The Man-Nurse Diaries

The bitter divide between sedation and coma

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Fri, 15 Jun 2012 21:55:00 +0000

Is she not waking up because she's sedated?

Are the medications making him stretch and move like that?

Are the pupils not working because of the sedation?

No....no, we're not using sedation. This is from neurological injury.

I can never get over the implications of the difference between sedation and coma. A comatose patient and a sedated patient often look the same to visitors, loved ones, people walking by, and even consulting physicians or residents who first walk into the room and have to ask me if we're sedating the patient. But the difference is the entire world. Their entire world, that is. It's the difference between them waking up and getting out of here, or possibly (probably?) never waking up again

In a single sentence we're declaring with finality the next several months or years of their life. Are they going to return back to normal? Or will they require months of intensive rehab, or a life of nursing home care, or hospice, or will they die right on our unit in the cacophony of a failed resuscitation?

It astounds me that I have to have this discussion with people at, say, 3 am on the phone, in the night shift lull when I'm just starting to get tired. Sometimes the patient has been here a week and I feel like I'm the first person saying to this person that their coma is probably due to them being in a coma, not to sedation: "No, they've been off sedation for days." Or maybe they haven't heard the other times, or they need to hear it again, to have every possible second, third, fourth opinion. I think I would even do that.

I also reflect on how I was never trained to deal with these situations, but I'm still the front line 9 times out of 10 to break this news to people. And that goes whether it's a new emergency admission, or a patient who's been laying in our bed for a week. It's hard to tell a wife or husband or fiance or adult child or young child that the person we're talking about is not waking up not because of drugs we're giving them, but because they're just not waking up.

"All Nurses Should Be MSNs"

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Thu, 19 Apr 2012 06:39:00 +0000

See, this is what scares me about nurses. This was a reader response to the APNs saying no to the DNP I posted about:

Kudos to you and your physician colleagues for supporting the idea (whose time is long overdue) of a well-educated nurse!!! I have always believed that if the AMA [American Medical Association] said, "We want all nurses to be minimally prepared at the masters level and all advanced practice nurses to be prepared at the doctoral level (research and/or practice) by 2015," that it would happen!

Regina L. Payne, EdD, MA, MSN, RN, CWOCN

I don't even know where to begin. All nurses having a masters? Do you want the industry to commit suicide?

Who is going to get their masters to make $50,000/year starting pay?

And why do we need to be validated by physicians? Nurses operate hospitals. Physicians put their patients in hospitals to be under our care. We are not coworkers or coequals; we are not comparable or competitive workers in the same career field. We do different jobs.

I have a feeling doctors don't care about validating this nurse, either. In the real world, nobody talks like this. But this professor of nursing is willing to sacrifice US healthcare in order to achieve a pipe dream only she and other people like her care about.

Thankfully this would be such a burden on healthcare that it will probably never happen. But if this is how nurses in the academic establishment and the political lobbies think, I'm genuinely frightened.

What's happening to nursing anyway?

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Mon, 16 Apr 2012 05:06:00 +0000

Does anyone else feel like nursing is going down the toilet? Man, I must be getting old if I'm saying something like that.

I was speaking with some of the more experienced nurses on the unit...some have decades, plural, of experience. Don't get me wrong, they love their jobs, and they're happy people. They're not your typical grumpy nurses. But they've seen a drastic shift in how nurses can work. You used to be able to work anywhere. You used to be able to quit and come back. Moms would leave for their kids and then come back years later; people would try stints in home health or agency work and decide to come back to the unit. You had total job security.

Nursing, one of them said, used to be in the hands of the nurse. Now it's in the hands of administration.

These people were hired the day they interviewed. Some of them were told to show up in scrubs for their first job interview, in case they needed them that day on the floor.

I can't even imagine that. If I quit, I don't think I'd be able to come back. I certainly wouldn't assume it, anyway. And I wouldn't assume I could get a job tomorrow. It's not just because the job market is dismal, but because the whole hiring process is now controlled by human resources, administrators and nursing officers I don't even know, etc. Even if your boss likes you, that doesn't mean they can take you back even if there is a position open.

There are other signs, too. It seems like every few weeks there's a new requirement placed on us. Not that I mind or shirk expectations, but many of these have a concealed threat to our job; if you don't perform, you're out, because you're easily replaceable. And they know you're not going anywhere else fast. The specialty certification is like that; it's mandatory or you're fired. That wouldn't have been possible ten years ago, I don't think.

The most significant change to me was that they decided that the 36 hour week (three 12 hour shifts), long the standard full-time schedule of the RN, is no longer full time. It's considered part time, with part time benefits. That's just mind-boggling. The only way they're getting away with it is they've grandfathered in the current 36 hour people. So generous of 'em. But all new hires are like this. I can't imagine how that's going. "Want a job? Well, guess what - you're going to have to work a standard full time nurse's week, but you're only part time. Hey, do you want this job or not?" You have few other options in today's market.

It can't be just the market, though, can it? I think in the last five or ten years there's been a change in how nursing and administration have interacted, and it's not in nursing's favor. I realize administration has to run a hospital like a business, but that means that at the end of the day we're an expense rather than an asset. Despite the fact that hospitals don't exist without nurses.

I'm starting to see the appeal of unions.

Paging Dr. Nurse...

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Sat, 14 Apr 2012 13:00:00 +0000

An interesting thing about the issue of the Doctor of Nursing Practice is that the news coverage and opinion pieces about it are mostly centered on what doctors think. Doctors, obviously, are not generally happy with nurses being called doctors. It is true that "Doctor nurse" seems like an odd title; however there is a valid point that pharmacists, dentists, and even many physical therapists are now doctorate-level clinicians but nobody gets up in arms about that. Doctors are obviously worried because we do frequently the same tasks, so DNPs infringe on their turf. But to me, that's neither here nor there.

I'm more concerned with what nurses think about it, and that information is a lot harder to find. I think the only nurses who write or publish in any venue are the ones behind this sort of thing.

In fact, the only published thing I could find was a statement called 'Advanced Practice Nurses Say "No" to a Mandatory Doctor of Nursing Practice Degree' (may require free registration at Medline) by Wendy Vogel, an NP in Georgia. Her statement, the readers' letters it generated, and her response to those letters are well worth reading. The upshot?

Increasing the education requirements will only sharpen the nursing shortage. In fact, other medical fields have already experienced this:

Nursing looks to pharmacy, medicine, and physical therapy and sees the need for a clinical doctorate to have "parity" with these professions. Yet, if one examines the Department of Health and Human Services' report to Congress about the pharmacy workforce, the conversion from the Bachelor of Science in Pharmacy to the Doctor of Pharmacy degree is deemed a major factor contributing to the nationwide shortage of pharmacists. We also see evidence in both pharmacy and physical therapy that required doctorates have severely influenced PhD enrollment.

This seems so obvious that I don't know what the problem is. I've complained before that the shortage of nursing faculty in general is partly due to requiring Masters-level education even to be a first-semester clinical instructor. This is obviously absurd. When a nurse can make great money at the bedside, why would they expend the time, money, and effort to get their masters and then teach for minimal income? It's ridiculous. The only explanation I can find is that cushy academic jobs (in this case, those who run masters in nursing education programs) need a justification for their existence.

