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Friday, April 30, 2010

Bag 'Em, Tag 'Em

Mr. Smith was dead when I arrived at my shift. Apparently he had died a few minutes before I arrived.

I walked into the room and noticed his seriously yellowed-complexion. Hello jaundice. I was told that his cause of death was liver failure, but other than that, I really knew nothing about him.

"Have you done post-mortem care yet?" Kate asked me.
"No."
"Well, since he's not having an autopsy, we'll take out all the IVs, his ET tube, his central line, his Foley, all that stuff. Then we'll clean him up and then we'll bag him and tag him. We'll put one tag on his toe, one tag on the bag, and one tag on his belongings." She explained nonchalantly.

The monitors had been turned off and the room was quiet, but Mr. Smith's body was still warm. I donned a pair of gloves and gingerly began to peel the tape and the tegaderm off of his arm, preparing to remove his IV. I had never taken out an IV, a foley, or any kind of line before, so in some ways it was nice to learn on a dead person. After all, I knew I couldn't hurt him. I pulled out the IV and blood started to drip down the side of his arm.

"Can you hand me a four by four?" I asked Kate. By this time the blood was pooling on his pillowcase. I had no idea this would be so messy. I held pressure for a minute, peeked under the folded four by four, but he was still really bleeding. I continued to hold pressure while I removed the dressings around his arterial line.

"The A-lines can really bleed a lot, so be careful." Kate said.
Prepared with another four by four, I pulled out his A-line.

Meanwhile, Kate was removing the dressing and sutures for the central line. Mr. Smith had finally stopped bleeding, and I attached an empty syringe to the port on his Foley and drew out the saline. Armed with another four by four, I slowly pulled out the catheter. Kate deflated the balloon on the endotracheal tube and carefully removed it.

Prepared with a basin of soapy water, Kate washed his face and I cleaned up smears of blood. Together, we turned him onto his side. Upon death, Mr. Smith's sphincter must have relaxed and released a huge puddle of liquid stool. As we shifted him, what seemed like a never-ending supply of stool continued to drip into the bed. I dipped disposable washcloths into a basin and started to clean him up. Twenty washcloths later, I had finally cleaned up his bowel movement. I was the Queen of Feces.

Kate opened the white post-mortem bag and slid it part way under Mr. Smith. We turned him flat and then towards me, and Kate pulled the bag out on the other side. She put a clean gown on him and I tied one tag to the bag and one to his toe. Do I tie a knot or a bow, I wondered. Do I loop it through instead? I opted for the bow, it somehow seemed gentler. The slippery-smooth nature of the string prevented the bow from really staying tied, though, so I ended up double-knotting it. So much for that.

We were done. He was ready to go.

Goodbye Mr. Smith. I closed the zipper.

Monday, April 26, 2010

The hospital gown that left something to be desired

We were taking care of an elderly gentleman who had recently received a pacemaker. He was being recovered in the ICU so that we could keep close tabs on him and make sure that he didn't dislodge his new leads.

I had seen him about an hour ago with a nurse, coming off of versed and fentanyl not long after the pacemaker implantation. He was disoriented, thought he was still in his assisted living apartment complex, and was seriously irked that he was not wearing any pants. The nurse explained to him that he was in the hospital and that he had just received a pacemaker. A friend of his was supposed to arrive later with his pants. A lightbulb must have gone off and he started apologizing profusely:

"You guys should all line up and take turns kicking me in the butt." I walked away chuckling and went back to recording vital signs.

About an hour later, my preceptor, Kate, walked into his room.

"Where are my pants?" He demanded.

Kate started to explain to him that since he was in the hospital, he needed to wear a hospital gown. I came into the room after her, hoping to reorient him and explain that he was in the hospital and pants were on the way. His nurse came walking in a minute later.

He looked up at her and exclaimed, "these two broads think I shouldn't wear pants in the hospital. But I tell you, I've been wearing pants for the past 92 years and I'm not going to stop now!"

Saturday, April 24, 2010

Lisa

I walked back into the nursing area carrying a hospital dinner tray with the barely touched remnants of stuffed shells and a salad. The nursing stations were empty. Everyone was huddled outside of room 4.

