Hee hee...poop

Go visit Disappearing John. He has a great post about a surprise "delivery" that had me laughing so hard I almost dropped my computer off my lap.

Sometimes it IS a zebra!

In our ED we have some recliners that are where we put asthma patients to suck on their nebulizers. Unfortunately, when we are crowded, we put all sorts of patients there.

This weekend, I got a young gentleman who was complaining of shortness of breath and chest pain. He had a negative EKG, and on further investigation, he mentioned that he had smoked a little pot that morning and was feeling a little paranoid. He was a little anxious appearing, but was basically all right.

It was very crowded, and he was sitting around for about an hour, waiting to see the doctor. I was running around like a chicken with its head cut off, taking care of the actual asthma attacks, and some renal failures and cellulituses (celluliti?) that got put in the chairs, when I looked over and saw that he looked a little pale and dusky around the lips. I checked his O2 sat, and it was 89 on room air. He admitted that he was feeling a little "weird" and "freaked out." I told the charge nurse I would probably need a bed for this guy, started him on 100% O2 via a nonrebreather mask (one of the ones that has the little bag hanging off it to act as a reservoir for the oxygen), and decided to draw some bloods and pop a line in there just in case.

He warned me that he "didn't like needles," so I put his feet up in the recliner. Sure enough, as I flushed the line, he vagaled out on me: his eyes rolled back in his head and he did the little vagal dance with his hands and feet (you know the one--they clench and release a couple of times and then stop). I reclined him all the way back so he was a little upside down, and called his name a couple of times. No response. I reached out and shook him a little bit. Nope. So I did a sternal rub to see if I could get him to open his eyes.

And that's when I felt it. Poppity pop crackle under the skin of his chest. I felt around a little more and then yelled for a doctor.

Subcutaneous emphysema. The kid had a pneumomediastinum! Ding ding ding! You win a bed in the ICU! He woke up from his faint and was fine(ish), but got a monitored spot until we got the okay to send him upstairs.

The docs thought maybe he got the pneumomediastinum either from toking too hard on his joint, or from coughing too hard after smoking.

Once again, my brain hurts.

I just finished a three-hour online essay exam with eight questions. It took me two hours. This test was supposed to be on the "honor system": no using your notes to take the test.

The instructor provided us with research topics in advance. These were basically questions we had to look up and think about in order to answer. It was recommended that we interview someone as well, so I did that too. (OK, so I interviewed my mother. But lemme tell you, you will NOT find a better source on nursing education in the United States than her. Seriously. Don't get me started.) I organized and reorganized my notes. I memorized salary ranges and other facts and figures. I was literally busting at the seams with information when I sat down to take the test.

The first seven questions were straight from the research topics. I whipped through there in no time flat. I freaking kicked ass. I had quotable quotes, I named names, I gave sources. All from my little, overworked mind.

The eighth question? Completely out of left field. Ok, it sort of had to do with our basic topic. But NONE of the research topics given even HINTED at what was requested in this question. Seriously. NONE of it ever even occurred to me. It was SO FAR away from ANYTHING I had even looked at.

I fucking Googled it. And then I answered the question.

And now I'm consumed with guilt. How can the instructor NOT know that I freaking basically cheated on that answer? She knows she didn't give us any prior warning about it. There was no way of knowing it was expected. It was super-easy to find the answer on the internet. In fact, I knew exactly where to go. So I know I got my 10 points worth out of that answer.

Damn Google. Damn online class.

Idiot Box

As I've mentioned before, our ER recently got small flat-screen TVs installed dangling from the ceiling of all the patient areas. Isn't that nice. Too bad they're not like these.

Ours don't have touch screens that show patient information and x rays. Ours don't have movies on demand. Ours just hang there, controlled by a weird remote that dangles at the bedside.

When the TVs were installed, I was skeptical. Sure, this might keep patients happy during long waits to see the doctor. But I had a feeling that they would most likely be trouble.

Well, guess what? I was right. Go figure.

Yes, they do keep patients happy during long waits. But that's it. The doctors all complain that they are competing with the TVs for attention when trying to obtain a patient's history. All eyes go to the idiot box, and it's taking longer for them to get useful information out of people and their families.