Is it the same story for the DNP? I think it probably is. Academic nurses, in this case the doctors who want to teach doctorate programs, need a justification for their existence. But it's going to ruin advanced practice nursing for the rest of us. As Ms. Vogel puts it:

So why would a new high school graduate want to consider a doctorate degree in advanced practice nursing? Why not pursue the career of a physician assistant...or a physician or a pharmacist? As with many careers in the healthcare field, nursing is fraught with shortages, decreasing reimbursement, increasing demands, burnout, and job dissatisfaction. When one compares the time commitment of education with the potential remuneration of each profession, nursing may very well lose.

Academic nurses have been fighting for forty years to be on a par with physicians. I don't think they realize that achieving that vision is going to be its own undoing.

Speshull snowflaeks

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Thu, 12 Apr 2012 15:30:00 +0000

We're now required to achieve our specialty certification. For us ICU nurses that means shelling out a few hundred to sit for the CCRN exam, although we get reimbursed if we pass. I really can't complain, and I generally believe in specialty certification.

Especially if it's a scientific speciality.

I definitely think that there are so many nursing specialties out there that the "generalist" nurse could use more education than he or she gets in a standard "generalist" school in order to perform well. The fact that nurses without extra book-learning do well in these specialties is a testament to how rapidly they learn the practicalities of their field. But we in the critical care world, at least, know that not all nurses in our units are created equal, and this might bring some people up to par.

It seems blindingly obvious there should be a plain-jane nursing school, with offshoots or further study given for critical care, obstetrics, psych, etc etc. The advanced critical medicine we studied and the psychiatric medicine helped me be a more well-rounded nurse, but maybe not so much the obstetrics? I'm sure some of the nurses destined for the floors or doctor's offices got tired of advanced arterial blood gas interpretation after a while (slight understatement). And the professors all seemed to agree but shrugged that this is just how it is. "The generalist has to dabble in several specialties to be well-rounded." That doesn't explain why we did L&D rotations but not OR rotations.

Certification might help supply the lack of specialty education...however probably nothing will rectify the situation with the school. Unfortunately.

It is making many people upset, however. I mean, you can imagine if you've been a hard-edged ICU nurse for twenty years, you know you don't need the credentials, and you're going to resent the stress of sitting for the exam. Especially if you're a trauma nurse and you know that a bulk of the test is about advanced cardiac questions you never run into. I guess nothing is going to be that fine-tuned, however.

Don't talk politics

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Mon, 09 Apr 2012 05:21:00 +0000

I figured out one way to ruin a conversation at the family Easter dinner: talk a nurse practitioner student's ear off about the doctorate of nursing practice.

The poor student I was probably cornering agreed with me that the doctorate shouldn't be required, but I think they were taken aback by how much I thought it was unnecessary. I felt kinda bad, because I don't usually declare a position on anything in casual conversation; let alone things that don't directly affect my immediate life. Maybe I'm just being nuts about it.

I think I should modify or clarify my position. I think a doctorate-level position is fine, possibly unnecessary or inefficient in today's (or any) market, but I'm also not "there", not at that level, and I don't know what the extra classtime and clinical orientation adds to the table.

I still think the American Academy of Colleges of Nursing looks like a lobby for expensive academic institutions, and I don't like how they're trying to squash the more efficient, less costly associate-level nursing colleges. I still think this is mainly driven by a spirit of competition with, or a desperate need for respect from, medical doctors. And that's obviously ridiculous.

I still think this has the potential to dry up the supply of potential nurse practitioners, anesthetists, and APNs. Why bother? The only benefit to this academic route over, say, medicine, will be if you already have a nursing degree and can continue along that route. That means not much new blood from high schools or colleges, from people outside of nursing.

In other news, Happy Easter!

Repeat c-sections vs. VBAC

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Wed, 28 Mar 2012 17:29:00 +0000

Just wanted to draw attention to an excellent article over at S&S:

Science & Sensibility » Is Elective Repeat Cesarean Surgery Truly Safer Than Planned VBAC?

The short version is that in recent studies a vaginal birth after cesarean only has a marginally higher absolute risk over repeat c-sections. And this risk might be attributable to modifiable obstetric practices, like using induction drugs which are known to cause uterine rupture (!). The risk seems higher among practitioners who frequently abandon VBAC attempts and resort to a c-section--leading to, I would imagine, a higher instance of hemorrhage during an intrapartum (in-labor) c-section?

And none of the recent studies have taken the long-term effects of the cumulative scarring of repeat c-sections. I know some women who have had five, six, or seven repeat elective c-sections (I call them automatic c-sections), all because of an initial section. I know this is anecdotal, but some of the women certainly had problems later on, whether with their labors or with their babies. Makes sense.

Ruining Nursing: the Doctor of Nursing Practice requirement

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Tue, 27 Mar 2012 23:53:00 +0000

I work with a very smart, well-experienced ER/ICU nurse who has been working for a couple years on gaining entry to a nurse anesthetist (CRNA) program. She's considering abandoning it all, however, because all the programs she's applying for have changed to Doctorate programs. This is to be in line with the requirement that all CRNA programs become Doctorate level by 2015.

What this means, she said, is that the CRNA programs will still take three years to complete, just like when they were Master programs; however, 30 more credit hours will be crammed in, and the degree will cost $30,000 more. That's not chump change, especially when tuition is already $60,000 or more, and you already have to sign an affidavit swearing not to work and live off of loans. The total cost is already upwards of $100-150,000. And, like with the bachelor's versus the associate's for regular nursing, you're not going to get paid any more.

The selling point of the CRNA, especially in this day and age of healthcare reform, is that they cost less to train and operate than an anesthesiologist. One anesthesiologist MD can supervise an OR suite with several CRNAs for a fraction of the cost of several anesthesiologists. Outcomes consistently have been proven to be the same. So why would schools want to make it harder to become a CRNA? This nurse I know can't be the only well-equipped RN who is seriously reconsidering her plans to become a CRNA because she now has to become a Doctor of Nursing Practice.

The same story is happening with nurse practitioners. Their selling point is equivalent general care at a cheaper cost than a physician. However, nurse practitioner programs must start churning out doctors by 2015, and many programs are jumping on the bandwagon now to get a larger market share of the students.

What's the deal? The American Association of Colleges of Nursing is the lobby for bachelor and graduate nursing colleges. They seem to be a machine for nursing academia. Years ago they established an academic doctorate for nursing, the PhD in nursing. They've been fighting for a practice-oriented doctorate as well. In recent years they've adopted position papers, plans of attack, and outlines for academic change to force a transition to doctorate-level education.

It seems they've won.

What gives? Here's what I think is happening. Academic nursing is fighting for its own existence and respect, regardless of what it does to real nurses and nursing practice. This has been going on since the 1970s. Academic nursing rejected the idea that we're just "handmaidens to the doctor," that we're just a technical trade or service trade, rather than professionals. Independent nursing faculty and schools were created to replace the doctors who used to train us. As good as this backlash is, some of the results have been nothing short of ridiculous. Nurses can't diagnose things like pneumonia; therefore "nursing diagnoses" like "impaired respiratory exchange" were invented so we could diagnose alongside doctors. Hospital nursing schools were abolished despite a nursing shortage. Associate-level nursing programs have been under attack for decades, despite supplying (and preparing well) the gross majority of America's RNs. It's been suggested that all bedside nurses should have Master's degrees, a suggestion which could destroy American healthcare overnight. And an entire academic subculture of "nursing science" and publication was created, some of it worthwhile, some just serving to support the academic establishment.

