I’m sure most of us were riveted to our TV’s, radios, and computers on April 19th when the citizens of Boston and surrounding areas were advised to stay home and lock their doors.  Mass transit and normally busy intersections were empty.  Schools were not in session.  Businesses were closed.

Working with hospice and needing to send out nurses on a regular basis to help patients who are dying at home, I naturally wondered how Boston area hospices coped with having to stay away from their patients.

Our hospice patients call us for many different reasons; even if they don’t call us, some require daily visits.  Some need to have pump cassettes changed, dressings changed, or symptoms re-assessed and managed every day.  I’m sure Boston has had its fair share of weather-related issues, but those typically come with at least a day or so warning and arrangements can be made.  The shutdown that happened in April came with no warning whatsoever.

I was able to track down only a couple of Boston hospice nurses to chat with – they both said that their patients fortunately did not to require anything emergent that day.  I know that almost every time I work, I take calls from people who need a visit from a nurse to help manage symptoms that have suddenly gotten out of control (shortness of breath, pain) or who have died and need to be pronounced.  Catheters become dislodged, oxygen concentrators malfunction.  I guess under the circumstances, non-urgent concerns were put off until the lockdown was over.

I know I was very surprised when I started working in hospice to learn that things that are an inconvenience to us (the President visiting the area or major protests, both of which can shut down major roads and highways for a period of time) can be a huge deal to patients who are at home.  Hospice nurses have to figure out alternate routes (which can take much longer) or simply not visit at all in these cases.  And it doesn’t only apply to hospice – home health patients can also require daily dressing changes, IV medications, and have equipment malfunction (wound vacs, anyone??).

I will leave you with a story that one of the nurses related to me.  She was off from work that day, but wanted to share what her day was like.  If there are any hospice or home care nurses that want to share stories of trying to help patients during natural disasters (or not-so-natural disasters), please email me at codeblogrn at gmail.  Or use the “submit your story” link at the top.

Sarah Creed, RN writes:

I think that the day was so quiet because we were all glued to our televisions.  I can’t recall another time where I have been more paralyzed by fear than last Friday.  I live 2.5 miles from the house in Watertown where suspect #2 was found.  Here is the story of my day:

I woke up to a text message from my boyfriend (who lives 2 miles from the “boat” and 1 mile from where the news was reporting from) asking if I was okay.  After the rest of the week, I wasn’t sure what he was talking about, so I texted back saying yes, and of course went immediately to check CNN.   I read that there had been a shoot-out in Cambridge and Watertown and that the suspect was on the loose.  I called the DON of my hospice, as I am the nursing manager, and though I was supposed to be off, I wanted to help her call nurses.  But at 7:30 in the morning she had already done that, and all was well.  So I sat and watched.  I was supposed to be packing, as my boyfriend and I are moving on Saturday.  But I could not move.  I sat and watched as the SWAT team entered homes so close to where I live.  And then, the most terrifying thing happened – they stopped showing live news feed of the SWAT team entering homes.

We couldn’t drive anywhere, and even more than that we couldn’t walk anywhere, so my boyfriend and I were stuck apart.  All I could hear was the wailing sirens of emergency vehicles.  And then the whirl of a helicopter.  Lots of helicopters.  I looked out my window, and there were black hawk helicopters all around my building.  And they were no longer showing live news feed, so I had no idea where they thought the suspect was.  I was so afraid, because what if he was on my block?  I know my building is safe.  There are 2 locked doors to get into the lobby, and a lock and a deadbolt on my door.  But still, it seemed these men were capable of just about anything.  The day just continued like that.

We finally got the go ahead for people who had gotten out to work to come back home, so my boyfriend’s roommate picked me up on his way home, so that we could all be together.  We just sat and watched the TV, waiting, with a very high sense of anxiety.  The place was like a ghost town.  My mom, who lives an hour north of the city said that no one was out by her either.  I think that people just couldn’t walk away from the television.  We wanted answers.  One of my friends was friends with the MIT officer who was shot by the terrorists.  Another one of my friends is friends with Jeff Bauman, who is now infamous as the man in the wheelchair being pushed by the man with the cowboy hat.  He lost both of his legs.  These are people that my people know and love.  We wanted answers.

Then we hear that they didn’t find him, and that we can go outside.  So we go and sit on the porch.  And suddenly there are so many sirens, more than I had heard all day.  My boyfriend tried to re-assure me that there had been a lot of sirens all day long,  but I insisted that there were more.  And then it came across my phone that there were shots being fired in Watertown.  We were back to being glued to the TV.  We found a link to the police scanner so we were able to hear what was actually happening.  And then he was captured.

