The Man-Nurse Diaries

Getting All Hormonal: Type 2 Diabetes

mannursediaries@gmail.com (man-nurse) — Fri, 06 Nov 2009 17:38:00 +0000

Call me crazy, but I really like endocrinology. Hormones are up there with neurons in the category of weird, esoteric, but cool body systems. I picked up on it in Anatomy II and I've been studying it here and there ever since. I even doodle hormone maps when I'm bored in class: hypothalamus → TRH → anterior pituitary → TSH → thyroid → T4 → T3 = boosted metabolic rate.

I have a lot of ideas and theories about hormones which are (hopefully) not that esoteric and pertain directly to a lot of people with certain health conditions. I want to record them before I forget 'em.

My first idea is about diabetes, and has a lot to do with the concepts of down-regulation and negative feedback. First, hormones are extremely potent, causing big effects despite being present in extremely low quantities in serum. Hence, in the presence of dangerously elevated hormone levels, cells will decrease the number of receptors to that hormone on their exterior surfaces, so they become less responsive to the hormone. That's down-regulation. And in the presence of high levels of circulating hormone, the body will tend to produce less of that hormone. That's negative feedback. These are both healthy, normal compensatory mechanisms.

I think diabetes is better understood in light of these two concepts. If humans eat only when they're hungry, their blood sugar levels rise and fall periodically throughout the day. Following that, insulin levels rise and fall. But continual overingestion of starches and sugars can lead to a constantly high glucose level—and therefore a constantly high insulin level. Now, insulin is a potent hormone. It pushes serum sugar into cells (and shifts potassium too, right?). You can inadvertantly kill someone with insulin. So people with diabetes undergo a usually healthy compensatory response by making less insulin and becoming more resistant to insulin. In other words, they've down-regulated (reduced the number of insulin receptors) and have undergone negative feedback (reduced their production of insulin). The cells don't care if blood sugar levels are high, as long as they protect themselves from the high levels of circulating insulin and glucose.

This is why diet and exercise are so effective at relieving diabetes if it is not too far progressed. I remember thinking all diabetics had to inject insulin three times a day; that's not true at all. Many diabetics have up-regulated their insulin receptors and decreased that negative feedback response by diet and exercise (albiet often with the help of oral antidiabetic meds which boost insulin production or decrease glucose production).

When diabetes becomes extreme, it will down-regulate receptors and reduce insulin production so much that even in the presence of extreme hyperglycemia (high blood sugar), the body will enter a starving response, metabolizing the body's own proteins and fatty acids just to stay alive, producing potentially lethal amounts of acidic by-products in the blood (diabetic ketoacidosis).

In the hospital, and in acute cases, we inject exogenous insulin to push all that sugar into the cells regardless of whether the cells want it. My question is, does this do anything bad to the cells? I assume the cells have down-regulated for a reason. If they had the capacity to bring a 400 or 600 glucose level down to 100 just by storing infinite amounts of glucose, they would already do it, and we wouldn't have to force it with insulin. So what does this do to the various cells of the body? Anything? I'm not saying, of course, that we should avoid giving insulin for acute high blood sugar or brittle (unresponsive) diabetes; we have clear evidence of the harm that would cause. But I'm curious if research will eventually show any evidence of intracellular damage: i.e. DNA alteration, malignancy, etc.

Insulin image by Isaac Yonemoto.

What's So Scary About Healthcare? Putting Strangers In Charge of Yours.

mannursediaries@gmail.com (man-nurse) — Mon, 26 Oct 2009 21:37:00 +0000

The upcoming Halloween-themed Change of Shift centers on what scares you in healthcare. I feel like half my blog is about what's scary in healthcare. It was suggested that I should submit my ER story about an infant getting repeatedly and unnecessarily stabbed for an IV access. But I thought I'd write a little more about what scares me about institutionalized healthcare in general.

What scares me about entering a healthcare institution for services (i.e. as a patient or a parent) is that you're no longer in charge of yourself. You have to place your trust in people and institutions you don't know. You're subject to hospital policies and procedures when you sign the consent for admission and treatment. You're the subject of decisions by your doctor, who you hopefully know, and by whoever's covering for them, who you may not. You're subject to the decisions of nurses and nurse's aides whose education, skills, biases, and thinking ability you don't get to review before they enter the room. You're subject to a host of clinical decisions that you will never even see happen: the house supervisor might understaff the floor; the tired imaging tech who wants to go home might push your study off till tomorrow; the weekend pulmonologist might decide you can wait till Monday to get off the ventilator, even though you're ready to wean; the janitorial staff might've not sufficiently cleaned the C. difficile out of your bed. It's not cool.

My main contact with healthcare as a patient has been with midwives and with our family doctor. In both cases we've been able to discuss thoroughly where we're coming from, what our concerns are, what our priorities are, what will happen when this or that case arises. In other words, we got to know each other. Especially with the midwives—the interviewing and education process is extensive, since (unlike, unfortunately, most obstetric offices) it's one-on-one, occurs in the comfort of your own home (i.e. not in a rapid clinical environment where they're too busy for too many questions) and lasts for eight or nine months. And as I explained here, all the midwifery care we received was extremely consent-oriented. This is a model of care I'd like to see implemented in the 'real world' of healthcare. But I don't know how it's ever going to happen.

As a soon-to-be practitioner, it scares me that this busy, impersonal world is where I'll be practicing. But with all this in mind, I hope I'll do well. I've seen firsthand that a good nurse can rapidly establish rapport with a patient and their family, get down to their needs, and fit that into his or her day. Nurses often have to ask what exactly it is we're doing for a patient; then explain this to the patient and their family; and then hear the possible issues or concerns that the patient or family has about this treatment. Nurses, possibly more than any other healthcare staff, are poised to bridge that gap between the impersonal clinical environment of the hospital or office and the kind of personal, experienced patient-clinician relationship that I experienced with midwives or our family doc. The kind that people really need.

Are You Getting the Swine Flu Vaccine?

mannursediaries@gmail.com (man-nurse) — Thu, 22 Oct 2009 22:36:00 +0000

I've been mulling over whether to get the swine flu vaccine. Some hospitals in this area are requiring it of their employees. Mine are simply offering it. They almost seem hesitant to encourage it. There's a lot of controversy around it—you've probably heard of the lawsuit in New York against making the vaccine mandatory for healthcare workers.

Around here, some of my coworkers are for it, some are ambivalent, and many are against it.

The arguments: It's been rushed into production, the disease is not that harsh most of the time, flu vaccines apparently cause the flu, and then there's that whole thing with the 1976 swine flu immunization causing Guillain-Barré syndrome, leading to people suffering paralysis, needing mechanical ventilation, and more people dying from the vaccine than from the flu.

The rebuttals: The 2009 H1N1 vaccine is made the same way all the other influenza vaccines have been made, just with a different virus. Influenza vaccines have a good track record of being safe. And the 2009 H1N1 swine flu virus is different from the 1976 swine flu virus.

My take: I think the dead virus is probably safe to receive. I might wait and see how the vaccination program rolls out, as far as reports of adverse reactions. I certainly wouldn't get the live-attenuated virus, especially since I have kids.

I would recommend evaluating the potential costs and benefits, such as: is swine flu significant in your area? Does your patient population put you at a high chance of running into H1N1? As for Guillain-Barré syndrome, I'm not extremely worried, but I'm waiting to hear any reports of any adverse events occurring among vaccinees, especially when big cohorts like an entire hospital vaccinate. China says 14 had adverse reactions out of 39,000 swine flu vaccine recipients, but aren't saying what they were. As far as I can Google, no one else is reporting anything.