The worst of it right now is that academic lobbyists like the AACN, as well as nursing theorists, professional faculty, policymakers, and others who don't necessarily work in any professional clinical setting, are pushing for higher and higher educational requirements so we can appear to compete with medical doctors and so cush academic jobs can still exist. Practical jobs like the CRNA and the NP, which could really help the economy and really help people, are being elevated beyond practicality so the academics can feel better about our industry.

This same AACN laments the current nursing shortage. I don't think they get it. But lobbyists seldom do.

Wrongful birth?

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Wed, 21 Mar 2012 05:56:00 +0000

This is probably a bad post to write. If you don't like reading abortion talk, maybe you shouldn't read this. It's nothing personal though.

People are talking about this "wrongful birth" lawsuit where a Portland couple sued their obstetrician for failing to detect their daughter's Down syndrome. At two weeks old Kalanit Levy was diagnosed, and now that she's four years old the parents have sued, saying they would've aborted. The couple, Deborah and Ariel Levy, was awarded $2.9 million. The reaction is generally pretty negative. Arizona is trying to ban this sort of lawsuit. Even writers defending the case seem kinda squeamish about it.

The thing is, this is bound to happen. These people aren't abusing the system. This is the system. If abortion is available, and genetic testing is available, then this is going to be a reality. These parents deserved the same right as the estimated 87-98% of parents who currently terminate their Down syndrome offspring before birth. Nobody bats an eye at that.

Here's your options. Either you drastically limit abortion to, say, medical necessity, or you don't limit at all. Fighting for abortion rights but then taking them back when it's something you can't handle, like when it looks like eugenics, or when someone sues because they didn't have the chance to abort that everybody else gets—you can't do that. If you're pro-choice and can't stomach this, you need to reexamine your ethics.

GEE I'M GETTING USED TO THIS PEDIATRIC EMERGENCY ROOM!

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Wed, 14 Mar 2012 18:01:00 +0000

My three-year-old girl has spent a month or two thinking she's Clifford the Big Red Dog. Aside from telling everyone this, "ruff"ing in answer to things, and correcting us when we call her by her name, it also entailed running around the house on all four limbs. Let me tell you, with a month of practice a limber child can get pretty speedy doing that.

Well, she was flying across the living room and crashed right on her chin into the wood floor. She stopped crying within minutes (hey, she's the fourth child - she's pretty tough) but the split was gaping, so off to the ER we went. The four-hour $700 stay resulted in some skin glue. I spent most of the time thinking of three things:

1. Hospitals (or some healthcare entity) really need to establish non-emergency rapid care centers. I know urgent care clinics and day clinics exist, but they're rare or never open when you need them. Why would a busy, overcrowded, patients-in-the-hallway, 70,000-person-a-year ER not have an ambulatory or urgent clinic right next door, or down the hallway, or across the street? Why does each ER physician, nurse, and tech have to divide their attention between simple lacerations, car wrecks, and meningitis? Oh, your tooth hurts? Hang on, I'm also busy discovering this guy's malignant life-threatening brain tumor. Not only does this waste everyone's time, but it also must raise costs insanely.

2. The Disney Channel really needs to cater to late-night ER visits. What they show is reruns of those atrociously terrible teenybopper shows like iCarly. The only glimmer of happiness provided in between the horrendous hours of awful bad acting were the Phineas & Ferb commercials.

3. I really need to obtain my own damn skin glue.

Statin-induced cognitive impairment

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Mon, 12 Mar 2012 06:00:00 +0000

I've discovered the reason why I never post in this blog, why I never accomplish anything, why I forget simple tasks, etc. The FDA added new warnings to statin drug labels, including that in very rare cases statins are reported to cause cognitive impairment and memory loss.

Just need to find an explanation for the juvenile dementia in the prior three decades of my life.

Interestingly enough, googling "statin warning" pulls up several front-page results on what to do and what your rights are if the police arrest you at a gas station. I did not know such a topic existed. Also, there's a blog called "gas station without pumps" which posted about the statin warning, so that's definitely front page on Google now. As will this post when I start talking about my upcoming statin-induced confused rampage through gas stations across America. Complete with a photo. See?

On hopefully the good side, however, the FDA got rid of the need for repeated liver enzyme checks because statins pretty much never cause liver problems. This is a good thing, since the docs I see never seem to know what to do with those numbers anyway. (I mean, justifiably - I'm not cirrhotic, I don't have hepatic failure, etc. What do you do with normally fluctuating numbers in a normal walking-around person?)

I used the FDA link above, rather than a news story link, not because I like the FDA but because frankly I think the news industry does a lousy job reporting medical issues and I don't want to further promote their status as the single most important distributor of medical information to the public.

p.s. if you don't recall, I started using statins a couple years back when I discovered my LDL cholesterol was well over 300 and my HDL was in the toilet. I don't really like the idea of taking a drug to fix things, or blaming "genetics" or family history, but not even losing 20 pounds and frequent exercise and taking the normal starting dose of a statin really moved my cholesterol much. I know some people dispute whether a high LDL means anything, but frankly I'm not taking chances.

Writer's Block

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Sat, 18 Feb 2012 15:09:00 +0000

I just woke up from a dream about this blog. I dreamed that another blog writer was in an uproar about my fat baby post, and had done some sleuthing and tried to identify my wife and I by name—except they identified us as my distant cousins in another state. Bizarre. Anyway, I've had a bad case of writer's block about this blog for at least a year now.

Gratuitous Calvin & Hobbes illustration

Part of it is because of fears of being found out. Not that I think I'm doing anything bad, but blogs are not well understood. I don't think I'm overreacting when I say that I'm afraid of my company's "no tolerance" policy. They apply it mostly to social networks, e.g. talking about a patient on Facebook; but I doubt blogs get special treatment, even if they don't violate privacy. I'm just wary of having this blog "discovered" and subject to rash scrutiny. No tolerance is no tolerance, and I'm thinking there's not much room for subtlety or nuance. I don't think I violate anyone's privacy (patient, coworker, myself), the knee-jerk reaction to "blogging about your job" in the world of medicine is not a good one. I'd probably be assumed guilty before proven innocent, and I don't know I'd even get a venue to prove innocence. Of course, if I were some respectable attending physician, I'd probably be fine—heck, even picked up and featured by marketing! But I'm just a hospital employee.

Home life is busy too. The baby is starting to sit up, greedily grab everything within reach, and she has a tooth crowning. She's only six months old! We got a dog (are you crazy? I hear you scream) which has been a project in itself, although he's a very good dog. Settling into and fixing and modifying the home we purchased has taken its fair share of time. In fact, here's a handy flowchart to my writing process:

There's also the fact that I'm getting comfortable at my job. Nursing school and being a new nurse provided me lots of material for blogging, since those are hectic worlds full of idealism, issues, and controversies. Now that I'm settling into being a good ICU nurse in the real, practical world, it seems harder to write. Many things are too technical and nuanced for writing. Or I realize that the system of modern medicine, while broken, still works pretty well. In some areas of inefficiency or less-than-ideal practice, I realize I can't think of a better solution, and that makes me shut up. But there are still things I could write about, I'm still learning, and besides I'm still unsure about myself when the proverbial C. difficile ridden human excrement hits the proverbial fan.

