Allergies

You can tell a lot about a person by their allergies.  And I don’t mean the seasonal variety.

I don’t judge if you’re allergic to cats or dust or pollen.  I do, however, judge you if you’re allergic to morphine, oxycodone, ibuprofen, tylenol, Zofran, Reglan, Compazine, repositioning and hot packs.  Because, awe shucks, looks like the only thing left that you can possibly tolerate for pain and nausea management are dilaudid and phenergan.  At the same time.  While you’re eating a hamburger from food service that you’ve complained about but are still eating.  And it just so happens that those are the two most potent, euphoria inducing pain and nausea medications that we give.  Funny that.  (I just said that in a British accent)

There are some patients that think either their nurse is dumb or their acting skills are so stellar that I won’t see through their Oscar worthy attempt to get high.  I once had a 23 year old male that came in with a small bowel obstruction.  Not the most painful malady, especially after a decompressing NG tube placement, but certainly no walk in the park with your dachshund.  He just so happened to be allergic to every possible pain medication except Dilaudid, which is about 10x stronger than morphine.  So that being our only option I acquiesce to his request for pain medication.  As I’m drawing it up (with him twice verifying the dosage) to administer through his central line (his veins being rubbish after using them for other recreational purposes) he first requests that I not dilute it in saline (denied) and then as I’m administering it he performs a song and dance about how bad it tastes and if I could just “push it in faster” so the unpleasantness goes away quickly (denied).  Anthony Hopkins in the house folks! Somebody go get the golden statue! Little did he know he had just purchased his ticket to a slooooooow, American Society of Medication Safety by the book practice recommended 5 minute administration for every single dose there on out from this nurse.  I didn’t think I looked that dumb.  I am blonde though….

Another thing with allergies…you only know you’re allergic to something if you’ve received and had a reaction to it.  I hate when I’m researching a patient at the start of my shift and the first two things on their allergy list are Haldol and risperidone.  Shit.  That means that they’ve A) been in the hospital a few too many times and B) have needed an anti psychotic more than once, and C) what the hell’s left for me to give if I need it?!?

Gravity – Part I

Gravity.  We love it & hate it all at once.  It keeps us nicely grounded here on earth so we don’t go spiraling up into the cold nothingness of space (or into a giant spinning fan á la Charlie Bucket and Grandpa George after stealing Fizzy Lifting Drink!!)  Yet we fight it for all we’re worth when it comes to our bodies; our breasts, buttocks, jowls, skin, etc.

I’ve had some interesting experiences with said gravity in my line of work.  Take, for example, the 45 year old morbidly obese woman I admitted when I was just a fresh nurse.  I can’t recall what she was admitted for.  Maybe a COPD exacerbation.  What I can recall with almost photographic clarity is the image of her breasts that is burned into my retinas.  She had the largest breasts I’ve ever seen in my entire life, however, at the time I didn’t know they were her breasts.

When we admit someone, we make sure all their personal belongings find their way into the closet for safe keeping until they are discharged.  It’s not uncommon, however, for little old ladies to clutch their purses close at hand in case they need their checkbooks, lipstick or address book.  The purses get in the way, and I usually offer to put them in safe keeping while they sleep.  Every once in awhile they fight me on it, so I indulge them.  A little indulgence goes a long way.

So I was going through the routine admission process with this woman, and as I finished I asked her if there was anything that she would like to have placed in the closet for safekeeping.  She was sitting peacefully in the bed with her arms crossed over her chest and I noticed a giant lump down by her right hip under the blankets.  Assuming this was either illegal contraband or her purse, without thinking, I whipped the blankets off the giant lump by her hip and for a brief moment in time thought, “now that’s a funny looking buckle on her light brown leather purse”.  No buckle.  Or purse, for that matter.  Breast.  Giant breast.  Down by her hip.  It was as if someone had put a giant, country fair award winning watermelon inside a thigh high nylon and then sewn the top seam of the nylon to her chest and let gravity take care of the rest.  I can’t even remember what I said after this.  I’m sure I quickly replaced the covers, embarrassed, and mumbled some apology.  She didn’t care.  It didn’t even phase her, bless her heart.  But for the rest of my 12 hour shift it pained me to imagine those things hanging when she stood up.  Curse that gravity!

Excuse me…may I borrow that?

We borrow a lot of things from the outside world to put inside our bodies.  Metal for stents, plastic for joints, porcelain for teeth etc.  We also borrow things from other animals like pigs and cows for our heart valves and pancreas.  But what amazes me most is what we borrow from ourselves.  More like take, really, because it never gets returned to its original home.

There’s the obvious, like veins from our legs to bypass our coronary arteries.  The brilliant, like fat, tissue and circulation from our abdomen to make new breastsI (tummy tuck and new knockers all in one!).  And then there’s the slightly more bizarre, like taking colon to make a new bladder.  Neobladder.  Imagine the guy who thought of that one night after a few gin and tonics.  “Hey…I wonder if I can take that guy’s shitter and make a pisser?”