But it does bother me that no one knows what it is in vaccines that apparently causes Guillain-Barré—or seizures, high fevers, fainting spells, or the other adverse reactions that unquestionably occur (i.e. apart from autism) after immunization. So I don't balk at anybody being cautious about them.

Image courtesy of the Public Health Image Library

Orthopnea: Sometimes the Patient Does Know Best

mannursediaries@gmail.com (man-nurse) — Wed, 21 Oct 2009 18:32:00 +0000

We had a "respiratory distress" transfer to the unit some days ago. The woman, significantly obese, is wheeled down in the a large armchair. In her clothes. That's committing at least two cardinal sins against ICU staff right there—the rules for unstable patients (i.e. if you can't breathe) are, no clothes, and in the bed! So the nurses, suitably, had a cow. The woman and her floor nurse tried to explain that she has such difficulty breathing that she sleeps in a chair, even at home. So I suggested leaving her in the chair. I mean, really, she looked fine except for not being able to breathe. I'm not being facetious. She was gasping like a fish, and only able to spit out 3-4 words at a time, but she could walk! Obviously she was a long-term COPDer or something, so she was compensating for this. But her blood CO2 was over 100 (which I didn't even know is compatible with life), so, not wanting to have to code or intubate her in a chair, we compromised by putting the bed into a chair position.

Within an hour we put her back in the chair.

Orthopnea is not a cool thing. When some obese people lay flat, their entire abdomen pushes up against their diaphragm, and they literally can't breathe. I've seen obese people start to black out because they're being forced or coerced or strongly encouraged to lay down. Do you want to code a 400 pound man? I don't.

I once heard a local story—this is purely hearsay, so don't subpoena me—about an obese man with a host of the usual end-stage problems (diabetes, heart attacks, dialysis, lives in a nursing home) who presented to the ER for whatever reason, and was allowed to sit in a chair so he could breathe...until the night shift nurse, who was new, made him lay on the cart, argued with him about it, and eventually got orders to put him in restraints to keep him in the cart...where he coded and died.

Is the moral of the story that we need more obesity/orthopnea education, or that if your patient says "I can't breathe" we should listen to them?

This is not a funny subject, but part of me almost wants to see the Charles-Dickens-derived term Pickwickian syndrome come back.

Biomedically Engineered Birthing Beds!

mannursediaries@gmail.com (man-nurse) — Mon, 19 Oct 2009 17:23:00 +0000

Darn it, I still like my modern birthing beds post from ages ago. It's a mind-boggling idea. People made these large expensive Transformer-like contraptions just to facilitate laying women flat on their back to push babies out? And to defacilitate any kind of human contact with the mother, except by the doctor? Next they'll invent vacuum pumps to just pull babies out without any human touch whatsoever, like we're milking cows at a dairy plant. Except they already kind of do.

You could put the AVE turbo birthing beds driven by maternity commandos up against a giant robotic KOKEN LM-064 Full Body Pregnancy Simulator (with storage case) in some kind of postapocalyptic American obstetric horror film.

This bumping of a thread, of sorts, was brought to you by the Livejournal user I ran across who made the icon above. Thanks!

EDIT:

Sweet. Nuff said. Courtesy of VBAC Lady's graphic designer friend.

Healthcare Reform, Maternity Reform, Nurse Reform

mannursediaries@gmail.com (man-nurse) — Thu, 15 Oct 2009 23:37:00 +0000

The new participatory medicine themed Grand Rounds is up. So let's address something right off the bat. Which population participates in, influences, and affects the practice of medicine the most, besides physicians? RNs! How many RNs were represented in the participatory medicine coverage? Only three! (Well, two—I'm not licensed!) There was my feeble attempt at a nurse's point of view—since we've been doing this for years. Nurses have to meddle with medicine more than anyone else without an MD license, and we have a vested interest in making more patients do this as well! So where was everybody?

Amy Romano, nurse-midwife and Science and Sensibility blogger, wrote how the push to change passive patients into engaged consumers can start by changing maternity care. She makes a few excellent points. Engaging one maternity health-consumer affects two or more people. Many women (and men, thank you very much) begin their path to active participation in their own medical care by investigating their birth options. That's how I started. These families tend to raise their children to be active, medically-literate critical thinkers, so the improvement can be exponential.

Unfortunately, a "doctor knows best" attitude prevails in most maternity care settings. Rather than honing their skills as effective, engaged consumers, women are learning to be passive recipients of standard protocol.

Not to mention the cost of obstetric care is astounding. Some of it is arguably unnecessary, so any increase in patient literacy and active participation will lead to savings, especially in public aid. Even a decrease in precautionary c-sections would make a huge impact.

And then there's Barbara Olsen's nearly confrontational challenge that failing to increase patient participation is tantamount to increasing medical errors:

In highly reliable systems, the intended outcome is delivered under both normal circumstances and when conditions destabilize...It's fair to say that the 100,000 or so unintended deaths due to medical errors and healthcare acquired infections that occur in the US each year disqualifies our industry from being a highly reliable one. So what does participatory healthcare mean for patient safety?

Tons, but here's one of the most obvious: When a patient is seen as a participant in, rather than the object of, care, the system becomes more stable. At its most basic, patient participation adds a valuable redundancy at high stakes junctures of care...patients are uniquely positioned to uncover a wide array of errors that have been set in motion.

This goes back to maternity care; heck, it addresses everything. Skeptical patients save lives. They save their own lives, their own health, or (in maternity care) the lives or health of their babies.

Personally, I think we RNs need to be larger voices for participatory medicine. We already have the concept of patient advocacy, but it needs to be expanded. Patient advocacy still lets us be the boss; we advocate for the patient because we know what's best for the patient. That's a great thing while the public is still medically illiterate and subservient to medicine, but if it lasts forever, we'll begin to occupy the same master-servant relationship with patients that we're trying to chip away from doctors and insurance companies.

___
Also - Change of Shift is also up at Emergiblog, with a decided ICU/ER and nursing student slant. I like it!

Apparently I Don't Look the Part

mannursediaries@gmail.com (man-nurse) — Wed, 14 Oct 2009 21:42:00 +0000

I won a nursing school scholarship. It's divided into two payments, one in the fall and one in the winter semester (i.e. after January). Well, I graduate in December, so I thought I'd try my luck and see if they'll give it all to me this semester.

The scholarship foundation offices at the college recently relocated, so finding the office took forever. It was actually behind an unmarked door and I had to walk through a few other empty offices.

Finally I see a woman and ask her, "Is this the foundation office?" She eagerly says "Yes! You're here! It's right this way!"
Me: "..."
Her: "The copier! It's...it's...aren't you here to fix the copier??"
I awkwardly say something about winning a scholarship, and she's becomes mortified. "I thought you were from tech support!"

Apparently I don't look like a nursing student. I thought it was funny, and even offered to look at the copier anyway. She was too embarrassed to let me.

Participatory Medicine

mannursediaries@gmail.com (man-nurse) — Sun, 11 Oct 2009 14:13:00 +0000

The forthcoming edition of Grand Rounds centers on the concept of participatory medicine, which is a concept I'm familiar with even if the term is new to me. Participatory medicine is the idea that patients should be knowledgeable enough to competently manage their own healthcare; that physicians and healthcare practitioners encourage knowledge and allow participation; and that healthcare organizations, from hospitals to insurance companies, support this process financially and informatically (i.e. allowing access to your health information).