Lisa was our youngest patient in the ICU that night: she was only in her early thirties. She had been transferred from the surgical recovery unit to the ICU after her unit had called the Rapid Response Team due to post-operative tachycardia, hypotension and most likely some other stuff that I didn't know about. After she returned from her CT earlier that day, we learned that she had a big pulmonary embolism (I even got the intensivist to show me her CT!). She had been mostly bedridden for the the past couple weeks due an exacerbation of her Crohn's disease, which likely made her a pretty decent candidate for thrombus formation.

"E., get a crash cart."

I immediately put down the tray, unplugged the crash cart and rolled it into the room. It was all sort of a blur after that. I uncoiled the EKG leads and attached them to Lisa's chest. I put on the defibrillator pads. Someone was doing chest compressions. One of the respiratory therapists was bagging her. We stopped compressions for a minute. She was in coarse v-fib.

The physician gave the indication to defibrillate.
"Charging."
"Clear."

Lisa's body jumped a little. I looked at the monitor. She was still in v-fib. Her brother was now in the hallway, getting freaked out, madly trying to call his father on the cell phone. Everything had been happening so quickly that the doors to her room had never been closed, a curtain never pulled, and he stood outside the door watching as we started IVs, shocked her, and put in a central line. I pulled the curtain closed as one of my coworkers shut the door.

They shocked her again. She was now in fine v-fib. It was crazy. The whole scenario was surprisingly similar to the ACLS simulations I had attended earlier in the year. We were pushing what seemed like tons epinephrine and atropine, and later amiodarone. We had used up some of the drugs from the first med tray, so I opened another crash cart to get a second med tray. Dr. FavoriteCardiologist arrived to do a stat echocardiogram. Lisa's left ventricle wasn't pumping effectively at all and her right ventricle was huge.

Dr. FavCardiologist visualized the clot. They ended up giving her a thrombolytic agent even though she had recently had surgery. The tpA seemed to briefly help. Meanwhile, the intensivist was intubating her with the assistance of one of the respiratory therapists. It seemed like there was nothing we could do to stabilize her. Her blood pressure was tanking. Dr. FavoriteCardiologist asked Dr.GeneralSurgeon if he could do an emergency thrombectomy (surgically removing the clot). Somehow I missed the rest of the conversation, but I have the feeling it went something along the lines of:

Dr.FavCardiologist: She's going to die unless we get this clot out."
Dr.GenSurgeon: "I don't feel comfortable doing a thrombectomy."

*This is a small, rural hospital that has limited surgical staff and breadth of procedures.

It was strange to now see this patient - who had been talking and hanging out with her family not so long ago, now intubated and with a mottled complexion, her blue eyes half-open and fixed unnaturally upon the ceiling, her breasts exposed and her hospital gown pulled down around her waist in a bed littered with empty syringes, medication boxes, and cellophane wrap.

We continued to defibrillate her and administer more medications. I took turns doing chest compressions. This was the first time I had ever done chest compressions on a real person. After more drugs and more defibrillating, she was in sinus rhythm, then a slow wide-complex rhythm, then a junctional rhythm. One doctor felt a pulse and another did not. It seemed like these ACLS algorithms continued forever like some kind of medical choose your own adventure book..and eventually, no one could feel a pulse. I don't remember when we decided to stop, but she had been having PEA for quite a while, then asystole. We had gone through four med trays, and the code had been going on over an hour. One of physicians called time of death. It was 7:41 p.m.

The doctors who had participated in the code came out one by one. They quietly explained what happened to the family. The entire time I kept expecting some kind of dramatic lament from the family, but they were silent.

This was not my first death in the healthcare setting. I was surprised that this time I was less upset than usual. It's not that I wasn't deeply sorry for the family, but I also didn't feel like I had to go running out of the hospital as soon as possible to secretly cry in my car for twenty minutes. She was young and her death was unexpected, but for whatever reason, I just felt more fascinated with the twists and turns that her code seemed to take -- it was such an adrenaline rush. It was something new have a role and to be useful, and to have a basic understanding of what was going on.