It's increased the noise level of an already noisy department. The TVs come with these remotes on a cable that turn the TV on and off, change the channel, and have a little speaker so you can clip it to your pillow and hear the TV right next to your head. Patients and their families can't figure it out, so they stand on chairs to change the channel, turn the TV off and on, and they crank the volume so everyone in a three-mile radius can hear it. I've become the noise police--turning volumes down and instructing people on the use of the remote so they don't disturb the grieving family with the dying grandpa on the other side of the curtain.

And it's a good thing that people are happy during waits, because they are going to be waiting even longer, since now our transporters don't have to try to sneak to the lounge (where they are easily found) to watch the game on TV. They just hide around the ER, watching basketball or football behind curtains of unoccupied beds. We have to search and search before we find them. I've uncovered little Super-Bowl-partylike gatherings--complete with snacks from the vending machines, where transporters and techs are staring, fishlike, at the screen. I've learned, when no one can be found, to look at feet at the bottoms of curtains--lots of feet standing in a row = slackers watching TV. When you evict them, they just gather somewhere else. The techs just pretend to be doing patient care on some comatose old gal from a nursing home while they gawk at the boob tube.

Other nurses and docs have written about the American Looky-Loo (the relatives who don't stay at the bedside but who peer around and wander the floor looking for things at which to gape); I've found a new species that seems to be closely related: the ER TV Hog: Relatives who, since they don't want to deprive the patient of watching what he or she wants, will appropriate the next bed and TV. I had to constantly remind two men who were visiting their 90-year-old mother that it was not allowed to sit on a clean stretcher to watch their ball game and that if they wanted to watch TV, they should do it at their mother's bedside, not in a clean area. I even had to eject them when a patient was assigned to the bed.

And just wait! Soon the TVs and remotes will begin to break. Then in addition to pleas for cups of ice and food and sodas and juice and sandwiches, we will get, "Whys mah TV aint workin!"

I can't WAIT!

Sorry...

I haven't posted in so long...I've been struggling with schoolwork. Ech. I hope what I hate is just this class, and not being back in school. Ugh.

I thought of a really funny post tonight while cooking dinner but I can't remember it now. Serves me right for not writing it down immediately.

Well, I'm back to work tomorrow--maybe I'll think of something then!

Until then, say goodbye to Hallway Four--we'll miss her!

Brain Cyst

This is extreeeeeeeemly cool.



Apparently the cyst was caused by tapeworm larvae. And the brain is just one place it could go--but probably the worst. I love how it plops into the pan. And then the doctor says, "Big one, eh?"

Encyclopedia Brown Goes to Town!

Ok, so that was lame. Anyway, DR has been doing some sleuthing of his own on the "Case of the Piss in the Elevator."

We had yet another episode today in one of the other buildings. (Our co-op is a block-long apartment complex consisting of four buildings.)

Using the recordings from the cameras we had installed in our downstairs hallway plus speaking to some of our neighbors, he's deduced a possible suspect (cue "Law and Order" dum DUM! music).

This past weekend, our neighbor down the hall took out the garbage; he did not notice any urine in the elevator. Fifteen minutes later, his wife left to go run errands, and lo and behold the urine was there.

DR went back through the video that had been recorded. He saw our neighbor leave with garbage and return empty-handed. He saw our neighbor's wife leave. And in between he saw...

The newspaper delivery guy.

He saw him again entering and leaving the elevator in the other building just before the woman who reported the urine this morning left.

Who the hell delivers a damn paper and decides to take a piss in an ELEVATOR?!? This is a nice building! It's not some skanky smelly shithole tenement! Since we don't have a camera in the actual elevator, there's no way to finger the guy precisely; we only have proof of him being in the elevator when there also was piss in there. I'm dying to stake it out and see if I can catch him.

My brain is full.

May I be excused from the table?

As of today, I've started taking classes online toward my BSN. It's great that I can do the work whenever I want (like in the middle of the night), but MAN is it a lot of it! Lots of reading, hours of lectures to view, and (the HORROR!) a paper due in two weeks.

I just finished taking notes on the first two chapters (out of four) of this week's assignment. I would begin viewing a lecture but I think it would bounce off my eyeballs without sinking in at this point.

I've visited our class message boards and I can tell just from the few posts there who I would be flicking spitballs at if we were in a regular class. People have started asking dumb questions ("does this count towards our final grade?") and are already not following the professor's instructions: for example, answering a "roll call" on the message boards after the professor sent everyone an email stating to reply to the roll call via email and NOT ON THE MESSAGE BOARD.

