Saturday, January 31, 2009

Plagal Cadence

First he wanted the test. But he didn't want to consume the bowel preparation for it. So we postponed the tests. Then he complained about that.

"I'm sick of this," he said. "Ever since I came here, all of you people have been giving me an attitude."

"Well, it's probably you, then," I said.

His jaw slacked and he said "What?!"

It was beautiful. I wish you could have been there.

"If you think it's everybody else, then it's really probably just you that's the problem," I said calmly and quietly, arms at my sides, voice relaxed. I've been through this sort of thing before.

He told me to fuck off and said I had an attitude. Then he complained that nobody ever explained anything to him.

I told him not to talk that way and I assured him that I would explain things. I would have anyway. He demanded another nurse. I said "No" and told him that if he wanted anything, anything at all, he had to go through me. He demanded a doctor. I said "No."

Eventually we came to terms; he drank the prep, got the test, and he became my favorite patient of the day. He felt better after explanations. I told him that I was just the kind of nurse that he needed. At first he didn't believe me, but that turned around.


Another patient had a sitter because of expressed suicidal ideation. They were crying and complaining that "someone over by the window wanted them to jump out." I gave him (the patient, not the apparition by the window) Ativan, telling him that If he relaxed a little maybe he wouldn't suffer so much. He liked Ativan.

"If people who aren't really there are trying to hurt you, call me right away and I'll take care of it, Okay?" I told him. The sitter watched.

"Then what will you do?" the patient asked me.

"I'll politely ask them to leave. And if that doesn't work..."

"What?" he asked.

"I may have to get a little rough with them."


My next patient was a demented old guy who started the day in four-point restraints. I got him down to two, leaving the ankles on, pretty loose, because he didn't seem to care about them. He pulled out one intravenous during the day. After I put another one in, he pulled the tubing apart and got blood all over, but the IV site was still fine.

He wouldn't eat. Some people just stop eating. They could starve from dementia.

He got Geodon and Haldol.

His family was at wits' end.


Lastly: a young woman, high-school age, who had gotten into a knife fight with her fourteen-year-old little sister, who won. That left her with a punctured lung but other internal organs were okay. Surgery and a left chest-tube to water-seal. A visit from a nice police officer.

She was my "normal" patient.

Friday, January 30, 2009

Potato Bin

Sunday, January 25, 2009

The Margins

Not my chest X-ray, though an even trade for mine. This one shows a pretty nice right-middle-lobe pneumonia. Mine's RLL. The nice people at the urgent care center let me see the pictures. Now I know why I've been feeling like crap.

The nice urgent care people also did bloodwork, gave me some nebulizer treatments, and shot Solumedrol into my arm. Lucky me. The poor little boy in the next room got sutures. In his lip. I wish I could have helped. Poor little guy...

I took my prescriptions to a local chain pharmacy. In the parking lot there was a man fixing his truck. Here in Phoenix any open area, preferably with a little shade, can become an out-of-doors auto repair shop.

The woman at the door was collecting money to buy pet food for a local no-kill animal shelter. They're already on my list. I gave her ten dollars. She had a soft cast on her right leg. Her clothes smelled like stale cigarettes.

At the pharmacy counter I was met by "Mandy." She took my cards and prescriptions. I've used this place before so they had me in their system, but my coverage recently changed. Workplaces do that rather frequently; probably every few years on average.

Mandy asked me if I was the primary on my card. I said yes and indicated that my name was on it, along with those of my family members. She asked me if my name was "shrimp cocktail" and I said no, that's my kid. Mandy poked the computer keyboard.

A man in a car at the pick-up window caught my eye, as if to scowl; as if to ask what was I doing that was taking so long, what was the hold-up? He looked sick and old.

Mandy just looked marginal to me. Marginal finances, marginally marketable earning skills, marginal intelligence, whatever. I'm not being mean. My heart goes out to people who live on life's perilous margins. In my work I try to help them when their health is over that margin...

Every day I express gratitude regarding my own position on the manageble side of the margin. No, that's not all true. Sometimes I curse the margin.

Mandy said the prescriptions would be ready "in an hour." She was lying. I can always tell. Sometimes I hate that, too. Like when I go to movies or watch "Law and Order" on television. The actors are often required by their profession to lie considerably. That leaves me appreciating their art, but I'm not convinced. Rather, I am distracted. They try to hide their personal problems, but even really good actors are just themselves, after all.

Opera is easier for me, because it's so obviously and absolutely fake. They sing. All the freakin' time.

I left and passed the woman collecting donations for the shelter. The man in the car had driven around front and parked his car, a Bentley, and was now harassing the shelter volunteer about something.

He was barrel-chested from years of smoking and steroid use. Skin like paper.

There was a truck on the far side of the parking lot with a sign painted on its back window: Manes by Mandy, and it listed a website. For a hair salon. Mandy was a pharmacy tech and a hair stylist.

