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A Rambling and Some News and Some Other News

I took care of an elderly man recently.  He’d been dealing with multiple medical problems for almost 30 years.  Despite being in some very significant pain, he still made eye contact, still said “please” and “thank you.”

He wasn’t faking the pain.  He was very stoic, but I could tell he was hurting.  That tight-lipped grimace, the tachycardia, not moving a muscle unless it was absolutely necessary.  Still, manners prevailed.

My colleagues and I went above and beyond for him and his family.  There’s just something about being polite to others that makes those others want to help you and help you and help you some more.

I’m not saying that we don’t want to help those that aren’t overly polite.  It was just nice to be treated, well, so nicely.  I wouldn’t expect everyone in severe pain to maintain such decorum.  Every once in awhile you just click with a patient and it makes being a nurse so enjoyable.

So!  News #1.  Another of my posts has made it into a book.  It’s called “Lives in the Balance” and was edited by Tilda Shalof, who has written quite a number of books about ICU nursing.  I have read some of those books, so when she personally asked for one of my posts to be included I was quite flattered!

I’ve read the whole book, which is full of very compelling stories written by nurses who work in ICU.  I highly recommend giving it a read, and not just because one of my little posts made it in!

News #2 will only be news if you don’t follow me on Twitter or Facebook.  I am just over 10 weeks pregnant!  We are over the moon about this and can’t wait to meet him or her in late July.

And I guess the bonus news is that this blog is 7 years old this month :-)

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Change of Shift & The Doctor Anonymous Show

First of all, hightail it over to Reality Rounds for the latest edition of Change of Shift!  She did a splendid job of making it very spooky by renaming our blogs.  (I am Corpseblog!)

And tune in tonight at 6pm PST to the Dr. Anonymous show, where he will be interviewing me.  Talk about scary :-)  I am excited to finally be asked (I’ve waited years!) but also nervous because I am not exactly well-practiced in live interviews!

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Grand Rounds Volume 6, Number 6

Welcome to Grand Rounds!  This is volume 6, number 6…. and the 6th time I am hosting… during the week of Halloween.  Does anyone else find that creepy coincidentally satanic fascinating?!

(Incidentally, if you are reading this through RSS, I am aware that the formatting is less than optimal.  Very sorry about that and we are trying to fix it!)

For this edition, I thought we could go out Trick or Treating on Medblogger Lane.  I’m sure we will find some colorful stories along the way…

The first house we come to seems amiable enough.  The porch light is on and when the door is answered, some good old fashioned chocolate is put into my Trick or Treat bag!  Even though she is diabetic, apparently Amy at Diabetes Mine prefers to give out the real stuff instead of the sugar-free kind.  The reason may surprise you.

The next house also has the porch light on, but no one answers the door when I ring the bell.  Finally I notice a note that says I should just take some candy from the bowl.  Not Nurse Ratched is horribly sick with H1N1 and doesn’t want to spread any germs.  Read her first-hand account of what it’s like to be knocked out by this flu.

Dr. Bates from Suture for a Living is at the next house.  She has some great candy but it was kind of a pain to get.  She said that the candy was password-protected and that I had to prove that I had a professional responsibility to eat the candy, and would not eat it out of mere curiosity.  Take a gander at what happens when HIPAA is peering over your shoulder when you go looking around where you shouldn’t.

If I thought that was hard, I was not prepared at all for what I’d have to do to get the sweets from Barbara at Florence dot com.  First, I had to document that we did a time-out so that the correct candy would be given.  After that I had to document that the candy was received.  She actually made me eat some in her presence so I could document that the candy had no adverse effects on me.  Then she had me stick around to report off to the next trick-or-treater about everything that had just transpired.  You might be tempted to skip this house, but you can’t.  She shares her perspective about a recent study that claims nurses spend 35% of their time documenting documenting documenting.

The next house was just crazy.  When I arrived, they would only open the gate to let me in if I was wearing a face mask.  Laika from MedLibLog wasn’t taking any chances after watching this very descriptive video that shows how the flu virus is transmitted and starts taking over the cells in your body.  When I finally got past the gate, Dr. Val from Better Health informed me that she would love to give me some candy, but unfortunately the Big Candy Store down the block ordered it all up and now there wasn’t any left.  So I wouldn’t feel as though I wasted a trip (and a mask!), Dr. Anonymous sat me down and told me all about the candy H1N1 flu, including busting some myths about the vaccine and informing me of when it might be available.

