My vagina has a fever?

Recently we had an 18 year old girl on our unit for a few days after her open-heart surgery. Long story short, she was mixing her drugs with some not-so-sanitary things (pond water, among other things...) and shooting those up. As anyone with a shred of foresight could imagine, pond water does not belong in the circulatory system, and she developed massive bacteremia. She ultimately became super septic and developed lots of fun things like septic emboli to her brain, spleen and lungs; vegetations on ALL FOUR of her heart valves; and acute kidney injury.

I met her after getting all of her valves fixed. Amazingly, she came through the surgery beautifully. Because she had all of her valves intervened upon (two repairs and two replacements), she was on pump quite a long time. The combination of her massive amounts of narcotics we had to give her and her probable pump head made her a little weird.

Her only complaint after surgery? "My vagina has a fever." Not kidding. She was afebrile, had no rashes or anything weird down there. But she was adament that her vagina was too hot. She insisted on laying in bed, spread eagle, with a fan pointed directly at her vagina. Pulling her gown down over her lap increased the temperature, so she kept it pulled up to her waist. And she had a basin of ice water that we had to keep refilling that she would dip a washcloth in and wet the area almost constantly.

It was a little awkward. She had a young, male nurse. He thought it was awkward. Her mother thought it was awkward. Her father thought it was really awkward. She did not think it was awkward.

This lasted for two days.

Facebook, you don't know me at all

You know how Facebook (and all sorts of other sites) tailors their ads to individuals? Like, you google "Hawaii" and then you start seeing ads for hotels on Waikiki? Well, Facebook loves to give me ads for nursing and EMS related things, probably because those are listed as my professions on my profile. Usually I get things like scrubs, stethoscopes, steel-toed boots, etc. Recently though, I've been getting a lot of ads for nursing/EMS clothing.

These clothes are so cutesy and obnoxious and unprofessional and frankly embarassing. So then I started googling to see if these kind of things were common. They are. 

A sample: 

 

 

I mean really... who wears this shit??  For future reference, Facebook and your advertisers, not me! 

 PS: The parents wearing "My daughter is a paramedic" thongs, we've progressed to a whole 'nother issue I think...

You never really had chest pain did you...?

Communications: "Medic 14, you're going to Restaurant-Across-The-Street-From-The-ER for 45 year old male with chest pain."

...drive, sirens, etc...

Me: "Hello sir, what's going on tonight?"

Mr. Iwannamorphine: "Oh honey, got some bad chest pain."

...dramatically get into the amubulance...

Me: "Tell me about this chest pain."

Mr. Iwannamorphine: "Well my tooth is killing me and it hurts so bad that it makes me have chest pain. Gotta give me some morphine, you gotta."

Me: "Here's some aspirin. For your 'chest pain.'"

Mr. Iwannamorphine: "Naw, don't need aspirin. That chest pain is gone now. It's the tooth. Teeth only respond to morphine."

Teeth only respond to morphine. I clearly skipped that day in nursing school AND medic class.

We go to the ER (less than 1 minute transport time). He went to triage, because well he had dental pain... And to my surprise, come to find out, he had walked out of the ER 3 minutes prior to calling 911, after waiting about 15 minutes and not being seen.

 They only offer ibuprofen in triage... Making this a great idea.
 

History, more important than physical exam

So I ran this lady with AMS. And by altered mental status I mean, she was totally unresponsive. But her vitals were all perfect, she was defending her airway beautifully, her lungs were clear, her EKG was better than mine and her blood glucose was normal. Baffling.

So then I decide to read her paperwork, since of course, the report I got from the SNF consisted of helpful comments like "I don't work with her usually" and "I'm calling her daughter, so I can't talk to you right now."

In there I discover that she's had multiple admissions for sepsis where she presented with AMS. Aha! Lightbulb! I check her lactate. It's 6.5. I start her IV and hang some fluid. And then I go back to reading.

And then, there is was. In the nurses notes: "Recently, patient has been playing in her feces more. She has been seen rubbing them in her vagina and licking her fingers. Also, this morning Ms. CNA found a ball of stool in her coffee, which she was drinking."

...

