brewerish tonight. Sherlock is in his flat and all is right with the world.
Selasa, 24 Desember 2013
Kamis, 07 November 2013
It's never a good sign when. . . .
It was shaping up to be a pretty good day. I got up a little early, packed my lunch, put the dog outside, left for work on time, and made it to work without incident.
Where I walked in to find a patient, destined to be my project for the day, sitting on the floor of his room, screaming. And kicking and tantruming. Like a three-year-old. Refusing to get off the floor. Floods of tears. Demands that we call varied and sundry people.
I've got such a hangover from that day that I still can't form complete sentences.
Here's all you need to know: functional exam, drug-seeking, requesting Dilaudid (of course). Fourteen chart notes by the end of the shift just on my part. Approximately twelve hundred words from the various therapies. Screaming. Crying. More screaming. More demands for Dilaudid. Refusal of blood tests, vital signs, drugs, and therapies.
Drama.
I have had bad days before. Never ever have I had a day that made me question why on earth I became a nurse. (Not that I'm seriously questioning it now, but at about 1700 on that fateful afternoon? Definitely.) If somebody had made a cartoon of my leaving work, there would've been little puffs of smoke coming off the ground under my sneakers.
At one point the patient told the docs that we had left him on the floor for an hour as he screamed for help. (Note here that he did not fall; he simply sat down and refused to move.) The attending shot me a look, to which I responded with my best BlankStupidFace.
I just. . . .I just. . . .don't get that shit. And I don't play into it, either. Late in the day, the patient refused to answer the simple, yes/no question of whether he'd like to go to the bathroom. I told him to use his words.
Yes. I snarked. But I have had it with crazy junkies who fake strokes. I've also had it with attending physicians who, faced with a clear MRI, a gorgeously normal CTA and CT, and perfectly fine bloodwork (all collected before my little prince had his meltdown) decide to order vasculitis panels, autoimmune panels, and umpteen other tests to determine if there's a physical reason for The Cray.
Boo, this patient is acting out and acting up. He is so far off the chain that the chain itself is lost behind the horizon. He won't accept treatment no matter what we do, so let him go. Let him go home, sans hydromorphone, and do his thing.
And for God's sake, don't bring him back. In a town this size, there are certainly some acceptable medical facilities that are not ours.
Where I walked in to find a patient, destined to be my project for the day, sitting on the floor of his room, screaming. And kicking and tantruming. Like a three-year-old. Refusing to get off the floor. Floods of tears. Demands that we call varied and sundry people.
I've got such a hangover from that day that I still can't form complete sentences.
Here's all you need to know: functional exam, drug-seeking, requesting Dilaudid (of course). Fourteen chart notes by the end of the shift just on my part. Approximately twelve hundred words from the various therapies. Screaming. Crying. More screaming. More demands for Dilaudid. Refusal of blood tests, vital signs, drugs, and therapies.
Drama.
I have had bad days before. Never ever have I had a day that made me question why on earth I became a nurse. (Not that I'm seriously questioning it now, but at about 1700 on that fateful afternoon? Definitely.) If somebody had made a cartoon of my leaving work, there would've been little puffs of smoke coming off the ground under my sneakers.
At one point the patient told the docs that we had left him on the floor for an hour as he screamed for help. (Note here that he did not fall; he simply sat down and refused to move.) The attending shot me a look, to which I responded with my best BlankStupidFace.
I just. . . .I just. . . .don't get that shit. And I don't play into it, either. Late in the day, the patient refused to answer the simple, yes/no question of whether he'd like to go to the bathroom. I told him to use his words.
Yes. I snarked. But I have had it with crazy junkies who fake strokes. I've also had it with attending physicians who, faced with a clear MRI, a gorgeously normal CTA and CT, and perfectly fine bloodwork (all collected before my little prince had his meltdown) decide to order vasculitis panels, autoimmune panels, and umpteen other tests to determine if there's a physical reason for The Cray.
Boo, this patient is acting out and acting up. He is so far off the chain that the chain itself is lost behind the horizon. He won't accept treatment no matter what we do, so let him go. Let him go home, sans hydromorphone, and do his thing.
And for God's sake, don't bring him back. In a town this size, there are certainly some acceptable medical facilities that are not ours.
Rabu, 30 Oktober 2013
Let's talk about cancer.
Three years ago at this time I was lying on the couch, watching St. Elmo's Fire with Friend Pens The Lotion Slut, feeling rather giddy from a combination of red wine and Vicodin. I had just had the majority of my hard palate and all of my soft palate removed due to a case of oral cancer. If you want to read the whole story, go back to September of 2010 in the archives.
(St. Elmo's Fire is a good movie filled with terrible people. Skip it; that way, you won't have to wish for that two hours of your Vicodin- and red-wine-soaked life back.)
Let's talk about oral cancers. There are a lot of them, some of them frightening, some of them less so. All of them are on, as they say, the rise, due to a number of factors. Here are some interesting things about OC that you may not know:
1. A large number of oral cancers are due to the human papilloma virus. In different forms, HPV can cause warts on your fingers, genital warts, cervical dysplasia and cancer, or lumps in your mouth, or oral cancer. There are innumerable strains of HPV. Most of them are harmless. Some are really a bitch to get and to treat.