On my way to the next place, I passed someone dressed up as a shark.  That reminded me of Dr. Auerbach’s post at Healthline.com about shark attacks – why they attack and steps we can take to avoid being attacked.  I was especially amused at reading this: “…it is important to note that any shark, including the seemingly docile nurse shark, will bite a human if sufficiently provoked.”  I’m sure there are a few doctors out there who learned that the hard way.

I finally arrived at the Medblogger Lane Haunted House.  It was with much trepidation that I walked through the front door…

…and had to stifle a scream as I entered the room!  A mad scientist was performing various experiments on poor unsuspecting subjects.  You would think that a little playful squirt of lime would result in no harm, but Dr. Charles explains how it could end up badly.  The adjacent hallway was dark and a little spongy.  It seemed strangely reminiscent of a certain screening exam.  The Clinical Cases & Images Blog gives us the quick and easy Cliff Notes version of colorectal screening guidelines.  Allergy Notes describes the scary effects of sulfite hypersensitivity.  In another room Sharp Brains had specimens in jars and was performing tests to find out if caffeine had a sustained lifetime benefit or harm.

The last room had people who have had very scary things happen to them.  Trauma Junkie described a typical day in the life for a patient with Cystic Fibrosis and shares his newfound wisdom about how sometimes the patient teaches the practitioner.  Chris at Life in the Fast Lane relates a story with a very important lesson: sometimes we need to dig a little deeper and ask a few more questions before the medical mystery can be solved.  And Robin at Survive the Journey describes what it’s like to parent a child who has Cushing’s Disease, from diagnosis and management to terrifying flare-ups and hospitalizations.

After all that, I was ready to get back to some more trick or treating!  The next house I came upon was giving out gift certificates to iTunes!  I thought that was perfect because I could use it to check out some of the Anatomy software apps on Dr. Penna’s list.  As I was leaving, I overheard a conversation about a laptop being stolen from Blue Cross Blue Shield and the potential damage that could result.  Dr. Joseph Kim from Non-Clinical Jobs lets us know what to do in case we find ourselves in this predicament.

I finally arrived at a huge scary house… you know, the kind that is decked to the nines in Halloween decorations… the one that makes your heart go just a little faster as you’re walking up to the porch.  I rang the bell, said “Trick or Treat!” and waited.  And waited some more.  Surely a house as big and fancy as this would have great candy, right?!  Finally a piece of paper was slipped under the door.  It asked if I had any conditions that would be exacerbated by procuring and ingesting sweet edibles.  It further stipulated that I needed to meet a minimum threshold of candy before they would provide me with any more!  What was this?  Some kind of confectionery deductible?  I concluded that I had unwittingly arrived at the House of Insurance.

Instead of filling out the forms that had piled up outside, I decided to sneak in the back door to see if I could find out anything interesting, and boy did I ever…

Insure Blog was trying to figure out how Washington would handle 14 million new patients finding themselves on Medicaid if the Baucus health care bill is enacted.  Louise at the Colorado Health Insurance Insider was pondering the composition of hospital boards of directors – are they comprised of objective participants, or is there some significant conflict of interest going on?  And in the corner was a group led by Leslie at Getting Closer to Myself discussing the merits of marrying for love… or insurance coverage.

By this time it was getting late and I decided to head home.  I spotted a big bonfire along the way and decided to stop by to see what was going on.  Several people were gathered around the fire sharing experiences and information.  Jolie Bookspan at the Fitness Fixer described several ways to treat knee pain that do not involve scalpels. Jenni at ChronicBabe informed us about fibromyalgia and contributed a list of resources that provided education on how to live and even thrive with the disease.  Jeffrey at Nuts for Healthcare explained that fibromyalgia remains controversial in the medical community; however, while drug companies have been accused of fear-mongering to a desperate population for a handsome profit, recent neurological research has begun to unravel the biological manifestations of the disease in the hope to pinpoint a cause.

Novel Patient proudly described how she painstakingly stood up against her chronic illness and disappointing new diagnosis.  Rachel at talesofmy30′s divulged her secret for learning to love her body after enduring disordered eating patterns and a type 2 diabetes diagnosis.  Stacey at ACP Internist spoke about a possible reason as to why medical students are not going into primary care.  David Harlow at HealthBlawg gave a detailed account of his experience at the Connected Health Symposium 2009 conference held last week in Boston.  To finish the evening, Barbara at In Sickness and In Health shared with us a story she told her father while he was ill in the hospital.

