Saturday, April 29, 2006


This is snipped from a comment made to one of my previous posts:

"A hospital emergency room sent my mother [she was not fat, quite thin and petit] home with a broken arm (in two sharp pieces) with no more than bandages and a sling. It took over a week to get an appointment with a real doctor in his office. As soon as he saw the xrays he had her in surgery as quickly as possible."

This is not the last time you will hear of such a thing. I decry it. Yes, hospital emergency rooms are overcrowded and the nurses, technicians, and doctors who work these probably often feel that they are merely pushing a boulder up a hill only to have it roll back down again after all that vain effort made to get it to the summit.

But there is no excuse sometimes.

They first arrived at the emergency room with a complaint of shoulder pain and a feeling of "whooshing" in the chest. Labwork, chest X-ray, and EKG showed nothing unusual, so they were sent home.

A week later the pain had worsened and radiated into the abdomen. A CAT scan showed an enormous aortic aneurysm that extended from the aortic root all the way down below the kidneys. The original aortic lumen was actually smaller than the secondary along some stretches, and the secondary had calcified somewhat. One of the kidneys was fed blood supply not solely by the original aortic lumen but by the aneurysm lumen also.

A vascular surgeon of national reputation was called immediately to Gore-Tex the aorta from the root over the arch and down. Coronary and carotid arteries were re-attached through the new Gore-Tex. The operation, which must have been spectacular, took eight hours. After being on a pump all that time the patient went into Torsades and had to be shocked once or twice; irritable cardiac muscle and all that. A second-degree heart block later came and went.

After that things went as well as could be expected. The patient was relatively young and had no prior health issues or history to cause worry. The chest tube came out, the pleural rub dissipated spontaneously. The new aortic valve sounded wonderful, and the patient was walking laps in the hallways. A supportive family was very gracious and helpful to both the patient and the staff.

Prior to the operation the patient was your typical walking time bomb and they could have dropped dead any moment if the aneurysm had ruptured.

I would not want to have been the ER doctor that sent the patient home the first time they presented, but I suppose they had nothing really to go on.

Tuesday, April 25, 2006

Return to Sender

During my college years my best friend was a brilliant and artistic person, outspoken and strong-willed, but who constantly struggled with weight concerns. One summer they lost over 100 pounds, only to gain a fair portion of it back over ensuing months.

Later I came to understand just how typical this is, and I worked for a time in a hospital setting with bariatric surgeons and their patients. Now I am convinced that at this time the best treatment for many morbidly obese people is surgery; indeed, when I see a very large person, what I say to myself is not "that person needs to eat more sensibly," but instead I think that person needs surgery.

Many people do not understand this, and continue to think that diet will work for the morbidly obese. To such people I recommend this: go on a 1200-kilocalorie-per-day diet for the rest of your life, then get back to me. Good luck, and have fun.

Having said all that, some people are just fat obnoxious hate-filled pigs.

Like the patient in the corner room, whose call light was always on, whose family had continual little hissy fits over the most mundane things, whose nurse (thankfully not me) made every effort to please them and meet their needs only to get no appreciation for any of their efforts.

This patient was an unhappy sloth who saw it as their remaining life's goal to make as many other people also as miserable as possible, and after many decades of practice they had become quite proficient at this. And their younger family members, whose upbringing had convinced them that such ugliness was normal, played right along with it.

A sucking vortex of meanness and abject misery, plain and simple.

The day before yesterday was the patient's day to be discharged to whatever bright shining hell-hole they lived at, and the nurse was so happy in thinking that the patient would not be there in that corner room the following day. They rejoiced openly.

But on the way out to the stretcher van that was to transport the patient to their residence, the patient fell off the gurney and fractured a shoulder. They also probably broke a thumb, but the fear of a broken hip was ruled out on X-ray. The patient was re-admitted to the hospital and ended up in the very same room, much to the dismay of the nurse so assigned.

Paydirt. The mother load. Ka-ching.

Now the ugliness of their family misery was compounded by revengeful greed, and of course they've got a case.

