Pearls

He had a little turban of gauze wrapped around his shaggy blonde head. Perfect rows of white teeth and blue eyes. I imagined that when Jack Johnson was 4 years old he probably looked like him; brightly colored board shorts, a mini ROXY hoodie, and lime green flip flops.  Despite the bloody gash (thanks to a fall on his grandparents fireplace) he was chatty and informed me he loved visiting Canada because he could play in the snow, his middle name meant "wave" in Hawaiian, and that he'd rather have an apple juice than a spider man sticker thankyouverymuch. 

After I unwound the gauze and inspected his scalp, I had to irrigate the wound with some saline to clean up the bloody tangle of hair before stapling it. He brought his hand up just above his head and hunched his shoulders down while I cleaned it, but didn't cry or pull away.

I was dropping the used bandages and gauze into the bin and untangling the situation when he cocked his head in my direction, studying my face while I scrubbed.

I really like your earrings.

Aw, that is so sweet of you, thank you!

You're welcome.  

Can't think of the last time an adult complimented my jewelery while I was repairing their head wound. Mind you, adults in that situation are usually fallen down drunk and mildly abusive.

I almost feel like most of my patients in the ED have been part of an elaborate ruse to woo me into pediatrics. It's working people, it is working!!

My Face Is My Fortune...

...that's why I'm totally broke!

I had a feisty 8 y.o girl come in tonight. Her long blonde hair was pulled back in a messy pony tail, an oversized black Karate hoodie hung low over her leggings. I saw she had the beginnings of two black eyes, a bit of a swollen nose, and a bump sitting on the bridge. She excitedly told me about how she got accidentally head-butted yesterday in karate just before winning her competition. She then mock-kissed her biceps.


So what brings you in today? Are you worried your nose is broken?

Yeah, we need to check it out....this [said while circling her face with her index finger] is my money maker.

And that was when an 8 y.o girl became my hero. I mean, she had me at the bicep kissing, but that line cinched it.

Paging Doctor Blackbear

So the last week at work involved a couple of milestones. I am so sleep deprived right now that I can only think of one (thanks to two 6am shifts starts, Ryan's recent surprise 40th birthday keg party, and 11h of driving in the last 4 days).

My attending asked me to page the neuro team for one of our patients and I mentally froze. Lowly medical students do not consult with other teams in Ireland. What amount of detail should I go into? How much history do they want? Is it like a geriatric consult where you have to mention how many pets they have and if they can still drive themselves to get groceries? Or is it like a surgical consult where you say there is a fracture, please fix it?

I told the unit clerk my name (Albino) and asked her to page the neuro team for me. 

A few minutes later I was assessing another patient when "Dr. Blackbear please pick up line 70770 for neurology, Doctor Blackbear" came over the PA . At first I was reflexively tuning out the sound of the announcement as it crackled into the room. Then I realized the call was for me! Yes, the title wasn't accurate but I have to admit it briefly made my stomach flutter with excitement. I know it sounds cheesy but I've been ignoring that interruption while in hospital for the last 12 years. It hit me that sooner rather than later I would actually be Doctor Blackbear! It is quite an exciting (and frightening) prospect.

Most days this journey feels so long that I almost forget that at some point the tuition payments end, the paychecks and different responsibilities begin, and new goals appear on the horizon. Hearing my name paged overhead was a jolt of reality: in a year from now I won't be able to ignore those calls and the next chapter will be beginning.

Excited!!!

Peds Say the Darndest Things....

I had a patient who came in with a very itchy rash over her entire body. It was a busy day and she waited with her dad for about 3 hours before being seen. She readily jumped up on the bed and pulled up her dress to show me the angry red bumps on her belly, then kicked off her black boots to show me the bottom of her feet, which had been spared.

Her little thighs were raw with scratching and I felt terrible for her long wait. I said to her, "I am so sorry that you had to wait so long to see a doctor, especially on this lovely day".