That’s all for this edition of Grand Rounds.  Next week, Grand Rounds will be held at nonclinicaljobs.com.

Have a safe and happy Halloween everyone!

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Blog World Expo 2009

Last week I attended the Blog World Expo conference in Las Vegas.  This is the first year that medbloggers had a track all to ourselves!  The sessions I attended were interesting, and as part of the audience I was delighted to watch my fellow medbloggers on the panels.  There were lots of thoughtful questions & answers, and many silly antics (how many times DID Doctor Rob get onto the big live Twitter feed anyway?? blogworld blogworld blogworld!)

Unfortunately, due to a splitting headache, I was not able to attend the last session, but I had plenty of chances to meet and spend some time with medical bloggers that I have been reading for years.  It was truly great meeting each and every one of you and I’m looking forward to seeing everyone again!

Meeting Terri from Nurse Ratched’s Place was a real treat, as was meeting Kim at Emergiblog.  Kim posted quite a bit about the conference – you can read her post here, which contains LOTS of pictures!  Kim and I shared a lovely (albeit sugary!) lunch together AND managed also to do a joint interview, which can be seen here. (The MJ Propofol anecdote?  True story.)

Here are some other thoughts from the bloggers that attended, namely Doctor Rob (one of these days I will earn a golden llama for my blog.  It is a blog goal of mine), Dr. Wes, Dr. V, Kerri (congratulations!), Kevin MD, Doctor AnonymousNick MD, and Dr. Ramona Bates.  Ramona made a beautiful quilt that we all signed.  It was given away as a door prize to one very lucky person, who did not happen to be me.  I was really thrilled to meet one of my favorite bloggers who is also the medical blogger I’ve known for the longest time (7 years in December!) GruntDoc.

A big thanks goes to Dr. Val (also fantastic meeting her finally!) who helped arrange the whole darn thing, and Johnson & Johnson and Medpage Today, who sponsored us.

2010, anyone??  :)

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Grand Rounds

Grand Rounds is up at Sharp Brains today!

Next week, Grand Rounds will be held here at codeblog for the 6th time (Yes, GruntDoc, I counted!)  Use the submit your story/contact form at the top of the page, or email to codeblogrn gmail.  There is no theme, but it will be very close to Halloween, so if you want to submit something super-scary, I’m all for it!

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Choose Wisely

He knew she was angry with him.

“Whenever I come to see her, I reach out and take her hand, but she looks away.”

Husband and wife for well over 50 years, they had been through a lot.  They met in another country in another time, and to hear him tell it, it almost seemed fated that they’d end up together.  Since then, they’d moved many times, raised a family, supported each other through myriad illnesses.  They were growing old together.

Unfortunately, “growing old together” doesn’t always work out like we hope it will.  Diseases and illnesses ravage our bodies; dementia ravages our brains.  She’d long ago given up on their little garden in the backyard.  It was her favorite hobby, but she couldn’t manage it anymore.

She had dementia, and she weighed less than 100 pounds.  Though not a result of her dementia, she was unable to eat properly and had slowly grown smaller and smaller.

She had done all the right things.  She was a nurse and she knew how these things could go.  She had an advanced directive filled out; not only signed and dated, but specific treatments and procedures were addressed – feeding tubes, antibiotics, tests, organ donation, resuscitation – really almost everything you can think of.

Many people designate a DPOA – Durable Power of Attorney – along with filling out an Advanced Directive form.  When in a condition where making one’s own decisions is impossible, a DPOA is a person chosen by the patient (in advance of illnesses and while the patient is considered competent) to make decisions for them.  The hope (for us, as healthcare workers) is that the patient has had a long, frank discussion with their chosen DPOA as to what their wishes are.

In her case, although they may have had this talk, her wishes were also explained in great detail in a written document.  A document that we had a copy of in her chart.  A document that her family readily provided to us.

In the condition she was admitted in, she would need IV fluids, antibiotics, x-rays and tests.  She wasn’t completely unconscious, but she wasn’t very coherent either.  Add in her element of dementia, and it was clear that she wasn’t able to make decisions.