Later that day I saw a couple strange-looking creatures, like the space lizards in Zathura only a little smaller, poking around until they finally found the patient and entered the room.

While they were visiting the patient did not put on their call light.; not even once, for about a half-hour. Then they wordlessly walked out and down the hall, eyes straight ahead.


The surgeons decided that the patient was not a candidate for repair, so the plan was to discharge them the next day with a sling for their arm and shoulder. Naturally "I'm so glad I have tomorrow off" was the nurse's constant refrain.

Friday, April 21, 2006


Sometimes you hear somebody resort to the old cliche "you can't tell a book by its cover," which in these faith-based anti-liberal hate-filled days of Republican screed is so not true... consider the epic tomes of Michael (fake name Savage) Wiener and Ann (Adam's Apple) Coulter, for example, whose titles alone eloquently save you the bother of actually reading the contents inside.

The Young One Who Pays No Heed to Parental Authority has lately ironically discovered, thanks to me, the songs of the Beatles. So the "White Album" has been in the CD player and as you know the cover of that doesn't tell you anything at all except the name of The Beatles when that was who they were.

Plain white wrapper, music of glorious beauty and variety inside. Who'd 'a thunk it?

He had been bleeding from the moment he returned from the operating room. The doctors had surgically incised a few cysts from each armpit. I didn't see any external sutures. Looked like they slit each open, espressed whatever ooze was in these, (there were a few) and then sent him back to us.

He wasn't my patient, but the looks on the faces of the nurses involved told me to take a stroll down that way. My little team was under control, which I rarely have the pleasure of saying. I'm a magnet for the most unpleasant things usually. Feces, degrading cardiac rhythms, sagging blood pressures. That's my ilk.

The patient's nurse, a nearby nurse, and the admission/discharge/transfer nurse were all taking turns holding pressure on the guy's armpit, but it was still oozing a steady trickle of blood. I brought a few boxes of 4X4 gauze. Then I took a turn myself, holding pressure with a wad of gauze while his nurse injected morphine.

He was talking on the phone while holding his left arm straight out above shoulder level to his side, so we could try to soak up the blood trickling from his armpit. Blood was on the sheet under his arm.

"Careful, he's HIV," said his nurse to me. She looked like she was about to cry, but it wasn't an emotional thing. She was fronting down a case of double pink-eye. I was properly gloved.

Once every few minutes I'd peek under the gauze to note the trickle. The A/D/T nurse spelled me, but I came back later to hold pressure again and see how things were going.

The surgeon who excised the cysts was off, so he told the nurse to try the on-call trauma surgeon, and he just said that he was 45 minutes out and to "hold pressure." The nurse explained that we had been doing that for like over an hour but he had no more to add.

The medical doctors she tried to call deferred it to surgery, but eventually a medical resident showed up and wrote orders for blood pressure meds (170/105 last, 205/110 before going to the OR.) He also ordered some STAT labs so we could check the anticoags and hemoglobin.

A little blood goes a long way. I was holding pressure again when the ADT nurse spelled me and I took a look at the blood.

It looked like blood.

Sure, it was HIV positive and Sam knows I wouldn't want to take that home with me. But it looked like plain old blood and nothing else.

After a couple hours of various nurses holding pressure on a one-centimeter-length armpit incision, it finally eased off bleeding. They'd wrapped a wad of gauze with kling to hold it over the wounds, and no blood was visible. He had his arm down.

I wondered. The next time I have a patient with uncontrollable bleeding from the armpit, I will have him hold his arm down. I do not know why; it's an instinct thing. I mentioned it to the guy's nurse, but it didn't really seem important. It's probably nothing.

"At night all cats are gray."

To which I might add: "At night all black Labrador Retrievers are... gray?!"

Sunday, April 16, 2006

It's About Time For One About Nursing

You want a chocolate cake, fine, I know a dozen recipes just off the top of my head because when I was about 10 years old my mother got sick of me asking for cake and told me to bake my own, We pulled the old Betty Crocker batter-stained cookbook down and from then on I was the family cake wholesaler.

But I'm no pastry chef, and we wanted to make apple turnovers so we went to the local gourmet market to get pre-made pastry and a snack.