She shrugged and said, "It's okay, I know you have lots of other patients to see too!"

She was six years old.

In five years of emergency nursing and three years of medical school I've never had an adult respond with the same selfless and realistic view of the situation.

Adults of the world, take note. Children of the world, stay awesome.

Peds? Really?

First of all, I love pediatrics!

Children are such completely different animals. My experience so far with pediatrics has been fairly limited to the odd asthma, RSV, gastro, or rash that presents to general emergency. But working exclusively in a pediatric emergency department has been a completely different reality. I have really been enjoying the challenge of trying to connect with children, like figuring out ways to make clinical exams tolerable to them or jazzing up the neuro exam to make it like a game. I get to be kind of silly and fun, disguising the seriousness of it all. It's a treat, especially when you can get on the level with a kid. Most of them seem to lack the hang-ups that adults have around illness and disease. They are stoic but not in the look how stoic I am being, so stoic that I am actually not providing accurate information to my health care providers way that adults are. There is a different kind of job satisfaction that comes with helping to name a new teddy bear (Mr. Fall off the Wall) or getting an energetic high-five from a kid who was burying himself in his mother's skirt for most of the history. 

Plus, I always thought that (because I am really not that great with kids in the real world) I'd dislike pediatrics. And then there is the crazy parents, who also frighten me. But it seems that crazy parents are not as common as I'd imagined. Or maybe I am just not noticing them because my interaction time with parents is more limited, compared to when I was nursing.

The hospital is beautiful, brand new, and completely child-centered. T.V in every room, popsicle fridges at every corner. The staff seem to really love their work. I'm so impressed at how they are able to balance between the focused intensity of acute care while making it fun and minimally scary for the wee patients. Everyone is just so nice. Maybe it is harder to be a curmudgeonly pediatrician or crotchety nurse, I don't know.

It's been a great learning experience also, being put in with the residents for all of their teaching sessions and tutorials. Their simulation training has a dedicated faux trauma bay in the department, complete with all the drugs, pumps, and machines that go bing! We did a session on Thursday with mannequins that are very realistic (heart, breath, bowel sounds, as well as pulses, intubatable throats, seizure capability, etc.). All the mock codes were run in real time, that is, you wouldn't just say, "I would start an IV and give ceftriaxone", you actually assign the task of IV start to one of the team, they put in a line, someone draws up the actual drug and sets up the infusion. The enthusiasm to teach and job satisfaction of the attendings is contagious and I must admit I look forward to every shift.

It is strange though, being in a new city. I feel like I am regressing as an adult. No phone, no car, no idea how the city is laid out. I walked for over an hour in the hopes of buying a new burner only to  find they were sold out. The saleswoman kindly advised me to call ahead next time. I gently pointed out that I didn't have a phone, hence why I was trying to purchase one! Sigh.

And so, getting settled in. Trying to enjoy each day for what it offers. I have already managed to locate and join a yoga studio for the month, so at least some physical activity will take place. Did I mention there is also a very decent wine store down the street allowing me to finally taste my favorite American grapes again (in Ireland you're lucky to find Ernest & Julio). It's Friday night, I'm post hot-yoga and ready for a glass of red and my new book.

Back to work tomorrow, the adventure continues.

I Guess I am a Final Med?!

Today was my first day in the Tiny People Only emergency department.

I arrived to town last night, still feeling jet lagged and disorientated from the packing and moving. The chaos of the last few days had me finding my toothbrush wrapped up in an ipod USB cable and a stethoscope stuffed into a running shoe.

Falling asleep last night I realised that I needed to be up at 0630h and had no alarm clock. I listened through different selections on my "Deep Sleep" app for my ipod and tried to choose the most annoying piece to set for an alarm in the morning. Word of advice: do not choose music from an app designed for sleep, if what you want is to be woken up.

So I picked one of the chanting/meditation ones, hoping the incessant gong ringing would rouse me. Instead I found myself in a deep sleep, dreaming that I was walking along a lake shore in Nepal.