2. Oral cancer, which used to be the province of men over the age of 60, is increasing in young women. Part of this has to do with the near-ubiquity of HPV in the population. A lot of it has to do with the fact that young women now smoke more and drink more than young men. Alcohol or smoking predisposes you to oral cancer; doing both at once is a great way to lose chunks of your tongue or jaw.
3. Oral cancer is underdiagnosed in young people. Part of this has to do with the fact that the thinking on OC hasn't caught up with the reality. Part of it has to do with how often young people visit the dentist. I go to the dentist twice a year; my OC was found by The Fantastic Hygienist at my dentist's office. It had grown from nothing to a two-centimeter lump that I had not noticed in half a year.
4. Oral cancer has a huge impact on your life, no matter how minor it is. I got lucky: all I have to do for the rest of my life is wear a metal-and-plastic prosthetic that protects my airway and allows me to speak, and get yearly checkups (complete with MRI and CT scans and all the associated radiation) to make sure that I still have no evidence of disease. Some people, like my pal Mary, have lost much, much more than that to this disease, and the consequences are ongoing.
5. Oral cancer can hit you even if you don't smoke, or drink, or have sex. Mary, for instance, had a stage III squamous cell carcinoma of the tongue that was HPV negative. She is a lifelong nonsmoker and nondrinker. OC doesn't play favorites.
6. Which leads me to THE MOST IMPORTANT POINT OF ALL: If you see or feel a weird bump in your mouth, get it checked out. If you've got a gut feeling about it, don't stop asking for answers until you know what's really going on. OC is still one of those things that docs don't expect to see in people my age (forties) without other risk factors. I was incredibly lucky in that I had a dentist who was paranoid as fuck about the thing on my palate. Other people have not been so fortunate; as a result, they've had to undergo things like feeding tube placements and the loss of all of their teeth.
My cancer, polymorphous adenocarcinoma, doesn't have known risk factors. The article in Wikipedia on it is still only a stub. It's rare, it's non-invasive (usually), and can normally be treated with what's called "wide excision," also known as "taking out most of your mouth and changing your life forever." The type of cancer I had was indolent, meaning that it didn't spread or grow very quickly. It could happen to anybody. It happened to me.
So, on this third, give or take, anniversary, I have this one request: think about oral cancer. Go to the fucking dentist. It doesn't matter if you haven't been in fifteen years; they get off on that stuff. Get your mouth checked out. Avoid what I went through.
(St. Elmo's Fire is a good movie filled with terrible people. Skip it; that way, you won't have to wish for that two hours of your Vicodin- and red-wine-soaked life back.)
Let's talk about oral cancers. There are a lot of them, some of them frightening, some of them less so. All of them are on, as they say, the rise, due to a number of factors. Here are some interesting things about OC that you may not know:
1. A large number of oral cancers are due to the human papilloma virus. In different forms, HPV can cause warts on your fingers, genital warts, cervical dysplasia and cancer, or lumps in your mouth, or oral cancer. There are innumerable strains of HPV. Most of them are harmless. Some are really a bitch to get and to treat.
2. Oral cancer, which used to be the province of men over the age of 60, is increasing in young women. Part of this has to do with the near-ubiquity of HPV in the population. A lot of it has to do with the fact that young women now smoke more and drink more than young men. Alcohol or smoking predisposes you to oral cancer; doing both at once is a great way to lose chunks of your tongue or jaw.
3. Oral cancer is underdiagnosed in young people. Part of this has to do with the fact that the thinking on OC hasn't caught up with the reality. Part of it has to do with how often young people visit the dentist. I go to the dentist twice a year; my OC was found by The Fantastic Hygienist at my dentist's office. It had grown from nothing to a two-centimeter lump that I had not noticed in half a year.
4. Oral cancer has a huge impact on your life, no matter how minor it is. I got lucky: all I have to do for the rest of my life is wear a metal-and-plastic prosthetic that protects my airway and allows me to speak, and get yearly checkups (complete with MRI and CT scans and all the associated radiation) to make sure that I still have no evidence of disease. Some people, like my pal Mary, have lost much, much more than that to this disease, and the consequences are ongoing.
5. Oral cancer can hit you even if you don't smoke, or drink, or have sex. Mary, for instance, had a stage III squamous cell carcinoma of the tongue that was HPV negative. She is a lifelong nonsmoker and nondrinker. OC doesn't play favorites.
6. Which leads me to THE MOST IMPORTANT POINT OF ALL: If you see or feel a weird bump in your mouth, get it checked out. If you've got a gut feeling about it, don't stop asking for answers until you know what's really going on. OC is still one of those things that docs don't expect to see in people my age (forties) without other risk factors. I was incredibly lucky in that I had a dentist who was paranoid as fuck about the thing on my palate. Other people have not been so fortunate; as a result, they've had to undergo things like feeding tube placements and the loss of all of their teeth.
My cancer, polymorphous adenocarcinoma, doesn't have known risk factors. The article in Wikipedia on it is still only a stub. It's rare, it's non-invasive (usually), and can normally be treated with what's called "wide excision," also known as "taking out most of your mouth and changing your life forever." The type of cancer I had was indolent, meaning that it didn't spread or grow very quickly. It could happen to anybody. It happened to me.
So, on this third, give or take, anniversary, I have this one request: think about oral cancer. Go to the fucking dentist. It doesn't matter if you haven't been in fifteen years; they get off on that stuff. Get your mouth checked out. Avoid what I went through.
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