After awhile, we mustered up the courage to go outside and to the bar across the way.  And the coolest thing, there were people cheering on the law enforcement personnel that were coming back to the station.  Everyone at the bar was in a celebratory mood, and playing “American” songs on the jukebox.  We survived.  But, I have to tell you, it is still pretty traumatizing.  One of my coworkers is having a pretty tough time – she was visited by the SWAT team that day and heard the shots.  Forum, on Boylston St, where the second bomb went off, is one of our favorite restaurants.  We are looking forward to going back there when it re-opens, but of course the innocence is gone.  We had just been out on Boylston street on Saturday night before the bombing.  We had been shopping in Watertown on Sunday.  We feel violated. This is too close to our homes.  But, we are strong, and we will move on and get through this.  I can’t believe that the Boston One Fund has already raised over $28 million.  We are so proud of that.

I know this is long – but this my story.  It doesn’t pertain to hospice care.  But this is how I know my hospice patients spent the day – glued in front of the TV, and very afraid.

So, I’m considering a career change.  It’s probably far off, as my little baby is only 1 year old and won’t be starting school for awhile, but I wanted to start preparing as much as I could.  I am interested in hospice, either in-hospital or in a home setting.

Are there any hospice nurses out there that read this blog?  If so, please contact me – codeblogrn@gmail.com

Thanks!

For Nurses’s Week, Timeberland PRO Renova offered to send me a pair of shoes to try out.

I chose these, the Professional Slip-On.  I usually wear athletic shoes for work and those have served me well for over a decade.  I did try backless shoes once, but I kept shuffling my feet in them for some reason.

I’ve worn the Timberlands for a few shifts now, and I have to say that I like them.  They kept my feet cool.  Honestly, my main criteria for good work shoes is how my back feels at the end of the shift.  I get suspicious that my shoes are wearing out/aren’t good when my back starts to ache at the end of a shift.  Timberland claims to have some fancy “anti-fatigue technology.”

Whatever technology these shoes possess, I have to say that my back and feet felt great.  For a die-hard tennis shoe gal, I found these to be very comfortable.  I also found that going up a half size from my tennis shoes worked well, so keep that in mind if you want to try these!  I’d definitely recommend them.  There are a variety of styles, colors, and patterns.

Some interesting tidbits from the “Always on My Toes” survey:
*    Always on their toes – literally!: 54% claim the longest shift they have ever worked has been over 16 hours, which is double what a typical person works in a day.
*    Caught Stepping Out: 35% have worn their nursing shoes outside of work because they are so comfortable and a whopping 92% also noted style was important when it comes to their nursing shoes.

Disclaimer:  I was given a free pair of shoes to test out, but this review is my own. I really just have nothing bad to say about them!

We have to crush pills sometimes.  Either the patient (through aversion or physical limitation from stroke) can’t swallow whole pills so we crush them and put them in applesauce, or the patient gets their pills through a tube, so we crush them and dissolve them in water.

When I started nursing, we had a mortar and pestle. (Yes, it’s an affiliate link.  They all are.)

Anyway, this is what we used to crush pills.  (Pro tip:  the mortar is the bowl, the pestle is the bat-shaped object)  I always found it very satisfying to fill the mortar with pills and grind them up with the pestle. Of course, we had to then clean both very well afterwards to avoid cross contamination of pills, but overall it was a good system and worked well.  It felt good to crush up the pills and also offered a gratifying CRUNCH sound. Bonus:  Whenever the mortar would inexplicably get separated from the pestle, you could still crush pills!  You’d just take the pill (still in its package), put it on the counter and bang the hell out of it.  A professionally and socially acceptable way to vent your frustrations :)

Cost?  About $10.

Then came along the plastic pill crusher:

This is a very simple contraption.  You put the pills in, then you affix the top and turn … it’s like a giant screw.  Every once in awhile I’d get the pills in there just right, and would be rewarded with a very lovely CRACK.  Unfortunately, it wasn’t extremely efficient – I’d usually have to unscrew it, jiggle the pills and redo it a few times in order to get them ground up enough to dissolve in water.  Cost?  About $5.

For whatever reason, TPTB decided to do away with the mortar and pestle and pill crusher.  Our then-manager decided to get us something called the Silent Knight. Maybe the cross contamination became an issue, I don’t know.  But with this device, you would put the pills in a plastic pouch and crush them.  You’d then dump the crushed-up pills out of the pouch into a med cup, mix with water, and viola!  The only clean-up involved was throwing the pouch away.

This device was pretty handy, I guess.  No pleasing cracks or crunches, unfortunately, either tactile or aural.  Cost: about $90, and from what I’ve seen, pouches are about 5 cents apiece!!  Doesn’t seem like much, but it adds up, and keep in mind that the pouches end up being one more thing taking up space in the trash.  Boooo!

