Wednesday, May 30, 2007


Sometimes when I'm slumming it in the various online newspaper discussion boards I have found myself writing things like this:

Let's say that your child is seriously injured or develops a nasty illness. You take them to the hospital. You have healthcare insurance through your employer. After a couple weeks of intensive treatment, tests, consulting specialists, and rehabilitation, your child is released and gets to go home.

But the insurance copays force you into bankruptcy.

"BOSTON and CAMBRIDGE--February 2, 2005--Medical problems contributed to about half of all bankruptcies, involving 700,000 households in 2001, according to a story published today as a Web Exclusive by the journal Health Affairs. Families with children were especially hard hit -- about 700,000 children lived in families that declared bankruptcy in the aftermath of serious medical problems. Another 600,000 spouses, elderly parents and other dependents brought the total number of people directly affected by medical bankruptcies to more than two million annually.

Surprisingly, most of those bankrupted by medical problems had health insurance. More than three-quarters were insured at the start of the bankrupting illness. Among those with private insurance, however, one-third had lost coverage at least temporarily by the time they filed for bankruptcy. Often illness led to job loss, and with it the loss of health insurance. Out-of-pocket medical costs (for co-payments, deductibles and uncovered services) averaged $13,460 for those with private insurance at the onset of their illness, vs. $10,893 for the uninsured. The highest costs -- averaging $18,005 -- were incurred by those who initially had private coverage but lost it in the course of their illness. Many families were bankrupted by medical expenses well below the catastrophic thresholds of high deductible plans that are increasingly popular with employers. The authors comment that even their own coverage from Harvard leaves them at risk for out-of-pocket costs above levels that often led to medical bankruptcy."

The headline of the Harvard news release cited says that most of those Americans that were bankrupted by healthcare emergencies were middle-class and insured.

From Holly Sklar:

William McGuire, of UnitedHealth Group, the nation's leading insurer, was the third-highest-paid CEO on the Forbes list. His pay of $124.8 million could cover the average health-insurance premiums of nearly 34,000 people.

"While executives are richly compensated, patients are tightening their belts," Dr. Isaac Wornom, chairman of the Richmond (Va.) Academy of Medicine, wrote last year. "Premiums, deductibles and co-pays are up, while benefits continue to shrink. One million Virginians -- that's one out of seven -- have no health insurance at all, and this number is increasing. . . . Half of the uninsured work full time for small businesses that simply can't afford the inflated rates."

You work hard, you're patriotic, you put food on your family, and what do you get if you or one of your loved ones is stricken by a catastrophic illness? Nothing.


Tuesday, May 29, 2007


From 73 Poems by e.e. cummings:

all which isn't singing is mere talking

all which isn't singing is mere talking
and all talking's talking to oneself
(whether that oneself be sought or seeking
master or disciple sheep or wolf)

gush to it as diety or devil
-toss in sobs and reasons threats and smiles
name it cruel fair or blessed evil-
it is you (ne i)nobody else

drive dumb mankind dizzy with haranguing
-you are deafened every mother's son-
all is merely talk which isn't singing
and all talking's to oneself alone

but the very song of(as mountains
feel and lovers)singing is silence

The rhythm of this sonnet is displaced every second line which has only nine syllables instead of the traditional ten. Perhaps these missing syllables are "silent."

Monday, May 28, 2007

Tombeau de Couperin

You just have to love some people, just because. Just because they have good humor, intelligence, and graciousness. The patient in the last room was such a person and I took an immediate liking to them. Luckily I wasn't having a hair-on-fire screamer of a busy day so I chatted with them a bit on every round I made.

A few years ago they'd had bariatric surgery and they were so successful in losing excess weight that they needed a tummy-tuck to remove some annoyingly large abdominal skin folds. Part of the pre-operative work-up included a routine CAT-scan.

The radiologist called them as soon as they got home from the scan and told them to go to the hospital immediately.

Surprise. The scan revealed a seven-plus-centimeter abdominal aortic aneurysm. Not so bad in and of itself, but it if ever ruptured the patient would very likely die from internal bleeding in a very short time, so surgical repair was required.