Guys, I think I found the problem.

Nope, didn't want those labs

Me: "Hey, I wanted to check on some pending labs for Mr. Imactivelydying."

Lab tech: "Sure, what are you looking for?"

Me: "That repeat CBC from around 2330."

Lab tech: "Oh, that was cancelled and thrown out."

Me: "WTF?! Why was it cancelled?"

Lab tech: "Well that patient had a CBC two hours prior and another two hours prior to that, so we didn't think you needed it."

Me: "Seriously?! For one, if I sent you the lab, we probably want it run. For two, how is that your decision to make?! And for three,  did you notice that those other CBCs were distinctly abnormal?? Which maybe would have prompted you to think that maybe we were actively doing things to fix his H/H of 2/12 and wanted to see a repeat?! No? None of those? Ok, please run the next one I send down. Thanks." click

Ugghhhhhhhhhh. Angry face.

We have different definitions of "code"

So I was working the other night when I heard the code bongs going off. The code was in the surgical observation unit, which I literally don't think I've ever heard before. (Basically overnight observation for routine procedures where you're expected to be discharged in the am. Things like biopsies, some laproscopic ortho and abdominal procedures, lots of plastics and ENT stuff, etc, etc...)

Much to my fortunate luck, I got a call a few hours later that I need to take that patient in my lonely one remaining ICU bed. Reasonable, I think... resuscitated codes should probably take the last ICU bed in the house.

And then I got report.

Obs RN: "So Mr. S is 83 years old, day of surgery from a lap hernia repair. No complications. He's voided after his foley out and all that good stuff. So I put him on his home CPAP and put him to bed at like 2100."

Me: "Mhmmm... yea... mhmmmm." Thinking: "I bet he got overnarc-ed and forgot to breathe for awhile. 

Obs RN: "Well then when I went to take his vitals at like 2330 his SBP was in the 70s!" pause for dramatic effect

Me: "Mhmmm... yea... mhmmmmm..."

Obs RN: "So then I called the code, of course."

Me: "Mhmm... wait, what?"

Obs RN: "He got hypotensive so I called the code."

Me: "Oh so that's when he arrested? It was like a hypotensive/PEA kind of arrest thing?"

Obs RN: "Oh no, just that one pressure of 70 systolic. The next one was 130/80 once I woke him up."

Me: "I'm sorry I'm confused. So he didn't stop breathing or anything?"

Obs RN: "Oh of course not. So anyway, neurologically he's a 15, moves everything, ambulatory, pupils equal and.........."

Apparently "code" doesn't mean pulseless/apneic to everyone...?

New rule

New rule.

If you squirrel my call, a stabbing that of course was the only interesting call of the night, you then have to also squirrel the next call I get toned for (which, by the way, should have been your call).

This second call, of course, will be a nice rectal bleed at the nursing home.

Not that this happened tonight or anything...

PSA for bikers in all black

Dear lady on the bike,

Kudos on your healthy lifestyle. Not many people have the dedication to be riding their bike to whatever destination they may need to get to when its raining and 230am. But you, clearly are superior to them.

However, I just want to inform you of one little thing. You are incredibly lucky I didn't kill you tonight. And if I had done so, no one would hold me liable. Because you see, you're an idiot.

Only an idiot would 1) wear entirely black clothing, 2) including a solid black helmet, 3) while riding a black bike, 4) that doesn't have any lights or reflective striping, 5) in the middle of the night, 6) when it is raining and foggy and 7) run a red light without even slowing down, 8) cutting in front of an ambulance with it's emergency lights on.

Not only is that an incredibly idiotic combination of life choices, a good portion of them are illegal. (I mean, what did you do, pry off the little reflector thingy that's on the back of every bike I've ever seen??) However, I'm very glad I didn't hit you and kill you. I feel very lucky. Because ambulances are known for their precision stopping, especially in the rain. (Siiiike.) And I really don't want to kill anyone.

Good luck next time.

xoxo,

A

No I wasn't driving that car...

So the other night at about 0300, I responded for a motor vehicle accident at a busy intersection. Well, it's a busy intersection at not 0300. But still, apparently busy enough for some guy to T-bone another guy.

