Sunday, June 28, 2009

A Knob of Widgeons

The poor old guy had been using an empty plastic cleaner bottle, for dish detergent or something, as an impromptu urinal. He was weak, suffering from congestive heart failure and a cardiac arrhythmia.

Anyway, he "got it stuck." He had been home for days with his penis stuck in a plastic bottle before he decided it was time to get into the system so he could get things fixed up. Maybe the bottle just got full.

At first the ED team couldn't effectively remove the bottle; they tried cutting it but this just left ragged edges in the plastic which tore into his sensitive member. Finally a talented urologist was able to remove the object without causing harm to the poor old guy.

Then his real treatment began. A diltiazem drip for atrial fibrillation and aggressive diuresis for his heart failure. A few ultrasounds showed that his anatomy was intact.

He had a daughter who lived away in another city. When she called to find out what had happened to her dad (she had been told there was a foreign object involved,) they handed the phone to me. They always do. Fuckers.

Religions are so anthropocentric. Science and evolution are not.

I think that if you practice enough introspection you will eventually come to realize that not everybody is like you. The more you explore the singularity that is yourself, the more you will be open to the diversity of all humankind.

Before you get so sick that you have to go to the local emergency department, you first have to build a hospital and train and hire the staff.

Music as we know it to be is not capable of self-replicating independently. It's more akin to a virus, which must enter something, a cell, before it can reproduce.

It now appears that the disequilibrium of protons around deep-sea alkaline vents may be the kind of energy source that enabled the first living things to occur. Disequilibrium is essential to life. Well, that explains a lot in my life, anyways.

We gave them paint and what did they do with it? They painted targets on things; everything, in fact. So let us not give them bullets.

Saturday, June 27, 2009

In The Pocket

PorkPie getting into the groove.

Friday, June 26, 2009

Once Upon Below

Hydrothermal Life Maker

From the February article:

Lost City is exceptional, Kelley says, because chemical reactions in the seafloor produce acetate, formate, hydrogen and alkaline fluids. All these substances may have been key to the emergence of life, according to work published recently by Michael Russell and A.J. Hall of Glasgow and William Martin of Germany. In addition, acetate and formate found in Lost City fluids may have been an important energy source for the ancestors of methanogens, microorganisms that live off the methane at places like Lost City. It's perhaps one more bit of evidence about where life may have originated, Kelley says.

This could very well be the sort of place whereupon, hundreds of millions of years ago, geochemistry evolved into biochemistry.

Tuesday, June 23, 2009

Jogging Blood Products

I could hear the whirring sounds of the pedals going 'round.

I knocked and entered the patient's room to check their vital signs again. They were sitting on the arm of the couch that each room has. For exercise we had provided them with one of those bicycle-pedal things, and the patient was spinning away.

They were also using the little hand-held barbells to work out their arms.

They paused for a moment so I could get new readings of their temperature, blood pressure, heart rate, pulse oximetry, etc. I checked the IV line to ensure that their transfusion was proceeding well. It was.

The patient was doing their work-out while they were also getting a fucking blood transfusion!

I will never again complain that I do not have time to sneak in a little exercise.

This particular patient has a chronic condition that requires relatively frequent hospital treatment. Needless to say, all of us nurses really admire their spunk. You have to respect a person who puts that much effort into their own care.

Friday, June 19, 2009


I haz its.

No, Thank You

"I don't believe it."

That's what the doctor said over the phone when Lori called him about Mrs. K. As if one of us would wake him up in the middle of the night just to fuck with his head a little.

"The other doctor is right here and I could have him read it to you," Lori told him. No, the doctor replied, adding that she shouldn't have bothered him about this, the patient had been having this pain all along, he had been adjusting her medications for it, and he already knew all about it so why was she calling him again. That sort of thing.

Mrs. K. had been in for an illness unrelated to chest pain and she didn't have a cardiac history. Her lungs were crap and we all know that can cause pain, but this was different.

"She says her pain is like a heaviness, she's guarding her chest, and I've never seen her do this before," Lori told the doc. Lori had ordered an electrocardiogram and had pulled labs off of Mrs. K.'s PICC-line. X-ray was coming up to do a quick portable chest.

"Who ordered all that?" the doctor asked Lori.

"It's a Telemetry floor, Doctor Phlegm. It's what we do."

Since he had declined to have the other doctor, a younger guy on his first hospitalist job, read the EKG to him over the phone, Lori suggested that they just fax a copy of it to Dr. Phlegm. He acquiesced to that, but still insisted it was no big deal.

Two minutes later he called back and ran off a breathless list of orders including labs, an EKG, oxygen, morphine, nitroglycerin, the chest X-ray, (all of which Lori had already initiated) as well as a drip and transfer to intensive care.

I got the story at seven in the morning when I got in for my shift and Lori was reporting off. She speaks with the tiniest bit of the most elegant accent. I don't think Dr. Phlegm likes accents.

They still had a copy of the EKG and it showed definite T-wave elevations in leads II and V6. Mrs. K.'s Troponin levels were twenty times higher than normal range, too. That's pretty much how you define and diagnose myocardial infarction these days.

Lori had nailed it. She did what all of us nurses live for, what we dream of doing; that is to say, she did her job. And all she got for it from the doctor was shit.

Saturday, June 13, 2009

10th Street Mission Slaughter

I will
Think of it as a compromise, or a mad flirtation.

Trois Pistoles

Sasha, self-exiled.

PorkPie iz warmie onn teh ampiflier.

U haz Bonz fur me Fechienne nowz?

Dimes and Punishment

There are different value systems. That which makes a work of art beautiful is aesthetic value. Ethical value informs good moral behavior. The so-called laws of supply-and-demand are said to regulate the value of goods.