You can be on more than one margin. That's not necessarily better.

Friday, January 23, 2009

Party Treat

I heard this story while I was in the car listening to Randi Rhodes.

Sasha and Malia Obama didn't accompany their parents to the balls in Washington D.C. last Tuesday night. Instead they had a party at "home," the White House, for all their new friends from school. As part of the festivities they held a treasure hunt.

One of the surprises: upon opening a door the "treasure" hidden behind it was the Jonas Brothers.

Unfrickingbelievable. You don't have to be a little schoolgirl to be impressed by that on a number of levels.

Monday, January 19, 2009

What They Say

Designated Driver

It's time for a long and plentiful celebration, but remember: safety first.

Dirty Face

All hail Janacek, master of the back wall and watcher of birds,

A Fall of Woodcocks

Citibank is worth, in toto, about as much as the wardrobe of 1970's clothing I have stored in the back of my closet.

Many professional football players are religiously insane.

If you suspect that you are having too good a day and your faith in fellow mankind is suspiciously upbeat, read the comments section of the Arizona Republic opinion page. It'll bring you right down.

I used to have a bumper sticker that read "cancer cures smoking." Somebody stole it. I guess they liked it.

If you have a dog that likes to chase its own tail, that dog is a capitalist.

Perhaps you drink too much coffee. Think it over while you're having another cup.

A long time ago when I was a nursing assistant in a small intensive care unit I was helping one of the nurses do something with a patient. The nurse (his name was Ed) explained to me that Dopamine is dose-dependent and the conversation took several other turns as we worked with the ventilated patient. "The patient always dies," he told me, but I already knew that.

The national debt of the United States is no longer "astronomically high." There are not enough stars in our galaxy for that to be so.

Arizona ranks 49th out of the 50 states in education spending per student. If Russell Pearce has his way, we will soon be rated 51st. Or even 52nd. He feels that strongly about the issue.


Friday, January 16, 2009

It's a Miracle But Not a Mouthwash

Put some fucking chickenwire on the front of the jet engines already, m'kay?

A local television news affiliate did a story out at Sky Harbor, touting the chilling possibility that the Salt River could flood and if a plane landed in that it would be big trouble.

Nobody would drown. Nobody would even get wet.

Must. Walk. Dogs. Avoid. Television.

Good Pilot! Have a biscuit.

Tuesday, January 13, 2009

Counting Down

Let's say you have a disagreement with somebody over a real estate issue. They set off fireworks and some of them landed on your lawn. They've got kids. So you kill those kids.

There. All better. Fixed.

Suppose the managers of a business are keeping two sets of books. They embezzle every last penny. They happen to be Republicans (they usually are,) and they have friends in government who see to it that they get billions of taxpayer dollars to keep the firm solvent. Then they use the money to buy yachts and Aspen lodges.

No problem.

Let's say your ay the end of your presidency and you want to put on a press conference, but not enough people show up. Nobody shows up. So you round up a bunch of low-level staffers and pages to fill empty seats. Cameras on. It's a go.

Now go.

But keep in touch. Don't leave the country. You know; warrants and all.

Wednesday, January 07, 2009

Huwaida Arraf

This video over at Juan Cole's essential website Informed Comment is at once frighteningly beautiful and too sad at the same time. Hat tip to The Pants-Challenged Quaker.

Remember: Just say no to tanks and soldiers killing children in your neighborhood.

And another thing: Modern warfare is "asymmetrical." That means that the side that kills the most people, loses.

Not Yet

Health care workers and facilities could all, to a one, make incredible amounts of money if but a single thing were allowed, that thing which all other businesses are permitted to do: refuse customers.

Instead, huge amounts of money are spent on people with no ability to pay for services rendered. Then there are the people who indeed can pay, but doing so renders them bankrupt. And jobless. And in many cases homeless. All because they had the audacity to get sick or injured.

I don't personally mind so much, because I get paid regardless of the patient's legal status, insurance, or lack of such. But hospital nursing is a stressful and difficult job, and if nurse paychecks even just begin to suffer a little because of these things, you can fully expect the already dire nursing shortage to get a lot worse.

Nurses don't want to get rich. We only want to be able to sustain a reasonably healthy and safely comfortable middle-class family lifestyle. If we can't have that, then we get stressed-out and sick, and if that happens you won't have any fucking nurses at all.

Samantha is here illegally. She stayed in the U.S. after her student papers expired a few months ago. Things aren't so well in her home country, largely because of U.S. foreign policy and war, but that's another story. Over the past couple months she'd been feeling sick.

The school clinic sent her to the hospital along with reports of bloodwork they'd drawn. Her blood urea nitrogen levels were over 100 and her creatinine was 17.9. That's
bad. Most of the glomeruli in her kidneys, those little filtration tubules that do the work of cleansing the bloodstream and concentrating urine, had lost function. Who knows why.

