icu

Another reason why medicine needs feminism

Because full grown male residents don’t bother to ask a woman if she’s menopausal and make the connection that this is what threw off her otherwise controlled diabetes into DKA. Because estrogen aids in glucose control and protects against rising insulin resistance. 

 And I, as the only female on the team today, asked her, researched this, and defended this theory. With papers. For which I got laughed at repeatedly and told “that’s not a real thing.” Physiology and endocrinology are real things, assholes. We get tested on them. 

 And guess what. The attending, a man with twenty plus years of experience and a great breadth and depth of knowledge of medicine and respect for women, said I was 100% correct. And he straight up told the male residents “duh. It was so obvious. Why did none of you ask her these simple questions? Use your brains!" 

 Moral of the story: Defend your female patients. Don’t discredit them. Educate the ignorant, fight for your patient’s health. Even if it’s with your colleagues. Protect and listen to female patients.

Hey New Nurse

Hey new nurse,

You terrified yet?  Have you wanted to quit or reconsider your career choice yet?  

If not… you probably will.

But, little nurse- take heart.  Please take heart.  You are not alone.  

That confident nurse you admire so much, the one whose work is done on time and is always available to help out.  The one who everyone asks questions and who can usually offer more ideas than the doctors. The one that always gets the hardest assignments and who you hope to see in a code.

That nurse was once where you stand.  They also once shook a little starting an IV.  They were also afraid they put the catheter in the wrong hole.  Their voice also quivered when they talked to their first ‘mean’ doctor.  They also woke up, put on their scrubs, looked in the mirror and thought. “OK…I can do this.”  

The thing about nursing is, you don’t know everything.  You never will.  But, that is both the beauty and the pain of the job- you never stop learning.  So, little nurse, hang in there.  Because that nurse that you admire so much didn’t get to where they are now by quitting.

There’s no feeling like walking into the ICU Monday morning and finding someone else in your patient’s room.

A patient you spent all last week taking care of, playing constant catch-up with the vitals on the monitor. 

A patient you rushed to CT. Holding back tears as the scan came up on the monitor in front of your eyes.

 A patient whose parents know you by your first name and ask you how you’re doing when you step into the room. 

A patient who had improved by the very next day, giving you hope.

 But even then you knew they would still be in ICU for weeks.

Confused, you look up at the board and grab a list, a little panicked now, looking for her name. 

“Where is she?”

A patient who, even after you tried everything, passed away.

With parents who asked your residents to personally thank you.

Residents who understand your tears. Help you debrief and give you time to process.

Just in time to meet your new patient.

Here is a true story for all to read and to share so others may benefit. A while back, there was a 12 year old boy who fell from the merri-go round on the playground at his school. He was dazed for a moment but acting fairly normal. He was taken to the school nurse after which he was brought home by his mother. Once home, the boy complained of a headache but nothing more. After dinner time, his parents noted him to be sleepy and disengaged. Both thought he was just tired and considered putting him to bed early in hopes he would feel better in the morning. But a mother’s intuition kicked in and she knew something was wrong.

She took him to the emergency department to be evaluated. At the emergency department, the child was very sleepy but would arouse, talk, and then quickly fall back asleep. He simply seemed to be very tired. A CAT scan was performed showing a large blood clot over his brain. The blood clot was putting pressure on the brain. I was the Neurosurgeon called to evaluate the boy in the emergency department that evening. I reviewed the CAT scan, examined the child and recommended emergency brain surgery to remove the blood clot. The parents were beside themselves as they had considered putting their child to bed that night to see if he would be better by the morning. If they would have done so, the boy most likely would have not woken up the next morning and could have very well died in his sleep. The child was in surgery within the hour. At surgery, I found an enormous blood clot pressing on the brain which was easily removed. I found a hairline skull fracture which had ruptured an artery and resulted in the bleeding. Post-operatively, the child did well. He was back to his normal self after surgery and was discharged to home with his parents several days later.