"You've got a good vascular surgeon," I had told the patients, "I'd let them work on my kid." True enough. The patient was glad to hear that and said that they were confident that things would go well and they expected to be up and out of the hospital in a couple days. Exactly what I myself expected.

I sent another patient home; an unrepentant drinker and smoker holding off hepatic encephalopathy and its accompanying dementia only by taking loose-stool-inducing lactulose four times every day. They'd felt a little sick and stopped taking the stuff. Their blood levels of ammonia shot up well into three figures. That's bad for the brain. They got confused and were brought in by their spouse.

After a day of resuming the lactulose and some IV fluids they were back to being themselves and their labwork had shown an improving trend. They spent more time outside smoking than they did in their hospital room.

From the National Institute of Alcohol Abuse and Alcoholism:

"Positron emission tomography (PET) analyses of a healthy person and a 47–year–old alcoholic cirrhotic patient with mild hepatic encephalopathy. The blood flow through the brain (i.e., cerebral blood flow [CBF]) differs only minimally between the two subjects. However, the cerebral metabolic rate for ammonia (CMRA) and the permeability–surface area product (PS)—a measure of the extent to which ammonia can pass the blood–brain barrier and enter the brain—are significantly increased in the alcoholic patient, as indicated by the wider distribution and enhanced brightness of the light areas."

The brain can do very little to protect itself; for example, relying on the liver and the diaphanous blood-brain barrier to fend off a host of toxins. As goes the liver so goes the brain.

If that patient keeps his promise to me and resumes his tobacco and alcohol abuse, he will invite early senility or cancer into his life.

As if there isn't already enough senility and cancer in the world.

Friday, May 25, 2007

Treated Lumber

Wandering Charges

From "I've Seen Ghosts" over at Surgeon's Blog:

"In no community hospital are there as many doctors present around the clock as there are in teaching places. If I get run over by a truck, get me to a trauma center in a university setting. If there are a few people running around with minimal experience, so are there plenty with plenty."


"When I was in training, I believed evangelically that the best surgical care anyone could get was right there, not despite but because of all of us trainees and attendings in the mix. After a couple of years in practice in a community hospital, devoid of students at any level, I came to feel the exact opposite (meaning the best care was in that community), and I still do, except for certain highly special situations."

As a nurse I've worked in small rural community hospitals with less than 100 beds and also in large urban level-three trauma centers with a greater number of employees than the total population of some towns in which I've lived.

In the big teaching hospitals there's always a wide variety of expert doctors from various fields and all the diverse residents to choose from when calling upon others for assistance. If there's trouble with a patient sometimes one of the first problems to be solved is just who to call first. Usually it's a resident, who might then seek out an attending doctor or consulting specialist for advice.

In the community hospitals you just "call the doctor," who in many cases is the patient's family practitioner.

I'll call this one "Dr. Lerner."

He lived along one of the lakes outside of the village and he shared an office in a beautiful old clapboard house a block away from the main street. It was one of a handful of family-practice outfits in town. We hospital nurses were on first-name basis with their office staff. We spoke to them regularly both in and out of work because we were all basically neighbors and saw each other weekly at the local mexican restaurant.

One evening I was sitting by the ICU and Telemetry monitors charting my assessments when I saw this:

The rhythm came back after a six-second pause. He'd had others but this was his best yet. I called the floor and they said the patient was fine. I called the doctor and he said he'd come in to place a temporary pacemaker and ask one of the surgeons to place a permanent one in the morning.

We wheeled the patient into an ICU room and put him on a fluoroscopy table with blocks under the wheels that held him in slight Trendelenburg.

The radiology technician had brought in the C-arm and some lead aprons so we were all ready when Dr. Lerner arrived. He even let a family member put on an apron and stand beside him to watch as he inserted a central line and threaded the pacer wire into the heart. I dialed up the device and presto, pacer spikes.

Party over.

In a big city hospital it would never have happened this way. Family practitioners just don't do that here. But out in the mountains among the lakes and forests sometimes they do.

Thursday, May 24, 2007


Since the world is one in which values sometimes conflict, it is occasionally difficult to maintain a strict and absolute commitment to any given ethical position.