My first thought as a nursing student was that this is something nurses already do. We are not licensed to practice medicine—that's what the MDs do—but our daily work involves participating in that discipline. Whether it's carrying out medical decisions, questioning them, or suggesting them, nurses routinely use their knowledge to influence and alter the practice of medicine. It's defined in the idea of patient advocacy. We speak up for the patient when they are unable to, or lack the knowledge to do so. We speak on their behalf to physicians, hospital administrators, insurance companies (through case managers), and other health workers like physical therapists. There's nothing intrinsically bad about these other groups; but due to the busy nature of their work, and how they're spread across multiple patients, there are countless incidences when a patient would have a less optimal or adverse outcome if not for a nurse speaking for them to these groups.

The Society for Participatory Medicine delineates four types of people or groups for need to facilitate participation: the patient, the practitioner, the healthcare organization, and society at large. It occurs to me that nurses are possibly the only group to regularly take on two of those roles: that of the patient (as advocate) and that of practitioner.

Clearly most nurses enjoy this role, but they just as eagerly want patients and caregivers to shoulder more of this burden. We're not always there to advocate for you. We're can't call the MD for you like we do in the hospital. We can't drive you from home to the ER, deal with the insurance company, or handle family disputes about your care. Patients—people—need to be active and competent managers of their care 24 hours a day. How many hospital stays could be avoided by judicious management of heart failure or diabetes by the person suffering it, or by their family?

However, I think there are two major obstacles to participatory medicine. The first is that we, as a society, almost always relegate our own healthcare to physicians and institutions. I don't think an individual or a caregiver needs to have all the knowledge a physician or nurse has; but there's no reason they can't have competent knowledge of their particular condition. Competent enough to stand up to physicians or nurses making wrong decisions. The Speak Up Campaign is an excellent voice for this.

The second obstacle is that we, as a society, are very isolated and fragmented. We emphasize independence so much that even in intact families, you'll find parents and adult children and aunts and uncles in very loose contact, if at all. Every time I encounter a patient who fell in their home and laid there for days before being discovered by a neighbor, I wonder about this. It's terrible: they come in delirious, starved, dehydrated, septic, with skin sloughing off their arm or leg or whatever they were laying on...and they often don't survive it. But this didn't happen out of nowhere. These people almost universally had conditions which led to their fall: obesity, diabetes, weakness, heart failure. In the hospital we would assess them and call them a fall risk. There's an official nursing fall-risk scale, but it's almost always a common sense judgment. Why didn't their families do the same? Why are they living on their own? Or why isn't someone checking up on them regularly? And it doesn't have to be a drastic life-threatening condition; anytime I see a dinner tray sitting untouched in front of an elderly patient, and a family member sitting there idly, I wonder why it doesn't occur to them to do the basic, human thing of encouraging them to eat, or feeding them, or getting different food. In other societies, we humans take care of our parents as they age. It makes sense. But the US is different for some reason.

In sum: participatory medicine is great. Nurses are already doing it. Patients and their families need to be encouraged to do it more.

Should Nursing Students Be Allowed to Blog?

mannursediaries@gmail.com (man-nurse) — Sat, 10 Oct 2009 17:00:00 +0000

Code Blog ran a story about Nina Yoder, a nursing student who was expelled for blogging about patients. Later she sued her way back into school, on the grounds that she didn't violate confidentiality, professionalism, or her school's code of conduct; but not everyone agreed with the outcome of her case. The comments are illuminating, especially since someone posted an archived copy of her original posts.

Obviously this has implications for me, as a student blogger. I feel that it is within my rights to discuss healthcare and disease processes, using examples from the actual cases I see. I also feel I am allowed to write about being a student nurse and a working nurse assistant, and my thoughts on what it will be like to be a nurse in the current hospital system.

But not everyone agrees that you can write whatever you want about patients, even if you don't use their names, or you change facts about their cases. I have to say I agree. There's something not quite right about blogging from a professional stance just in order to complain about work or school, using specific patient stories as examples. I also don't like how sometimes we gossip about patients. And changing the facts doesn't sit well with me either. Blogging about patients is never quite like writing case studies for a journal, but I think it should strive to be something close to it. Publishing case studies, like blogging about patients, involves stories about nameless patients, but case studies are supposed to be educational and edifying; they instruct you or cast more light on some issue or problem by making it individual. I think good blogging can do that, too. Many issues in healthcare—say, poor treatment of the elderly, or depersonalized obstetric practice—can be strikingly illuminated by telling the individual stories which only we nurses, physicians, family members, and others involved in their care can tell.

I think it almost goes without saying that a certain amount of maturity and openmindedness is involved in doing this. I think the difference between Ms Yoder and myself is that she was using her blog to vent, to complain, and to air opinions which some would call honest, but others would call immature or naive. And I do think, as I commented in Code Blog, that nursing requires maturity and objectivity, and that nursing professors can and should prevent you from moving further in your education if they feel you're acting in an immature manner. I can't promise I always think, or write, like a mature and experienced nurse should write. But I try. That's partly why I subscribed to the Healthcare Blogger Code of Ethics. I'm also writing a privacy statement for this blog, based on what I've researched about what you should and should not be able to say online, both in respect to HIPAA and to the principles of nursing professionalism.

But I can see why nursing instructors who may be sued or lose access to a clinical site (i.e. a hospital refusing to let students from a your school come back) would have a hair-trigger sensitivity about nursing students who blog. I'm not sure how to allay those fears, except by blogging semi-anonymously and by strictly adhering to the Standards for Privacy of Individually Identifiable Health Information set forth by the people directly responsible for enforcing HIPAA. This includes no names, numbers, specific dates (birth, death, dates of care), and locations smaller than a state.

One note, however: Ms Yoder complained about her school, saying clinicals are 99% a waste of time. I'm sure this clinched the case against her in her professors' minds. But while it may not amount to constructive criticism, I have to say I've felt my time was wasted in certain clinicals and with certain clinical instructors. There are few ways to express this without getting into trouble, or at least having your comments fall on deaf ears—but I feel anyone would be justified in saying it, if it's true. We students have precious few hours in the real clinical setting before we're let out the gate as real world RNs, and every clinical hour should be productive.

Emergency Room Edumacation

mannursediaries@gmail.com (man-nurse) — Thu, 08 Oct 2009 21:18:00 +0000

Part of our clinical rotation this semester involves rotating to the emergency department to follow a nurse for a few days. Then we're supposed to write a paper about the experience, following an outline they gave us. I left the outline sitting on a desk on the unit where I work, and one of the ICU nurses helpfully scrawled the following answers on the paper:

1. Identify the assessments made by ED nurses when they encounter patients experiencing acute complex alterations in homeostasis:

HE'S A DRUNK

2. Relate examples of the levels of illness which the emergency triage system encounters:

I HAVEN'T HAD A BOWEL MOVEMENT IN 24 HOURS

3. Observe the role and responsibilities of the ED nurse and explain how these differ from the responsibilities of a floor nurse.

FLIRT WITH THE PARAMEDICS

4. Relate methods of crisis intervention for patients or families in crisis in the ED.

LOCK THE DOORS - KEEP FAMILY OUT

5. Develop a beginning knowledge of the nursing interventions which ED nurses must implement for patients in the ED.

TRANSFER TO ICU STAT

6. Relate the teaching needs of the short-term ED patient.

DON'T COME BACK.