His post-operative CAT scan showed the blood clot to be gone. I have seen him back in the office several times since his discharge. He is a normal 12 year boy back to life as usual. With his parents permission, I have included the pre-op and post-op CAT scan images to show you what an epidural hematoma pressing on the brain looks like before surgery and how the brain looks after the blood clot is gone. This real life story nicely illustrates the power of a mother’s intuition, especially regarding her own child. Always trust your gut instinct when you’re not sure of something. More often than not, you’ll be right. This young boy had what’s called an “epidural hematoma” which is the same type of blood clot that actress Natasha Richardson died from in 2009. She was married to Liam Neeson at the time. She died after falling on a bunny hill while taking a ski lesson at a resort near Montreal. She initially felt fine, was awake, talking and acting normally. This is called the “lucent interval”.

She declined medical attention at the resort because she felt fine and subsequently returned to her hotel room. Within hours, she fell sick complaining of a headache and was rushed to the hospital where she was declared brain dead many hours thereafter. She never made it to surgery. She was not wearing a helmet at the time of her fall. An autopsy revealed that she died from an epidural hematoma. Natasha Richardson’s death may have been preventable if she or anyone else around her would have had a higher degree of suspicion for injury or if she had accepted treatment when she had the chance. There is power in knowledge. Unfortunately, no one strongly suspected an epidural hematoma or brain injury when she was initially acting fine. Obviously, hind sight is 20-20 and I don’t have all the details surrounding her death to make any conclusive statements but you get the general idea. Always have a higher degree of suspicion for injury when someone hits their head, especially if they are complaining of a headache or acting tired afterwards. Epidural hematomas cause increasing pressure on the brain as the blood clot enlarges.

The most common symptoms include headache, sleepiness, nausea/vomiting or altered mental status. If you note someone having these symptoms after hitting their head, you should have them promptly evaluated at your local emergency department. And remember, always follow your natural instincts on these matters because usually they are right, especially when it pertains to a parent’s intuition. On a final note, always encourage, and if you can, make your children wear a helmet when they are riding their bike, skate boarding, roller blading or skiing. That one simple measure, which they will certainly fight you on, can save their life. If you have found this post interesting or helpful, PLEASE SHARE for others to read. And stay tuned for more Real Life Neurosurgery stories to come a www.BrianMatters.com.

- Brian Hoeflinger, MD

Things they don't teach you in nursing school

This I’ve seen time and again over the past couple of years: When your critically ill patient’s vitals suddenly get better for no apparent reason and without you changing anything, it’s not time to celebrate. It’s time to get the crash cart. Bad things are about to happen.

The living will a nurse...

Dear Colleagues, 

If there is a situation when I end up admitted here, this is what I ask….

1. Please make sure (unit creeper) is not in the room when you put my foley in.

2. Never let (list of unit dumb-asses) be my nurse.

3. I’m sorry for my mother.

4. and my sister.

5. I want to remember none of my stay. Sedate me to the gods.

6. I swear to God, if you motherfuckers give me c.diff, you’re dead to me.

7. Yes, I want a warm blanket.

8.  Also don’t let (nurse-frenenemy) be my nurse, she will def. try to kill me.

9. Please do not turn me every 2 hours. That shit’s annoying.  

10. If my “story of how I got injured” is embarrassing or humiliating, y’all better fucking lie.

11. I’ll pretend to be confused disoriented & combative just for the opportunity to punch some of you.

Today I woke up feeling like I had a hangover. I’m starting my 4 day break from the ICU, after working 6 of the last 8 days. I drug myself down the stairs and starting cleaning house as I normally do on my days off. I glanced at myself in the mirror at the bottom of my stair case. Horror. My face blatantly shows the pure exhaustion that I feel, and my hair looks a complete mess. “Thank god I’m off work today and my patients won’t have to see this worn out version of myself” is my first thought.