Some people think that there is an underlying abstract "goodness" which crosses over from one value-system to another. In some ways I agree. My taste in music and my ability to determine what is "good" in a particular artistic style often informs my moral behavior.

The good in nursing practice consists of the same shadowy stuff as the good in a Lennon-McCartney song.

Having said that, there are of course problems in assigning capitalistic value to ethical, aesthetic, and other parameters of excellence or value. That perhaps is why capitalism cannot ever really work. It is in fact meaningless. Money is meaningless and in itself has no value. It's paper. It's numbers. It defies poetry. It is shit.

Precisely because it is itself worthless, incapable, and ugly; money is used as a medium of exchange.

Saturday, June 06, 2009

What the Rose Is

I am not easily disgusted. Perhaps that is one reason why I've been able to maintain participation in my profession, although I must admit that in my particular area of nursing practice I do not see a lot of trauma. Enough, certainly.

I medicated Jackie with a small boatload of Ativan and morphine before changing her arm dressings. A few weeks ago she had bumped her arm on a table while helping her son move into a new house. Because she regularly took Coumadin due to heart valve surgery years ago, she thought nothing of the bruise she developed on her forearm. Not at first, anyways.

Necrotizing fasciitis. It really doesn't occur all that often, thank the stars. Maybe a thousand cases each year in the U.S. Sometimes it takes a while for people to see that they have a big problem because early symptoms are typically just increased pain at the injured site and flu-like symptoms.

The pain is usually out of proportion to the injury, but pain is subjective. The disease is rare and even many emergency department personnel may not have seen examples of it. Unfortunately it gets missed; that is, until the swelling and bulbous blisters develop. Then all fucking hell breaks loose. Pandemonium.

The most common organism causing necrotizing fasciitis is Group A Streptococcus, which is basically everywhere and comes in a hundred or so variants. It can give you a sore throat or it can kill you.

Back to the patient: Jackie was watching one of those home-and-garden television channels. When I went back to her room after giving the drugs a few minutes to take effect, she began to tell me her plans for redecorating her hospital surroundings.

"I'd like to repaint the walls sea-green and maybe put in a water feature," she said in all seriousness. Then she pondered out loud about patterned material for new window drapes.

When I took morning report the nurse had warned me that Jackie freaked out a little when she initially saw her affected arm the day before when the dressings were changed for the first time after surgery. That's why I was somewhat generous with the drugs.

Oh fuck that. I'm always appropriately forthcoming with pain and anxiety medications. I work in a fucking hospital, for pete's sake. It's stressful for people. (Note to seekers: We can tell you're lying.)

The necrotizing fasciitis had affected her arm from elbow to hand. The outer aspect of her forearm had to be thoroughly debrided. The doctor, a local plastic surgery genius, took muscle and skin grafts from her thigh and reconstructed the arm.

If you are unfamiliar with these sorts of wounds it might appear as if someone took a blowtorch and a sledge hammer to Jackie's arm to make human meatloaf. I feared that perhaps she thought so. But upon my inspection, it actually looked good. Considering the circumstances.

I pointed out the neat lines of staples that secured the edges of the skin graft. The flexor digitorum profundus was intact and working for her and she could move her fingers. But the muscle over it had largely been excised. I explained that her arm would look as if a palm-sized half-inch of the outer aspect of her arm had been scooped away, and it could be lighter in color than surrounding intact skin.

"This muscle graft swelling will go down eventually," I told her, "That's why I'll wrap this up when we're done, and you'll keep it elevated on pillows."

"Oh, that's a nice print!" Jackie said, referring to the television show. "Can we use that for the pillows? Purple silk is so cool and comfy," she added.

I worked very slowly, explaining every step. Her fingers were good, uneaten by the disease. I carefully pulled away the petroleum dressings which had remained nice and moist. Using sterile technique I gently rinsed the wound, not that it really needed it.

We discussed new furnishings. "Maybe a solid lobster-red for the chair instead of that drab print," said Jackie.

"It's like you're reading my mind," I proclaimed. "I love that color!"

Soon the wound was covered with yellow sticky-moist petroleum gauze, covered and protected with sterile cotton gauze, re-splinted to prevent contraction, and wrapped just-right in ACE stretchy bandages.

Then on to the donor site, which was probably about the size of your computer monitor screen. "It looks good," I told Jackie, "And we can secure the dressing with this mesh stuff that you can pull up like a stocking over it. That way it won't fall down when you're walking." I think I used six, maybe seven, five-inch-by-nine-inch Xeroform dressings to cover the whole site then protected it with gauze and ABD's.

Usually plastic surgeons prefer to do these changes themselves; maybe have a physician's assistant or nurse practitioner do it. He must trust us. You have to be fucking careful as all get-out when you're working on donor sites. Very clean, very slow. If you accidentally pull up the donor site you can give the patient a wound that might never heal, and if you introduce another infection then you can just kiss everything off right there.

Same goes for the newly repaired and grafted site too, of course.

In the old days, maybe just twenty-five years ago, they would have just cut her arm off.

Later that day we sent her off the get a PICC line for home antibiotic therapy. She would basically be hooked up to a continuous twenty-four-hours-per-day Penicillin infusion for a month, which sucks a bit less than being one-armed.

She had a line of staples along her inner thigh from her groin to her knee, where they took donor muscle. "This doesn't even need to be covered, Jackie," I said. "But let me know if you want something thin over it so the staples don't rub on anything."

There. Done. Half an hour later she was sleeping.

My boss gave me one of those gift-card things we sometimes use for patients, and Maria the nursing assistant had a few minutes to run to the gift shop to get a little vase with a rose in it. She put that on Jackie's hospital table so she could see it the moment she awoke.