Friday, July 31, 2009

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.

Friday, July 24, 2009

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.

Wednesday, July 22, 2009

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...

Friday, July 17, 2009

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).

Monday, July 13, 2009

Wishful Thinking

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


I had a very long, very hot drive from Whistler to last nursing contract. Can you believe that one can drive for over 1400 kms and still be in the same province? Sigh. I love this country.

I kept myself entertained by "My Sister's Keeper" on audiobook, along with an emergency lecture podcast series with topics ranging from 'ASA toxicity' to 'bronchiolitis treatment' to 'syncope in the ED'. Both so good that I found myself actually wanting to get back on the road and into my listening booth on wheels.

Day one of the drive was 10h long as I had to make a small detour to pick up a few things I had left behind at my last shoes, laptop speakers, mandolin, and mini blender.

Welcome to my life and my essentials.

During the first day of the drive I was in what I call 'dad mode' which is the get up super early and stop only when decreased LOC from hypoglycemia or bladder explosion are fighting to be your next presenting complaint in an ED.

Day two of the drive I realised I didn't need to be in a huge rush, I had gotten another early start following my truckstop breakfast and only (only! ha!) had 717 kms to go. So I meandered my way here, stopping for fruit then stopping again to eat the fruit at a picnic table with a view.

I took another detour and found myself alone at yet another picnic table beside a raging river. I rolled out my yoga mat and attempted to stretch my legs and spine back to the length they had had 1200 kms ago. At one point in a wide stance forward bend I opened my eyes as the wind picked up causing pine needles to rain down on me from the looked and sounded like some kind of weighty scented earthy snow. I lay down in the shade with my straw hat covering my face and enjoyed the beauty, the sounds, and the breeze that surrounded me. I was just so thankful to have that moment, the stillness.

I arrived later in the evening and was invited to a BBQ at one of the nurses houses...starving and without groceries I was grateful for the grub and the company.

So I am here, safe and sound. Worked one shift yesterday and had today off, which was great because I was able to finish my book, "Late Nights on Air" by Elizabeth Hay. Ummm...amazing book. It resonated with me since I have spent some time in Yellowknife (where the book is set) a few years ago falling in love with the North and a person in it. Ah least my relationship with the North ended up being a little more long lasting.

Thursday, July 9, 2009

First of Many Goodbyes

My apologies for the long pause between posts.

Last week I said a final goodbye to all the great staff in the ED I've been haunting off and on since Dec 2006. This past year it was as close to a 'home base' as I've had since leaving Whistler.

Last summer it was me working mostly night shifts and studying for the MCAT during the quiet times. Initially I was hesitant to ever bring up that I hoped to get into med school, partly because I was dreading telling everyone about the rejections that were sure to come. I didn't want all the negative comments I was fielding at school to start bombarding me again. But much to my surprise, once the word got out, the staff became immensely supportive.

The docs gave me extra time, going over lab results, showing me xrays, letting me do minor procedures, talking me through others...the nurses would tease me by calling me "Dr. Blackbear", check in all the time on how my applications were going, help me prep for interviews, etc. Last Friday I went to a wedding of one of the nurses (who married one of our ATLS paramedics). At the end of the night as I was heading out I got waylayed by many hugs, email exchanges, more hugs, photos, words of encouragement and congratulations. Some surprise send offs as well from people I would have never guessed I'd get kudos from. One nurse who I've always thought figured I was a flake...came up to me and took my hands saying "you are an amazing nurse who will make an amazing doctor, you have the heart...and you have the brains." It was possibly the kindest thing a colleague has ever said to me...especially coming from someone I wouldn't consider myself buddy-buddy with.

It was tough saying goodbye. I started to feel those stirrings in my stomach of sadness that come when you see a chapter of your life ending. Working in the ED means you deal with the belligerent drunks, the devastated parents, the scared children, the high maintenance malingerers. You deal with these people together and go through the spectrum of human experience with your colleagues. This is something unique to being in the trenches. So above the gossiping, the drama, and the politics, you become a group that genuinely looks out for each other and feels somewhat protective of one another. The wedding was a great way to see everyone in a relaxed and celebratory environment. My last image of the night was seeing my 60-something boss laughing while doing the twist with her husband. I am still smiling thinking about it.

These last few days have been bliss. Housesitting for a good friend in Whistler and getting a chance to charge my batteries with daily dog walks in the forest, yoga at my favorite studio, sleeping in, eating out, reading, and drinking some delicious vino with my manfriend. Tomorrow I start the 2 day drive to my next (and final!) nursing contract before moving to Ireland.

It's going to be a hellish schedule. 2 days, 2 nights, sleep, repeat. Ugh.

Ah well, it'll be my last chance to enjoy the beauty that is this amazing province and be still.

This last little bit of sand sure does seem to slip through the hourglass more quickly!