_____
15% off Mens Nursing Scrubs with coupon "medcases" at scrubsgallery.com

Osteological Anticlimax.

mannursediaries@gmail.com (man-nurse) — Fri, 02 Oct 2009 14:00:00 +0000

We had the most boring lecture in the world.

We're senior nursing students. We've just come off an intensive series of fascinating lectures and tough exams on the most advanced cardiac and respiratory stuff there is—arterial blood gases, electrolytes, CVPs, Swan-Ganz catheters, wedge pressures, open heart surgery, cardiac arrest, ACLS, respiratory acidosis, respiratory alkalosis, metabolic acidosis, ventilator modes, tracheostomies, chest tubes, pneumothoraxes (pneumothoraces?), chest trauma (bullets, knives), lung resections, laryngectomies, radical neck dissections, ventilator weaning. People have been saved from the clutches of death left and right in our young student minds these past couples weeks. So you can imagine our excitement, our intense interest, when we entered lecture the other day to find the subject was...

OSTEOPOROSIS!!

Not that it's a bad subject. It's just kind of...you know...first semester-y. It's a basic "care of the elder adult" subject. You can't talk to students about how nice it is to make sure people get calcium in their diet when the students are still thinking about how Ca²⁺ enters intracellular fluid in phase 2 of myocardial depolarization to produce heart contractions. (It is phase 2, isn't it?). We were almost too astonished to be bored.

Why I Dread Taking My Kid to the ER

mannursediaries@gmail.com (man-nurse) — Wed, 30 Sep 2009 23:18:00 +0000

Haven't I used this subject line before?

I'm in the ER for a couple of days, following a nurse. A baby less than 30 days old was brought in with a sniffly nose and "vomiting x2". First of all, I don't think vomiting counts when it's a baby. Unless it has blood or green or black stuff in it, it's spitting up.

Besides that, the kid has nothing else wrong with it - no fever, no history of recent fevers, nothing. But the doctor wants IV access. No fluids or antibiotics yet - just access, just in case.

So for thirty minutes we get to hear little neonatal screaming that no one should ever have to hear for that long. It's awful. Toddlers scream because they know what pain is and they're afraid of it. But babies scream because they're in pain and have no idea what the heck is going on. They're abandoned and disoriented. It's the worst sound ever. All that fear and trauma and catecholamine activation can't be good for a baby, or their relationship with the parent, or their nursing relationship, and whatever else. The general rule should be to keep pain and suffering (and parental detachment) to an absolute minimum. At the very least they could've given up and tried again later, but ERs being ERs, you have to try to get stuff done now.

Then the doc decides the baby needs a sepsis workup. Apparently every kid under the age of 30 days who's sick needs a sepsis (blood infection) workup, since sepsis in a baby is pretty much the kiss of death. But this baby with no fever doesn't meet the criteria. So you know what that means: another round of stabbing the baby trying to get blood.

In the middle of Round Two of baby torment, a new doc comes on, wants to know why the heck we're working the kid up for sepsis, and says to CANCEL EVERYTHING.

I realize doctors have a right to want not to get sued, but I don't want to take my kid to the ER and have them treated like the avoidance of litigation and covering all our bases is the first priority of care.

image by addrox of addstudio

Holy Intestines, Batman!

mannursediaries@gmail.com (man-nurse) — Tue, 29 Sep 2009 23:04:00 +0000

So my baby swallowed a penny a couple of weeks ago.

A week goes by, and every day of that week my wife is asking me about what's going to happen: is she going to perforate her intestine and instantly die? Should we get an x-ray? I said I think she'll probably have a distended belly and be very unhappy in time for us to get to the hospital. And I don't think they just do x-rays on demand.

So then she was going to die of copper poisoning. I said I think they're made out of some kind of copper alloy now, because new pennies don't turn green like copper does. So she googled it and found that you can't get copper poisoning because the copper in a US penny is bound to zinc, which holds the copper in.

So then it was zinc poisoning. I forget what happens with zinc poisoning—nerve damage, hearing damage? I still say the alloy is pretty stable. I assume that's why they make coins out of alloys now: so they don't wear away by being decomposed by your sweat...or your baby's GI tract.

So the week passes. Now I'm starting to worry, too, but I still don't know what to do - go to the MD or ER and say "We think, but we're not sure, that my baby, who is in no distress at the moment, swallowed a small and metal something about a week ago?" (By the way, this is probably why RNs never go to the ER when they're having a heart attack—they wait for it to go away, and when it doesn't they feel too foolish to go and say they waited a week.) My wife in the meantime read stories from other parents talking about it taking up to two weeks to pass a coin.

After two and a half weeks, it comes out. But it wasn't a penny. It was a blue heart-shaped Miraculous Medal which nobody had ever seen before.

Of course, my mother-in-law has lots of used medals and other Catholic items, so she might've picked it up there. But it could've been a miracle.

I said we should sell it on e-bay. My wife wants to put it on a necklace and give it to her for her sixteenth birthday in front of her friends. And a friend of ours suggested putting higher denominations of money in to see if we get a first-class relic.

SIR! Metoprolol succinate, SIR!

mannursediaries@gmail.com (man-nurse) — Wed, 23 Sep 2009 23:23:00 +0000

One of the RNs said to me "Hey, you're a student nurse, you'll know this. Which is longer-acting, metoprolol succinate or metoprolol tartrate?" I said succinate. Another nurse said yeah, probably the sux. Then she went to a cardiology fellow (who I swear was younger than me) and asked him. He didn't know. Or he thought it was the tartrate, I forget. Anyway, they go back and forth about it, and I'm like...succinate! Succinate!

Hey, I'm in nursing school. I have to be able to answer snap questions this like I'm in boot camp!

ALMOST THERE!

mannursediaries@gmail.com (man-nurse) — Tue, 22 Sep 2009 03:10:00 +0000

My final* nursing care plan for all of nursing school is DONE.

Original patient: pH of 6.8, died before I could get to 'em!

Actual patient: ICU status post open heart surgery, lots of complications

Number of pages: 66

Number of words: 22,688

Number of words a friend said that nurses actually need when I boasted about my word count: two ("Yes, doctor")

Number of days spent writing: SIX

Number of sources: 10

Number of shifts worked during that time: a 12-hour in the ICU (what was I thinking??! Oh yeah, I was thinking "It's Sunday! I can do homework!" Of course all the poop hit the fan that day.)

Number of my children who just about developed behavioral disorders and/or got sold to the gypsies because of how they acted while dad was busy for six days in a row: 3, maybe all 4 of 'em.

Number of my children who sorely missed me while I was working on this stuff: 4

Number of wives who probably almost forgot they had a husband: 1

Number of things learned: plenty! ABG interpretation, acid-base disorders, vent settings, cardiac dysrhythmias, electrolyte balance, and drips. That was nice for a change, compared to most care plans.

* Wouldn't be surprised if they sprung another one on us. Just for good measure.

If Nothing Else, I Learned Why Twinkies Never Freeze.

mannursediaries@gmail.com (man-nurse) — Sun, 13 Sep 2009 14:45:00 +0000

I've been looking to fetch this post from my Livejournal and republish it here. Now I finally am. I wrote this when I started working at my first hospital job as a nurse's aide, about four years ago. It's about an ornery but likeable old cuss who I still distinctly remember.