Nepal. Something isn't right. Sighhhh. Listen to that nice chanting. Monks. Hmmm. Chanting. Wait. Ringing, why is ringing bad, why? Ohhhhhh nooooooo! 

So I didn't sleep in too much, but long enough to be in a panic. First squarely hitting my shin on the corner of the wooden bed frame while leaping into nylons at record speed. I believe the entire bowl of oatmeal fell down my throat with one gulp, followed by two gasps of lukewarm coffee.

This really was not how I wanted to start my first day as a final med.

I scurried down the streets trying to locate my bus stop. Lost and convinced I'd missed the bus, I felt my shoulders drop, realizing that things were going from bad to worse when the bus appeared and took me where I wanted to go.


It was a long and busy day. It felt strange to tell people I was a final year student. A little daunting to step into the role of Canadian medical student where you are expected to immediately hit the ground running, perform assessments, establish diagnoses, elucidate care plans, and order tests. Plus these aren't the patients I am used to dealing with, they are all so little. The little humans. Don't get me wrong, I like it! But it is very different to the medical student role in an Irish hospital, to be sure.

For now, I am not going to worry too much about all of it. I am just going to sleep. 

911 Call of the Night

We got the call from the ambulance, just before 2 am informing us that they were bringing in a man who'd called 911 for scabies.

Yes, that was his chief complaint. Which may win the "are you kidding me that you called an ambulance for that?" award.

The two night nurses debated on who would be the one to put the scabies cream on his back. The matter was settled by the ER doc putting a paper clip in one hand and letting the more senior RN choose which hand. She chose poorly.

We all itched and scratched for the rest of the night.

Downside...it cost taxpayers approximately $1000. Upside...the guy had a place to sleep and a change of clothing in the morning.

*Shudder* Image from here.

Is There a Translator In the House??

We had a very sick patient who spoke very little English. He presented to the emergency department acutely short of breath with oxygen saturations in the 70's (a.k.a badness). He needed a chest tube but we couldn't get a proper consent since we couldn't explain to him what we were going to do. We also didn't know his resuscitation status. No next of kin. Fingertips blue, lips blue, respirations labored, shallow and >30 per min. Not good.

The hospital is small, as is the town. There is no translation service on site. I asked one of the nurses what I could to do help and was handed the phone book, "Start calling restaurants to see if anyone speaks his language". 

So I did. The waitress answered the phone, I explained the situation and asked if they had any staff that spoke Vietnamese. The receiver was placed down and I could hear muffled voices:

There is an emergency at the hospital....Vietnamese...they'll pay for a cab...yeah...but I'm working...no no go then...OK. 

Then a man's voice into the phone, "I am on my way".

Soon after our improvised translator approached the desk, within minutes the anesthetist was explaining to our patient what was going on, what needed to be done, and what the risks and benefits were. The chest tube was inserted, his fingertips became skin colored again and he stopped using his entire body to breathe. Today I walked by and saw him sitting up in bed tackling a plateful of peas.

Little hospital medicine: where we make pediatric armboards from tongue depressors and find medical translators in restaurant kitchens.

I (Heart) Rural Medicine

In the last 48h have included having the opportunity to:

-catch a baby
-cut a piece of glass out of someone's face (and then stitch them up afterward)
-surgically assist with fusing toes, replacing hips, replacing knees
-perform a D&C
-assist with a hysterectomy
-sew up knife wounds
-assess / treat / discharge about 75 emergency patients
-learn how to insert an IUD

Despite the exceedingly damp climate my hands are cracking from so much handwashing, I'm surviving solely on t.v. dinners and instant soups, clean underwear is becoming a scarce commodity, and I've spent every day (except one) in the hospital since my arrival. And I couldn't be happier.