Recently, a new contraption showed up in our med rooms – the First Crush (oh wow, not sold on Amazon!)

Now we’ve gone completely automatic!  You put the pills into one cup, put the second cup on top (so that they nest, not form a dome) and put it in the machine.  Then you choose the desired level of crushedness (“standard” or “extra grind”) and press a button.  It then whirs into action!  Whereas the Silent Knight is, well, silent, this machine isn’t very quiet at all – you get all kinds of cracks and crunches and machine-like sounds.

It’s very efficient, but also a bit wasteful as well.  You can add water to the bottom cup containing the pill powder and use that instead of the medicine cup, but you just throw away the top cup, which is wasteful.  The bottoms of the cups are “wavy” and the pill powder often gets stuck in the waves and it takes awhile to stir it all up.  The cups cost about 5 cents apiece, and you need to use 2!  If it were just one, it would be okay since you would have had to use a med cup anyway.  Cost: About $200-300 plus the cost of cups.

So we’ve gone from the mortar and pestle, which is cheap, immensely satisfying to use and creates no extra waste, to this electric machine that’s a whole lot bigger, a whole lot more expensive, and creates a whole lot more waste.

WTF?  If they’d kept the mortar and pestle in the med room, I’d just continue to use it, but they got rid of it!

I wrote an article for Kevin, MD and he was gracious enough to post it.  Thanks Kevin!

Let’s start with the links.

I am a big fan of Atul Gawande.  His latest article in the New Yorker, Letting Go, had me riveted.  If you are familiar with my blog, you know that I am a big proponent of knowing when to say when where advanced medical treatments are concerned.

There were many passages that resonated with me, but this one did so the most:

The difference between standard medical care and hospice is not the difference between treating and doing nothing, she explained. The difference was in your priorities. In ordinary medicine, the goal is to extend life. We’ll sacrifice the quality of your existence now—by performing surgery, providing chemotherapy, putting you in intensive care—for the chance of gaining time later. Hospice deploys nurses, doctors, and social workers to help people with a fatal illness have the fullest possible lives right now. That means focussing on objectives like freedom from pain and discomfort, or maintaining mental awareness for as long as possible, or getting out with family once in a while. Hospice and palliative-care specialists aren’t much concerned about whether that makes people’s lives longer or shorter.

Yes.  That exactly.

Next, I wanted to share a YouTube video that I saw at Head Nurse.   It’s called Orthopedia vs. Anesthesia and it touches on the single-mindedness some specialists have.   I laugh out loud every time I watch it.  As Jo says, it’s well worth the 3 minutes and 22 seconds that it will take to watch it.  Go!

If you haven’t read the Letter from Afghanistan on GruntDoc’s blog, you need to go do that.  Also well worth the few minutes it will take you to read it.

Lastly, there’s a new girl in my life.  She was born on July 22nd in the wee hours of the morning.  I went through the labor and delivery completely med and epidural-free.  Since there are apparently no medals handed out at the end of such an accomplishment, all one really gets are bragging rights, which I am going to take full advantage of right here.  :)

I am the luckiest mama in the world :)

My son accidentally ingested peanut butter yesterday.  He’s allergic.

He’s done this once before, which is when we found out about the allergy.  He had some really awful hives 3 hours after he ate that small bite of peanut butter sandwich but that was all.  His allergist told me that it would most likely never get worse than that.

He managed to eat some more yesterday.  I braced myself for the hives to come, and we dosed him with Benadryl.  An hour later he vomited.  The pediatrician’s advice nurse advised me to take him to the ER.  At the time I thought it was overkill.  He wasn’t having any breathing difficulties beyond the cough he already had (he has a cold).  He definitely wasn’t acting quite right, though, so off we went.

I barely made it down the street before he started having very long coughing fits.  He was breathing okay in between, but he just kept coughing so much.  He couldn’t go more than 10 seconds without coughing.  About a mile from the hospital (this is probably 1 1/2 hours after ingestion) he started putting his fingers in his mouth but wouldn’t tell me why.  Itchy tongue?

It was the longest ride of my life.  Traffic, red lights.  Imagine being the 13th car at a red light when you have an emergency!  Of course there was no parking when I got to our nearest ER.  I hastily parked in a “reserved” space (sorry, director of geriatric services) and ran in.  Although the waiting room appeared to be full, there was no line at registration.  When I put him on the counter, I noticed that his lips were bluish.  I told the lady at registration and he was in triage within about 30 seconds.