Her family waited quite awhile to bring her in.  They were managing her pneumonia at home until she started having trouble breathing.  That is when they brought her to us.

And this is where she and I met.  They only thing she would say to me is, “I want….” but would never finish the sentence.  She seemed to really want whatever it was and I hope I was able to provide it with everything I tried.

Her husband came in to see her, and this is when we had our conversation.  He told me that he knew she didn’t want any of this.  Definitely did not want a feeding tube, but that’s the direction we were going to have to go in in order to treat her.  He said that he knew she didn’t want it, but that he was her Power of Attorney, and it didn’t matter to him – he was going to ask us to give her one anyway.

It was obvious he was grieving and in denial.  There was no malice, only a very matter of fact manner.  And a deep underlying sadness.  It appeared to me that he was simply unable to carry out that which she had painstakingly directed.

He assumed that this was the reason for her anger; the reason that she wouldn’t look at him anymore.  She had trusted him not to put her through this.

I sometimes take care of patients that are clearly terminal.  They often don’t have their wishes written out in a detailed manner; many people don’t even understand what we as medical professionals are capable of doing to them to keep them alive.

My patient knew.

But she chose a person who was unable to follow her wishes when the time came to actually make the heart-wrenching decisions.  We assume it’s our spouse or closest family members who would be our best advocates, but sometimes that isn’t the best way to go.  Of course, then you are stuck choosing someone that will have to go against your family at a most critical and emotional time.  Do you know anyone strong enough to advocate for you?  To make sure your wishes concerning end of life care are honored?

I very gingerly tried to get him to tell me why he would go against her wishes, but he wasn’t able to give me a straight answer.  I could tell that he already missed her so much.  I hope she can forgive him.

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What Can Nursing Students Blog About?

When University of Louisville nursing student Nina Yoder blogged about her experience watching a patient give birth in a post entitled “How I Witnessed the Miracle of Life,” she may have thought she was just blowing off some steam. Well her school saw things very differently.

When school officials read Yoder’s post, which included a description of the baby as a “creep” and “a wrinkly, bluish creature, all Picasso-like and weird, ugly as hell, covered in god knows what, screeching and waving its tentacles in the air,” they moved to expel her from school by calling her into an office, searching her for weapons (apparently because Yoder had separately blogged about her support for the Second Amendment), and informing her she was no longer enrolled at the school.

That’s right. No hearing, no notice. Expelled from nursing school for blogging.

Not surprisingly, Yoder sued the nursing school in federal court for reinstatement–and won. U.S. District Court Judge Charles R. Simpson III ordered that Louisville reinstate Yoder because her blog didn’t violate the school’s honor code, confidentiality provisions, or principles of professionalism; the judge concluded that although the post was “crass and uncouth” and that Yoder’s attempts at humor were an “abject failure,” it wasn’t written in a professional capacity or from the view of a representative of the nursing school.

The school had argued that Yoder broke confidentiality principles and the school’s honor code by disclosing “the following identifying information about the birth mother: the number of her children; the date that she was in labor; her behaviors; the treatment that she underwent (an epidural); her reaction to labor (vomiting); and the reactions of her family.”

The court rejected that argument, though, finding that such information was non-identifying; types that would be considered identifying, according to the judge, include “the birth mother’s name, address, social security number, or the like….age, race, or ethnicity….‘financial’ or ‘employment related information’ [and] where she was in labor.”

Yoder maintains that her blog post (and others, such as those in which she mocks a suicide patient and calls alcohol abuse “a choice”) “is a mixture of fiction and satire, aimed to be an emotional relief from daily stress.”

Well Yoder won this round in court, but what do you think? What should students in RN programs be allowed to blog about? Did Yoder cross the line?

Guest post by Michelle Fabio, About.com Guide to Law School and frequent contributor at LegalZoom.com.

My particular take on this is that she crossed the line.  I’m not sure that she crossed it enough to be expelled without due process, though.  She was technically within the lines of HIPAA and thus did not break any laws.  But there are more appropriate ways of letting off steam.  Others will probably disagree with me, which is fine.  I personally found her comments very unprofessional.  -ed.

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Some Tips for a Safe Hospital Stay

I meant to link to this awhile ago but didn’t think about it again until today.  Get Better Health posted an article outlining some tips for patients describing ways to stay safe while in the hospital.