My days are so full and varied, with such fantastic teaching from the docs here. It's hard to sleep at night, completely wired and excited by each day's events. I feel so fortunate to be here. I'm starting to believe that saying about how "there are teaching hospitals and then there are learning hospitals". Say what you will about rural medicine...but my experience is that people working in remote areas have half the egos and double the desire to teach.

I've been spending a lot of my retractor-holding and trying-to-sleep time thinking about the (soon arriving) residency application process. Today I truly felt like a few things have started to crystallize in my mind about what I want to pursue...

As always it is a work in progress, but I think that will have to be a post for another day.

In the meantime, check out my new O.R clogs while I try to get some well deserved sleep.

Yes, yes I did.

Paradigm Shift

I've had a hard time writing about the transition from nurse to doctor, mostly because there have been so few reality checks that cause me to stop and think: holy crap, I am going to be the DOCTOR one of these days, not the nurse! YIKES!!

There is so much overlap* (whether doctors like to admit it or not) between the two that I haven't felt some big jump yet, from one role to the other.

Most of the time while I am in school, it just feels like I am in an advanced nursing course and I forget that I am in medical school. When I was doing my 'observership' in the hospital last summer it was somewhere that I also worked as a nurse, so I always felt more nurse-y than med-student-y, to the point where I felt awkward around my fellow nurses sometimes when I was in the observership role. I wanted to say to the nurses who were around while I was being pimped, "what are your differentials?" because I knew they had several to list as well.

Last night I had one of those "holy crap I am going to be the doctor" moments in the USMLE prep-course. We were talking about epiglottitis and my heart reflexively constricted in fear remembering the horror stories I had been told about non-immunized drooling babies showing up in ED's and dying due to mismanagement/misdiagnosis. It was drilled into me in every ED course, exam, orientation, and neonatal resus certification class:

do not agitate the baby
deliver high flow O2 in the least invasive way possible
don't even try to get an O2 sat if it is going to agitate the baby
do not attempt to look in the baby's mouth, etc. 

So, when we got to the question about the case of epiglottis and the prof asked what you do I reflexively answered all the above.

Um, no...you intubate, immediately. 

Right, of course. My thought box on the matter was how I would react / treat the patient if I was the triage nurse. Those are the steps I would take until I was able to get the patient to the doctor.
[Small line drawn through mental list of things to do when presented with a patient who has epiglottitis.]

Now that part of my brain contains the following info:

Holy crap. You're the doctor. DO SOMETHING!!!

---

*At least I have found this in the ED and in the Arctic.

Tim Hortons "Double-Doubles" as Emergency Outpatient Department

Honestly, if I never eat another Timbit for the rest of my worldly existence, it will be too soon.

http://www.flickr.com/photos/megbee/4681323082/

It seems no matter where I work in Canada there is always a rock-hard raisin Tim Bit to be found somewhere in the emergency department. You see it when you come on shift and wonder, "How many days has that been there? Where did it come from? Has it fallen on the floor? Where are the raisin doughnuts which supposedly give rise to these revolting timbits? Is that a sugar coating or a MRSA coating?" yet by three am the only question is "Where the HELL is that raisin timbit??" Gnom, gnom, gnom.

I think it is safe to say that most Canadian emergency departments are fueled mostly by T-ho's and *Bucks. So it seems like a natural (and horrifying) transition that a West coast emergency department had to actually use the Tim Hortons as an overflow department last week. In reality the headline (of course) is not really as shocking as it sounds; the coffee shop is right next to the ED, not open to customers at that hour, and the patients were separated by screens.

I have had to treat patients in much less civilized environments which never made headlines because they were considered 'part of the department'. But really, gangrene-limb dressing changes in a packed ultrasound waiting room, bed pan toileting in the main hallways under the 'privacy' of a blanket, infusing blood into demented septic geriatrics stuck on gurneys for days near the constant swoosh of the ambulance bay doors...it is all completely inappropriate and dangerous. Yet just part of the day to day challenges of the emergency department.

