Friday, March 25, 2011

The Froggy Test

                                                 A South African Clawed Frog

The other night I had a patient in her mid 70's who had been a lab technician in a hospital for 40 years, having just retired in 2007.  I like to make small talk while starting an IV, so I asked her about her job while I stuck her in the arm. "You must have seen a lot of changes during your career." I told her as I hooked her up to some normal saline. She mentioned that one of the most interesting changes was in the area of pregnancy testing. She still found it amazing that pregnancy tests were now sold over the counter with results in minutes. I asked her if there had really been a rabbit test. She affirmed that there had been, but stated that the test in her hospital's lab had involved a frog. I definitely had to hear about this, so I asked for details. The patient described the testing process: obtaining the potentially pregnant woman's urine, injecting it into the frog, and then waiting.
"Then what?" I asked her.
"Why then you catheterize the frog, of course"
Wow. I have cathed 90 year old ladies and elderly men with ginormous prostates, but a frog? Now that is some delicate work.
I thought this was pretty interesting, so I googled it when I got home. Indeed frogs had been used for pregnancy testing up until the 60's in the US and 70's in some other parts of the world. Many of the Google results, however, had a modern twist. Several species of frogs are dying off today as a result of the pregnancy testing from decades ago. The ideal frog for these tests was the South African Clawed Frog, which was subsequently exported all over the world. Apparently a nasty froggy fungus circulated around the world with it. Now other frog species who are not immune to this funky fungus are dying off all over the place. Who knew?

Thursday, March 17, 2011

Taking Notes

I was working in Preop Holding the other day when another nurse emerged from one of the rooms with a large spiral notebook in her hand. "Someone left this behind" she said. We decided we would try to reunite the notebook with its owner later, but also noticed that the notebook was opened to a page filled with scribbled notes on the patient's care. I'm not sure why the note taker wrote all this stuff down. To understand the care of their loved one? For ammunition in future lawsuits? Who knows. But it was pretty interesting. The notes went like this, spelling and all:

Socks on bed  nightgown on bed  plastick bag on bed Put clothes in plastick bag
Sine paper
Start hose in hand
Lactade Richard's in hose
Vankamyson 4 Mercer in hose
U want warm blankit   6 minutes to get warm blankit
Nurse won't let u drink water
Tony come to sit with us
Tony want warm blankit   8 minutes to get warm blankit
Nurse won't let u chew gum
Anastisiologist talks to us say u will get pain med
6 minutes to get pain meds fetanil
Dr come to room to rite on arm
U ask if u can get fed meal after   Dr say yes
Nurse come to take cpap to recuvery room for after
Lisa and Michelle come to sit with us want to take some more socks home
Ask for more fetanil nurse say she cant give u more
U go to your sergery

Was it Chili's or Applebees that used to have the timers at tableside where if your meal was not delivered in 30 minutes, it was free? I guess this person had the same concept in mind.

Saturday, March 12, 2011

Mercy or Murder? Who Decides?

As I have mentioned in the past, whenever I work in Preop Holding, something strange or confusing seems to happen. One night last week it involved a hip repair on a 90 year old. Hip repairs or pinnings are something we see everyday, typically in elderly patients after a fall. However, this particular situation brought some very strong opinions out into the open.

Anyway, a couple hours before the scheduled surgery, I called the patient's floor nurse for a report.  Instead of reciting the usual vital signs and statistics, the nurse stated that she was unable to give me report. She told me that the patient's daughter refused to give consent for the operation and had just left to go home.  The floor nurse explained to me that the patient had advanced Alzheimer's and was therefore unable to give informed consent and all that legality nonsense. 

So, since I've been in Surgical Services awhile now, I immediately understood what was the most pressing concern here. Thus I let the OR charge nurse know the situation, so that the surgeon would not be kept waiting. Surgeons, I have learned through various tirades, really, really do not like to be kept waiting.  So now that I had my priorities straight, I could move on to other things, such as maybe finally getting to pee nine hours into my shift. But that was not to be. The orthopedic surgeon in question, with resident in tow, came storming into the unit, demanding answers that I did not have. I had gotten the daughter's phone number from the floor nurse, so I handed it to him and suggested he call her. Before he made the call, he ranted for a while about how the patient was being sentenced to death by her daughter, the patient would be dead within a week without the surgery, that this was the most ridiculous situation he'd ever encountered in his twenty years as a surgeon, etc, etc. His face beet red with fury, the surgeon stomped out of the room to call the patient's daughter.

