Who Knew?

Who knew moving to a new country and starting school there was going to be such a tedious process? I have to keep taking a breath and reminding myself that I wouldn't be going through all this stress if I hadn't gotten into medical school. I guess I ought to be down on my knees thanking the admission GODS that I am spending my final days in Canada standing in line at the car registration place instead of drinking wine spritzers on a deck somewhere surrounded by the adoring faces of my friends and family. Yes. That is how it ought to be....

It is weird, I feel like I am jumping into a black hole. No idea what to expect from school or life in Ireland. My apologies for the dearth of posts lately but I have been staying in my mothers basement (which looks like it has been occupied by a schizophrenic who is conducting a garage sale there...) and she has DIAL UP (horror of horrors) and her phone was recently on the fritz. Frustrating? Yes. Life threatening? Almost. Speaking of mothers, I believe there is a direct relationship to the distance one is moving in relation to the degree of smothering that occurs.

More packing and unpacking to do. Two days until D-day.

My Last Shift as an Educationally Unadulterated Nurse

I finished my final contract up North on Thursday. Suffice to say it has been quite an interesting summer up there. The majority of the docs were very supportive and excited about the fact that I was going to medical school, and thus gave me as many teaching opportunities and hands on experiences as they could.

Last week I did my first subcuticular sutures with a facial laceration (under the direct observation of one of the MD's). I was brought back to one of my first shifts as a nurse in the ED when this patient came in who had been hit in the face with a broken beer bottle. His cheek was basically hanging in a flap about the size of a coffee-table coaster, off to one side. He came in from the bar hollering some story about how he had just been breaking up a fight between a man and a woman, how he'd been minding his own business, etc. etc. Amazing how he didn't work a burning bus and saving a poodle into the whole chain of events...regardless, his face was a mess.

I tried to watch the ED doc fix up this man's face. It involved many many subcuticular sutures and the whole laceration was very large and seemingly complicated. I had to keep leaving the room for fresh gulps of air because looking at this guy's cheek-hamburger was just a little much for my young nursing eyes. I was fascinated and totally impressed at this physicians ability to restore this man's face, but the 'everything-going-red-in-the-corner-of-my-vision-is-that-the-spins-now?' part was forcing me to step outside from time to time. When it was all finished, he had one line of sutures falling along his laugh line, from just beneath his eye crease to the corner of his mouth. It looked fantastic. I recall thinking--I really wish I had the skill and stomach to do a repair like that.

Fast forward 6 years--HEY! I did it!

It was by no means as beautiful and artistic as Dr. S's repair many moons ago. But I suddenly realized that I was doing a procedure that I could hardly watch in the past*. It was an exciting night for me and I was very pleased with how the final product turned out**.



These confirmations that I am doing the right thing by choosing to go into medicine are coming faster and with greater frequency than before.

During my last shift as an unadulterated-by-medical-school-nurse one of my colleagues commented on the fact that I was entering a different phase in my career which had no turning back.

It is true. I've thought about how from now on I will have one foot on the lily pad of nursing and one on the lily pad of medicine. I think there will be times where this divide is going to make for some interesting interpretations of my role with patients and co-workers. I wonder how I'll feel the first time I ask someone to do a task that I am normally expected to do. Why would I ask a nurse to put in a cath when I can do it myself? Or put a dressing on when I can do it to my liking in less than one minute?

I know these issues are a long way off as when I return to Canada to work in the summer I will be working with the constraints of my nursing license during the day, and trotting around behind docs as a med student by night. Still, I wonder how others have made that transition.

I was in the shower the morning of my last shift. I could feel a small lump in my throat as I thought about all the wonderful colleagues and friends I would be saying goodbye to. Life, so far has been nothing if unpredictable and though I do plan on returning to the ED I once haunted, who knows when and how that will happen.

Nursing has done me well and I have learned many many valuable lessons about standards of care, the focus of the different professions within health care, the opportunity for nurses to develop unique bonds with patients and family members, and the importance of having strong and super-smart nurses on the floor with you.