What baffles me is the shock that this has happened. Um hello, if you fire facilitate retirement of senior nurses, decrease medical floor staffing, and close or cut feeder hospital services in the face of the oncoming silver tsunami then, guess what? A lot of flotsam and jetsam is going to back up in the emergency departments.

The only question I have about this whole ordeal is how plopping the fast-tracks into the T-Ho's wasn't a major health code violation for the restaurant. I guess now the MRSA will come free with your extra large double-double. 

It is actually good that this happened because I can guarantee that for at least a few days some magical discharges will happen, beds will suddenly appear, staffing levels will be startlingly appropriate, and at least a handful of people who've been rotting as inpatients in the ED will finally get access to a room with a shower and a toilet in it. Oh, and the ability to turn off the overhead lights. What luxuries.

Damn though, now they also might want a honey cruller with that...

"Aha!" Moment

I went for a run this afternoon with Prof. Goljan and listened to the part 1 of the cardiac lectures. 
He was talking about aortic aneurysms and aortic dissections and so of course my mind wandered off, recalling the most traumatic ambulance nurse escort I've ever done (outcome aside).

Dr. Goljan mentioned one of the salient features of aortic dissection: the midscapular back pain. This was the complaint which alerted me to the aortic dissection pathology in my 'mild chest pain' patient that day in the emergency department.

In passing Goljan said, "of course the pain is different than cardiac pain because the aorta is retro-peritoneal so it radiates into the back not down the arm".

OF COURSE!

In anatomy we have had to go through cardiac pain, and referred pain a million times, and the dermatomes, the arm, the jaw, blah, blah blah...and then other times we've talked about abdominal structures, retro-peritoneal verses intra-peritoneal, etc. etc. and the aorta being a retro-peritoneal structure.

But I never really thought about the connection with aortic dissection and the pain pattern!

(I know this has probably been dead obvious to all of you nursing/medical people reading this, but it just clicked in for me today).

AHA!

I have known for so long: mid-scapular back pain =  red flag = do bilat leg/arm BP's = ?dissection.

But it wasn't until today that I understood why that was the case.

Ok medical school, we've officially kissed and made up this week. I (heart) you again.

Oh right. Patients!

Just getting ready to crawl into bed after a long and harried day with the ALS crew. Oh and what a day it was. The glory of emergencies!

I mean, real ones...not the 'I saw an old guy going slowly down the street with his walker so I dialed 999' [true story that happened on my last shift].

I even managed to make myself useful and do a good thing. After a day of trailing with a kit bag it was nice to feel useful instead of useless for a moment. But that is a story for a day when I don't have to wake up again in 6 hours.

A nice reminder that I am learning applicable things! Information that is making my differentials more astute, my understanding deeper, and my realization that 'holy crap I don't actually know anything' crystal clear. It's always good to be reminded of the light at the end of the tunnel and what this is all truly about--patients! Not spotters, or papers, or OCASE's.

It is also good to realise that wow, I'd never want to work as a nurse in that hell hole of an emergency department. I thought the situation was dire in some of my previous Canadian haunts but, well, it was the Hilton in those places compared to what I saw today.

Sleep time.

EMS excitement!

Tomorrow I start my week of shifts with one of the ALS paramedic crews in town. I really enjoy spending time seeing things from another health care providers perspective. My experience is so limited to emergency departments, I find it fascinating to see what goes on in the pre-hospital setting before our worlds collide in the hospital.

Always thought I'd want to do trauma medicine (especially flight medicine when I was working up north). So this will be another exposure for future consideration. Most of the time I think my emergency stint is over, but...who knows?

Hopefully I will get some pinches to the old adrenals over the next few days to get me out of this holiday stupor!

Happy/Sad

Today I got a little care package from my sister in law (who is this beautiful, athletic, hilarious, thoughtful, supermom/superwife). She sends me these parcels from time to time, and they are always such a treat.

Everyone hates licorice so there is always plenty left for me. 