Just the other day, in fact, I had your "classic" ICU transfer: we're bringing you this young patient, obviously crumping and going to die, probably been dying all day but no one can figure out what's wrong, here's a really insufficient report because the night shift floor staff doesn't know this person from Adam, by the way there are no good ICU physicians on consult and the residents are all out of the hospital at a class, HERE YA GO! I needed the help of three or four nurses, poured in fluids, started pressors, hung drips, took them back down, scrawling drug calculations on paper towels at the bedside, started lines, enlisted doctors to the bedside who weren't even on consult, etc., and in the middle of all this I'm talking to and trying to reassure the young spouse who has to go home and take care of little kids. All this time the patient is laid out and not moving or responding to anything—in the back of my mind, I'm thinking probably nobody's home. Come to find out days later the patient is weakly nodding appropriately to questions, which is a huge, huge thing in our world. And all I could think was...they pay me for this? I mean, I really saved a life that night. If I found a guy down in the street and did CPR, I wouldn't expect someone to walk up and pay me $30 an hour for my efforts. Nursing is weird like that. See? There I go talking about patients again. How do you write about being a nurse and not bring up individual stories? Hence, writer's block.

I've also been downshifting into what you might call lazy adulthood. I'm entering my thirties, and for the first time in my life I'm making decent money and don't have to go to school. Granted, my job would like me to get my bachelor's in nursing, my CCRN, eventually a master's...whatev. I mean, I endorse all these things, but you know what? My paychecks are still coming in, and they won't go up when they do these things. My focus right now is on enjoying life with my family, enjoying my house, building my finances...and walkin' my dog.

My Son vs. His Toe

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Tue, 13 Sep 2011 09:23:00 +0000

This story might be gross. Just warning you.

My son broke his big toe. Yes, it was that son, the four-year-old who's always hurting himself, the one who's always getting into things, the one who got attacked by poison sumac with a vengeance. He flipped off a bench he was crouching on top of, and the bench slammed down on his toe on our tile floor. Ouch. What's worse is that we had just come home, it was 9 o'clock at night, and we were busy putting things away and sorting children and trying to get ready to get ready for bed (an arduous process around here), and I didn't really pay attention when he hurt himself--he's always doing it, right? So he actually had to hobble over to me before I noticed that he was crying a little more than usual and there was blood all over the floor. That's probably when I earned my dad of the year award.

I carried him to the bathroom and realized we probably had to go the emergency room. The nail was loose and already reddish-black, he had a big laceration down the front of the toe, and he was crying so hard he was almost dry-heaving. I felt so bad for him. I tried to gently wrap it and put ice on it. We arranged for a "babysitter" (my wife's brother...in other words, just an adult body to remain in the house, and most likely the kids would be up eating candy and watching movies all night) and I carried him to the van. He stopped crying so much and became more concerned why we were going to see a doctor about it. Poor guy. Then we drive to the hospital with a crying baby and a crying kid with a bleeding toe.

Luckily the hospital is so close. I carry him into the emergency room and he stops crying. The registration person at the desk asked me his name and birthdate. I can never remember his birth year. This happened a while back with my insurance company, too. She tried to calculate it with me -- let's see, he's four, this is 2011, his birthday is X, so... Then my wife walks in after parking the car. It turns out, ironically, that our registration lady is the same person who registered us at a different hospital's emergency department a few years ago (with the same kid, I believe) and once or twice over the years has seen us at church. So she recognized my wife! Which is nice, though it doesn't seem like a generally good thing for ER registration people to start recognizing you. At any rate, she and my wife are discussing on our new family events (new births, etc) while I'm wheeling him down the hall to triage.

The triage nurse unwraps his foot and his toe is still bleeding pretty hard and looks awful. She asks him how it feels and he, trying to look unconcerned, says "It's fine."

She gave him some ibuprofen and sent us for an x-ray of the toe, which I figured was just a formality. I assumed he just needed some sutures.

Eventually we get to a room in the pediatric ED, and we wait. And wait. Eventually we're seen and the doctor informs us that the distal phalanx was fractured. He doesn't know if this will require pinning or not so he'll send us for a consult first thing in the morning for a plastic surgeon or a podiatrist (it's now 11pm or midnight). He shoots the toe with some lidocaine and sends the ED tech in to irrigate and clean the toe.

Do you see it?

The tech was very nice but very busy with lots of kids, being the only tech in the pediatric wing of the ED. At that point I felt like telling them I'm a nurse and volunteering to do whatever they need done--I had the impression the doc could work on the toe now, but had to wait for the irrigation to be done, so he had moved on to other kids.

During the clean-up the hard-working tech told me all about how he was a single dad of a few kids, since his kids had flatly insisted on staying with him after the divorce. He pulled a lot of hours as a paramedic and ER tech to put them through school and now college, spent the rest of his free time with them being a dad, and said he was going to vomit if another woman told him what a nice guy he was (since he's developed the theory that women say they like nice guys but really they like total scumbags.) I hope he didn't mind me as a fellow hard-working dad telling him what a nice guy he was. Readers--high-five that guy.

Anyway, back to the toe. After another long wait the doctor wants to suture the toe and see what he can do about the nail. The nurse has the foresight to have me hold a towel up so my boy doesn't have to watch it (why don't physicians ever think of these things?). But it's still not numb. Apparently big toes (and thumbs) are hard to anesthetize. He has to inject and re-inject the toe probably a dozen times to try to get to the nerve root. And this is what really hurt him the most, after the initial injury. He was crying but he tried so hard to hold still, and when the towel I held up slipped a bit he grabbed it and threw it over his own head. Still, as much as he squirmed, he held that leg totally still.

The doctor left to wait for the toe to numb up. My son tells me "I wish I was made out of metal."

The toe was sutured up but the nail was a loss. Removing the nail took forever. My son fell asleep during it (thank God for lidocaine). My wife had to leave the room to avoid passing out. I was a little grossed out myself. That's the irony of blood and guts, by the way. If I was in charge of the toe, I would've been fine. As it was I still had a job to do, so I was okay watching it but a little queasy. If I just had to stand around watching it, or if I had to hear about it, I'd want to barf. (Yeah, I know. I'm making you hear about it. Sorry!)

The doc asked me if I want to save the toenail. I was surprised but he said they could possibly clean it up and try to suture it back on. That sounded like more of a hassle (trying to keep it from getting caught on things, trying to keep it clean). It got forgotten about and tossed with the trash, however, so it's a moot point.

The tech redresses the toe. The physician assumed I'd see a doctor first thing, so he thought one dressing was enough, but the tech had the foresight to stuff a bag full of dressing changing supplies. Which was great, because we couldn't see somebody first thing.

