Exhaustion.

I’m done.  Stick a fork in me.  Cooked.  Tired.  Knackered.  Straight up worn out.

Y’know how I know?  Every little bug knocks me down.  I want to sleep but can’t.  I wake up more than I’m asleep it seems.  Even with chemicals.

That said, I’m taking the rest of the year off.  I get on a plane tomorrow and head for Arizona hoping to recuperate and recharge and maybe stem the bleeding that is my will to continue as a nurse.  Burnout is a terrible thing.  So I’m going to enjoy a white Christmas in the White Mountains with my family.

Hope everyone has a wonderful Christmas and a great New Year.  I’ll be seeing you in 2012.  Promise.

 

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Happy Birthday

Happy Birthday Mia Rose.

You would have been 4 years old today, August 10th, but you left so suddenly and so unexpectedly.

I know it’s been 4 years and maybe I should have moved on, moved past or otherwise just moved, but some days I find it hard to do, well, anything.  I still have the snippets of images in my mind when I reflect, quick flashes of memory that can take me from normal to an emotional wreck in .25seconds.  It’s changed me.  Your life changed me.

I think of all the milestones you would have had, walking, talking, temper tantrums, special simple moments, that didn’t happen.  I wish I had reported the nurse who we think killed you, but the shock and trauma of it all had rendered us numb.  It’s like I let you down and now can’t forgive myself for it.

At least we’ll always have those small quiet moments where your Mom and I would just hold vigil in your little room.  The nurse would leave us alone in there with you, giving us some space to be a family.  It was dark in there, lit only by the blue bili lights and we would talk and dream about our future, your future.  We knew you heard us as you would calm down and seem to rest easy hearing those voices you knew so well if  only for a short time, the voices of you parents.  I treasure those moments.  When things were calm.  When things were hopeful.

All too often though I forget those special moments and remember the sheer terror of running into the NICU seeing them doing half-hearted CPR.  It was so bright in that room, thing were washed out by all the light streaming in but all I could see was your lifeless body and them looking at me.  I remember the pity on their faces, the pain they mirrored when they asked if I wanted them to continue.  I had to tell them to stop.  I let them stop.  I didn’t want to, but I knew it was far too late.  When you died, so did a little bit of me.  And I’ve had an empty hole ever since.

There’s still something missing in our lives.  Our life would have been nearly perfect with you in it, complete.  There are days where the rage is palpable, the sadness suffocating, the hopelessness immobilizing and I get into a funk so deep that all I want to do is hide in our house and bury myself into TV, praying to numb myself.  Perhaps this year is harder as I stopped the antidepressants, so I’m finally feeling the emotions again.  And while it feels good to feel again, it’s not easy.

But I’m trying to focus on the good.  You were with us for 8 days.  And what an impression you made.  Even though you were so young and so fragile, we could see your personality beginning to develop, our tiny little individual.  I’m lucky to have known you, one might say blessed (although I hate saying that I’m “blessed”…).  So I’m going to minimize the bad while remembering the good.

Happy Birthday baby girl!  We’ll never forget!

You can read Mia’s story here, here and here.

Add Another to the List

From the folks that brought you…

fibromyalgieurs

chest painieurs

methadonians

chronic drug seekieurs/chronic painieurs

comes a whole new group of fun-time pains in the asses:

*drum roll please…*

gastroparesis-ieurs

Yes, you too can have nebulous complaints that never seem to be fixed without the aid of “dilauntin”.

Why pay rent when you can convince the docs that your symptoms are still sooooo bad that you can’t go home?  And in spite of having a jejunostomy tube, you too can be a bulimic by sucking out the stuff you just swallowed through said tube.

Ran out of IV fluids and phenergan at home?  Come on down, we’ll hook you up!  Mix some dilaudid in the IV piggyback bag they now make us use for phenergan and throw it all down at once…it’ll be great!  Just don’t complain that, “I get bigger doses of phenergan at home!” because we just might tell you to go back there!