Maybe a little white lie or perhaps a lie by omission is not to be avoided, if instead the pure truth would cause bad feelings among people that have your respect. Or sometimes it might just seem best to let a petty annoyance slide on by rather than call a person on it.

There are probably times when two wrongs do make a right. I can't think of any, though. It's been a long day. I'm tired.

But I must ask something that's been on my mind lately, a question concerning honesty:

How do you lie to yourself?

Not that I have any pressing need to know. It just seems like an interesting question. And a lot of people appear to be able to do this effortlessly. How do they manage it?

Tuesday, May 22, 2007

Planting Vines

My kid loves this song. I grew up with this stuff, and it just amazes me how good these guys were.

Sunday, May 20, 2007

Saturday, May 19, 2007

How I Got My Nursing Exam Results

Back in the day we took nursing board exams in a gigantic conference room at the state capitol. There were thousands of us stuck in there for sessions held over two days. The tests were written. No computers then.

It was a total pain in the ass. None of this "the computer turns you off when you've answered enough questions to pass" nonsense. We gutted it out for entire days.

Bathroom trips were accompanied by an escort. No snacks or drinks allowed for four hours at a time. A stern old schoolmarm-type oversaw and sniffed over our every scratch and mark. In my memory she carried a stick or a switch, presumably to swat down an errant hand reaching for cribnotes or power-bars.

When the ordeal was over I drove home a few hours away and then...


Weeks turned into months. Finally the fateful day came when the mailman delivered to me what I'd been working towards for so many years: somebody else's nursing board results.

Someone who lived about forty miles away from me had my same name but a different middle initial and social-security number. They passed. I got their phone number from Information and called to give them the good news and to let them know I'd soon be forwarding them their exam results.

No, they didn't get mine.

I made a few more phone calls the next day and was told that my paperwork was also in the mail. No reassuring tones, no apologies. I got the feeling that the people I spoke to were honestly puzzled that I would call about such a trivial matter as sending NCLEX results to the wrong person, complete with personal information.

Before I got my results I had to mail the exam-administration company more money. Everybody did that year. They made us all fork over another benjamin after we'd already paid for and completed the test!

A few years later I received a letter inquiring about a suspension from a downstate hospital in which I'd never worked. That was also a case of mistaken identity. After some months it was all cleared up. I still have the paperwork in a filebox. You never know.

To "study" for the exam I did a couple pages of review questions several times a week. Almost every day. The questions are supposed to make you prioritize patient needs but that's just an excuse. Actually, a lot of them were just so poorly written you really couldn't tell what the fuck was even being asked. So I generally just concentrated on figuring out the kind of language I'd have to muddle through to make a decent guess.

Every student in my graduating class passed their boards the first try.

If the instructors had even suspected just a teeny bit that one of my fellow nursing students might not get by, they were axed months before. There were some that I thought would've been great to work with if they had just been helped along a little, but that wasn't how it worked.

Apparently it's more important for a nursing program to have a reputation for its graduates passing the boards on the first try than it is for the teachers to more fully address the perennial nation-wide nursing shortage by helping students.

My own little evening class section only had about fifteen students and three got tossed before the boards. The whole two-year rotation sent less than 70 graduates to the NCLEX exams, out of over 90 people that had entered the program.

One who was sent away was fresh out of highschool and had a little difficulty keeping up with the workload. Chop chop. She was a friend. I went skiing with her.

Another was a single mother working full-time while she went to school. It was painful for me to see her get shafted after more than three-and-a-half semesters of hard work. Very harsh, that. I'd offered to help her study but she'd have to get home to her kids.

The last was someone who had a previous career and four-year-degree in athletic training, and for some reason the instructors just hated his guts. I stayed away from him, even though he was a good guy.

Too bad. It's all for nothing anyways. The diploma and license just give you entrance to a job, and that's where we all learn everything, not in school. An apprenticeship-style nursing education would probably be quicker, better, and cheaper in getting nurses into the job markets than this antiquated and miserable nursing-school system we have now.