Gach. Wish me luck. And now, I'm going to have a beer and make some meatballs.

It's a MYSTERY!

Call Scooby and Shaggy!

For the second Sunday in a row, there is a pool of urine in our building's elevator.

What the h-e-double hockey sticks!

Last week DR cleaned it up and wrote a large epistle on our building's Yahoo community group AND posted a note in our "lobby" stating that it was NOT our dogs who did it, and stating that while he understood that sometimes accidents happen (for humans AND for dogs), it would be nice if the responsible party cleaned up after themselves or their animal.

And then, it happened again. There are no other dogs that live in our building. Perhaps we have a guest dog visiting; one of our neighbors said he noticed "some drips" outside his door on the second floor.

But HA HA! The joke is on the perpetrator! For now we have occasion to use the new security cameras that were installed in the downstairs lobby. We can see if a strange dog has entered the building.

I'm curious to see what happens next.

Race and Pain Control

According to a recent article in JAMA, whites are more likely to get narcotics for pain control than are blacks. (Other minorities such as Latinos and Asians also are more likely to get narcotics for pain than blacks.) The article intimates that doctors are more likely to think of blacks as drug seekers, rather than patients who have legitimate pain. Even for kidney stones, blacks receive Advil or Toradol more often than morphine or other narcotic analgesics.
The article I read also states that "blacks are the least likely group to abuse prescription drugs."

I didn't read the JAMA article; I read a story about the article here.

I'm not sure what I think yet. But I must admit, in my deepest little corner of my brain, a tiny voice is saying, "OF COURSE! you know it's true."

I'm a white person. I would like to think I treat everyone as they deserve to be treated, and do not base that treatment on the color of their skin. At least I hope I do. All in all, I have to agree with a doctor who was interviewed about this study, who said, "If anybody argues they have no social biases that sway clinical practice, they have not been thoughtful about the issue or they're not being honest with themselves."

When I go back to work tomorrow, I guess I'll have a little food for thought during the day.

Any opinions, blogosphere?

ADDENDUM: Thanks, Dr. Whitecoat! See WhiteCoat Rants for his take on the JAMA article above, with a link to the actual article here.

Two Successful Recipes

I made two things over the holiday season that were big hits: My artichoke-crab dip, and linguine with baby clams (actually cockles, but whatever...). Here are the recipes:

Hot Crab and Artichoke Dip

1 9-oz package frozen artichoke hearts
1 red bell pepper, finely chopped
3 tablespoons butter
2 tablespoons all-purpose flour
1 1/4 cups half and half
3 scallions, thinly sliced
2 ounces finely grated Parmesan cheese (about 1/2 cup)
1 1/2 teaspoons fresh lemon juice, or to taste
1 1/2 tablespoons minced drained pickled jalapenos
1/2 teaspoon salt
1/4 teaspoon celery salt
3/4 pound jumbo lump crabmeat, picked over (I actually use canned white crab--less expensive and tastes great)

Preheat oven to 375F
Cook artichoke hearts according to package instruction, then drain well and finely chop. Cook bell pepper in 1 tablespoon butter in a 3- to 3-quart heavy saucepan over moderately low heat, stirring occasionally, until softened, about 5 minutes. Stir in artichokes and transfer mixture to a bowl.

Melt remaining 2 tablespoons butter in a saucepan over moderately low heat, then add flour and cook roux, stirring, 3 minutes. Add half and half in a stream, whisking, and bring to a boil. Reduce heat and simmer, whisking, for 3 minutes.

Remove from heat and stir in artichoke mixture, scallions, 1/3 cup parmesan, lemon juice, jalapenos, salt, and celery salt. Gently stir in crab. Transfer to a buttered 1 1/2-quart shallow baking dish and sprinkle with remaining parmesan.

Bake dip in middle of oven until bubbling, 20 to 25 minutes. Serve warm with crackers or cut up baguette.

Linguine with Clam Sauce

1/3 cup extra virgin olive oil
1 medium onion, chopped
6 cloves garlic, finely chopped
3/4 teaspoon dried red hot pepper flakes
1/4 teaspoon dried oregano
1/3 cup dry white wine
1/3 cup bottled clam juice
1 pound linguine
2 pounds small cockles (up to 1 inch across, about 5 to 6 dozen)
2 tablespoons cold unsalted butter, cut into small pieces
1/3 cup chopped fresh flat-leaf parsley

Heat oil in a 5- to 6-quart heavy pot over moderately high heat until hot but not smoking, then saute onion, stirring, until golden, about 4 minutes. Add garlic, red pepper flakes, and oregano, and cook, stirring occasionally, until garlic is golden, about 2 minutes. Stir in wine and clam juice and boil, uncovered, stirring occasionally.