But in all seriousness…

I know that gastroparesis ican be a debilitating medical problem, whether from diabetes, destruction of the vagus nerve, what have you, it can make one’s life miserable.  I feel bad for those that truly have it.  These aren’t the ones I speak of.

Lately we have had a string of patients with “gastroparesis”, where the etiology is more psych related that physical.  And these are the patients that wear you out physically and emotionally.  Manipulative?  Yep.  Borderline personalities?  Probably.  Entitled?  You better believe it.  It’s almost like they have a local club where they get together, talk “shop” and trade secrets and regale each other with new stories of how they pulled it over on Doc So-and-So.  Several of them have implanted ports and administer IV fluids, pain medications and anti-emetics at home, but “decompensate” and get admitted to our observation unit for treatment of “nausea and vomiting.”

They seem to be the ones where nothing you throw at them works.  Zofran, compazine, phenergan never seem to take their nausea away.  (Maybe next time I should suggest droperidol or thorazine…)  Their favorite for pain relief? The Big D, baby.  Dilaudid, or as one so eloquently put it, “diluantin”.  And not small, infrequent doses either.  1-2mg q2 hours.  Srsly.  One even sets their cell phone alarm to when they can have it next.  And boy do some of them have tolerance.  One had an endo and received 10mg of Versed IV and   300mcg of Fentanyl IV.  If you have given me that last week I would still be gorked today.  But it did “nothing.”

Luckily though, the docs are wising up.  The one I had the other night had written in the orders section, “NO NARCS!” in bug, bold strokes.  Two of them have been black-listed from our observation unit as they tend to stay for days-weeks at a time instead of the obs stay of 24-48 hours.  I’m sure that as of now, they are passing the info and will soon to migrating to another local hospital for the cycle to begin anew.  I hope.

One last thing that bugs the shit out of me:  when you ask for nausea medication, don’t ask for 2 yogurts, some graham crackers and a turkey sandwich to wash it down with.  The nausea you’re feeling is probably just hunger pangs…

The Least of Your Worries

If you have end-stage cancer, and it’s incurable with whole body involvement, you’re in pain and don’t realistically have much time left, one would think it is time to consider hospice, palliative care or using medications like opiates to help you live out the rest of your days in some semblance of comfort.  Declining medications to quell the pain as you are worried about addiction is, in the light of everything else, seems kind of silly.  Worrying about being addicted to opiates is really the least of your worries.

Your cancer is going to kill you before you become “hooked.”  Yes, addiction is a scary thought, but I would think living out what little time I had left in excruciating agony to be a far worse fate.

But that’s just me…

What’s Your Pain?

It’s something we ask all of our patients.  As nurses we want, no, need to know if our patient is in pain.  So we ask, “On a scale of 1-10, with 10 being the worst pain you have ever had, how would you rate your pain?”  Or we use the faces method, or whatever method of assessing pain is in vogue at the moment.

So very often with a straight face, the patient looks at you and says, “I’m in 9 out of 10 pain.”  Just like that.  Straight faced.  Vitals are completely normal.  Face calm, nearly serene, talking and laughing on the cell phone, with not a single outwardly visible sign of any discomfort.  Since we rely on out patients to report their pain to us, it is not something we can objectively monitor, you have to accept what they say it is.

Now I know people in chronic pain.  I know that you can learn to block, modulate, go into a Zen-like trance to mitigate your pain.  But I have never seen anyone in true 9/10 pain who is calm.  That would be impossible.  I always try to give a scenario with pain, so that the patient will understand what I mean.  I’ll say, “0 is no pain, 10 is being doused in gasoline and set on fire.” or for the ladies, “10 is giving birth.”  But still I get the odd answers.

The reason I bring all of this up is that we have had a preponderance of folks in “pain”.  These painieurs always report their pain is 9/10 and that the only thing that works for them is Dilaudid.  They watch the clock and call 5 minutes before they are due to “remind” us that their meds are due.

We actually had one come up to us who immediately complained about 9/10 chest pain.  The nurse, being thorough asked, “What do they give you normally?  Nitro?”  “No” she replies, “They just give me Dilaudid.”  Straight-faced, looking like she is in a café ordering a latté, yet still having 9/10 chest pain.  To me it is a total disconnect.