So we get on scene about the same time as the engine to find two sedans, one with pretty decent intrusion on the driver's side (the T-bonee) and one with a crumpled front end (the T-boner). I went to see the T-boner, while my partner went to see the T-bonee with the engine company in tow to maybe cut him out of his smushed car.

As I approach the T-boner car, I see a young male in the front seat with a fair amount of bleeding from a nice lac on his head. He seems a little dazed when I start talking to him. He's a little squirrelly, but talking to me.

Then the cops show up. Which they usually do for MVAs... My friend Mr. T-boner took one look, jumped out of the car and bolted for the woods.

Me: "Uh guys... guys...?"

Police Department: "Who's that guy? Why's he running?"

Me: "He probably caused the wreck... and doesn't seem happy to see y'all. And I'm definitely not chasing him."

Cue multiple officers running for the woods as well.

They come back a few minutes later with my lovely patient in tow. Turns out drunk and bleeding from the head makes running stealthily kind of difficult.

He denies that he was the driver. He seems confused over the fact that he can still be arrested while denying that he was driving. Even though 1) I IDed him. 2) His driver's license that he conveniently left on the front seat IDed him. 3) He has an otherwise unexplained bleeding gash on his forehead. And 4) the police caught him running from the scene. But I mean, we should probably take his word for it.

He blew a 0.22. I'd be confused too.

Old people rule!

So we went to pick up a lovely 91 year old lady in the middle of the night, who had no chief complaint and didn't want to go to the hospital, but whose family wanted to go to sleep. Or at least that's the best I can figure.

She was super demented, but friendly and chatty. On our way out, she quipped, "Does it really take 4 men to carry me out?"

I came back with some sarcastic comment about them being weak.

To which she promptly proceded to put up her dukes, started air boxing and yelled, "Let me at 'em. I can take 'em."

Love her. Want to keep her.

Feijoada

I think one of the best things to cook for a group of people coming and going is soup. It can stay on the stove, people can grab a bowl when they get a chance and everyone's fed. Not to mention, soup is generally pretty easy to make. The problem is though... soup gets boring. You can only eat chicken noodle or tomato soup so many times.

So I like to try new soup recipes. I came across this one for feijoada, which is apparently the national food of Brazil. I got my inspiration from this recipe. The author states that her recipe isn't that authentic, and since mine is altered from hers a bit, I guess mine is really not very traditional at all.


 -olive oil
-1 small red onion, chopped
-1 tbsp minced garlic
-10 sausages
-2 handfuls of baby carrots
-1 tsp balsamic vinegar
-1/2 tsp cumin
-1/4 tsp thyme
-2 pinches of salt
-1 tin of tomato puree
-1 1/2 cups of red wine
-1/2 cup water
-1 can of red kidney beans (16oz)
-1 can canellini beans (16oz)


In a large pot, start with a healthy drizzle of olive oil. Heat and saute garlic and onions for several minutes. The garlic should be fragrant and the onion translucent. Add the balsamic vinegar. Meanwhile, slice the sausages into bite-sized pieces. Add sausage and carrots to the pot, allow the sausages to begin to cook over medium-low heat. Season with the thyme, cumin and salt.

While the first ingredients are heating up a little bit, mix together tomato puree, the wine and water. Once blended, pour into the pot. Adjust heat to a light simmer, cover and allow to cook for 30-40 minutes.

After that time, add the beans to the mix. Stir in gently so the beans don't get mashed up. Let cook at least 15 more minutes. It can cook on low for as long as you want, which will let the flavor meld more and more.


Fair warning, the wine flavor is strong. I'm sure the alcohol is cooked off, as I don't seem to be stumbling about, but you can definitely taste the wine. I think next time I would use some spicier sausages too for some extra flavor.

I loved this recipe and all the boys did too. You know soup is good when all my boys eat it.

Yes, definitely call 911 for that

Communications: "Medic 41, for the unknown problem... Caller reports that a man is trying to cash a check on foot in the drive-thru lane of the bank."

......? This is a EMS issue...?