We go home around 1AM, go to sleep, and call the consultant in the morning. It's Monday morning at 8:30 and I'm calling the office as soon as it opens. It turns out he's a hand plastic surgeon, and doesn't do feet. His secretary also said this was the second injured toe call they had since they opened, and somebody in the ER needs to stop referring toes to him. I call back to the pediatric emergency department and talk to a nurse who gives me the number of their pediatric orthopedic surgeons' group. With this unofficial (yet obviously accurate) referral, I went there the following day.

We waited in the waiting room forever. We watched Phineas & Ferb for the first time, which is a grand show. Finally we see the physicians--the orthopedist, his resident, and a pediatric resident--and they say there's no surgery to be done, keep it clean, he can walk on it all he wants, but--get this--try not to let him run or jump on it too much. Ha. Ha. Ha.

For the next week we keep him from jumping on the trampoline and riding his bike. Which was sort of like trying to tell him not to eat and breathe.

We're supposed to follow up with an appointment with the orthopods, not for an x-ray or anything about the bone, but so they can look at the nailbed. The nailbed is healing great and, for a gross-looking ex-toenail, is looking fine. So of course, me being a nurse, and a nurse with a high deductible health plan, I haven't bothered to set that appointment yet. I probably still should. Especially since he's gotten in fights with his siblings, kicked things, and had his toe stepped on I don't know how many times.

Do I sign my kid's birth certificate? Do you know any lawyers?

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Thu, 11 Aug 2011 06:08:00 +0000

In the past, I've signed my children's birth certificates as the "attendant". This is not something I really ever planned to do. I think it originally just sorta happened. You go downtown and find the vital statistics people in the basement of the courthouse where they create these arcane documents, and when you say that you didn't have a licensed medical attendant, and there's an empty line to be signed, somehow you end up signing as the father and as the attendant.

I also vaguely recollect a midwife claimed once that whoever cuts the cord (this being, she also claimed, the only 'medical' act that occurs in many home births) is the attendant. But that's probably false—on both counts. It still probably reinforced my mental justification for signing.

Now I'm not sure that's a wise thing to do. It might have been fine when I was an unlicensed nobody, but now that I'm subject to the Nurse Practice Act I'm afraid I could be accused of practicing nursing outside of a licensed facility. Or practicing medicine, that old standby. it just seems I shouldn't have my name on a public record in the capacity of a birth attendent. I've never had a felony. I've heard those things stay on your permanent record.

This could be a viable alternative.

But wouldn't family be exempt? I would assume it would keep me exempt just like before. Assuming I was ever exempt. Did I say I signed anything? I meant hypothetically. My, uh, friend signed it.

I'm just not sure what the alternative is. Would my wife sign as attendant? Should it just be left blank?

IT A GRIL

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Sun, 07 Aug 2011 02:36:00 +0000

Go to Cakewrecks. It's funny.

We totally had a baby yesterday. It went like this. A couple days of false labors starting and stopping. Then yesterday morning she's going into what seems like real labor, in the bathroom, while I'm going about the house cleaning up and getting the kids ready to go off with Grandma. Then the midwife arrives and I pop into the bathroom to see how the wife is doing. I'm sorta surprised to see that she's having these really long powerful contractions pretty close together! Glad I was paying attention.

The next few hours develop as labor tends to do, getting harder and stronger and more intense. This one seemed more painful than the rest. The baby was originally posterior and we weren't sure if she had turned. (Posterior labor = badness.) At one point she had my hand in a death grip, crunching my finger bones against my ring. It's just kinda funny because it's not like I can complain, right? Another time she had her face on my knee while I was sitting next to her, and I thought...I don't know what I'm going to do if she bites me.

At one point the midwife said there was a 'lip', where the cervix or some other woman innard gets caught under the descending head, so my wife had to stop pushing. She almost couldn't handle that, and I thought we were in for a day of misery. But after a bit the midwife determined she could start pushing again. And then things started moving fast. Really fast.

I don't know if you're squeamish, but at some point after that the midwife calls my attention to the posterior region. The baby's head is already totally out—but still in the bag of waters. Imagine a baby's head in a water balloon, sticking out of somebody. A WATER BALLOON. Despite four other home births I've never seen that before. In fact, we had one other baby 'in the caul' before, but that midwife broke those waters before I saw. The midwife didn't have to break these; her arm was half-up and in a show of baby might she shoved it out of the bag herself.

She popped right out and was in mom's arms. After a little while she was nursing like a champ.

Right away I could tell she wasn't as big as the last baby (11 lb 6 oz). We guessed weights with the midwife, and we all agreed she was probably in the 9 to 10 pound range. Ironically I'm getting handy at gauging babies in the upper bodyweight divisions. Actually she looked small. And she still does. A pound makes an enormous difference in a baby. And despite the 'lip' and the pain, my wife said it was a much easier labor than last time—understandable right? Actual weight: 10 pounds 4 ounces.

She's a doll. She's cute and easy to please. Well, all babies kinda look like chubby old men, but as far as miniature chubby old men, she's cuter than most!

Uniform policy time.

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Thu, 28 Jul 2011 10:37:00 +0000

Pregnancy update: which is that, um, we're still pregnant. We're past due day three now, I believe. This baby is low. Everyone applaud my wife for going to the gym yesterday! Everyone boo for that not instigating labor, however. Though I would've felt kinda bad for her class instructor if she went into labor then.

-----------------------------

There's a semi-confirmed rumor at work that we're going to adopt uniforms for nurses. This will be house-wide—every RN in the hospital will wear the same thing. The argument is that patients have complained that they don't know who the nurses are. I've heard this argument elsewhere, and I frankly don't believe it. If someone comes at you wearing a stethoscope and carrying a needle, you can kinda figure they're not the housekeeping staff. (If they're are, at least you'll be on the news.) It takes about three milliseconds for a nurse to introduce themselves and establish a professional rapport with the patient they'll be caring for over the next 8 to 12 hours. Do patients forget in that timeframe? Probably not.

I think in all truth it's the physicians who are complaining. We're a huge teaching hospital, so there are literally thousands of physicians. Outside the circle of residents and specialists you always see, I don't know most of these doctors from Adam (or Eve). And they're lost wherever they go, especially the poor primary care physicians trying to find their patients. I'm sure they've complained that they can't readily identify the nurse for their patient, standing at attention and waiting for orders. Heck, they usually can't even find or recognize their patients, but at least they have gowns on.

But on the other hand, I do have to agree that we nurses are a bit, shall we say, casual. At least where I work. The hospital and individual units have frequently issued t-shirts. They bear hospital or unit insignia with varying levels of discernability. They were made back when they were trying to achieve Magnet (big nursing award) status and instill unit pride and all that. Probably more than half of us wear them to work. But I have to admit that a t-shirt and scrub pants feels like working in pajamas.

In fact this was about to be my next scrub purchase. Including the pipe and slippers.

Half the time my stethoscope has been flung somewhere and my ID badge is flipped over or hanging off my waistline or hiding, so I can understand that you probably can't figure out who I am if you don't know me. Of course, like I said, my patients know me; but random physicians appearing at random times who are already frustrated at not being able to navigate the unit and find charts? Not so much.

To make matters worse, some people *shifty eyes* have gone on to just wearing plain t-shirts when they're running out of work shirts. Or we sometimes wear the hospital-issued green scrubs, so we look like residents.