People who aren’t nurses always tell me, “You only work three days a week? Wow! That must be great. I wish I had your schedule!” ..Only three days a week? ONLY!? I wake up at 4:30AM, shake off my fatigue, drive an hour to work, and then begin my scheduled 12 hour shift. 12 often turns into 13 hours or even more depending on the patient load and if I were able to keep up with my charting. When I’m done and finally clock out, I drive home arriving around 8PM, where I strip out of my scrubs and collapse onto the couch where I snuggle my cats and tell my husband about my day until I pass out from exhaustion. I slip upstairs to bed, to the disbelief of my husband that I could possibly be so tired, and I set my alarm and prepare for my next shift.

ONLY 36 hours a week. But does anyone who’s not a nurse know what those 36 hours consist of? Juggling all my nursing tasks for each individual patient while also trying to communicate with the doctors, pharmacists, respiratory therapists, PT, OT, social work, our aides, the patients themselves, and their families?! Yes, that’s right, I communicate with all of these people on a daily basis. I am personal coordinator for my patients. I am their voice, their advocate. I must be aware of my patients needs at all times. Room 101 is going up stairs to cath lab at 0900. 102 wants their pain medicine at 0915. 103 needs to be turned at 0930. Got it. My mental check list is a never ending dynamic that I must prioritize and rearrange constantly.

My job is scary. Always thinking, always analyzing, ALWAYS aware of my actions. I could cause a patient to lose their life if I am not critically thinking about everything that I do and every medication that I give. Is this dosage appropriate, does this patient need this medication? It is all my responsibility to keep the patient safe.

Even when I am doing everything that I can it isn’t always enough. I’ve had family members displeased that I took a little longer to answer a call light. I’m sorry that I couldn’t get you a coke right away, I was busy titrating a lifesaving medication in the room right next to yours. I have been asked by a family member if I were qualified to even be a nurse, surely I was too young for that. I have been told that I am too weak to help lift a patient when in reality I can lift more weight that I weigh. Nursing is hard. I take all these comments and offer a kind response to remain professional even though it can make me feel really small at times. Not feeling appreciated is hard when all I am trying to do is help.

I have been there when a patient said their lasts words before being intubated and never being able to come off of the vent. I have been there as a patient has taken their last breaths on the earth. I have been there when a patient has decided that their body can no longer fight, and they would like to receive comfort care. I have provided comfort care as family members are silent, with tears streaming down their faces, as I turn the lifeless body of their once resilient family member. I have been there when a doctor has told a healthy, active patient in front of their spouse that they have stage 4 cancer, and will not survive. I have stood and held my tears to remain strong for family members who have had their hearts shattered by the news that their loved ones will not be coming home again. I have sobbed on my way home from work because my heart is shattered too. I am so sorry that you have to go through these things. I am so sorry that your loved one has cancer. I am so sorry that myself and the doctors couldn’t get your loved one to wake back up after being sedated on the ventilator. Nursing is hard. I am human. I care about my patients. How could I not? My heart breaks along with my patients and their family members. Then I go home and try to pretend that I have not been broken during my shift. I don’t want to burden my husband with my sadness, and I need to pull it together so I can go back to work in the morning and do it again.

So how do I do it? How do all nurses do it? How do we manage ONLY 36 hours a week? Because nursing is beautiful. I have been there as a scared patient on a ventilator has woken up so I held her hand and told her that everything would be okay. She could not speak as she had a lifesaving breathing tube down her throat. Somehow she managed to grasp a pen with her weak hands and wrote “I love you guys.” My heart exploded with joy. I have provided comfort to someone when they were far from comfortable. I have been there when a patient has come off of a ventilator after being on it for a week, and watched as they cried and said they were so happy to be alive. I helped bring that person relief. I have bought lip gloss for an elderly patient whose son forgot to bring in her lipstick. The smile on her done up face was priceless as she put on the lip gloss to complete her look. I have made a patient genuinely happy even though she is sick and in the critical care unit. I have been there providing comfort care to a dying loved one and family members have hugged me and thanked me for being the angel that their family member needs. Nursing is beautiful. Life is beautiful. I watch lives change, I watched lives end, and I watch lives get a second chance because of the care and medicine that I have provided.