I have had the chance to visit remote parts of Canada and India because of nursing...I was able to work 6 months a year and travel, ski, cook, and climb the other 6. Overall it's been a sweet gig and I cannot pretend that I will not miss many aspects of it.

And so, in less than 2 weeks now, a new chapter begins. I hope that I will be able to continue with some interesting content on this blog...but if past performance is any indicator...the postings will start rolling out as soon as the studying is supposed to start (note last summers daily blog postings as I was meant to be studying for the MCAT).

Thanks for coming along for the ride.







*This bodes well for when I get into the OR, but that is another story altogether.
**Photo taken and used with patients permission.

Just When I Thought I HAD Seen It All...turns out I hadn't...

Yes indeed dear blog readers.

Blister guy came BACK to the ED today.

His chief complaint: "infected blister?"

I call him to triage.

"So...what brings you in today?? Since we saw you here yesterday for your blisters..."

"I wanted to come in 'cuz my blister popped, thought I should get it looked at."

*She walks into med room and hits head as hard as possible against narc cupboard in an effort to wake herself up from the reoccurring nightmare of 'worst abuses of emergency departments which I pay for with my hard earned tax dollars'. Yet she doesn't wake up. And then she hears screaming and soon realises the screaming is coming from her own mouth.*

I wish I was making this up. :)

I Can Now Retire as an Emergency Nurse--I Have Officially Seen It All

I've learned not to roll my eyes at a chief complaint when I pick up a chart in the ED. Whenever I have done this it always comes back to bite me in the ass.

Like the time I rolled my eyes when I saw the cc was "sliver". When I called the patient in I could not hide the 'are you kidding me?' in my voice when I asked him about the 'sliver' that brought him to the department.

He calmly rolled up his sleeve to reveal a piece of wood thicker than my thumb just under his skin from his wrist to elbow. Yeah, he worked in a lumber mill and a piece had gone flying off a piece of machinery and into his arm.

Wow.

Lesson learned.

So today I picked up a chart and see "blisters on both feet" as the chief complaint.

I am starting my mental diatribe but then caught myself--assess the patient, he probably slipped and fell into some hot oil and has full thickness burns to his feet or something...

But no.

He had a blister on each foot from walking. Right on the heels.

I had to ask why it was an emergency.

"Because it hurts to walk on them so I called the nurse line and they told me to see a doctor".



*She throws in the towel and walks away, shaking her head*.

A Non Sequitur Completely Random Quote That Made Me Laugh

This was written in the 'comments section' of one of my favorite blogs:

“The problem with both karaoke and nudism is that it’s usually the wrong people.”

Nice.

Code Blue Nursery

I participated in my first neonatal cardiac arrest resuscitation today. I am not ready to write that much about it as I am still processing...but it has been a day where I oscillate between the medical aspect of the event and how much I thrived on being a part of it...and the emotional part of my brain that bobs to the surface bringing with it a wave of overwhelming sadness.

When I got home from work I realised that I had pulled into the driveway, opened my car door and had been sitting there with one leg out of the door and the rest of me in the car for several minutes, totally lost in thought.

Decided that a long tortuous session of power yoga would clear my head, but instead it just made me feel claustrophobic, I needed air.

So I cranked up some Philip Glass and walked to the harbor, watched the sun go down and then walked home. And somehow I still am trying to grasp the dichotomy between how detached I felt during the code and how distressing it became later once I got home from work.

The brain works in mysterious ways. More on all of this later.

Two Cool

2 days ago we had a confirmed (by CT) case of mastoiditis!! This may not seem overly exciting to some folks, but really, it is quite a cool and rare thing to see in North America. Mostly because it is a complication that can arise from an untreated inner ear infection (which almost never happens because ear infections--often viral and self-limiting--are usually overtreated with antibiotics). It was in a patient who had had ear pain for several days following a dive, but had left it until he became unable to sleep due to the discomfort. He presented to the ED with abd pain and dizziness but as he was checking in also mentioned his ear ache.