So I know I'll feel more professional if I'm forced to actually wear scrubs. But in the meantime, I'm going to keep looking like I'm at a pajama party because that's what's allowed and it works for us. If I thought that patients were really misidentifying me, I'd worry about it. But you know what? People will still think I'm a doctor even if I'm wearing a white dress, white tights, and a red cross on my hat.

I HAVE NOT POSTED SINCE MARCH OMG.

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Wed, 22 Jun 2011 12:11:00 +0000

What a busy couple of months. So we bought this foreclosure house which has occupied pretty much every waking hour aside from work. It's structurally sound but a combination of neglect and a former owner who thought he could DIY a lot of this stuff equaled a lot of work for us. We had to fix the plumbing, yank out old wiring and satellite cables, rewire a bedroom and a bathroom, repair the drywall in almost every room (and ceiling), paint every everlovin' surface of the house, play some more plumbing "where is this leak coming from?" games, clean out the gutters (organic sediment since 1994, probably disposed of some good fossils), rehabilitate the lawn and kill some grubs, install some appliances purchased on Craigslist, fix said appliances purchased on Craigslist, and I don't even remember what else. It culminated in having electricians discover exposed live wires (thx former owner) all over our attic. My favorite part was when my wife's aunt came over and, looking over the ladders and tarps and paint cans and dust, asked who was doing all this work for us - who our contractor was. I am my contractor. And I'm a pretty unsatisfyingly slow one.

It's been a learning experience for sure. I had no idea how to do 90% of these jobs, but thanks to the internet and a couple of how-to books—that sounds safe, right? :-) Makes ya want to live here. Anyway, I have tools for everything now. I'm mostly impressed by the fact that I can fix walls. Got a hole in a wall? I can make it disappear.

For all this work we're getting a nice brick home on a beautiful lot that's double or triple the average lot around here in the city. The kids love it. It's close to family and my job. It's good.

Now we have to unpack and settle in.

In other news, baby number 5 is slated to emerge in August. My wife is feeling okay, taking a lot of naps. It's hard to schedule midwife appointments in with all the other work and house stuff going on.

In work news, I am forgoing the BSN program. I'm a bit busy, no? I am thinking about doing a little CCRN preparation. The coworkers were listening to the Laura Gasparis review CDs (well, mp3s these days) and she was hilarious.

Thanks for the well-wishes and the concerned comments and emails. We're doing well. Just really busy!

The Bachelor's of Nursing. Tell me again why I should get it.

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Mon, 07 Mar 2011 16:17:00 +0000

Some days ago I was assigned a nursing student from a university to follow me in the care of one of my ICU patients and give certain meds under supervision. I've done this before and I'm always surprised at how easy they have it. The instructors, when they come by, are very nice, helpful, and never expect them to know anything. For instance, she was asked how many units of insulin the patient should get, and she hesitated a second and then seemed to venture a guess. The instructor teasingly called her out on it. A guess? In my day, if I hadn't been prepared with an answer, let alone tried to guess on a medication as important as insulin, I would've had my head stuck on a pike in front of my school as a warning to students forever.

Like 57% of nurses in the US, I was prepared by a community college and received an associate's degree in nursing. So tell me: do you think I will learn anything more about taking care of sick human beings by completing a bachelor's degree in nursing with her university? Because I could. The school is associated with my hospital and will get paid by my hospital if I go there.

No one in nursing acadème or nursing administration comes out and says that an associate's degree is not enough to be a nurse. But they do fixate on the idea that it's not enough to be considered a professional. Not enough to be considered independent or autonomous. Not enough, in other words, to compete with physicians. Going back at least to the 1980s, nurses have been trying to get out from under the paternalism of physician-led healthcare. The general public thinks we're just order-followers, med-passers, and scalpel-hander-overs, and we're still trying to shake that image. For some reason, we think the only way to shake it is with academics. So there are countless RN-to-BSN programs out there, and our hospital system will gladly pay for us to go through them—so I can't really complain that they want us to do it.

Okay, yes I can.

It's kind of silly. My degree is a two-year degree. The four years at a university school are typically divided between two years of general education and two years of formal nursing. In other words, it's a two year degree. But, they say, a university program also includes coursework on research, community health, ethics, and nursing theories. So did mine. So what's the formal difference? A formal degree. Something that academics and administrators can point to. But probably not anything that's going to help you in the care of sick human beings—in bedside care.

The irony is that at the same time we ADN nurses are encouraged to get our BSN, we're also told we don't need a BSN to be good nurses, and that the BSN program is not going to teach us very much we don't already know. They might as well say: it's basically pointless, or it only helps a little, but more importantly it achieves some ulterior goal aside from improving you as a nurse. Goals like being able to say you have more BSN-prepared nurses for your Magnet award application.

The reality is that a nurse doesn't need a higher-level liberal arts education in order to be a nurse. That doesn't make us unprofessional. There's a science to nursing, but there's also an art; there's a logic to nursing, but there's also a knack. We don't like to admit that we're basically like car mechanics, but we are. We know can interpret pulmonary measurements and blood gases, but we can also just eyeball a patient and have a good idea if they'll fly or crash when taken off the ventilator. How different is that from a mechanic who knows how a catalytic converter works but also knows whether a knocking sound is benign or bad? The idea that an academically-prepared professional must fix your body but mere 'skilled labor' can fix your car is absurd. The difference is the degree of knowledge, not the category. Whether you're a car mechanic, a nurse, or a neurosurgeon, you're basically exercising your knowledge as you do tasks. This includes physicians. Physicians are not artists or philosophers. They're task-oriented like everyone else.

What does this have to do with my BSN? Well, since physicians are in the same ballgame as the rest of us, and not an elite group of Ph.D.s, I don't see the need to compete with them academically as long as I can achieve my goals in patient care. I've never met a resident or physician who cares what degree I have. They care about my license and expertise.

But I'll go for it. I'm open to learning new things. It's a stepping-stone to advanced practice, and I don't have to pay for it. But I still kinda worry about the efficiency and efficacy of this: in five years, will it matter than I spent this much time and effort away from my family to do this? Will I think I wasted my time? Most likely there's no increase in pay or status. Am I just submitting to some outdated dream of nurses who abandoned patient care for academic politicizing? I don't know. I just hope this effort helps me more than it helps them.

That's no excuse!!

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Sat, 19 Feb 2011 19:44:00 +0000

Sorry for the dearth of posts. We're trying to buy a house, for real this time.

Also...we are pregnant.

I'm not going to say how many kids this makes.

Surviving the Blizzard

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Sat, 05 Feb 2011 13:37:00 +0000

We were shortstaffed, had no nurse's aides, our supply of linen was cut off, doctors weren't calling us back...in other words, it was a typical night shift.

My normal commute to work

Our blizzard shifts really weren't that bad. Getting to and from them was an issue. Some nurses drove four hours to get to work. But within the confines of the hospital we were sheltered from the weather, got free food, had the ability to sleep over if we wanted, etc. Several stayed for 16 hour shifts or even slept over and stayed inside the hospital the entire three days. Other than that, things were pretty normal. I know, it's disappointing that I don't have any heroic stories of saving people who were half-frozen and stranded on the highway, or buried up to their armpits in snow. But I think most of the populace was pretty sensible and stayed indoors. An ER nurse did tell me about a few heart attacks from shoveling snow (lesson: stay in good cardiovascular shape the rest of the year!). And that some people came in completely covered head-to-toe with snow. So did I. But at least I didn't have to walk or dig my car out. Luckily, I got rides to work.