With the tea she also included a little card from my niece and nephews, which was both delightful and depressing. 

My favorite line is from Aidan, my 10 year old nephew: "hope you have a good Christmas, where ever you are". Totally got a lump in my throat as I read it. I really miss my family, and getting to see the little ones growing up. Everyone is going to be in Australia for Christmas but I am staying here to do a project for school (shadowing ALS paramedics) so that I won't have to do it in June (when I'll need to be studying for the USMLE). 

I know that my travels are abstract in their little worlds, and I've been away for the last eight Christmases (usually working), so this is nothing new to them. It's just that sometimes I hate being the wayward Auntie that is always away. 

Seriously

That was one helluva strange night. It was like the ED axis was spinning just slightly off kilter. Whatever the chief complaint was,  it had nothing to do with what was actually bothering them.

Chief complaint: shoulder pain
Actual problem: Baker cyst x 3 months causing leg stiffness which resulted in a fall which resulted in the shoulder pain which resulted in exasperation over Baker cyst, which resulted in ED visit despite impending surgical consult for removal of cyst very soon.

Chief complaint: shoulder dislocation (2 weeks ago)
Actual problem: scabies (and alcohol abuse)

Chief complaint: dizziness
Actual problem: desire for expedited nursing home placement

And it went on like that.

I had the husband of an IV ABX dental abscess refuse to look at me and just kept repeating over and over again, "I want to speak to the doctor". He wasn't quite getting the concept that there was NO doctor in the department at the time and at 0100h NO doctor is going to come in from a warm bed or give orders on a patient unless the NURSE makes it happen.


Then there was the completely obtunded teen that drank himself into a bedwetting stupor.  He awoke from the depths of a Silent Sam induced coma to drag himself to the ED patient washroom. He then pissed all over the floor, wall, sink and escaped out the other entrance to the bathroom. When mom arrived to pick him up a few minutes later I went to get him out of the bathroom only to find a trail of urine footprints out the other side. I did some frantic searching through the few unlocked doors on the main floor and into the basement, worried that I might find him head first down a stairwell or something. Then saw that the pissy-prints went out the front door. I offered to call the police to help find him but mom was fairly certain that he'd just wander to a friends house and pass out there for the night.

Needless to say I was more than relieved when she called to say that he'd stumbled home. Heart attack by me averted.

There was more, but I think I'll give those ones some time and space. It is a small town after all.

Needed That

Had a wonderful night with three hilarious nurse-friends from the hospital. We had planned to go to a movie tonight after dinner at Rae's but in the end we sat and ate a lovely feast of fresh summer salads, enjoyed delicious beverages, stared at the ocean, and told stories.

I thought about how our conversation rolled along the whole perspective of life--from defining when life starts to what it feels like to watch a prolonged death. We laughed so very very hard at stories about the quirky people that populate our lives in and out of the emergency department--from the overly energetic nurse that falls asleep watching Inception, to the practical jokes we play on some of the docs, to the names we've been called during the night shift by drunken patients.

In these exchanges I hear sadness, frustration, humor, humility, love--every raw emotion possible.  I think about how many times those emotions have washed over us in the hospital. When those stories start rolling one really develops an appreciation for what we see in those buffed MRSA coated corridors.

It was better than any movie we could have watched. It was just what I needed.

Kicked in the Face

This morning we got report about a woman who was in the trauma bay waiting to be sutured by the doctor of the day. She had come in during the night, a head injury with two facial lacerations. There was alcohol on board so she had no recollection of how she had received said injuries. She denied that it was her husband that had inflicted them. He was at the bedside, in faded blue jeans and a thick black sweatshirt. When I walked by I saw that he was holding her hand through the siderails of the stretcher.

I had a brief glimpse at half of her face as I proceeded into the ICU to say good morning to my cardiac patient. What I saw momentarily jarred me. Her head looked deformed from the swelling. I didn't want to stare but it seemed her skull was double the size it ought to be. Jagged streaks of dried blood still criss-crossed her face. I heard howling coming from the room later as she was being frozen for her sutures. I tried to block the sound out.