All I remember thinking as I walked out of the doors of the hospital and looked at the flowering spring foliage was: this is definitely what I want to do.

Friday, April 23, 2010

Daffodils and rhubarb

This is a picture I took last spring, standing at the top of my driveway. I've been meaning to take some pictures of our wacky heirloom daffodils, but I've lost/misplaced the adaptor cord for my camera.

I just saw the sign back up (after it had been taken down for the winter) for the "U-Pick Rhubarb" a couple miles from my house. There's a family that has a huge patch (50 plants) of rhubarb in their backyard and charges 1.50/bunch. They define a "bunch" as a cluster of stalks that is six inches in diameter!

Last year I made rhubarb crisp, some strawberry rhubarb freezer jam, and about a gallon of rhubarb-infused vodka (that ultimately turned hot pink after a few weeks). I'm trying to decide if I should go and get some rhubarb later today with MiniMan (my toddler), but I think I'll probably wait since I'm working all day tomorrow.

I figure it's probably wise to fulfill my domestic urges right now, since in all likelihood, soon there will be comparatively a lot less time for anything other than working, sleeping, and studying.

Thursday, April 22, 2010

Order of prereqs

I've finally come up with a plan for how to complete the rest of my premedical prerequisites. I'll be working overnights on Thursday, Friday, and Saturday (12-hour shifts), and then going to class during the week. I had planned to arrange my courses like this:

This summer:
Chem I, Chem II

Fall:
Physics I
Bio I

Spring:
Physics II
Bio II

Next summer:
Orgo I, Orgo II

Then I started to wonder if maybe I should lump my chemistry closer to my organic chemistry, and if I should do physics or bio this summer. All these courses are available to take over the summer, which is awesome. Are there some courses that would be more valuable to have a fresh recollection of before the MCATs than others? Does it really matter that much? What would be optimal?

Tuesday, April 20, 2010

Are dumb people more popular?

It seems like lately, I have been having this problem more and more often. I'm in a weird situation. My current job (hospital aide) is about as low on the totem pole as a patient care job at the hospital can get. I guess it's slightly higher since I work in the ICU, versus the med-surg floor, etc.

Still, I've been working in health care (in the nursing home, and as an EKG tech) for about three years, and I have generally been eager to learn. I like to read and I like to ask questions. I try not to be annoying and drive people crazy by asking questions, and try to limit my quantity of questions.

Still, sometimes I'm really amazed that people don't know the answer to my questions, like the time when I was reading a heart catheterization book and casually asked a group of cardiac nurses:
"What's the difference between sclerosis and stenosis."
This was followed by no one knowing the answer, and having us all look it up together. I was just really surprised. I thought they would know. ..or at least one of them!

Today in the ICU, one of the monitors alarmed. I printed out a strip, and said to one of the nurses, "hey, have you seen OtherNurse? Her patient had a couple little atrial runs."

Nurse then replied "those aren't atrial runs, it's just tachycardia."

"It looks like a string of PACs* to me. When I scanned Holter monitors in cardiac services, we would call any runs of PACs atrial runs."

"You shouldn't call it an atrial run."

"Ok." (It's not worth arguing with her).

The thing is, I really have no idea what her rationale is for this (other than the possibility that she has a mediocre understanding of EKG terminology). It seems like by not being dumb, I always manage to piss some nurses off and get myself into trouble. I sometimes feel like I further inflame the relationship because I want to become a physician instead of a nurse. I generally try to be humble and quiet, but with this situation, I was just trying to communicate. And still, I pissed her off! I can't win.


*Premature atrial complexes (or contractions)

Sunday, April 18, 2010

First ICU overnight

I walk up to the ICU, coffee in hand. It's a little before 7:00 p.m., I've never been in the unit this late. Volume in the hospital appears to be at an all-time low, as I walk past empty room and nursing stations. I turn the corner and see a cluster of nurses huddled around the schedule.