Partially the disconnect comes from the fact that we color the patients’ report with our own perceptions.  The other week I re-injured/aggravated an old ankle/foot injury.  It throbbed mercilessly and then it would spasm.  At times, the spasms were so painful that I felt like I would vomit from it.  Even my wife looked at me grimacing, sweaty and pale and asked if I was OK.  Sure I was being John Wayne-esque about it and stoic, but it hurt.  I popped a couple of Tylenol, grabbed the ice pack and put my foot up.  Even with me almost vomiting from the pain, I would only have rated the pain a 7, maybe a soft 8 of 10.  I can imagine what 9/10 pain feels like and I have no desire to feel that.  I know that if I was truly in 9/10 pain, I would not be calm.  That’s why it is so hard.  You wish you could tell the patient to “cowboy up” and deal with the pain, but you can’ – although I did overhear an orthopod tell his patient we was going to have to do just that.  We have created a culture where it is never OK to have some discomfort.  Just look at the rash of relatively healthy folks showing up to EDs complaining of the sniffles and low-grades temps thinking it is the flu.

So sometimes you don’t ask.  You observe from a distance and document.  Even when you’re assessing the patient, unless they bring it up, you stay away from it.  What I hate the most about the painieurs is that they color your assumptions of everyone else.  Where you normally would try to reduce the pain of your patients, you ask yourself, “Are they faking it?  Do they just want the buzz?”   And I hate they have done that to me.

I know there is no easy answer to this dilemma.  I try to take the road where unless they have proven themselves to be dodgy, I treat the pain full force.  But with some that you deal with time after time after time, you know that they are drug seeking and all they want is the rush.  But moreso I try not to let my own perceptions of pain color my view.  I may be able to deal with 7/10 pain better than others due to my nature, so I can’t let that get in the way of effective treatment.  And for the most part I don’t.  It is just those rare occasions where I question, but more often than not I give the meds and hope we’re not being taken advantage of.

And as for the patient who only wanted Dialudid?  The nurse called the doc who pretty much said they were a known drug seeker (which we knew already) and she would not provide their drug of choice.  The patient realizing they were not going to get Dilaudid promptly signed out AMA.

New Friends

You need new friends when in a drunken drugged out stupor they lodge a pear in your rectum that needs to be surgically removed.

You need new friends when they give you with dirty heroin that causes you to stroke then develop rhabdo when you’re left lying on the floor for 22 hours after they bail on you.

You really need new friends when during some “sex play” they insert a foreign object into your urethra which ultimately causes a rampaging case of Fournier’s gangrene leaving you half the man you used to be.

With friends like that, who needs enemies?

Neurosurgical Set From Early 19th Century | bored-bored.com

Neurosurgical Set From Early 19th Century | bored-bored.com.

Too cool.  Glad we’ve moved beyond this, kind of.  What passed for medicine in the 19th century really seemd to be more like butchery and until the realization of germ theory and infection control, odds were pretty grim.  Not to mention lack of anesthesia!

Mapping Prescription Narcotic (over)Consumption

Check out this interactive map: Prescription Narcotic Consumption.

It is more than fascinating, it is mind-blowing.  The sheer amount of presciption narcs out in circulation, based on this map (which I can’t vouch for the validity of, but…) is any wonder why we have drug seekers sowing up ERs daily, or why our post-op patients are requiring higher doses of more potent narcotics, and even why they are now running anti-prescription drugs ads aimed at scaring families with children (my favorite is the one with the sleazy guy who says, “I used to be your kids’ dealer, now they just steal it out of your medicine cabinet.).

According to the map, we’re (Oregon, that is) is #2 in Methadone consumption (better than, ahem…Lousiana), #16 in Oxycodone and #18 in Hydrocodone.  The statistics are just left as that, numbers with no explanation.  No in-depth reasoning or analysis, just straight up numbers.  I guess we either have many, many ex-heroin addicts, or an astounding number of fibromyalgieurs or other chronic pain condition sufferers being treated with methadone.  Personally based on what I’ve seen on the floors, it is the latter.