I busied myself with my ICU patient and then went back out to the floor to bring in emergency patients.

I went into her room to start a saline lock in order to give her some I.V antibiotics. The sutures were perfectly aligned and identical. A vertical line of knots traversed her face in two places, each about 8-10cm long. Her eyes were nearly swollen shut. Her mouth looked almost like a snarl due to the swollen, abnormal position of her lips. Her nose was broken, but not displaced. Sadly, I doubt it was the first time.

I asked her how she had received the wounds to her face. She said she'd been at a party and had gotten into a fight with some people. I asked if it was fists that had cut open her face. She said, "no, their boots".

I remember the first domestic abuse patient I had as a shiny new grad working in the emergency department. She came in because she was having a hard time breathing. Her story was that she had fallen down a flight of stairs. There was a perfect imprint of a boot tread on her neck, starting to turn bluish-purple.

A boot tread.

That image haunted me for years, though time caused it to fade into the background. I had forgotten that woman until today.

I worry a little about the shell I have developed in the past 7 years. Back then, the image would have been right behind my eyelids every time I closed them for a couple of weeks. This time, I felt a pang of sadness and despair for the patient, but was able to carry on my day without much more thought.

When I scrubbed away in the shower tonight I wondered how I had gotten so callous. The irony is I devote myself to this work because I believe that health care is a way to make a positive impact on humanity. Yet somehow it seems that through the years I've lost some of mine along the way.

Cartoon and OR Theme

The recent post by Doctor Grumpy reminded me of this clip my friend Aaron sent me a couple of weeks ago. It is particularly pertinent given my recent activities.

Rae (fellow emerg RN) and I gave each other report in these voices today and drove everyone insane. Does make hand-off much more entertaining mind you...

Enjoy!

Back in the Saddle

Yesterday was my first shift back in the ED after 10 months away. I received a genuinely warm welcome from all of the staff which made the first day seem all buttery and smooth.

I have been chuckling at all the things I have forgotten (how to turn off alarm monitors) and all of the tweaks I am noticing to my practice (ridiculously long patient histories). Also, now I have these urges to perform unnecessary assessments on patients. For example, I suddenly feel the urge to palpate everyone's lymph nodes (and name them off while doing so). I also want to locate apical beats, listen for carotid bruits, and attempt to elicit reflexes.

It had been pleasing to be back in direct patient contact land--for the most part--until I had to be at the other end of a call bell belonging to a *very* curmudgeonly old man who spend most of the afternoon yelling at me and shitting in various locations in the ED. One clogged hopper and sweaty procedure in the patient bathroom later I was ready to throw in the towel on the old nursing gig. The doc I was working with took that moment to remind me of my recent spiel on how I "loved being back at the bedside again". It was well played.

---

I had an ICU patient this morning who was an elderly woman, not doing so well post-op. It was decided that she'd be switched to palliative, as her pre-op wishes were DNR. Yesterday she was very fidgety, puling at her ART lines and central lines, so had to be put in restraints. Thus my first order of business today (once the status had changed) was get all those invasive lines out and take off the restraints. She looked so much more comfortable and settled once all the tubes and wires and drains were removed.

I heard later that she'd passed away after being transferred upstairs. It gave me a small moment of thankfulness that I'd been able to make that passage a little more comfortable. Those feelings always make me think "...hmm...palliative care? Maybe."

I do feel accomplishment for both letting patients go peacefully as well as traumatically bringing them back to life.

Tomorrow I am going to be a medical student. I am following one of the surgeons in the OR, his exact words as I left today, "don't worry, we won't let you burn anything important tomorrow". Gotta love the twisted hospital humor. Looking forward to the day. Fingers crossed I won't get the spins and water brash like I usually do when I step under the lights with a mask on.