I work at a hospital now, and if the people there aren't always as strange as they were at the nursing home, at least they're more diverse conversationalists. A few days ago I escorted an old guy out to have a cigarette. He alarms everybody because he's somewhat forgetful, he refuses to wear a hospital gown, and to top it off his brother is a patient down the hall. So he looks like a visitor in his jeans, flannel shirt, and Teamsters hat, sitting in his brother's room. He wanders the hospital with a box of cigarettes and a heart monitor in his shirt pocket. It wasn't long into my shift that they called a missing patient alarm on him; turns out he was just getting some coffee.

He said he's sick of hospitals and doctors. His wife was taken in to a hospital for a UTI, and some damn Filipino nurse, in his words, gave her 32 shots of Demerol over a 72 hour period. She came home visibly worse and died a few weeks later. He's convinced that the painkiller did it. I have no idea what Demerol can do, or if it was really unnecessary; I have no idea if he's accurate about the number of shots. I've heard this sort of thing before, though, so I didn't think a whole lot about it. But then there's his dad. When he was young his father broke his ankle handling timber, and he was put in traction in a nursing/rehab home. This put so much pressure on his heel that it rotted off. That got my attention, because I've seen rotted heels. All my life I thought the term "bedsore" meant muscle stiffness, and even after learning about pressure ulcers in class didn't quite prepare me for seeing how nasty they can be on the floor. I can't imagine this average guy noticing this on his dad, never having seen one before. There's no excuse for bedsores, but I guess that realization is kind of new in the field of medicine, and I can almost imagine that the people at this home probably shrugged it off as common. So I think that's where his real mistrust came from; but being young, it probably didn't formalize into open rebellion until that thing with his wife.

Then he began talking about food preservatives, which he thinks give everybody cancer. This I've also think I've heard before, until he says he hauled the chemicals himself for thirty-five years. He could describe taking a chemical to one factory to be made into ethylene glycol—antifreeze—and the same chemical to another factory where after two more steps it was made into propylene glycol, a food preservative. He hauled chemicals which flavor cigarettes because they don't let them cure long enough. All very encouraging. Of course, he was smoking the whole time, but he said he avoids certain preservatives like the plague.

But aside from seeing antifreeze go into your Twinkies, it had to be crazy being a chemical hauler. Probably still is. He said "between your boss and the guy you're delivering to, nobody cares if you live or die." He hauled a chemical to one client who, because of recent construction, didn't have eyewash and a chemical shower ready next to the delivery pump. So he refused to pump. His boss and the client were furious, but he didn't back down. They sent him out again to the same client six months later; his boss said they should have everything set up by now. They didn't. They tried saying there was a sink 300 feet away. He said that if he called OSHA and they came out and stood right next to him, he would do it. His boss never sent him on that route again. The next guy who went was an inexperienced driver, and when he opened the huge stainless steel latch over the pipe, he didn't completely secure it. There's always some caustic soda around the rim of the pipe, and this latch slammed down and a drop popped up—right into his eye. He had to run the 300 feet, but by then his eye was gone. So get this: his boss signs an "agreement" with him that if he won't sue, he'll have an easy lifelong job in the yard at truck driver pay. The driver agreed to it...and a week later the boss fired him. So my friend convinced the kid to sue, and he got a quarter million out of the boss and another quarter out of the client. But he's only got one eye.

Note: a comment left to the original post gave me a now-defunct link that claimed that the cream filling of Twinkies never really do freeze.
photo by Larry D. Moore

Code Blue During Clinical...Almost

mannursediaries@gmail.com (man-nurse) — Thu, 10 Sep 2009 16:40:00 +0000

I always think about what might happen if one of my patients codes during clinical. What would I do? What am I allowed to do? Can I push epinephrine? Do CPR? Should I get out of the way? Is the code team going to look at me, in my absurd geeky white school uniform, and tell me to scram?

Well, I almost had my chance already.

Patient comes in the day before in a hypertensive crisis - extreme high blood pressures. At the start of my clinical, I immediately gave blood pressure meds (for pressures 200/115+). Then I sent them off to a scan. Unbeknownst to me, the scanning people call the real RN and say the patient's unresponsive. She says don't call me, call the rapid response team!! So they call the rapid response and the location on the overhead loudspeakers, and my heart sinks. That's my patient. I knew it shouldn't be anything I did. I hit the patient with three strong meds, but they're sustained release and this patient has been taking them for a long time. But still - if you give somebody pills, and then they code, that's a great way to feel like your degree (or your license) is going up in smoke.

Anyway, the RN runs past me shouting something about her blood sugar. I had a brain freeze and couldn't remember it - what if she's low? I should've known! But then I remember it was 160+, high. She should be fine. I ask the instructor if I can go to the rapid response, and then I run.

When I get there, everyone is clustered around the transport cart. At first I hang back, but then I thought This is my patient and I push my way up to the front. That was good, because I could answer some questions nobody knew - labs, history, how long that central line has been in, etc. Blood pressure was normal. Heart rate, respirations were fine. Sugar was great. No temp. But the patient is moaning and minimally responsive. The residents start talking crazy stuff - oh, we know this patient, they come in all the time with a sickle cell crisis. Um, no they don't - they don't have sickle cell anemia! The hemoglobin is 15, abnormally high! Not exactly anemic. Looking at the patient, I thought it was something neuro. With high blood pressures there's a high risk for a brain hemorrhage. The initial CT scan was negative, but that doesn't mean there's no bleed now.

Once we were stable, the code team left and allowed the scan to continue, leaving only me, the scanning tech (who was extremely wary of having this patient!), and another nurse. During the scan I took the blood pressure again, and we were back up to 230s/120s. All I could think was that we need a head scan, need a nitro drip or something to get the pressure down, and we need to be in ICU. The scan is rapidly completed and we head up to ICU. Technically I'm not supposed to rotate to ICU yet, but I helped get her into the ICU bed, the receiving nurse had me do a quick neuro check, and then I took off and went back to my unit.

It was a great experience for me. I could've not gone. But this was my patient. I knew the labs, the history, and their clinical course since they were admitted. I knew, at a basic level, what the plan of action should be. My mind was racing through why the blood pressures were so high and why we were unresponsive - was it neuro? Renal? I wanted to see the outcome - did they do a head scan? What drips did they start? And I feel terrible for the patient; I watched them go from awake and cranky to almost coding. And a little part of me, as a (student) nurse taking care of a patient, is intensely relieved that it was not anything I did - or failed to do.

photo by brykmantra.

The Final Stretch?

mannursediaries@gmail.com (man-nurse) — Fri, 04 Sep 2009 18:45:00 +0000

Gosh, I've been gone for a while. Well, right before my final semester started in August, my wife and I packed up the four little ones and boarded a plane to see my family in Florida. Yes, that's right...four kids under six on a plane. Kinda like Snakes on a Plane but scarier. I've flown with one, two, even three kids, but four—when they outnumber the adults two to one, I start to question my decision not to make a road trip. But they all did quite well. The two older ones are troopers, having flown at least once a year all their lives. Busy airports, takeoffs, landings—they're fine. My third child, a two year old boy, kept saying things like That plane is gonna crash into us! (gleefully) on the runway and Ha ha! We're fallin'! during takeoff. I tried to inform him that other passengers probably don't want to hear these things. The baby thought it was a blast, with all the people around and not being locked into a carseat. So we might, if we brace ourselves, do it again.

I'm entering my final semester of nursing school, and let me tell you, the instructors have us shaking in our absurd white school uniforms. This is the last stop before we take our boards, become registered nurses, and start practicing on real live people by ourselves—and they have made it perfectly clear that they tolerate no excuses, no errors, no mistakes, no omissions, and no ignorance.