I think that if nothing more, it shows a marked shift in the prescribing habits of doctors with a more liberal attitude towards narcotics.  In relation to that, is the societal aceptance of said narcotic uses.  It appears more acceptable these days to be on prescription pain medication than it ever was before, showing a shift in cultural mores and attitudes.

Does this translate at all for nurses?  You better believe it.  First, there is more access, bringing on the occasional spate of OD’s and the frequent drug seekers to our doors.  And second, there is the tolerance factor for folks undergoing surgery, planned or unplanned, requiring higher doses of pain medication to remain comfortable. I’m sure there are more than that, but this is what came to mind.  We try to ease pain in our working lives and sometimes dealing with a set-up where nothing, except the total abscence of pain, will make a person happy, it gets frustrating. I guess what my point is here, is that we have been set-up in a way by the liberal prescribing of narcotics, illustrated (in my opinion) by the graphic above.  Since we nurses are the front-line, we take the abuse.  We can’t just tell our patients to “cowboy up” and not treat their pain.  But what does one do when treating the pain becomes physiologically dangerous?  And what happens when expectations are that there will be no pain at all?  We have all seen it where the patient is getting enormous amounts of narcotics and still complaining of pain, but to give more would be akin to completely knocking out their repsiratory drive.  It’s a conundrum with no easy solution.  Sometimes a little pain is the reminder that is needed that something has happened to our bodies.  I always try to let my patients know that odds are, I won’t be able to reduce their pain to nothing, but try my damndest to get them comfortable.  Maybe this is what the docs are doing:  just trying to get people comfortable.  Maybe we need to be a little uncomfortable at times.  Maybe a little pain is a good thing.

How I Spent the 4th.

Getting the snot beat out of me… I don’t know if the guy who gave me this as a prize was commenting on my masculinity (or lack thereof…) or that maybe, he instinctively knew I was a nurse and knew the true roots of “Girl Power!” My second thought was, “Is it that obvious I work with all women?” He must have been a psychic as well as a carnie.

The coolest thing though happened to me at work this morning. I always feel weird around those who I’ve performed CPR on – those that have survived. So imagine my surprise the other night when our Code from the Night of Many Codes came back to the floor. As committed team member I went in with another nurse to get a patient cleaned up for the day. It was a bit odd, as laying here was a patient who last time I had seen them was quite nearly dead, if not truly dead. That night his pressures had been dropping all night and just didn’t look good. Respiratory status diminishing, really working hard. I pop in to see if the the nurse needs anything and end up finding the blood pressure as 60 palp. Things progress to a full blown Code. Luckily, being a fresh post-op heart, the wires were still in place. But until we got them hooked up to the temporary pacer, we had to do CPR. On a fresh heart. At least we didn’t have to worry about breaking ribs. The strange thing was the supple compliance of the sternum being held together by surgical steel wires. CPR was downright easy on this patient.

Now imagine my surprise when they’re pretty much neurologically intact, granted they stayed a month in the Unit and their kidneys went to hell, but they’re alive and talking to us. As we go about the tasks of turning, moving, sliding, rearranging linens, getting a new sling positioned (did I mention they can’t help much with care..) He says, “Hey,watch out for my chest!” pointing at their sternum. “It still hurts, had a lot of trauma to it.”

The other nurse looked over at me and we both grinned and chuckled. He continued, “What’s so funny?”

“Nothing,” I say, “We know you’ve had some trauma there. And let me just say I’m sorry about that.”

I didn’t fill him in on the fact I had been pumping on his chest 3 weeks ago or anything like that. Just took the opportunity to say sorry!

Fun With YouTube

I’ve been on a little bit of a sour note of late, and thought I needed to share some fun.

Went and saw it on Saturday night and it was…awesome. Big, dumb, loud, brainless fun. But a great adaptation of the Ironman mythos.

And I’m very excited for these last 2:

There’s a new trailer out in the theaters that’s even better than this. I just hope the movie lives up to the hype and anticipation.

And some local flavor:

Why you should wear a helmet…