Nursing is hard. Nursing is stressful. Nursing is exhausting. It drains me both physically and mentally. I come home tired, sweaty, and defeated. Not all days are good days. Nursing is not all sunshine and rainbows. But nursing is my life. I dedicate my life to saving the lives of others. Those break through moments when a patient miraculously recovers, when a patient holds your hand and tells you how thankful that they are for you, and the moments when myself and a patient can share in a good laugh. The feeling of pride I feel when my patient came in on a ventilator but walks out at discharge, makes it all worth it. All the wonderful, precious moments are why I love nursing. The great moments are what get myself and my coworkers through the long, difficult 12 hour shifts. Thank god for fantastic coworkers. My coworkers are like my family. I know that they understand the mental turmoil that I go through after a hard day. Only nurses understand truly what nurses go through.

So the next time that you want to tell a nurse that it must be great to work ONLY 36 hours a week, please be mindful of what those 36 hours are like. Give a nurse a hug today, and be thankful that we continue to do what we do, and don’t judge us when we drink a little extra wine. If it were easy, everyone would do it.

Sincerely,
the exhausted,
but still smiling ICU nurse.

—  Kelsey Van Fleet, via Facebook
Tuesday

Doncha just love it when someone comes in to your office as a walk in actively dying from like 4 different serious conditions? Sounds like it would be some big, rare, exciting event in a rural primary care office. 

I calls it Tuesday. 

So there I was already 2 patients behind because I was following up with a patient who had been admitted with a septic joint and bacteremia from a bug I’ve literally never heard of (and the ID doc admitted he had only seen once before), and then this dude stumbles in to the office. And I mean stumbles. He can barely make it to the chair. 

The front desk alerts my nurse that there’s a dude in the waiting room who doesn’t look like he can wait. She helps him into a room, lays him on the table, and gets his vitals. She then calmly comes and knocks on my door and gave me a stern, “I need you in 6 now please. 

I headed to 6. There I found a man with a through-the-roof blood pressure, fast-enough-to-kill-you heart rate, kussmaul breathing, teetering-on-the-edge-of-respiratory-failure O2 sat,  and hey-at-least-something’s-normal temperature. Dude was gray. 

From the moment I walked into the room I knew he was leaving in an ambulance. I just had to figure out why. While we waited for the ambulance I got a blood sugar (400ish, of course) and an EKG which showed some heart strain, but no active heart attack, thank goodness. I did a thorough physical exam. 

I started to form a differential: A fib with RVR, SVT, sepsis from pneumonia, possible PE, diabetic ketoacidosis, stroke, hypertensive urgency/emergency, MI, intoxication, and the list went on. As I did my exam, I couldn’t really rule out anything on my list except SVT and A-fib. His vitals said sepsis. His lungs said DKA and pneumonia. His legs said CHF. His mouth said severe dehydration. His mannerisms said delirium

The patient asked me what I thought was wrong. I answered honestly: “I think you have 3 or 4 different things going on, and any one of them is enough to cause some serious damage.” I explained my thoughts. “So you gonna start me back on my medicines?” he queried. “Nope, but the hospital will when you get there.”

“Oh really, which hospital?” he asked. “The one that has an ICU,” I fired back.

This man truly had no idea how sick he was. He had one foot in the grave and wanted to go home. Luckily some friends with him convinced him to go. 

On the following tuesday we got a stack of hospital records. New diagnoses were being added every day. He had had every test the hospital could have possibly run, I thought. I called him in his ICU room and he updated me on his myriad new diagnoses and lengthy medication list. He was now almost back to normal and hoping to go home in a few days. 

The next tuesday I saw him in hospital follow up. His discharge summary read like a soap opera. Pulmonary embolism. Pneumonia. Heart attack. A fib. Heart failure. Renal failure. Liver failure. DKA. Everything failure, essentially. 

And yet this man sat before me looking perfectly well, no longer gray or delirious, now back from the brink of death. Just another tuesday afternoon.