She's a dialysis patient now. The hospital is absorbing the cost of her care and is putting in an AV shunt, but soon we will have to discharge her to her country of origin. Her family hopes she can get a kidney transplant there.

Maybe that will happen. Probably not. If not; say for example she is discharged from the hospital, cannot follow up with thrice-weekly dialysis sessions due to cost, and she ends up very sick, she can present right back at our hospital and we will have to take her in. Dialyse, stabilise, and discharge. Repeat as often as necessary.

Define "stable."

You know what? If your kidneys are basically dead and you need dialysis for the rest of your life, your health is never going to be stable. At least not for more than a couple days at a time.

Speaking of you: Your health insurance premiums don't even cover the costs of your own care, let alone that of others. And your taxpayer dollars, while these help, do not come close to reimbursing hospitals for all the charity care they must provide.

Arizona figures for 2005-08

Centers for Medicaid and Medicare Services Section 1011, which dictates how hospitals get paid for care to illegal immigrants:

Arizona figures for 2005-08

Centers for Medicare and Medicaid Services made payments to Arizona for health care services based on the estimated number of illegal immigrants living in the state and the number apprehended. An estimated 283,000 illegal immigrants live in Arizona, and apprehensions are based on the number of people apprehended the previous year.

Payment Year Apprehensions to Arizona
2006 600,838 $47.6 M
2007 565,239 $44.5 M
2008 415,218 $37.9 M

For bug-eyed bigotry, hate, and general ass-hattery, you really can't beat some of the comments that accompany that Tucson Citizen article. Try to resist. Anyways...

A lone large Arizona hospital can rack up $40 million in charity care in any single year. One hospital. And they can't, by law and by good conscience, say "no."


Sunday, January 04, 2009

Sunday Plath: On What Precipice?


This was the land's end: the last fingers, knuckled and rheumatic,
Cramped on nothing. Black
Admonitory cliffs, and the sea exploding
With no bottom, or anything on the other side of it,
Whitened by the faces of the drowned.
Now it is only gloomy, a dump of rocks ---
Leftover soldiers from old, messy wars.
The sea cannons into their ear, but they don't budge.
Other rocks hide their grudges under the water.

The cliffs are edged with trefoils, stars and bells
Such as fingers might embroider, close to death,
Almost too small for the mists to bother with.
The mists are part of the ancient paraphernalia ---
Souls, rolled in the doom-noise of the sea.
They bruise the rocks out of existence, then resurrect them.
They go up without hope, like sighs.
I walk among them, and they stuff my mouth with cotton.
When they free me, I am beaded with tears.

Our Lady of the Shipwrecked is striding toward the horizon,
Her marble skirts blown back in two pink wings.
A marble sailor kneels at her foot distractedly, and at his foot
A peasant woman in black
Is praying to the monument of the sailor praying.
Our Lady of the Shipwrecked is three times life size,
Her lips sweet with divinity.
She does not hear what the sailor or the peasant is saying ---
She is in love with the beautiful formlessness of the sea.

Gull-colored laces flap in the sea drafts
Beside the postcard stalls.
The peasants anchor them with conches. One is told:
"These are the pretty trinkets the sea hides,
Little shells made up into necklaces and toy ladies.
They do not come from with Bay of the Dead down there,
But from another place, tropical and blue,
We have never been to.
These are our crêpes. Eat them before they blow cold."

Sylvia Plath
September 29th 1961

Britanny, France is called "finisterre." Lands' end, the westernmost tip of northern France, jutting out into the Atlantic. This idea must have been occupying Plath because the poem she wrote just previously to this one, Blackberrying, also uses lands' end imagery. It too ends looking out over the ocean.

Plath and her husband Ted Hughes moved their family to a thatched-roof cottage in the little village of North Tawton, England. They spent much of fall 1961 working on the old place. It had cobblestone floors and the walls were three feet thick.

They worked in the overgrown gardens, made friends with neighbors, hung curtains in the cottage; that sort of thing. It was a productive time for them with their new home and also with their busy writing careers. She had just won a prestigious award. Yet Plath wrote these two poems about high cliffs overlooking the endless sea...

They were using a borrowed dining table that belonged to Assia Wevill.

Hughes would have an affair with Assia. Plath would then leave Ted. Then she would die. He would later father a little girl with Assia.

Assia would also commit suicide, taking little Shura with her.

Of course Plath had no way of knowing that all this would happen over the next few years. But on some level she must have felt that she was at a pivotal time. Her Ariel voice would soon emerge. Perhaps that is why imagery of overlooking seaside cliffs occupied her so.

My spouse, ever the Jungian, says that elevation (as on high escarpments) indicates "spirit." The ocean often symbolizes the womb or the subconscious. Plath was searching there for her Ariel voice, which would soon boil over into her life's work. Just as the events of her life itself would force changes as great to her as the vastness of the sea.

Friday, January 02, 2009