Yeah....no.

I think we were all subconsciously affected by the constant news reporting of how everything in the world had shut down - so everyone within the hospital was moving slower. Things were relatively quiet. It seemed like we shouldn't do anything non-essential.

The kids loved it, of course.

The only thing better than a trampoline is a SNOW-COVERED TRAMPOLINE!!

I took more photos, but they're your typical deluge-of-snow images you can find everywhere. My favorite photographic article so far is at the Daily Mail UK, including a satellite composite image showing most of the Northern Hemisphere under ice and snow and many amazing pictures of how completely the snow shut our city down.

Breastfeeding and SIDS prevention - and sleep apnea? and orthodontics?

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Sun, 30 Jan 2011 11:20:00 +0000

Brian Palmer is quite an interesting dentist. He has an entire website (albiet in premodern html) devoted to the importance of breastfeeding. He maintains that infant feeding techniques have an enormous impact on the human oral cavity and airway, which in turn has an effect on infant problems such as SIDS and ear infections, adolescent problems such as overbites, and even adult disorders such as obstructive sleep apnea.

I won't get into all of his hypotheses here, but I was interested in what he says about SIDS. Human babies have unique mouths and airways. Their epiglottis, or the flap that covers the airway when you swallow, is high up in the back of the mouth. It comes into contact with the soft palate, or the soft back of the roof of the mouth. The soft human nipple encourages the tongue and lower jaw to come forward in the mouth, and pulls the epiglottis up, reinforcing its position.

The epiglottis is that thin white thing clamping onto the back of the roof of the mouth, preserving airflow from the nose to the lungs. From a slide by Palmer.

This is the position all other mammals have as well. It lets them hork down food more safely while still breathing. Eventually, however, your baby's epiglottis will adopt a position lower in the throat. This is weird and complicated and unlike other mammals, but it does two things: it enables human speech, and it enables the tongue to drop back and block the entire airway (which is what happens with obstructive sleep apnea). But you were breastfeeding, so your kid's tongue and lower jaw will be anatomically correct position: forward and away from the nose-to-lung airway path. Human nipple feeding also molded your baby's hard palate (the bony roof of the mouth), making it wider, which enhances airflow around the tongue.

Note the gap between the epiglottis and the roof of the mouth, allowing the tongue to nearly block the airway. Also note the lower jaw is pushed back. Palmer notes this adult probably had sleep apnea. In an infant this may cause SIDS.

Using a hard preshaped plastic nipple pushes the tongue and jaw back and the epiglottis down. It also mis-molds the hard palate into a more narrow shape. Excessive pacifier use does these things as well. Significantly, the epiglottis drop normally happens after the age of SIDS prevalence (5-6 months or so), presumably when the baby can stir itself to reposition and breathe should the airway become blocked. Forcing this to occur early may be a contributing cause of SIDS, allowing the tongue to fall back and block the entire airway.

You can read his presentations (in PDF format) on SIDS and breastfeeding here. They're a bit anatomy-heavy but have fun slides like this:

Those are some nice teeth.

He also theorizes that this same process of bad mouth molding due to poor infant feeding practices contributes to obstructive sleep apnea in children and adults, otitis media in children, of course there are the dental and orthodontic implications of having your bite messed up by plastic nipples and pacifiers. I haven't even begun to dig through his three-part text The Importance of Breastfeeding to Total Health which may cover all these topics more generally.

Maybe this doesn't seem interesting to everyone, but to me, SIDS is a perplexing event that requires explanation. Also weird is the occurrence of "difficult airways" at work: people who are just really difficult to intubate. Sometimes it's due to overweight, or biting, but I wonder how often it's due to misshapen palates, jaws, and oropharynxes. A difficult intubation in an emergency can be absolutely fatal. Breastfeeding might help in more ways than we have previously imagined.

The Illinois Home Birth Safety Act did not pass

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Sat, 22 Jan 2011 19:06:00 +0000

Get 15% off a scrubs jacket with promo code "jackets_t3c"

So SB 3712, the Illinois Home Birth Safety Act, did not pass. Despite passing the Senate it failed to pass the House by a larger margin than any of us thought it would, mostly because the Illinois State Medical Society went completely apes**t about it.

The good news is that they really paid attention to this bill. You can see on their website that the ISMS is still freaking out about the midwife bill:

Seriously? Seriously.

The bad news is that the ISMS and the American Medical Society (which is centered in Chicago) have a lot more money and lobbying power to defend their market. It's amazing to what extent the Illinois State Medical Society was willing to jump to conclusions about midwives to scare people about this bill, neglecting to mention that more than half of the United States can safely use legal certified professional midwives. But despite the ISMS's "action alerts," nobody I know in real life was concerned about this bill, and most people didn't even know it existed. I don't think their campaign reached that many voters. Maybe it wasn't intended to. But apparently enough State Representatives were concerned about this bill -- representatives who probably don't have to answer to too many home birthing families at fundraising dinners. Physicians and physician lobbies are another financial matter altogether, and probably explains why a disproportionate number of reps were concerned when the general public and the news media were not. This is what the ISMS means by "physician support" against the bill.

The fact of the matter is that physician groups in this state, notably the ISMS, the American Congress of Ob-Gyns, and the American Medical Association, have a history of refusing to look at new and more efficient models of care, regardless of what the people want. They fought or tried to restrict the very existence of advanced practice nurses, nurse practitioners, nurse anesthetists, and nurse midwives, and they lobbied against and tried to restrict pharmacy clinics. This despite the improved patient safety, patient outcomes, and decreased patient costs that these entities have brought to Illinois. CPMs are another group of practicing professionals who, despite being tested and proven in the rest of the USA, threaten the inflated practice costs and the exclusive domains of practice that physicians are trying to maintain.

The Illinois State Medical Society is right: some form of this bill will be back. It has to. Our society and our market are not going to continue to support the higher expense and poorer outcomes that occur when birth is the exclusive domain of surgeons and hospitals. The only thing holding it back is the money physicians already have, and in this economy that might not last forever.

You can read my summary of SB 3712 The Home Birth Safety Act here. (Be careful, it's soooo scary.)

Gabrielle Giffords and the drama of neuro-intensive care

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Tue, 11 Jan 2011 12:58:00 +0000

US Rep. Gabrielle Giffords

Last night it was interesting watching Anderson Cooper and Sanjay Gupta sort of stumble over trying to describe the medical care someone receives after surviving a gunshot wound to the brain. They were, of course, talking about the assassination attempt on Rep. Gabrielle Giffords. They didn't seem very certain what they were talking about (at least, that's how it seemed, but it was closed captioned and I was running on a treadmill) but the AC360 blog video, "What Helped Giffords Survive Brain Shot", is a lot more clear. It's interesting to see the public news media grappling with the strange concepts that are dealt with in neurointensive critical care on a surprisingly frequent basis. There are also articles trying to answer why Giffords is in a medically induced coma and highlighting the "new" procedure of decompressive craniectomy (I don't think it's that new?), with more or less accuracy.