Vital signs were unremarkable, pt was a fit, middle aged man.

We had a brand new doc on, doing her first locum in an ER so we were all just getting acquainted. When she came out of the room and asked the radiology tech to be called in to conduct a CT of the head we all looked at her like she had two of them. The charge nurse was clarifying,

'For an abd pain?'

'I think he's got a mastoiditis.'

Ohh kaaayyy.

Naturally I went in to take a look, because I am nosey. And I wanted to see why she was suspicious. It is a bit of a zebra diagnosis for an ear ache.

He was exquisitely tender even as I gently pulled his ear up to look in with the scope. I saw a very boggy, swollen, angry looking tympanic membrane with some bloody drainage in the canal. Ohhhh. It looked ugly. And I have seen MANY nasty ears in my time on Baffin Island (hence the colloquial term 'Baffin Ear'). He had only mild post auricular edema and no remarkable adenitis. So we had been a bit skeptical to call in the tech as well as waking up the radiologist who is on call EVERY night and never gets a day off. But sure enough, the CT showed (not the actual CT below but one stellar comparison) the fluid filled area where air ought to be---note the right sided mastoiditis on example below. His looked exactly the same.


So he was admitted, ENT consulted for the morning, started on IV antibiotics and analgesics. We all complimented the doc on her good catch. Many would have sent him packing with an amoxil script. She said the main thing that caused her to suspect the diagnosis was the level of pain that this guy who 'didn't seem like the type to complain' was expressing.

Cool part one.

The second cool thing that happened was I got to give my first cortisone injection! It was a combo of cortisone and marcaine (the marcaine is a longer acting anesthetic--what your dentist uses to 'freeze' your mouth). It was on this guy who was complaining of severe, chronic shoulder pain. He was a very tall bodybuilder and had massive shoulders, covered in tatoos. This made the bony landmarking somewhat of a challenge but apparently I did a bang up job because he said he never even felt the injection. About 15 minutes later he walked out of his cubicle, came up to me and said 'my shoulder has NEVER felt this good, I cannot remember a time when I didn't have pain!'

Ahh, that was just the marcaine talking. But I took the compliment nonetheless. He then asked if I'd do his other shoulder while he was in the department! It was great. I was happy to have the doc talk me through it and glad that the outcome was a positive one (and that I didn't rupture his tendon or something!!!)

All in all, it's been a good week.

Today's Major Event

I just sent this email to a friend and then realised how truly absurd it is...

"I just killed the largest spider I've ever seen in an attempt to free it to the great outdoors. It took me about 20 mins to dispose of the body as I had to psyche myself up for every stage of the removal. Let's just say it took a spinach container lid, several reams of paper towel, 6 squares of lysol wipes, and two plastic bags. Did I mention I am a COMPLETE arachnophobe?

Strange how I can stick my finger in strangers' orifices, get vomited on, pick maggots out of festering wounds, pull crushed fingernails out of the socket, and spill blood on myself but coming within 5 ft of an arachnid pinches the ol' adrenals into overdrive.

I don't get myself."

I know arachnophobia is not an uncommon fear but I wonder sometimes what really scares people like soldiers, HAZMAT workers, exterminators, high rise window washers...

That's A Negative, Ghost Rider

A couple of months back I read the book "Outliers" by Malcolm Gladwell.

I have to say it didn't impress me as much as his book, "Blink", but there were a couple of interesting chapters. The one I found most fascinating was the one about Air Korea and their increasing number of deadly crashes. Forgive me if you've read it but I'll flesh it out a little for those who haven't...(and also forgive me/correct me if I recall some of this sloppily as I've already passed the book on to a friend and can't reference it now for complete accuracy).

In brief, Air Korea was having so many plane crashes that it was in danger of losing it's ability to fly in North American airspace and going under as an airline. Experts were brought in to look at why the crashes were happening. In reviewing the documented dialogue between pilots/flight engineers they found the language that was being used (both to air traffic controllers and colleagues) often did not convey the seriousness of problems early enough for them to be corrected. It was often vague or the seriousness of the situation was watered down.