"Do you want to float to MHU*?" One of the nurses asks me.
"This is my first overnight in the ICU. I don't know who my preceptor is tonight, but it might be good to stay here so I can see the routine."
We discuss this a little longer, and eventually come to the conclusion that I should go to the MHU with whichever aide is floating there, so that if I have to float there by myself I'll be familiar with their unit.

Jen arrives. She's worked as an aide for something like at least five years, first on the med-surg floor and then in the ICU. She told me went to nursing school for her RN, but was working some insane amount of hours concurrently, had some bad-influence slacker boyfriend and generally wasn't too serious about school. She flunked out. She's now doing an LPN program, in hopes that her improved grades will give her the groundwork for continuing for her RN. I was sort of surprised. She seems smart. It seems like she's learned a lot by osmosis, which is part of what I love about the ICU.

We've been assigned to float to MHU together. She's clearly irked about this (not her favorite unit). When we get there, I find out that we've been assigned to do a 1:1 observation on a patient who is planning to commit suicide that night by tearing up her bed sheets. Looks like it'll be a 2:1. One of the psych techs gives me a clipboard with a log. We sit down near her, and every 15 minutes, record what she is doing.

The psych tech comes back, asks me if I want anything to read. I ask if I can read one of their medical journals that I saw in their nursing area. Turns out that it belongs to one of the physicians and I'm not supposed to read it. This seems totally backwards to me! Mental note: when I'm a doctor, I will make an effort to share my journals with curious staff. The psych tech ends up bringing me one of her own magazines, Women's Health, and I read an interview with Pink (the musician). She's gone through the magazine and highlighted sections. I can't decide whether I should be awed by her thoroughness, or baffled as to why she is memorizing health information from a popular magazine. Maybe she has loaned it to many others, and someone else has gone crazy with the highlighter.

Eventually someone asks if I want to "round" on the patients. There are only about 12 in the adult unit, so I memorize their names (lots of patients have pulled off their wristbands). I walk around the unit and write down what each patient is doing at 15 or 30 minute intervals (depending on the patient). I had no idea that they document this 24 hours a day.

11:00p.m. Our four hours of float time is up.** We walk back to the ICU. Now that it's over, I can say it was quiet. Three beds were occupied in a sixteen-bed unit. Two of the patients were on ventilators. I have never seen never seen it that empty.

This gives me plenty of time to stock. It seems like the task of stocking supplies in the ICU is endless. We stock the med room (not medications -- that's the pharmacy's job, but other supplies); linens in the rooms; syringes, needles, ABG kits, tubing, and about four different sized bags of saline in each room's locked drawers; supplies in the cabinets: yankauer tips and tubing, suction liners, 4x4s, 2x2s, abdominal dressing pads, chlorapreps, tegaderms, biopatches, emesis basins, tape, hygiene supplies (no-rinse soap, shampoo, shaving cream, razors, toothbrushes, toothpaste, combs, lotion, barrier ointment, deodorant, perineal area spray cleanser). The list goes on and on. It was good. There are definitely supplies in the ICU that I'm not familiar with. We also periodically restock procedure carts (and crash carts -- including a Broselow!) which have cool stuff -- intubation supplies, temporary pacemakers, central line kits, etc. Stocking and finding stuff in our clean utility room took up the better part of the night.

The remainder was uneventful: vital signs every two hours, running EKG strips, fingersticks, blood draws, emptying and replacing the suction liners and tubing, and baths for the patients on vents. During one bath, I saw some complicated patient with a seriously edematous scrotum (the size of a cantaloupe). He had pretty bad edema in his hands, legs and feet, too. I guess places without musculature to squeeze fluid back into the body get hit hard. I felt really bad for him. At least he was sedated.


*Mental Health Unit
*Do people float at your hospital? One facility about 30 minutes away from us has a "float team." They hire nurses specifically for the float team, and they never have a home unit. I have no idea what happens when volume is down in the hospital.

Friday, April 16, 2010

Losing my phlebotomy virginity*

*This does not count the one-night phlebotomy stand I had at a small party in college. I will save this story for another day, because it seems to disturb people.