Win a New Message for Your Answering Machine

From the candidate's campaign website, running for Prince William County Commonwealth's Attorney in Virginia:

"Ham has known adversity. Ham was completely cleared of any involvement in the death of Mama Cass Eliot, a scandal which threatened to derail his political career until the baseless charges were shown to be a fraud. This experience has helped Ham to understand the importance of proper prosecutorial conduct, and inspires Ham to ensure that only criminals face the justice system.

Ham is a strong supporter of civil rights and the concept of innocent until proven guilty. Many a time people have said that a prosecutor could indict Ham Sandwich when Ham was not guilty of any crime nor in most cases anywhere remotely near where the alleged crime had been committed."

If there were to be a running mate, I suppose that their campaign posters might include this:

Tuesday, May 15, 2007

Lava Cake

We needed milk and such. Waiting in the checkout line ahead of me and my young one was a man and his child; the kid appeared to be maybe ten years old.

The father was explaining something that they must have heard on the car radio, from what I could overhear. He was telling the boy that Jerry Falwell once said that one of the Teletubbies was a homosexual, adding that a homosexual was a man who "married another man instead of a woman like mommy."

The youth took that in stride and said "I know," but asked his father "what else did that man, the one who died, say?" The father added that Falwell didn't like those kind of people and he said that when they died god would send them to hell.

The boy thought about that for just a moment then said "that fucking son of a bitch."

My young one looked at me, I looked at them, and we giggled in half-voices.

After we paid up and walked to the car my child said "they must be liberals."

"Like me?" I asked.

"Like us," my pride-and-joy replied.

Friday, May 11, 2007

On the Patio

Out of the Corner

They were assigned to me for two shifts, and during that entire time they hiccupped. Reglan, compazine, ondansetron (which always seemed to me to be a good name for one of Santa's reindeer, if he should need a robotic one,) even a touch of intravenous ativan; nothing relieved this.

They hiccupped in their sleep.

Otherwise this patient was doing well. Chest tubes pulled, pain okay with occasional perc(hic!)ocets, up walking, incentive spi(hic!)rometry to 1200, the whole nine yards.

"The whole nine yards" isn't copped from football, as I once believed. It's origin is probably much older.

"While looking into it, I’ve seen references to the size of a nun’s habit, the amount of material needed to make a man’s three-piece suit, the length of a maharajah’s ceremonial sash, the capacity of a West Virginia ore wagon, the volume of rubbish that would fill a standard garbage truck, the length of a hangman’s noose, how far you would have to sprint during a jail break to get from the cellblock to the outer wall, the length of a standard bolt of cloth, the volume of a rich man’s grave, or just possibly the length of his shroud, the size of a soldier’s pack, the length of cloth needed for a Scottish “great kilt”, or some distance associated with sports or athletics, especially the game of American football.

Few of these have anything going for it except the unsung inventiveness of compulsive explainers. For example, a man’s suit requires about five square yards of material; anyone who thinks a soldier’s pack could measure nine cubic yards is dimensionally challenged; and I’m told it takes ten yards to earn a first down in American football, not nine."

Speaking of "the whole nine yards," there was this other patient, a 95-year-old who had been injured in an auto accident. They were similarly doing well; chest tubes out, leg repaired and splinted, out of bed with assist, pain-free. Their spouse was also hospitalized, but unfortunately at a different facility, and this was of great concern to my patient so we arranged for them to chat with one another on the phone daily.

My patient said that their spouse was "the best in the world" and explained that this was not the first marriage for either of them, adding that they were eighty when they got married.

Whe gets married when they are eighty years old?!

Really optimistic people, I guess.

Like this guy, Baba Fauja Singh, currently the world's oldest marathoner. Again I ask, as much in admiration as in bemused empuzzlement, who lines up at the start of a marathon when they're ninety-five years old?!

Well, at least one quite optimistic and obviously enthusiastic person.

This lady is named Olive Riley. Her caregiver Amber Rowe is with her. Olive is currently the world's oldest blogger.

Her "blob," as she calls it, is The Life of Riley.

I feel like I just absolutely have to read her blog before she dies, but found myself getting caught up in it nonetheless, unobligated.

We nurses work with the elderly all the time, but rarely have more than a few moments at a go for much talk with them. Olive's blog is wonderful for that because it's a bit like sitting down beside a remarkable woman, a very old remarkable woman, and listening to her stories as she flips through her collection of photos taken over the years.