I condemn you to hades

Middle of the night... 60ish year old white guy walks into the ER through the ambulance bay carrying a lady of about the same age in his arms like a baby. Thinking she was dead or something, several of us ran over.

"Sir, sir... what's going on??"

"Well you see. This is my wife. 'Bout once a year or so she just does this. The doctors say she's cat-o-ton-ic or some such. Pretty sure that just means crazy. But she'll wake up in a few days."

He lays her on a stretcher, write his phone number down on the white board in the room, and walks out, saying, "Y'all just call me whenever she wakes up."

This lady is not actually catatonic. She does a fairly good job of playing possum, but when you sneak your eyes open to peek at me when you think my back is turned, I can tell you're faking. But she was determined to keep up her charade, so we just kind of worked around her.

So I'm sitting on one of those roll-y stools, drawing blood out of her hand. One of the techs is standing up near her head chatting with me. She literally hadn't moved in the past 2 hours or made any noise. So we both turned towards her when suddenly she yanked all of her limbs inward, sort of fetal position-esque, and made a noise that can only be described as a cross between a pterodactyl attacking and a dying pig.

Then she flung all of her limbs out, punching Jack the tech in the face and kicking me square in the chest. Jack gets knocked against the sink, whereas I went flying backwards, falling off the stool when I hit the glass door of the room. I lost consciousness briefly from my head hitting the glass and/or the floor. Five seconds later, I wake back up to Mrs. Catatonia pouncing on me on the floor. She starts clawing my face and neck. And then she moves on to attempt to strangle me, speaking her first real words of the night.

"I condemn you to Haaaaaadesssssss."

Around about then, Jack came to his senses, grabbed her off me and threw her back on the bed. Simultaneously about 30 other staff members came running in because of the ruckus.

It's kind of funny now. It wasn't really funny then. Let me tell you, there's not much in life scarier than a wild-eyed crazy lady jumping on top of you and condemning you to Hades.

PS: This story is way better when I tell it verbally. Say "I condemn you to Haaaaaaadessss," in a creepy, gravelly voice. And picture this:

I beg to differ

Trauma is the only way you can enjoy help save lives during a gory bloodbath?

The ICU begs to differ...

Buffalo Chicken Lasagna

Lasagna is an easy, filling, universally-loved firehouse meal. I mean really, what's better than lasagna? Lasagna with buffalo sauce and lots of cheese! Yummmmmm... I'm really embracing the idea of taking traditional pasta and mixing it up with totally different flavors. Multiple people emailed me later to ask for the recipe after I served it to the troops. It's cheesy and tangy. Easy as squad meals go too. This recipe's inspiration came from here. I did change it a wee bit though.

-lasagna shells
-2 lbs chicken breast
-1 jar of Frank's Buffalo Sauce
-3 jars of Alfredo sauce
-30oz ricotta cheese
-1 cup of egg substitute
-1 cup of shredded sharp cheddar

Preheat oven to 350*. Do all the prep things: cook chicken and noodles if needed. I poach my chicken. And I used no-cook lasagna, but cooked noodles would be fine. So cook them now. Once the chicken is cooked through, chop it up into bit-sized pieces.

Get two separate bowls. Mix Alfredo sauce and buffalo sauce in one bowl. In the other, mix together ricotta, egg substitute and chicken (chopped into small pieces). Start by spooning a thin layer of sauce across the bottom of a 9x13 pan. Place a layer of noodles, then more sauce, followed by a layer of the ricotta mixture. Continue layers until ending with a layer of sauce. Bake for an hour covered. Sprinkle cheese over the top and cook uncovered for about 15 more minutes.




Then inhale :)

Ambulate before carry

So once upon a time, there was a kid in our first due who, in the time I've known him, has weighed anywhere between 350 and almost 500 pounds. (By the way, I'm not exaggerating about his weight... he could only be weighed on one special scale in the hospital and I've seen those red numbers flashing and he doesn't fit on our "bariatric cot.") Back when he was closer to 500 pounds, he was a cardiac arrest at home. He was successfully resuscitated by some of my colleagues and walked out of the hospital like a month later. Did I mention he was only 17 at the time? I can't swear to you what caused him to code, but I'd wager that his extra 300+ pounds didn't really help the situation. We go to his house a lot, not always for him, but also for his mother and grandmother who have a variety of medical problems of their own. This kid had no chance... both Mom and Grandmom has BMIs > 40 or so.