Yesterday I went to the lab and trained with some of the techs. I drew 13 people's blood. At my hospital each tech/nurse has to do 40 patients to draw blood without supervision. I probably would have had more patients to practice on, but a bunch of people refused to let a person in training draw their blood. I guess I can understand that, especially after my recent unpleasant blood draw. Sometimes it's of frustrating, though. There's no way to perpetuate skilled services without allowing people to train on real patients...and it seems like the easygoing patients have to bear the brunt of this.

I seemed to be faking confidence well! I started it with a winning streak. The morning was good. Everybody had veins like garden hoses and the sticking was easy.

Then things got harder. I had some little old lady come in who had these tiny, tiny fragile little veins. I had an oncology outpatient who had tons of scarring. I had shallow veins and veins that rolled. I still feel like I am not always sure which needle would be the most appropriate to choose.

Overall, though, I think it was a successful day. I just need to find me some more veins to practice on. Any volunteers?

Saturday, April 10, 2010

First 5k of the year...

Every time I go for a run, I always ask myself during (and afterwords): why don't I do this more often? The hardest part is motivating myself to put on a pair of shorts and sneakers and walk out the door. It seems like running is often a bigger mental challenge than physical.

I ran in a 5k kidney benefit today. And it was the same deal. You could choose to run or walk. I had signed up to run, but I hadn't been for a jog in about two weeks. Some of the cardiologists whom I work with were planning to go, and I just felt stressed out by the prospect of running in front of them.

The sort of sad thing is that what actually motivated me to go was the free t-shirt (a smiling cartoon kidney in a sneaker). I ended up finishing today at 28:33, and I was okay with that. I wasn't in the mood to totally bust my butt, but I think I'm getting better at pacing myself. It was definitely a couple minutes faster than the last 5k I ran (although that time I was pushing a stroller).

Next 5k? Maybe May (local free clinic benefit).

Tuesday, April 6, 2010

Life Insurance

My husband decided that we should both take out life insurance policies. This has been mainly inspired by plans to attend medical school.

If I die:
He gets left with a zillion dollars in medical school debt, loses our house, and lives the rest of his life alone with our son on a ramen diet. He does, however, inherit a large collection of chichi gourmet cookbooks and a large itunes collection that will probably be useless to him. He will sell these for more guns.

If he dies:
I don't have enough money to continue financing medical school, lose our house, and live the rest of my life alone with my son on a ramen diet. I do, however, inherit a huge collection of shotguns and rifles. I live off the land and we eat squirrel and rabbit stew for dinner when we run out of ramen.

So, we've decided to buy us some life insurance. This makes me feel comparatively old and boring.

Yesterday, they sent out a lady to "evaluate" us. I don't know that it was really much of an evaluation. I think it was more like a screening visit. I peed in a cup. She took my blood pressure. She asked me my weight, height, any medications. And then, she proceeded to get ready to do a blood draw.

I never mind lending my arm to someone. I am well known for letting people practice blood draws/IVs and glucometer sticks on me. I love donating blood (it's a place to snooze AND get free raisins).

I told her I was an easy stick.

This is how I jinxed myself.

She inserts the needle into my median cubital vein. It looked like she hit it dead on. She pushes the vacutainer into the holder. Nothing happens.

She shifts the needle a little bit. Nothing happens.

She proceeds to dig around with the needle for what seems like a prolonged period of time. A small amount of blood trickles into the tube.

"How about we do another stick," I say.
"Oh, don't worry, I'll get it." She continues to jab the needle around.

She eventually decides to try another tube. She turns around, holds a shaky hand to my arm and goes through her bag.

"I can hold the needle for you until you find another tube."
"I'm used to doing this with one hand," she confidently replies as the needle torques in my arm.

She finally finds another tube and my blood sprays into it. I feel vaguely queasy. I sense the beginning of a relatively impressive bruise. I now completely understand why some patients get so freaked out about needle sticks. Good grief.

Monday, April 5, 2010

On being meek..

As I prepare to end my days as an EKG tech and demote myself to a hospital aide, I've been giving a lot of people a heads up about the move: aides, nurses, information systems staff, the lady at the coffee shop who knows me too well, and the cardiologists whom I work with..