I go to what many people consider the toughest nursing school in the area, but I haven't flinched so far at what they've given me. I've made good grades and impressed my clinical instructors even while working full time and being a dad. But I was honestly scared the first two weeks of this class. There's a final-semester teacher who is legendary for being tough (many say mean) and failing people. She allegedly flunked four of the eight clinical people assigned to her last year. So guess who my clinical instructor is? This person! But as I've met her, and she's talked to us, I can see where she's coming from. You walk on a razor's edge with her, but that's because that's what you do in the real world. She doesn't tolerate mistakes because if you make an error or do something stupid in the real world, either by action or ignorance, somebody could die. And she's extremely knowledgeable and very good at sharing her knowledge. So as I've survived actual clinical days, I've become more confident: if I can make it through her, that means I can do this job. And I know this stuff. I know how to be a nurse, or if I don't know something I know how to find out. I just have to put it all together and apply it.

So wish me luck! I'll try to post when I can.

Change of Shift Volume 4 Number 3

mannursediaries@gmail.com (man-nurse) — Thu, 06 Aug 2009 12:36:00 +0000

Now in its fourth year, Change of Shift is the blog carnival for nurses, by nurses. I'll be your host today. It's August and school is looming around the corner, so kids everywhere are scrambling to waste time and do as much nothing as possible. What better way to dampen your brain activity than with video games? So here it is, your video game themed Change of Shift Vol 4 No 3: The Revenge!

You might have heard that two nurses in Texas were fired and charged with felonies because they reported concerns about a physician to the Texas Medical Board. They reported their concerns anonymously, but were tracked down by the sheriff's department at the instigation of the physician. No, I'm not joking. Taralynn Mackay, a Texas nurse and attorney who authors the excellent blog A Nurse Attorney's Thoughts, gives her impression of the situation here and also offers contact information for the county attorney in their case if you'd like to help.

Speaking of controversial lawsuits, Reality Rounds posted about Catherina Cenzon-DeCarlo, the New York nurse who alleges she was coerced into assisting an abortion, in "Forcing" a Catholic Nurse to Assist with an Abortion: A Nurse’s Perspective. The comments are as interesting as the post, coming from real-world OB and OR nurses. And be sure to follow RR's link to the original New York Post article.

Amy Romano, the nurse-midwife who heads up the blog Science and Sensibility, submitted the article When Push Comes to Shove. It's an analysis of the evidence against fundal pressure, the practice of pushing down on a woman's belly to assist a vaginal delivery. Since L&D nurses are often asked to perform fundal pressure, she wanted to run it by the CoS readership. S&S in general is a great blog for research summary and analysis, with a healthy dose of critical thinking, and this is no exception.

Kim McAllister of Emergiblog published a great article in ADVANCE for Nursing about a recent study on violence against emergency department nurses. She talks about how to improve the culture of safety in the ED and how to stand up for yourself. One of her excellent points is that a nurse who is discouraged against reporting acts or threats of violence is being victimized twice.

Kim also posted about having been a nurse blogger for four years, thanks all those who mentioned her blog-birthday, and gives some cool geek-stats (1,026,888 pageviews, 0.55 posts published per day), in With A Little Help From My Friends.

RehabRN posts about a week in the life of a rehab nurse, which includes exploding colostomies, ghosts, and dealing with the deaths of patients.

Over at NurseConnect, Nurse Kathy writes about encountering yet another customer service brainwashing program, full of catchy acronyms, themes, posters, classes, which promises to overhaul her hospital's image and make all their customers happy. She gives her opinion on the one thing that really gives people a good impression of their healthcare staff, in Brag About Your Colleagues. I have to agree; if you're complaining about the night shift in front of a patient, you're not imagining how it must be for that patient who has to sleep in the care of that night shift. Also at NurseConnect, Nurse Laura talks about what makes a scrappy, persistent nurse tick in Extraordinary Nurse Secrets? Blood, Sweat & Grit!

Sean Dent talks about reading doctor's handwriting ("You did take the 'hieroglyphics' class in school didn't you?") and how nurses are often not much better.

Milk Chocolate Midwife, who remembers being uncomfortably handled, literally, by a know-it-all nephrologist, wants fewer "good patients" who are afraid to ask questions or complain, and more patients who are actively involved in their own healthcare, as she writes in Playing Doctor.

The anonymous author of Hands Are For Catching, a CNM blog, is upset at the American College of Nurse Midwives (ACNM) for their legislative actions against non-RN midwives. It seems ironic that the representative body of CNMs, who have themselves been in danger of being legislatively eliminated by obstetricians, would in turn try the same with "lay" professional midwives.

Running Wildly, an ED nurse (who may be delivering her new baby any day now), posted in "Nurse!" about how her five year old, his friends, and indeed the whole neighborhood think of her as the nurse, the person you go to when you need information, advice, or (if you're five) help with your scuffed knee.

Pallimed published an article about Improving Palliative Care in the ED. Because palliative care is such a problem (otherwise why would these people who have MDs who presumably should be doing palliative care are instead coming to the ER?) they're asking anyone with experience in palliative care to define it as a specialty (in one sentence, if they can). I thought it could use some nursing input, so have at it!

Edwin Leap posted a column in Emergency Medicine News about how the time-out before surgery, which we, as nurses, are supposed to initiate in order to ~~save doctor's careers~~ protect our patients, may not be completely appropriate in all situations, i.e. preparing for emergent chest tube insertions in trauma.

Dean Moyer at the Back Pain Blog analyzes a study of massage therapy in advanced cancer patients with chronic pain, in Massage Therapy and Back Pain Relief. He's encouraged by the results and thinks it might apply to back pain sufferers—of which more than a few are nurses.

Emily Thomas listed the Top 10 Nurses in Pop Culture (I did not know that nurse being kissed by a WWII soldier had a name) as well as 50 Terrific Social Sites for Nurses. I can put a good word in for allnurses, which I go to frequently for career advice (there's 5,000 people on there a day - somebody has the answer to your question!) as well as their extensive and searchable history of news stories submitted by members.

Finally, my brother just graduated nursing school and, believe it or not, is having difficulty finding a job. For his sake and anyone else who might benefit, here's Sample Nursing Interview Questions and Answers, submitted to this edition of CoS by an interview help site.

THANK YOU! BUT THE PRINCESS IS IN ANOTHER CASTLE! That's it for this edition of Change of Shift. Comment if you saw something you liked, and please mention it in your corner of the blogosphere. The next edition is at Emergiblog on August 20, and you can submit to it by filling out this submission form. And remember you can follow all the Changes of Shift by subscribing to its feed.

In the making of this Change of Shift, my two-year-old managed to raid the fridge, walk around the house with a gallon jug of milk, splash Betadine all over the bathtub (where the heck did he get that?!), steal my stethoscope out of my bag, and paint his entire body with watercolors.

Family Reactions To Dying

mannursediaries@gmail.com (man-nurse) — Wed, 05 Aug 2009 02:05:00 +0000

Two women and their husbands. One was a respiratory arrest the night before, and I mean arrested - she was blue and not breathing when they found her. She's intubated, unresponsive, and looking up to heaven. The very nice husband feels she's aware of what's going on by her eyes. A friend kept encouraging him to talk loudly to her, to get some kind of response out of her. I felt bad for the husband—he's in an awful position. She's probably not "really" or sufficiently alive (my grandma stopped breathing eight minutes before her pulse went away), and every doctor and resident who rounds asks what his personal feelings are regarding life support. What are you supposed to feel about it?