I went there the other day for the kid. He's like 20 years old now and has lost a fair amount of weight. A trim 375lb or so? So now his BMI is only like 54...

His complaint was "shortness of breath." He clearly had a cold. Was telling me about his runny nose, his cough and never actually mentioned being short of breath. In fact, he denied dyspnea when I asked him point blank.

Because I knew his history (and really didn't want to code him again), I did my initial assessment in the house, including a 12-lead. Everything was stole cold normal, so I offered my hand to him and said, "Ok let's go to the truck." He stands up and we start walking out.

Mom and Grandmom start rushing waddling into the room.

Cue the screeching...


"What do you think you're doing?!"

"You're making him WALK?!"

"Sit down baby... you're too sick to walk!"

"Y'all better be carrying him out of here!"

"Go get that cot girl. After I call, you work for me and I say carry him out to that ambulance!"

Seriously? How do you even say that with a straight face to me? I'm literally a third of his size. And I'm supposed to pick him up?

I carry out people who physically can't walk or those whose condition could be exacerbated by exertion. Chest pain, dyspnea, bad trauma, seizing/post-ictal or unconscious patients. This does not include obesity. (By the way, at this point the kid has already made it halfway to the truck, with no adverse effects.)

The mother and grandmother continued to scream at us until finally I pointed out that the kid was in the ambulance and so it was a moot point.

And I wish I were kidding... but the mom and grandmom proceeded to sit back down on the couch, eating chips and watching TV while we took the kid to the ED. Not stereotypical at all.

I think a little more walking would do the whole family some good...

My new favorite

I wish I were as funny and satirically accurate as these guys...

http://www.gomerblog.com/

Happy Reading!

How to be a good resident, from a nurse's POV

I think being a resident, especially being an intern, is basically legalized torture. It's physically and emotionally draining. You have to learn a new unit/service/specialty/whatever every month. That lengthy month you're on that rotation, you better know nuances like that Attending 1 needs silence until after the first retractor is in in the OR, or that Attending 2 likes to round from the back of the unit forward, or Attending 3 prefers to review all the day's X-rays with his morning coffee before rounds start. If you call an upper level for something they think isn't worthy of their time, you get yelled at. Conversely, you get yelled at for not calling them if you didn't do what they would've done if you had called. You get paged constantly by nursing, pharmacy, the lab... You get up at the crack of dawn and work long hours. (Seriously, when do you guys sleep?) Not to mention, you literally make life and death decisions on a day to day basis.

But you want to be a good resident right? You want to provide the best care for your patients and get beaten down as little as possible in the meantime.

So without further ado, a nurse's tips on how to be a good resident:

• Assess your patients. At least lay eyes on them. (And preferably hands... And maybe a stethoscope...) This sounds pretty obvious, but it's amazing how many residents have not seen their patients with their own two eyes. Then you have a reference point when the grouchy fellow or hurried attending notices something amiss and asks you if it's new/old, better/worse. 

• Communicate with your upper levels before it's 0300 or they're in the OR. Ask them what they want to be notified about, get parameters to act on your own (ie: transfuse Mr. B for a HCT <30%) and know what decisions they're comfortable with you making on your own. 

• Don't try to do procedures that aren't emergent/urgent at shift change. Ok, re-intubation, sure probably needed. But you can wait 30 minutes to rewire the arterial line or pull the chest tube if you need help from the nurses. Prepare to get the evil eye from the day shift and the night shift nurse when you interrupt them to ask them to put the patient back to bed (who got up 10 minutes ago) so you can pull a chest tube. 

• Learn ACLS. (Or PALS for those of you who like the little humans.) It is just embarrassing if you're attempting to run a code while looking at your ACLS cheat sheet algorithm you just fished out of your pocket. It's really not hard to memorize... you learned way more complicated things in med school, I swear.  