I was a little hesitant to come to this hospital.  About a year ago I had a panic attack, which I had never had before.   I had been hyperventilating for a couple of hours (due to a reason not related to the panic attack) and then it occurred to my CCU trained brain that hyperventilating for a few hours might be Very Bad for my serum pH level.  This made everything exponentially worse and I was immediately convinced that I was going to die.  Convinced. It didn’t occur to me that debating whether my pH was above or below 7.1 might be indicative of the fact that I was most likely just fine.  I think if one’s pH is really 7.1 they aren’t debating much at all!

So we went to the nearest ER late at night.  I was doubtful that I’d make it there alive, visions of ABG’s being drawn and intubations happening… I was really scared and really quite irrational.  But my CCU brain was still there, feeding into it all, convincing me of all the bad things that could happen.

When I got to triage, they could not have been less impressed with me.  A ho and a hum and a normal pulse ox later, I was thrown to the waiting room.  I’ll admit that the normal oxygen level calmed me a bit but I was still hyperventilating for some reason and could not stop.  Already long story short:  Panic attack caused by hyperventilating caused by a probable reaction between two commonly prescribed drugs that I’d taken earlier for The Worst Headache Ever.  Whatever it was wore off, I calmed down, we went home.

So I wasn’t sure, running into that same ER with my son, how responsive they’d be.  I had nothing to worry about.  The triage nurse exuded a level of calm that blanketed over everything.  It wasn’t an unconcerned or disinterested calm.  It was a “I’ve seen this before and know exactly what to do” calm. She handled my son (and me!) perfectly.  She wanted to put the pulse ox probe on his finger and told him that Elmo had been there the day before and had had the same sticker put on.  My son doesn’t know very many cartoon characters, but he knows Elmo very well.  If she’d said Dora or Mickey Mouse or Barney, he wouldn’t have had a clue what she was talking about.  But because Elmo had had it the day before, he finally reluctantly let me put his finger out.

His pulse ox was 90, which is not very good.  Normal is about 95-100 on room air for a reasonably healthy person.  I told them it was an allergic reaction to peanuts and they got us back to a room so fast our heads spun.  When his oxygen level dropped to 85, once again my CCU trained brain had visions of Horrible Things happening, but it never came to that.  After some oxygen, Benadryl and IV steroids, he was back to almost normal.  The hives did show up 3 hours after ingestion on the dot, and they were uncomfortable but not as severe due to the meds he’d received.

So being a highly trained RN is a bit of a double-edged sword when healthcare becomes personal.  On one hand I never needed to ask for clarification about what anyone was saying, and I had no trouble understanding the conversation between the doctor and nurse.  I knew the reason for and possible side effects of every medication they talked about giving him.  I knew what all the equipment was for and what the normal numbers were supposed to be.

On the other hand, I knew exactly what they were talking about, I knew what everything was for and what normal numbers were supposed to be.  When I realized they weren’t normal, I was pretty freaked out.

I intuitively knew why we had to put an IV in, but couldn’t help thinking about possible infection of the site and infiltration.  I wasn’t worried about giving the Benadryl as he’s had that several times in his life for various reasons, but the Solumedrol he needed?  That’s a drug I’ve probably given a thousand times, and never have I seen a reaction from it.  But this was my son, and how was it going to affect him?  Did they know how to calcuate the dosage based on his weight?  Would there be a miscalculation while drawing it up?

Everything turned out fine.  Everyone was professional and competent and knew just how to deal with a sick kid and his anxious mother.  Kiddo is completely back to normal today and is no worse for the wear from the whole experience.

But now my complacency about peanut butter is gone.  The hives were certainly awful but not life threatening, so I hadn’t really been overly concerned.  I’ve been careful, of course, as have those who watch him, but 3 year olds are 3 year olds and they are amazingly fast.  Now that I know it can affect his airway, I’m even more concerned about the times that he won’t be in my direct control, especially when he starts to go to school.  I feel like I’m going to need to tattoo it on his forehead.  I think the public in general (and schools in particular) are more aware of allergies, which is a tiny bit comforting.

He’s also allergic to eggs, which I used to think was the bigger pain in the butt.  There’s a lot more that he can’t eat due to eggs than peanut butter, but his reaction to eggs is very minor comparatively.  I used to even think that if I had a choice, I’d rather he not be allergic to eggs.

I’ve changed my mind.

So unbelievably true.  This is really how we see you, and this blogger put it perfectly.

(thanks to GruntDoc for the link)

Benefiting the Childhood Brain Tumor Foundation.

The author at Suture for a Living doesn’t only suture up people, she also sews quilts!  And she made a lovely lobster quilt to auction off to benefit this foundation.

All the details can be found here.