Nice scene at lunchtime. A musician outside. An outside sandwich grill going, too. As well as the usual mid-Phoenix scenesters and characters: the tall newsguy dude we feel sorry for, the guy with the Bouvier de Flandres dog, and other regulars.

I think I recognize a woman at a table with others as we settle into an outdoor table ourselves. I sat at the opera next to her last year, and she cried out loud when Magda stuck her head in an oven.

I listened in as they talked about job turnover wherever it is that they slave away their weekdays, and I noted that she had a baked apple smell about her. Perhaps it was the perfume she wore to the opera also? Maybe not. Who wears apple perfume?

In the twelve years I have been a registered nurse I've held seven different positions, most of which have sooner or later involved bending over and grabbing my ankles with my hands while keeping my knees locked straight.

Old joke. But what isn't really funny is this:

"America’s nursing shortage has worsened and is eroding the quality of patient care. A recent study found that 60% of registered nurses are now over 40 years of age and projects that if present trends continue, the nationwide shortage of nurses will exceed 400,000 by 2020. According to the Acute Care Hospital Survey of RN Vacancies and Turnover Rates report by American Organization of Nurse Executives, the average RN turnover rate in acute care hospitals is 21.3% with an average nurse vacancy rate of 10.2%."

When I first came back to the city of Sonoran Tile-Roofed Endless Sprawl, I had been recruited by a large metropolitan medical center. Even though they gave me an appreciable relocation bonus of well into 4 figures, I quit before my orientation ended and I returned the bonus.

Is there a statistic for that? Is it called "nurse turnover" if you quit while still an orientee?

On one of my training shifts I witnessed a perfectly decent nurse, my preceptor in fact, drop a pill on the floor only to pick it up and administer it to a willing patient. So what? you may ask. Five-second-rule and all that.

Not me. Not my style. Okay, so sometimes I bark at the moon and scratch my ear with my foot. But, I don't eat off the floor.

Later that same shift one of the other nurses was talking about shooting cans with his new gun. He went on to say "You know, Mexicans, Africans, Puerto Ricans... Creeped me out totally. And besides that, he kept looking at me funny.

So I quit. That was a Thursday. By Friday afternoon I had completed a couple few interviews, caught up on my sleep, and landed a job that matched the sign-on bonus and even paid a little more in salary.

Of course you may think that the magic invisible hand of the free market, guided by the infallible laws of supply and demand, is responding to these issues of nursing turnover and shortages. Then again, maybe not.

"According to the National Council of State Boards of Nursing, the number of first-time, US educated nursing school graduates who sat for the NCLEX-RN®, the national licensure examination for registered nurses, decreased by 10% from 1995-2004. A total of 9,353 fewer students in this category of test takers sat for the exam in 2004 as compared with 1995."

On my next job, the entire staff of my little 28-bed telemetry unit turned over during my first year there. There were days when I was the only worker on the unit who was not an agency nurse who had just come in for a shift. We went through travellers like Mike Tyson went through ears.
The second year, during a meeting the director of nursing informed me that the turnover rate was only 87%. Much better.

Then she got canned, and my unit supervisor left. He was the guy that had hired me, and I always liked him. His replacement lasted a few months, then the "new" director of nursing was also let go. Sometime during all this we purchased Shrimplate Manor in the central corridor, and I wanted to work at a place closer to home.

I called the guy-who-had-hired-me ex-supervisor, and he insisted I join a specific organization. Before I could even finish my online application, they were calling me, and soon I was working at The Great Muffin Factory.

The turnover rate here is probably about normal, which is to say a lot less than 87%, but I see people come and go.

Things are much worse in nursing homes and long-term-care facilities:

"In May 2005, the National Commission on Nursing Workforce for Long-Term Care released Act Now for Your Tomorrow report which found that there are nearly 100,000 vacant nursing positions in long-term care facilities on any given day, and the nurse turnover rate exceeds 50%. The shortage is costing long-term care facilities an estimated $4 billion a year in recruitment and training expenses."