Tuesday, May 08, 2007

Infinite Primes

The even-order symmetrical magic square in the upper right corner of Durer's famous Melancholia engraving fascinates me.

It's relatively easy to construct odd-order magic squares by following simple formulas, but the even-order, numerical pun, and symmetry of Durer's is a thing of beauty.

And of course the engraving itself is absolutely stunning. I saw a print of it once at the Clark in the beautiful Berkshires, where I sometimes would drag anyone who'd go along to see the great Impressionist collection there.

I ran into the Durer by accident. That's the best way, I suppose.

Lucky for me I've had a few days away from hospital nursing in which I could think about such things. Sometimes when we work, the vast beauty of our world is not what we first consider. Too busy.

Sunday, May 06, 2007

Blackhawk Down

On the "things to do list:"

Take a deep breath.

Drink a glass (or bottle) of water.


Maintain shelter.

Maintain family.

And friends.




These are a few of my favorite things.

Oh snap. I forgot clothes. Too late now. And I must update my blogroll. And sex. Can't forget that. Prioritize clothes before sex? No problem. There are these things called "holes." Big ones. Heheheh.

And coffee. Pizza, of course. And explanations. Don't we all need those?


Friday, May 04, 2007

Is the Spice of Life

It was one of those multi-tasking moments. A new patient was due any minute from surgical intensive care. Another patient was getting a couple units of packed red cells. While going over discharge materials with a patient and their family I heard a call light. And I was waiting on a phone call from the discharge patient's nephrologist to make sure they would also clear the patient to go home.

After excusing myself I went to the other room where a sweet little old lady, admitted with syncope, said she needed to hit the loo so I walked her in. Then my phone rang and while I was chatting up the nephrologist the sweet little old lady sitting on the toilet rolled up her eyes and curled her arms bunnyhop-style.

"So we'll keep him for another night of fluids and get labs tomorrow," I confirmed with the nephrologist, then I said "I'm sorry doctor, actually I'm here in the bathroom with another patient and she's just lost consciousness so if there's anything more I'll call you later," and the very nice nephrologist said "Oh."

I pulled the bathroom call light for help. Like that would do any good. I considered screaming. Sweet little old lady was still out for the count and quivering. Quivering is okay. Dead people don't do that. Much. Well, sometimes.

"Why don't you wake up a little, Mrs. K.?" I asked, and she opened her eyes and asked "Where am I?"

As we walked her back to bed I explained what had happened over the last half a minute. Then my beltphone rang (like I have a batphone or something) and it was the telemetry room calling to tell me that one of my patients just had a "six-second pause." I thanked them saying "Well, that's good to know."

Something like that.

Soon she would be the proud owner of her very own pacemaker. But first I inserted a foley, got some vitals (142/77) and called the doc, who asked us to have Cardiology see her. One of the best cardio guys in the city was on-call; I'd run into him earlier.

Oh... did I say that I put external pacer pads on her and wheeled the crash cart to her room?

Then I gave the bad news to the other patient who had to stick around for another night. They were nice about it.

There are other kinds of asystole. I suppose anytime the ventricles rest you could call it that. A "pause" is asystole that gets better. A lot of people with atrial fibrillation have pauses sometimes as long as a couple/few seconds. That's common enough. Nobody has a perfect sinus pacer node, really.

This sinus node isn't on a great game:

Nothing a pacer can't help. But I'll bet good money that patient never got one, even in Hollywood.

Then there's asystole that doesn't get better, which is therefore more difficult to treat:

You read occasional stories about people banging on the inside of their morgue door or some such thing, but mostly when you see a rhythm like that it's time to dig a hole. Or at least turn off the monitor. After everything else has been tried, if that's the patient's wish.

Another kind of asystole is almost as bad but may get better with pacing:

The pacer node is trying to get through to the ventricles but the message is lost in the mail.

The same thing sometimes happens to me a lot. But the message instead gets lost somewhere between my brain and my mouth.

One's from a dog.

The nephrologist stopped by late and let us send that other patient home, after all.