Also compounding that, the deference that the 1st officer has toward the captain (as a cultural implication) does not really allow for him to a)take over the controls if the captain is screwing up or b) tell the captain that he is royally screwing up and get him to change his actions. Even in the face of imminent death these 1st mates could not or would not violate the cultural norms to do as they are instructed in emergency situations (i.e take over the controls if the captain is making a grave error). I have to say that reading the transcripts of the dialogue prior to the crashes was heart wrenching and fascinating.

So the company was re-vamped, retrained, and dissected to see how this behavior could be 'un-learned' when the pilots were at the controls. One of the changes that was implemented was that the crew were to address each other by first names, thus eliminating some of the power differential present in the language of titles. Once the 1st officers were trained to be assertive and see themselves on more equal footing with the captains, the company soared (literally and figuratively). The pilots were trained to communicate more effectively with all of the members of the team--the captains consulting with the flight engineers and first officers and vice versa.
Korean Air, as it is now called, is a top notch airline with a safety record better than most of the competition.

So this got me thinking about the dynamics that occur in health care. Pilot errors and physician errors (or health care related errors) are often compared. Pilots have very strict guidelines in terms of sleep and work related to job safety...most hospitals have nothing in place that is comparable for nurses and doctors. Look at the hours that residents pull!! Would a pilot ever have to be at the controls for an entire weekend on only a few hours of sleep here and there? Not on your life! (Ha!)

This thread then got me thinking about the 'safest' places I've ever worked. And by safest I mean...ER departments or outpost clinics that I felt their existed a harmony amongst the staff where one could ask questions, point out errors, admit to errors, ask for help, admit to being swamped, call attention to urgent needs...etc. versus places where none of the nurses would speak up if they didn't understand an order, or thought that maybe the physician was making a mistake, or noticed a patient deteriorating. Or where physicians would ask for input, feedback, collaboration from the rest of the staff (be it physios, R.T's, nurses, whatever).

Trust and mutual respect go an amazingly long way with regards to patient safety in my humble opinion. The more I reflected on examples of this the more glaringly obvious it was.

The parallels between the airline crew example and an ER department staff seemed pretty obvious. Right down to addressing one another by first names instead of titles.

I know these aren't new or groundbreaking thoughts on workplace dynamics in the ED but it got me thinking back to a post that Old MD Girl made on her blog* about being a doctor and being the "boss" of nurses.

Nurses (and other health professionals) certainly have a lot more respect in the workplace than they did 100 years ago when their duties included cleaning the doctors lounge and standing up whenever one walked in the room (I would have lasted about 5 mins as a nurse if I'd been born 120 years ago, BTW).

Today I see us as the 1st officers to a certain degree. I have had relationships with some docs where I have felt my opinion and input on a patient was seen as important information and I have worked with docs who made me feel like an annoying mosquito buzzing in their ear every time I opened my mouth.

I have had physician colleagues write "sedative analgesic" as an order and trust me enough to use my discretion with regards to what I am going to give a patient to make them relaxed and pain free. And I have worked with doctors who have angrily told me NOT to use the word "angina" when describing a patients symptoms to him because "angina" is a medical diagnosis and nurses do not make medical diagnoses. (Not even joking).

So what sort of utopian emergency department would it be if nurses and doctors could lose some of that power differential and see each other as colleagues instead of two very separate camps. I know that all work places are all about hierarchies and titles and posturing and inflated egos. But I have seen how these natural human tendencies can actually put patients lives in jeopardy and I think it is something worth reflecting (or ranting?) on a little.





*To my surprise I actually wasn't irked by this post. Overall I enjoy her blog and think that she has interesting and often funny anecdotes (which I can certainly relate to being 'old' myself).

Wishful Thinking

Don't 'cha just wish you could post this sign on the doors to the emergency department??