•  For the love of everything, talk to the residents who were on your rotation the month before. Learn from them the culture of that rotation. What time do rounds start? What do the attendings expect to be included in your presentations? Do we give morphine or fentanyl for pain control? Are you supposed to be in scrubs or street clothes? Does your attending prefer to round with a computer or paper printouts? Do you share your workload with a PA or an NP? 

• Listen to the nurses. We stay in this unit or clinic while you guys rotate through month to month. We can help you out with attending quirks.  We know what the upper levels want you to wake them up for at 0200 and what they'd rather hear about in the am. And importantly, we know a lot about nuances in our patient population. I'd go ahead and listen to an experienced neuro nurse who's telling you his patient (who looks exactly the same as the last time you peeked your head in) is evolving his stroke. Nurses who have been doing cardiac critical care for awhile can probably teach you a thing or two about cardiovascular hemodynamics and invasive monitoring. 

• Also important however, is to learn which nurses (and other caregivers for that matter) you should be listening to. See which nurses always seem to have the heaviest load or the sickest patients... that means the other nurses trust them. You should trust them too. Know who the charge nurse is. Refer to him/her if you are skeptical. I realize this is a little contradictory to the above statement, but sadly there are nurses who are not so good or smart. You listen to them and then the patient suffers, your attending is probably not going to like, "well the nurse said so" as an excuse. 

•  Caffeine. Caffeine is always the answer.

• Learn a bit about the specialty you're rotating through that month. Everything is relative in medicine. A blood pressure of 136/78 is probably reasonable for a trauma patient. 136/78 is perhaps too low for your little lady with a new ischemic stroke. And 136/78 is likely dangerously high for your patient actively dissecting his aorta. So you want to be a neurologist? Great... but this month you're responsible for the lives of gyn-onc patients... learn about them.

• Don't sleep around too much. The hospital is not that big. We allllll talk. You slept with a three nurses on your MICU rotation? We'll know all about it before your rotation with us starts. You're an intern and are caught with your attending? We definitely know about that and all assume you're too dumb to make it though without your sideline sexual favors. You don't want to be that guy/girl. 

•  Don't be condescending. Or simply an ass. This goes along with "listen to the nurses." You treat me like an uneducated peon, and I will destroy you in front your superiors the next time I get the opportunity.

• And as opposite from above, don't be a doormat either. Show some backbone. You made it through med school. You're smart! Contribute to the discussion. Don't just order every thing I ask for carte blanche... think about it. I respect a resident who thinks things through and discusses it with me, but then denies my request much more than a resident who is simply an order-entering monkey.

• Try to understand that we're required to page you with every little thing. Critical lab values, abnormal vitals, whatever. I know you're not surprised that the lady who has been spiking fevers all weekend is now 38.5, but the order and the damn hospital attorney say I have to let you know.

• Be ready early. If round are at 0600 and you're finishing your notes at 0545, I promise you someone will code at 0530. 

• Don't sign out onerous things to the next shift. Poor form! I know you've done twelve smelly, hunting-for-STDs pelvics today in the ER, but knock out that last one before you leave. And if the patient died on your shift, you do the death packet.

• Ask questions. You are here to learn after all. 

Wow... that went on longer than I planned. I probably have more too. Will stop for now. 

Shit nurses say

It was one of the those mornings after a hellacious night shift that we just needed to drink like normal dayshift people tend to do after work. Apparently it's called happy hour? For us it's called find the bars and restaurants that will serve alcohol at 0800.

Drinking ensues. Yelling ensues. Other customers leave their breakfasts behind in a rush to get away from stories of blood on the ceiling, guts falling out of dehisced incisions, and poop on shoes. Fast forward to May being pretty drunk after this breakfast "happy hour." Or totally passed out. Whatever.

Ellie: "May... May!! Wake up!"

May: Non-sensical grumbling

Ellie: "May... wake up. At least take your shoes and bloody scrubs off before you pass out!"

May: grumble, grumble

Me: "Whatever, let her sleep on the floor..."

Then May sits bolt upright, eyes still closed, pointing a finger at us.

May: "Charge to 200!"

Us: "What??"

May: "CLEAR!!!" falls back over, passed out

See nurses text