They are very good ideas, and I’d take the very last tip one step further.  When you are being discharged and your nurse is going over your discharge instructions, ask for a printout giving information about new medications you’ll be taking.   This should be available at most hospitals… and if it isn’t, it should be.  That way you’ll have a detailed reference you can look at later when you’re at home.

Here is the post. Enjoy!

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Jade is not just a gemstone

Just over a month ago, our unit had several H1N1 flu patients.  And they were sick.  Really really sick.  They were also fairly young – 30′s to 50′s.  I wondered at the time why the media hubbabaloo about the flu had died down when I was seeing more and more patients in my unit who had it.

Last time I worked there was only 1 flu patient and they weren’t too sick (yet?) to require a ventilator.  I was really glad to see the decrease in this particular patient population.  I won’t lie – it’s frightening to be a nurse caring for someone with a highly communicable disease.  Masks, gloves, gowns are all provided by the hospital, but I can’t ever shake the feeling that I’ve somehow come in contact with it despite these precautions.

And what of the times that we admit patients and don’t know they have a communicable disease?  At least one coworker I know of contracted H1N1 from taking care of a patient who had it before we knew they had it.

I’m sure she was quite shook up – every single patient who turned up positive for the flu in our unit in that time period ended up literally fighting for their lives on a ventilator.

The most harrowing patient we had was a woman in her 30′s who was pregnant.   Like the other patients, every time she coughed on the vent, her oxygen saturations would decrease to the 80′s and would take a long time to come back up.  Unlike the others, though, she was so fragile that sometimes merely coughing on the vent caused her to go into asystole.

I’m somewhat jaded about coding people at this stage in my career.  I remember, as a brand new ICU nurse, talking to a well-seasoned ICU nurse.  She said that hearing “code blue” being announced overhead didn’t give her any kind of adrenalin rush anymore.  At that time, I couldn’t imagine being in that frame of mind.  Being new, I was expected to go to every code blue that was called so as to get experience.  My heart started going into SVT at simply hearing the word “code.”  If the word “blue” came after I practically had to defib myself before running off to defibrillate the patient.

I eventually got to a place where I could fairly confidently go run a code without freaking out.  I’ve been an ICU RN for 11 years.  In those 11 years, there have been some awful codes.  Two stand out in my mind, and the absolute worst was on the pediatric floor.  When I heard “code blue, pediatrics” overhead, my first (naive) thought was, “little kids code???”  My second thought was to wonder if it was really an adult overflow patient.  Sometimes the gyne surgeries went to the pediatric floor if there was no more room on the surgical floors.  You know, maybe one of them got a little too much morphine and the nurse called a code.  A little Narcan, a few bagged breaths and everyone would sigh with relief and go on with their day.

No such luck.  After running full speed up 3 flights of stairs, I arrived at the room that had the most people spilling out of it only to find a bald, thin 5 year old in the bed.  I thought I was going to be sick.  PICU nurses – bless you all.  I could not do that for any length of time.

She didn’t make it.  Having been a nurse for a couple of years at that point, my naivety about the world already had a few chips and cracks in it.  But on that day a huge chunk fell out.

Since then I’ve come to be more like that seasoned ICU nurse that I spoke with so early in my career.  Along with the semi-jaded “oh crap, a code blue” comes a confidence in one’s abilities, so it’s not all bad.

However, watching that woman go into asystole, knowing that we would have to crash c-section her if she stayed in it?  That took me back to the days when I was new and inexperienced.  I’ve never seen anything like that happen.  Although I was perfectly comfortable with my (pre-arranged) personal role, the overall situation would be completely new to me.

Although HIPAA prevents me from saying much more, I will say that I did not have to experience that situation; not because I was off when it happened but simply because it never happened.

If it had, it surely would have made my top 3.

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Kim turns 4 today!

4 years ago today, Kim at Emergiblog wrote her first post.  Since that time she has become one of the most well-known nurse bloggers ever to have blogged.  She has remained quite dedicated to her blog, even during the writer’s block times – which is very hard to do.

Kim has done much to further the image of Actual Real Life Nursing through her blog, and for that I thank her.  Happy Birthday, Emergiblog!

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Author

  • profileI am Gina. I have been a nurse for 15 years, first in med/surg, then CVICU, inpatient dialysis, CCU and now hospice. This blog is about my experiences as a nurse, and the experiences of others in the healthcare system - patients, nurses, doctors, paramedics. We all have stories!

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