Cook pasta in a 6- to 8-quart pot of boiling, salted water until al dente, then drain in a colander. While pasta is cooking, stir cockles into sauce and simmer, covered, stirring occasionally, until cockles open wide, 4 to 6 minutes. (Discard any cockles that have not opened after 6 minutes.) Remove from heat and stir in butter until melted.

Add pasta to cockles along with parsley and salt to taste, the toss with sauce until combined well.

Serves 6 as an appetizer and 4 as a main dish.

Happy New Year!

I'm actually awake at this hour after working three straight 12-hour days culminating in New Year's Eve. Unfortunately, while it was insanely busy, not a lot of interesting things happened. A million cases of gastritis and gastroenteritis (including among the staff...we had a "rehydration station" set up in the nurses' lounge where some of the residents were getting liters of fluid and zofran boluses). A few lacerations. A lot of falls and septic senior citizens. A lot of cranky relatives.

Out in triage, we had entire families signing in to be seen. One woman brought her baby for evaluation of an upper-respiratory infection and wanted to be seen for "follow up" for herself. She was diagnosed three days before with an URI (aka a "cold"), had insurance, but stated she didn't have "time" to find a doctor of her own. She wanted to know when she was OK to go back to work. I told her she had been diagnosed with a cold and could go back to work when she felt well enough. She said that the "papers" she had been given (our system prints out discharge instructions for all sorts of diagnoses) stated that what she had was "contagious." I explained that yes, the common cold is contagious, that she should wash her hands very well and often, and use hand sanitizer. I asked if she worked with sick people, or with babies, or with immunocompromised people. She worked at a local newspaper. I told her as long as her runny nose was cleared up and she felt well, she could probably go back to work. She went on to explain that when she was sick, she felt VERY BAD and wasn't that dangerous. I told her that it's normal to feel bad when you have a cold, that you should drink a lot of fluids and take cold medicines that alleviate your symptoms, and get some rest. This line of conversation went on for what seemed like EVER.

Also a mother brought her otherwise healthy 11-year-old in. Complaint? Chicken pox. No respiratory distress. No pain. Slight fever, easily controlled with Tylenol. I asked why the mom brought the kid in. Because she thought she should be looked at by a doctor, and on Saturday, the doctor is closed. So this woman waltzed her virus-laden child through a crowded ER waiting room populated with elderly people and tiny babies, sat out there waiting to be called, and then looked surprised when I told her that her child was still contagious, and that she would have to be isolated.

However, one sweet and heartwarming thing happened. A 21-year-old mom came in for treatment of an asthma attack. She had a two-year-old and a two-month-old preemie with her. They all lived in a domestic-violence shelter and all of their worldly possessions were packed into the baby's carriage. We cleaned them all up, gave them some food and diapers, and then the EMTs who brought them in returned with warm clothes for both kids and a snowsuit for the infant. The young mom was very touched and thanked everyone profusely. Thanks nice EMT team, wherever you are!

At 11:15 pm last night, we got the first few ambulances of the idiot parade: a drunken-brawl victim; a young woman who drank two glasses of wine and now was vomiting and crying; and another woman who had three drinks and smoked some pot and then syncopized.

By 11:45, I gave report on the few patients I had left and ran into the nurses' lounge, where one of our techs offered a toast for all people going off-duty--some homemade coquito, kind of like a Puerto Rican eggnog, but with coconut and cinnamon. I grabbed my stuff, signed out, and was outside on the ambulance ramp by 11:59, just in time to give DR a New Year's smooch. We went to a party in the neighborhood, where the lovely and gracious hostess gave me some Champagne and a delicious pulled-pork sandwich. Then I ate some chocolate cake, and we said good night and went home.

Today is the annual all-day shindig at another friend's house. Lots of good food, lots of good drink, people we don't get to see nearly often enough, endless karaoke and a dance dance revolution dance-off. And I'm bringing my hot artichoke and crab dip.

Here's to 2008!