Dictation Errors

Often, doctors are too busy to type their own progress/history & physical/ED admit/surgical notes.  So they dictate them.  They dial up a phone number and dictate over the phone to a recording that then is analyzed by either a computer or a person (I’m not sure actually…maybe I should ask next time I hear one).  Sometimes its annoying because they do it on the phone in the report room where I’m trying to have lunch and watch an episode of 30 rock on my iPod.  However, it’s funny to listen to a doctor dictate because they have to also dictate their punctuation.  It sounds a little something like this… “patient presented to the emergency department complaining of extreme cramping abdominal pain period he stated it began the night before after consuming a large McDonalds meal comma after which he developed the pain and eventually vomited several times which provided partial relief of the pain period this relief was only temporary comma and he developed increasing abdominal pain overnight comma and also some explosive loose stools period”

I say that I am unsure whether it is a human or a computer who analyzes the dictation because some of the transcription/translation errors are so funny they almost have to be from a computer.  Or a guy with a degree in IT or something like that who can type fast and navigate his way through dictation software, but has no idea what a duodenum or a vulva is.

Example A: a patient was admitted for a gangrenous lower extremity that needed to be amputated mid shin.  This is called a “below the knee” amputation for obvious reasons. (as opposed to an “above the knee” amputation)  When we healthcare professionals talk shop to each other it is often shortened to “below knee” amputation, or BKA.  So here is an excerpt of this patient’s discharge summary. (paraphrasing, obviously) “Patient with gas gangrene of the left lower 3rd through 5th toes.  Did not respond to IV antibiotics and developed symptoms of sepsis which required a transfer to the CCU and an eventual bologna amputation.”  …. it took me a while to even get it .  I was confused at first.  What the hell? Bologna?  Then I read the sentence out loud.

Sometimes a fresh doctor or medical student does the dictating and forgets to use medically correct terminology, instead opting for a more lay term their dad used when they were a kid and scraped their chin on the driveway after riding their brother’s skateboard on their hands and knees (that never happened to me…) .  The medical term for pus is “purulence” and the adjective is “purulent”.

Example B:  patient admitted for a postoperative wound infection that they waited a good two weeks for it to stew and brew a nice rotten stinky hole in their abdomen before they went to the doctor.  The ED resident’s admit note sounded a little something like this, “Patient presented with leukocytosis and fever, blood cultures drawn and empiric Vanco started.  Upon inspection it was noted that patient had a very large, deep, foul smelling pussy area.”

Somebody should really do some proofreading.  Example B must have been transcribed by the IT graduate, and example A must have been the computer.  Lord knows I hope they never cut off my bologna or get a whiff of my crotch and live to tell the tale.

Post-Mortem Care

At the risk of sounding morbid or creepy, I enjoy post-mortem care. (Spell check is making me put a hyphen in between those two words and I do not like it).  Perhaps enjoy is not the appropriate word.  Maybe what I mean is value, or meaning.  I choose to see value and meaning in post-mortem care.  What would invariably creep others out is where I often find peace and beauty. Not many people really get to experience death and dying on a routine basis, and I often find myself contemplating the honor of having that experience.  I suppose my labor & delivery nurse friends might understand a little of what I mean because they experience the magic and beauty at the other end of the continuum.  The joy of a fresh new life.  The promise.  The potential.  We often think of one end as happy, the other end as sad.

I have been present at a lot of messy, sad deaths.  The remains of a CODE 4 strewn about the room, the residual epinephrine/adrenaline running through my veins and sitting stagnant in the veins of that who we were trying to save, the family standing stunned in the doorway.  Fortunately not all deaths are like that.  Many are beautiful.  Meaningful.  Accepted.  All are mysterious.  What and who was once there a minute before is now gone.  And it begs the question, what is the essence of a person? What is a soul and what does it look like?  It’s impossible for me not to get spiritual when I’m performing post-mortem care.  One final beat of the heart that has been beating nonstop every second of every day of every year and all of a sudden the person who was “there” a second before no longer is.   I look upwards.

When exactly does death occur and life end?  The final beat of a heart as modern science tells us? What if we can keep that heart beating? Loss of consciousness or brain activity? A body with a beating heart and only a beating heart is still “alive”?  The topic has stretched ethical discussion for ages, and I don’t think it will ever cease to.  At least I hope it doesn’t anyway.  Because questions we ask about end of life are also pertinent at the start of life.  When does life start?  The same way it ends?  With a beating heart?  I remember my mom grappling with the looming death of her mother who had been suffering from progressive Alzheimer’s for several years.  The last days of her existence were spent obtunded and I remember my mom saying, “It’s just her body, her shell.  Her soul is already free and in heaven”  This helped my mom process and cope with her own beloved mother’s impending final heartbeat which would only be a final detail in a death that had been stretching for days.  My mom also firmly believes that life starts at conception, that the soul is there from the moment the sperm and egg join.  There is no “shell” stage like there is at death, and the heartbeat is just a detail.

Sometimes I feel as though I’m desensitized to death.  It lost its novelty after the first few.  Removing lines, tubes, drains & airways from a lifeless yellowing body was once disconcerting but now has become routine  But where novelty is lost, meaning is not.  I strive to find value in every death whether its holding an abandoned grandpa’s hand while he passes on without anyone to witness or care, or fighting to let a family sit with their deceased for hours rather than have them carted off to the morgue to make room for another living body.  Meaning is in the eye of the beholder.  And I behold a fair amount of death.

Reading over this post, it looks messy.  Disorganized.  It bugs me.  But I think I’ll leave it that way.  Because that’s often how I feel about these questions and situations.  I hope we never stop talking, wondering, questioning, crying, laughing and valuing death.