I ran into Dr. Cardiologist today in the hallway, and figured I better warn him that I'm leaving. He told me he knew, that Dr. Slightly Younger (but arrogant) Cardiologist had told him. We talked for a couple minutes, and he said that it seemed like a good thing, that sometimes you have to take a step backwards to move forwards, that I'd learn a lot.

And then, I guess Dr. Slightly Younger (but arrogant) Cardiologist must have told him that I was working overnights so that I could finish my pre-med requirements. Okay. I realize this is sad. I realize it's insane that I never mentioned a word about wanting to become a physician to Dr. Cardiologist. I don't really have a good excuse for this. I am a wuss.*

Dr. Cardiologist continued to talk. He offered to talk about med school stuff any time, that he (and all his colleagues in his cardiology practice) had been through the process, that I could contact him whenever. He was really nice! I thought I was going to pass out. Or cry. Or cry and then pass out.


*I looked up wuss, and apparently it may originate from the word pussy. Some theorize that a wuss is "half-wimp, half-pussy."

Saturday, April 3, 2010

My husband tells me I'm dangerous...

I can't figure this out, but in the last few months, my car has transformed into an undiscriminating death-mobile. Watch out, neighborhood animal friends.

Yesterday I killed a deer on the way to work. This was very similar to the recent turkey scenario: it came out of NOWHERE and ran right into my car. This is the second deer I have hit this spring. It seems like this almost always happens when I am stressed, and all deaths seem to inevitably occur within three miles of my house.

My amazing husband recently combined our car insurance policies, and apparently our policy covers the cost of a rental car until the bodywork on my car is finished. So now, oddly, I am renting a Prius for free, for at least the next week or so. I had never been in a Prius (or any hybrid) before, and it's an interesting experience. I like the great gas mileage, but I miss the turbo engine in my car. However, it's probably not a bad idea to drive for a while without turbo and spare the surrounding wildlife.

Meanwhile, hopefully the cost of fixing my car will not be incredibly, incredibly scary. I received a letter of acceptance from a post-bac premed program in upstate NY. This was accompanied by the "please mail us your deposit within six days if you would like to attend our program" form. I can't believe they only gave me six days to decide if I want to go or not. As much as I would love the brevity, camaraderie, and advising and networking opportunities in this particular post-bac program, I have no idea how I would afford it.

All the other financial aid offers have come in, and I am more confused than ever. I just got my offer from top-choice state school, and the entire cost of tuition has been covered by grants. I was really amazed by this. The federal loans that I was offered might even be substantial enough to cover cost of living and allow me to not work. However, this particular program is a bioengineering program, barely any of my credits will transfer, and it will take 3-4 years to complete. It seems so pathetic to spend this long completing undergraduate coursework as a means to ultimately do something else. Then again, it could be totally awesome.

I received so much encouragement regarding taking my premedical requirements part-time from the MiM posting. When I had visited nearby moderately-competitive medical school, I was told that taking these courses part-time would not be the ideal (and could affect my competitiveness as a candidate). I had repeated this to female professor and physician when visiting top-choice state school, and she was somewhat disbelieving. She actually went on to e-mail the head of admissions at nearby moderately-competitive medical school and ask her if this was really the case. The answer from admissions was: I would need to learn more about this student, but if she hasn't taken most of the prerequisites I can understand why someone would have told her this; it would only make sense. The thing is, it doesn't make sense to me. It doesn't make sense to work full-time, be a full-time student with a daily 2+ hour commute and take care of my family.

I think it might be time to do things my way and stop being so hung up on the advice I'm getting from admissions. I think that might mean full-time job, part-time cheap state school -OR- force my husband to get a job with better benefits, and do part-time job, full-time cheap state school.

Thursday, April 1, 2010

Spring Cleaning

I submitted a poem to The New Yorker, but they rejected me. It is a William Carlos Williams knockoff:

This is just to say
I have obliterated all evidence
of the homemade pierogies
your ex-girlfriend left in the freezer.

Forgive me
they were frost burned and dehydrated
and the garbage can looked so enticing.