Of course, the involvement of highly skilled neurointensive care nurses is apparently nil. It's made to sound as if neurosurgeons and doctors are at the bedside watching these patients 24 hours a day. But hey, that's the media.

It is (obviously) possible to survive being shot in the brain, depending on several factors. First, it depends on the round and the trajectory. It doesn't have to be a through-and-through injury, but it probably helps if it's clean through and not explosive.

Secondly, the problem with brain injuries of all types is that even if the initial injury is survivable, the "secondary injury" is what kills or debilitates patients. I've heard war stories of soldiers being shot in the brain and surviving, awake and talking, for days, and then dying--presumably of swelling or sepsis. The brain swells like anything else after injury, but being in the rigid skull, it has nowhere to go. First the intracranial pressure compresses other brain structures (often the other cerebral hemisphere) which will cause neurological changes. Sooner or later the intracranial pressure can exceed the perfusion pressure of blood reaching the brain--we calculate this as a function of the blood pressure and using an intracranial pressure monitor, a thin catheter placed into the brain--and you have no flow. Swelling may also cause the brain to "herniate" through the hole in the bottom of the skull through which the spinal cord and brainstem connect to the brain, which also compresses those blood vessels, killing the brainstem. Spontaneous breathing stops, your most basic reflexes (coughing, gagging, and blinking) will cease, and there will be no response from the patient to painful stimuli. Death is inevitable unless the blood pressure is supported and they're on a ventilator, but a full brainstem herniation is ultimately unsurvivable. Persistent no flow and brain stem death will lead to a clinical diagnosis of brain death.

CT after craniectomy

So rapid transport to a hospital is critical, followed by rapid assessment, intubation to protect the airway, a head CT scan, and a neurosurgery evaluation. If the patient is a surgical option, they'll open the skull (a craniotomy) to remove clots, and may elect to leave the skull flap off (a craniectomy) to decompress the brain and allow it to swell. The skin is sutured back without the skull and we're on strict precautions (obviously) to leave that part of the head alone. The skull flap is preserved for later reattachment, sometimes in the patient's abdomen, sometimes presumably in some fridge somewhere in the hospital (hopefully labelled and dated appropriately, otherwise the secretary will throw it out--or maybe that's just my lunch).

After surgery the patient typically goes to a specialized neurosurgical or trauma critical care unit staffed by experienced nurses who take over the hour-to-hour care. The patient will be kept intubated and breathing by ventilator. The patient is sedated into the "medically induced coma" the media keeps mentioning, mostly to control pain and agitation. The brain injury, the surgery, the breathing tube, and being restrained to the bed by the wrists (which is done to protect the breathing tube, mostly) all lead to agitation, which sharply elevates intracranial pressure, so the nurse will be continuously managing those drips as needed. Usually it's propofol because you can shut it off quickly, but the rapid-acting benzo Versed is also used; and a continuous fentanyl or morphine drip for pain.

The nurses will examine the patient hourly for the first day or more, then every two to four hours as the patient stabilizes. Sometimes this will involve turning off the sedation and seeing what the patient does - do they follow commands, open their eyes and track and focus, etc. Otherwise a significant amount of neurological information can be gained even with the patient out - do they react to pain, move all four extremities equally, still have all their reflexes? It's hard to overstate the importance of these exams; the patient can look the same and be totally stable but have a blown pupil or have a diminished reaction to pain in, say, the left arm - these are huge easily overlooked changes that can occur in an hour. We can also determine if we're sedating the patient too much and reduce the drips as needed. If an intracranial monitor or drain is placed it will be monitored fairly continuously. If anything changes, a stat head CT scan is done and the neurosurgeon and critical care physician are notified. The patient might need more surgeries if there's rebleeding, more swelling, etc. The nurses will also administer antiseizure meds, meds to reduce swelling, and keep track of the rest of your bodily functions--heart, lungs, etc.

If all goes well, the patient can survive. The patient may need a tracheostomy and feeding tube ("trach and peg"). They'll be taken off sedation and the ventilator if they're able to breathe on their own, but only time will tell if and to what degree there will be any disability, personality changes, or decrease in cognitive function. Some patients are unscathed and others are not.

That's the extent of what I see - the patient is usually transferred to rehab and I don't see them after that. But eventually the skull flap will be placed and stay a night or two in the same intensive care they started out in, which is sometimes nice for us to see.

Spread some holiday cheer. Don't shoot anyone!

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Wed, 22 Dec 2010 14:11:00 +0000

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I was told this all summer, but I still can't believe it's really true. All summer we had violent crime victims, mostly GSWs (gunshot wounds) several times a week, sometimes daily. And that was just what came into our ICU; I don't even know the rate for the whole hospital. (At my old hospital, I'm pretty sure if you were shot anywhere we all panicked and you went to the ICU, but at my new workplace, if you're shot in a nonvital manner, you get patched up and go to a regular trauma-medical floor.)

But all the experienced people said the trauma season really slows down in the winter. And it has! I can't get over that.

Violence in the cold winter Midwest.

People are really out less shooting each other because of the cold. I mean, it kinda makes sense - most people can hardly oblige themselves to shovel their sidewalks. It takes me an hour to get the kids ready to go outside. I can hardly imagine trying to motivate your minion gangbangers to go perpetrate crimes in this weather. But honestly, you wouldn't think drug-addled hoodlums would care so much about it. Doesn't alcohol make you feel warmer?

Lest you think this wasn't written in the holiday spirit, it was: anyone braving the shopping malls at this time of the month should take heart that the hideous stress of last-minute Christmas shopping hasn't driven up our admissions - at least for violent crimes, that is. Make sure you don't slip on the ice and come in with a subdural hematoma.

Merry Christmas!

First MRI Images of Live Birth

noreply@blogger.com (Chris [The Man-Nurse Diaries]) — Thu, 09 Dec 2010 14:47:00 +0000

Although it's not as cool as x-rays of video game controllers, a hospital in Berlin performed an MRI scan of a live birth.

The exam was done in order to see why labor stalls and why women require c-sections. Of course, we already know that supine labor (pushing a baby out against gravity, on your back with your pelvis up) can stall labor. I would venture a scientific guess that it stalls 55% more often if you're crammed into an MRI machine - even an custom birth scanner.

Source: Daily Mail

I'm curious why every news source has flipped the woman onto her belly. That's her spine and tailbone above the baby there. Conversely, some of the images are oriented vertically. A step in the right direction, perhaps, but I doubt it happened that way! I haven't seen any supine images, which has to be how it really happened.

I'm thinking it won't reveal very much on why labor stalls, if I'm right in my assumption that labor stalls for positional (anti-gravity laboring) and hormonal (stress hormones inhibiting oxytocin, the labor hormone) reasons, as well as poor clinical decision-making like forcing labor (or non-labor) by induction and augmentation. I'd also think the mechanism of labor, the descent, is probably different when you're laboring in the more upright positions humans have naturally tended to labor in over the millenia. Laying flat on your back with no regard for spinal alignment or pelvis positioning or the weight of gravity does not strike me as an accurate way to do an imaging study of birth.

The Daily Mail Online: Doctors produce first-ever MRI scan of baby at the moment of birth
Medgadget: MRI Used to Visualize Live Birth
The Unnecesarean: Woman Gives Birth in an MRI Machine