There was a time when I did about a nine-month part-time stint in a nursing home back in The Dismal Wilderness. I went to work never knowing if it would be an 8 or a 16-hour shift, because if your replacement didn't show up, you had to stay all night. I didn't know much what I was doing anyways, having just come out of school and off an intensive care aide job where I had become familiar with cardiac medications but knew relatively little about stool softeners.

As trends continue, there will be more patients and fewer nurses, which will only increase nursing turnover rates and shortages, as well as good old-fashioned burnout.

It might be different if the magic invisible hand of the free market would respond to increased demand for nurses and retention of nursing staff by actually, you know, paying them more. But where oh where would we ever, as a society, find the money to do this?

Oh, I dunno, maybe here:

"Iraq was awash in cash - in dollar bills. Piles and piles of money," says Frank Willis, a former senior official with the governing Coalition Provisional Authority. "We played football with some of the bricks of $100 bills before delivery. It was a wild-west crazy atmosphere, the likes of which none of us had ever experienced."

We could abandon our notions of pre-emptive wars for oil fought against third-world countries, and in so doing usher in a new period of responsibility and commitment to the healthcare of our fellow Americans, or, as Theodoric of York, Medieval Barber would say, "Naaaah."

Wednesday, April 12, 2006

What Can VooDoo

Sure, many of us live within walking distance of local grocery stores and such. Or within a bike ride to get to work.

"Ervin Goodall, 56, a professional driver pumping supreme grade into his large sedan, was paying $3.29 a gallon.

"It's lot higher than last year, a bigger hit," said Goodall, who added that when it comes to personal driving he's scaling back: no more Saturday day trips."

The modern era of cheap fuel will not be saved from eventual certain oblivion even if a few of us make the ultimate sacrifice of cutting back on Saturday fun drives.

From this article on today's front page. The price of gas is creeping upwards, but drivers are not really cutting back. After all, how can they? Especially in the sea of tract-home suburbia we have lately created for ourselves? We have spent half a century developing a lifestyle that requires we must first drive in order to do anything.

It's like what Tracey Walter says as "Miller" in Repo Man: The more you drive, the less intelligent you are.

As applied to entire societies; well, yes.

Will the suburbs be abandoned and lapse back into fields of roses and local produce? Will the central core of city buildings grow tall and shady, filled with people who pedal to their jobs? How much will that really accomplish anyways?

Yes, I can walk to Basha's, but the avocados cannot. Nor can the coffee beans and the half & half.

Sunday, April 02, 2006

Four and More (Infomercial)

In my humble small kitchen, this Chroma 301 santoku is the knife I most often find myself using. It's blade maintains sharpness enough to get one through both episodes of Kill Bill, but I still have a Chantry sharpener at hand for regular blade maintenence. It's easy and it works on everything. I've never much liked the traditional knife steel. It's too easy to get the wrong angle.

I also like a traditional chef's knife, but I prefer a somewhat smaller blade, that being a simple six-inch chef knife. The bolster on the Wustof is thick and safe. Compared to other German cutlery, this style of bolster is much less threatening, even if Messermeister blades are themselves a little harder. If you compare bolsters you see what I mean.

The Chroma" knives I like have a nasty little sharp edge where the bolster would be if these featured ones. Instead these have a little "pearl" that juts from the handle to guard against getting the hand too forward to the blade.

I'm OK with this, but I have my young one use a German knife. They have their own little four-inch chef's knife which they are very proud of, and though I'd prefer a thicker bolster, they wouldn't trade their blade for any other at this time. Radish trimming. Kinda fun, really.

They picked it out at the kitchen store all by themselves, with good advice from the store cooking coaches. My little one sees no need for the Santoku style blade; instead, moving right up to the traditional cleaver, good for big jobs like quartering a chicken or working out the final episodes of the opera Salome.

We decided that knife blocks took up too much precious countertop space, so we have a magnetic knife rack. Looks way cool, and the blades are easier to inspect for cleanliness. I like the way these look stuck up against the wall above the counter, and it's way better than dulling them in a cutlery drawer.

And now back to our regular programming:

How much money has the Iraq war taken from your pockets so far?