Another woman comes in near-comatose, attributable to (take your pick?) her sky-high blood sugar, severely low electrolytes, a blood pH acidic enough to be lethal, a blood infection, or pneumonia. She has metastatic cancer everywhere. She has to be intubated. After intubation the doctors discuss her poor prognosis, and her husband says "Well, as long as everyone around here does their job and no one screws up, she should have a chance."

Also: a 90+ year old frail ill-appearing man undergoes major surgery but then can't be weaned off the vent. He doesn't even breathe good on the vent, gasping for air despite the tube, and breathing 40 times a minute. To me he looks like he's dying. After a couple of weeks he's trached. He looked even more miserable with that sticking out of his neck, along with chest tubes and black bile coming out of his nasogastric tube, still gasping. Eventually he became a terminal wean and died within an hour. It just seemed to me like we made a miserable dying process even longer. I don't know if the family really knew that they were—that he was—in for this.

Just weird situations that have been on my mind lately. When people come into the ICU whose bodies are actively trying to die, sometimes it's difficult to know what to do.

Emergiblog Turns Four!

mannursediaries@gmail.com (man-nurse) — Mon, 03 Aug 2009 23:00:00 +0000

Ahh, this is the age when she begins to dress independently, become a pickier eater, and learns to lie to get what she wants! Oh wait, that's one of my kids.

Emergiblog is one of the first two or three healthcare blogs I discovered. Reading her blog eventually inspired me (for better or worse) to start this one. She's a fantastic writer and thinker...but even aside from that her blog is veritable archive of crazy old black-and-white advertisements from a past world of healthcare: one full of justifiably angry doctors, swooning patients, eager-to-please nurses in dresses and hats, and my most recent favorite, menopausal women who are happy homemakers because they're jazzed up on amphetamines.

Highly recommended.

Call for Submissions: Change of Shift vol 4 no 3

mannursediaries@gmail.com (man-nurse) — Fri, 31 Jul 2009 14:24:00 +0000

Just a reminder that Change of Shift, the nursing blog rounds, will be hosted here on Thursday, August 6th! Change of Shift covers the best of the nursing web (the nursosphere?) every two weeks. Posts about nurses or nursing written by students, patients, family members, physicians, and other non-nurses are also welcome.

If you have a good post you'd like to see included, whether it's yours or someone else's, please submit it to mannursediaries AT gmail DOT com with "Change of Shift" in the subject line, or use the handy-dandy submission form. Deadline for submission is Wednesday, August 5th at 5pm. Earlier the better, since I'm working two jobs!

(And don't forget Grand Rounds is being hosted by emergiblog on the 4th.)

Babies After Heart Surgery

mannursediaries@gmail.com (man-nurse) — Mon, 27 Jul 2009 23:00:00 +0000

Recently in the course of my student nurse internship, I was given the chance to work in the pediatric surgical heart intensive care unit. It's a pretty staggering place. I didn't even know units like this existed. When a baby has an operation for a congenital heart defect, immediately after surgery it goes to a unit like this. The nurses there are extremely specialized in how to take care of these delicate infants. There are something like 32 heart defects, with many variations thereof: hearts that are backwards, hearts with the major arteries and veins reversed, hearts with holes in between the chambers. These nurses have to know how to deal with them all.

The infant I helped recover from surgery (if you can call it help—I mostly just absorbed!) was a hypoplastic left heart, which means he had only one functional ventricle. Most of us, of course, have two; one which pumps blood to the lungs, and one which pumps blood to the body. This baby's pump to the body never grew correctly, as well as the artery which comes from it. He could survive well enough in utero because fetuses have a few arterial detours in place for blood to bypass the lungs, which they're not using, so blood from the lung-pump went to the body instead. After birth, however, these detours begin to close, which means this infant will certainly die within a week to a month after birth. And these infants did die, until 1981, when a convoluted three-step surgical correction was developed to give these people a chance to live on their one (1!) functional ventricle.

This baby, at five days old, had the first surgery, called the Norwood procedure, which involves creating a neo-aorta (yes I said NEO-AORTA!) and attaching it to the right ventricle. The baby arrived in our unit much like adults arrive in the ICU after heart surgery, with what seems like the entire surgical team (surgeon, anesthesiologist, nurses) rushing the patient down the hall and into the room. Except it's not a bed, it's a crib! The baby has a ventilator, multiple IVs, oxygen sensors over their brain and kidneys, three chest tubes to drain fluid from the chest cavity, and an open (!!) sternal incision—the surgical site is left open (covered with a dressing) to allow for swelling. We immediately had to assess lung sounds, heart sounds, and systemic bloodflow. Since these babies have one pump to both the lungs and the body, they can easily shunt all their blood to their lungs (which is a normal response to stress on the body, and a good thing in most people!), causing rapid circulatory collapse and death.

Seriously.

And then, with everything on edge, the parents come in. It's one thing to see any human being in this position. People after heart surgery look like they're dead. They're ashen and limp, they've got big tubes with blood coming out of them and six to eight IV pumps putting things into them. Now image it's a tiny 3 kg baby, but the chest tubes and IV pumps and ventilator are still the same size. Now imagine it's your baby.

I asked the nurse what kind of outcomes these babies have. If they have all these problems with circulation and oxygenation in utero and out, do they suffer any mental or motor problems? I asked half-expecting to hear that they're trached and severely mentally disabled. She said they don't know how things turn out long-term, since nobody who's survived this is older than their 20s, but they're seeing correlations with things like ADHD and behavior disorder. I was astonished. I'd take ADHD over death.

That aside, it is amazing to see some of the stories and images of these kids online. Little Hearts has an impressively large number of patient stories. I can't get over the photos of these kids swimming and being active on one ventricle, or with other heart defects. There's even a section on what do you do when your kid's coach is scared to let your heart kid on the team.

She also said that some hospitals, including some major neonatal centers in this city, still recommend comfort care only for these babies. She met someone two years ago who lost a baby to this condition in a major university hospital because the physician was doubtful about outcomes after surgery. Another nurse on the unit remarked to me that you should probably always get a second opinion.

They want me to work in that unit. My initial reaction was that uncertainty about specializing so much (pediatric heart surgery is like a subspecialty of a subspeciality of a subspeciality!), thinking I should work with regular medical adult patients...but it's an attractive idea. It's an exciting field. There's only a few places like this in the world. And I was fascinated during our congenital heart defects lecture in school last semester; probably one of the few in the class who were.

Of course, the first day I returned to my adult patients, there was a guy yelling and cursing at us, and I thought, Gee, the babies don't treat you like this!

How My Wife Had An 11+ Pound Baby At Home And Didn't Die

mannursediaries@gmail.com (man-nurse) — Fri, 24 Jul 2009 14:38:00 +0000

Here's a guest post by my wife, about our most recent birth (November '08). I thought it would be interesting to share because, well, I think it was an interesting birth, plus our 'little' baby was 11 pounds and 6 ounces. I'm sure, given the size of the baby and the position my wife had to assume (standing up!) to birth her, in a hospital we would've just ended up with a c-section. As it was, well...you can read on to find out!