The resident, left behind by his leader, was muttering about euthanasia being illegal while he checked his Facebook. I went into the OR office for an update. The OR team for the hip repair was enjoying their unexpected leisure time in the office, along with another team in between cases. All were loudly vocalizing their opinions on the daughter's decision, which had ignited a fiery debate on the meaning of suffering and end of life care.

"It's murder" said one nurse "I heard someone was gonna call the police and have the daughter arrested"
"She just doesn't want her Mom to suffer more" said a scrub tech "we all talk about people being kept alive for too long. The daughter is doing the right thing"
"She'll suffer more if she doesn't get her hip fixed" chimed in the resident, who had gotten lonely and wandered into the office, still looking at his Facebook.
"I'm with the daughter. I wouldn't want to live if I was bedridden with Alzheimer's" asserted the charge nurse, a twenty year OR veteran "I put my dog to sleep when he was eleven years old and needed a second knee replacement. I didn't want him to go through that. Why don't humans get that right?"
"This is not a dog. It's a human being. Hellooo! I think the daughter is no better than a murderer. She's cold" said a scrub tech.
"Check it out" said a nurse "this is how healthcare rationing is going to start. You know...the death panels. The elderly won't be able to get surgery anymore. They'll just have to die"

 At this point I went back to my little area of the hospital and started preparing the charts for the next paperless system here yet! Soon the orthopedic surgeon came back, and the resident stopped playing on his iPhone and started paying attention.  The surgeon explained that he had managed to make the daughter feel guilty enough that she okayed the operation for her Mom. He told me to get the patient downstairs ASAP and "Chop, chop". Yes, he actually said chop, chop.

We sent for the patient. I called the daughter to obtain a telephone consent. When I spoke with her, she impressed me as a caring, kind person. She was friendly and cooperative on the phone. Another nurse and I witnessed the consent. Then the daughter spoke with the anesthesiologist to agree to rescind the DNR order during the surgery. It was done in less than ten minutes. The patient was prepped and whisked off to the OR within twenty.

The patient had been unable to speak, but groaned and lashed out with her arms when I got her vital signs and hooked her up to some fluids. She got extremely agitated when I pulled TED hose onto her nonoperative leg. She did not seem oriented in any way.

I had mixed feelings about the whole situation. It is too rare that a family has actually discussed the patient's wishes before illness either creeps up slowly or slices into their lives with devastating suddenness. I have witnessed these talks only a couple of times, but felt privileged to see them. It takes courage and love to bring this stuff up. It is so much easier to live in denial, not wanting to think about our loved one being weak or ill, much less close to death. Declining a vent or feeding tube strikes me as a very common sense option when a loved one is terminally ill and unaware of their own identity or situation. Declining a hip repair, I'm not as sure. On a 90 year old with advanced dementia, maybe that's reasonable. But love and fear of loss can make it hard to think logically. I don't know what I would do if that were my parent. What would you do?

I'm sure as budgets are cut and healthcare costs continue to rise, money will also become more of an issue in these decisons. Studies have shown that a huge proportion of healthcare dollars are spent on end of life care, often prolonging lives by only days, and not happy days either. I think there are certainly many times that hospice is a better option than aggressive, invasive medicine. Often these patients are vented in the ICU  while their families are hoping the next, newest miracle drug or treatment will fix them. A 90 year old is one matter. What if the dying patient is a child?  It is heartbreaking for all concerned. I know it is incredibly hard to let go, but unfortunately as the money dries up, the healthcare systems may start making that choice for us.

We see patients on a daily basis with tubes in every orifice, decubitus ulcers, and a grim prognosis. We meet families who want everything done, rib fracturing chest compressions, tube feedings, rectal tubes, endless blood and platelet transfusions, every antibiotic under the sun, painful, but futile treatments to add a little more time to a life whose quality has declined to almost nothing. We grumble about how we want DNR tattooed on our bodies and sigh as we carry out the family's wishes.