This story begins about 12:30 AM the morning of November 7. I got up to go to the bathroom, and lost a huge chunk of mucous plug. I thought, I'll call the midwife in the morning to report, and I went back to bed. around 2:30 I again woke up to potty, and again lost some plug. this time I held it up to the light and squinted a bit and.. it was streaked with blood! yay! dilation! I went back to bed, assuming I'd be going back to sleep, but I had what I thought was an uncomfortable BH contraction. laid down, had another... and another. after a while I sat up, more comfortable that way. my husband woke and saw me sitting, asked what I was doing. I told him I was trying to figure out if I was in labor or not. by 4 am I was convinced, and I called my midwife, reported the lost plug and the contractions about 12 minutes apart at that time. she said to call back at 5:30, and get some sleep in that time.

sleep didn't happen, and by the time I called back, contractions were 4-5 minutes apart. she said she'd pack her bag and call when she was on her way (she lives just over an hour away). I laid in bed a while longer, breathing through contractions, then decided to take a hot shower. I squatted on the floor of the tub, hot water running over me, breathing through contractions. my plan was to use up all the hot water this way, but it got hard to breath the hot stuffy air, so I turned off the shower, got dressed in between contractions, and curled up into a ball on one corner of the couch. clutching the arm and breathing through contractions. my husband brought me a bagel, but I hardly got in more than 3 or 4 bites.

the midwife showed up after 7, maybe 7:10. her apprentice showed up shortly after. our plan was to have my mom take the other kids for the day, but as I was already contracting hardcore, and the kids were all asleep still, my husband called her and told her not to come get them. the midwife told me to go pee one last time before the birth, and I suggested setting up the floor and couch with plastic and sheets while I was in the bathroom. I knew I would want to come back without my pants on. I knelt before the couch and rested my arms and head on the seat. this was my preferred position. the position I birthed my last son in, and assumed I would push this one out in as well. the contractions began to hurt more and more, and I knew it would be soon. but I didn't know how soon, and I didn't even know what time it was anymore. I completely lost track.

someone suggested using gravity to help things along, so I stood up against my husband and he held me as I bore down with each contraction. three things happened while I was standing: 1) my water broke. the midwife looked at what came out onto the white sheet and said it looked very clear. 2) my kids woke up, and they all came downstairs. the apprentice was very good about telling them before they came into the room that the baby was going to be born that day. my 3-year old son was the most interested, and got right there to watch. the older daughter and younger son hung back a bit, very quiet. and... 3) I puked up everything I ate. my husband held my barf bowl in one hand while holding me in the other,. he's such a great multi-tasker. after I'd puked up everything that would have given me any nutrition for the event, I decided I didn't want to stand anymore. I got into my kneeling position before the couch, and began to push.

of course I couldn't see anything going on, but the midwife said I could touch the head if I wanted. really? already? I reached down and didn't feel it right there. she said I could feel it during a contraction if I wanted, but I couldn't concentrate during the contractions. they hurt. a lot. I won't lie. but I think I was also having flashbacks of my previous birth, which was making it seem like I'd been doing this for longer than I had. it felt like forever.

finally the head began to emerge. I heard everyone else's commentary: my husband, "there's lots of dark hair." my 3-year-old son, "there's the baby's face!" and finally my midwife freaking out and telling me to bear down. like, yelling at me. I knew something must be wrong, but I had nothing else left to push with. I'm not very strong at the moment of birth, I've learned this with all my previous births. I couldn't push any more, so they decided for me that gravity would pick up where I left off. I was literally hoisted up back into my husband's arms, and continued to push with everything I had left, mostly standing, half squatting. finally, out came my daughter. white, then faintly purple, not breathing... and huge. apparently there was cord compression, and since she wasn't breathing either, she wasn't getting any oxygen until she was out and the cord could pulsate again. this was the cause of the yelling at me to push her out faster. the midwife picked her up and patted and rubbed her to get her breathing. the apprentice brought over the oxygen, but it wasn't used. I sat down on the floor next to them. finally, a little gurgle.. I took her into my arms and assured my older daughter that she did indeed get the little sister she wanted.

her breathing was still not great, though, it was very congested sounding, so the midwife bulb-suctioned her out. :P she needed it though. when her breathing sounded good, I attempted to nurse, but she wasn't interested just yet. I birthed the placenta onto the sheet on the floor, then moved up to the couch with my new daughter. we tried and tried again to latch, while my husband tied off and cut the cord, and the midwife and apprentice examined the placenta. there was a tiny spot of calcification, but the MW said it was one of the biggest placentas she'd ever seen, and that the cord was thicker than most she'd seen, too. I had to agree about the cord, my other kids didn't have cords quite so thick. I hadn't seen their placentas very closely, though.

[editor's note: seriously, that placenta was as big as an extra-large pizza!!]

this whole time, I was waiting anxiously for the weigh-in. I knew she'd be bigger than my last (and so far, biggest) baby, 10 pounds even. I expected something like 10 pounds and some ounces... but the midwife said... "eleven pounds and... six ounces." I didn't believe her. she weighed her again. and it was the same. I still didn't believe it. no way. I just pushed out a nearly eleven and a half pound baby!

oh yeah and I don't remember when but someone finally asked what the time of birth was, which the apprentice had apparently noted as 8:33 am. I couldn't believe that either! as I said before, I had lost track of time, but I never would have expected a six hour labor from first contraction to birth. this event was just full of surprises.

and the midwife said if I wanted, she could check for tearing. I'd never torn with any of my previous births, so I figured I hadn't, but then, I never pushed out a baby quite so big before, so I decided, why not? and I didn't have any tearing. not even a little nick. which I could've figured out later when I finally peed for the first time, because it didn't even hurt. normally it stings like crazy after birth, but not this time! I wasn't even raw.

the rest of the day was basically trying to get some sleep, watching my baby sleep, and getting her to nurse. my husband wanted some sleep, too, as he'd been up since about 3:30 as well, so he called my mom to pick up the kids then, and the 3 of us fell asleep together.

8:33 am
11 pounds, 6 ounces
22.75 inches

[My wife doesn't mention this, but the midwife estimated the baby to be at 43 weeks gestation. We weren't really sure of our conception date, but she went to 41/4 with the prior kid, so I guess it's possible!]

Traumatically Injured Kids Are Too Noisy!

mannursediaries@gmail.com (man-nurse) — Sun, 19 Jul 2009 19:57:00 +0000

Children's Memorial in Chicago is building a new hospital in the downtown area. Naturally, as the highest-volume pediatric hospital in the area, they're building a helicopter pad. Except a neighborhood alliance, the Streeterville Organization of Active Residents (ironically, SOAR), is trying to block it:

"The challenge is what a pilot is going to have to deal with in an urban nighttime environment," [SOAR member] Frost says. "You’ve got the tall buildings, you’ve got all the twinkly lights, which actually impair a pilot’s visible ability."

Pilot: AHHH! Can't see! The lights are so twinkleeeey!" *EXPLOSION*

I can't help but feeling that the issue here is not helicopter crashes but helicopter noise. Streeterville, aka the Gold Coast, is probably one of the wealthiest neighborhoods in the United States. This helipad will be on a level (31st story) with many of the neighborhood's high-rise condos, as the Streeterville association's panicky 'fact sheet' is quick to point out. I have a feeling that this comes down to the fact that, while these condominiums are noise-insulated against the high volume of downtown car traffic below them, they're not insulated against same-altitude helicopter traffic.

Living near a major hospital means you do hear helicopters several times a day. You grow accustomed to it. Maybe the government will help pay for new insulated windows, like they did for the people who live right across the street from Chicago's Midway airport. The neighborhood's alternative is to put a helipad on the ground by Lake Michigan, out of the neighborhood, and have the kids transported by ambulance to the hospital. In city traffic, during rush hour, that could take 30 minutes, and anybody who lives on the Gold Coast knows it.

photo by iirraa