Wednesday, March 9, 2011

Self Diagnosis

When asked if he understood the the procedure he was getting (repair of prolapsed rectum), the patient responded:

"All's I know is that they better be fixing my a$$. My a$$hole keeps falling out, you know."

Monday, March 7, 2011

Mean People Suck

My oldest child is a middle school girl. Unfortunately I have recently noticed some "Mean Girls" type of activity going on at her school. This kind of behavior is pretty typical of adolescence. I'd like to think that most of these kids will grow out of it and mature into secure, compassionate, productive citizens. I have met too many petty, backbiting adults to take this for granted though. I would also like to think that nurses would be above this kind of childish behavior. In nursing school I heard the saying that nurses eat their young, blah blah blah. I figured I was too nice and too hardworking for anyone to want to eat me up. Wrong. I've encountered a few cannibals in my time, but I'm not so young anymore, not so vulnerable.
I talked to a nurse the other day, however, who reminded me of this issue. I FINALLY took the 12 lead class I have meant to take for like five years. When I walked in, there were already about ten people seated in the auditorium. I smiled in my generally smiley way at everybody, and only one nurse smiled back at me. I recognized her as an RN who used to work on our Orthopedic post surgical floor. I had encountered her in the past when bringing patients to her from PACU. She had struck me as extremely hard working, smart, and helpful. A couple of us had suggested she come to the PACU, but she would need some other experience first, either ER or ICU. So, as I talked to this woman, we'll call her Nicenurse, she told me how she had transferred to the ER to get some experience there in order to hopefully eventually work in the PACU.
I have to explain: like so many others across the country, our ER is a zoo. It is a chronically understaffed, inner city, outdated, underbudgeted, overburdened mess. Staff turnover is horrendous. It hemmorhages nurses like a torn aorta. I know several agency nurses who refuse to go back. They seem to get a new Nurse Manager on at least an annual basis. I already liked Nicenurse, but I know how chaotic our ER can be. Now my respect for her has gone up substantially.
 She is so discouraged, though, she tells me. She has been in the ER for ten weeks and has no intention of quitting, but she says that the other nurses and the techs treat her like crap. This puzzled me, as I know she is hardworking and smart. Nicenurse told me that fellow ER staff criticize her positive attitude and are making bets on when she will quit and who can get her to quit. Apparently other staff have refused to help her at times and have told her incorrectly where items were located. I had no reason to doubt her story, but I just don't get it. In my mind more staff = good. I would want a decent nurse to come on board. Maybe if they could retain some more staff every nurse would not have to have 6 or 7 patients, including ICU holds.
I hope things improve for her. Do other professions treat themselves this way?

Friday, March 4, 2011

What Can I Say?

Diabetic Oregon Man 'Doing Fine' After Dog Eats Toes

Published March 04, 2011
| Associated Press

A diabetic man from Oregon who awoke to find that his dog had eaten three of his toes says he is recovering and hopes to leave the hospital soon.
Nathan Jones told The Associated Press on Friday that he is "doing fine" and resting, but he declined to speak further.
Jones called 911 on Tuesday to say his dog had eaten part of his right foot while he was sleeping, including three toes.
The hospital says Jones is in fair condition and was expected to go home Friday.
Jones had no feeling in his feet because of diabetes.
Roseburg veterinarian Alan Ross says the dog may have been trying to rid his owner of dead tissue, which is not uncommon.
The dog is at an animal shelter.

***Wow. First we started using leeches to help with grafting reattached limbs. Then maggots to debride dead tissue. Now dogs to gnaw off dead toes. I know some vascular surgeons who may feel very professionally threatened by this dog. With rising healthcare costs, this may be a medical breakthrough. With so many worried about little or no health insurance coverage and possible rationing of care, could canine assisted procedures be the answer? But why is the poor dog in an animal shelter? He may have possibly prevented an entire below the knee amputation with his proactivity. The doggy might have saved his owner from descending into full blown sepsis. Maybe his owner is getting some instruction in the hospital on how to properly manage his diabetes, dare we hope?


Courtesy of