Monday, April 5, 2010

What Gets You?

Everyone (and I mean everyone) who works in healthcare has an Achilles heel. Of course anatomically speaking we all have a tendo calcaneus but that is not what I am talking about.

Nope. What I am referring to is the bodily fluid, odor, sight, sound, sensation, taste, texture, illness, task, procedure, or person that you just can't stomach. That 'thing' that 'gets you'. It makes you weak in the knees (in a bad way), causes your vision to go a little red and fuzzy around the edges, your blood pressure to drop, your gag reflex to fire, sweat to bead, and hands to become clammy.

From geriatric lab techs to weather-worn nurses, crusty old doctors to gritty respiratory therapists--they have at least one 'thing'. And if they say they don't, they're lying.

I was having this discussion with a newbie medical student a couple of weeks ago saying how it'll be interesting to watch everyone in our class discover what their medical Achilles heel is. I know what mine is. Well, if I am completely honest I have quite a few Achilles heels. I always thought that over time they would disappear, but even several years of working in emergency departments hasn't numbed me to a few shudder inducing 'things' that still 'get me'.

1) Nails. I mean finger or toe nails. When they are severely deformed or overrun with fungus, shattered, or split I feel a shiver go through me. The last time I almost fainted in the ED was from attempting to overcome this issue by pulling out the shattered bits of finger nail from a crush injury.  My feeble attempt at medical aversion therapy. I'm getting better with them but still don't think I could watch an ingrown toe nail surgery.

2) Crepitus. That is the crunchiness you feel when there is broken bone under the skin (you can also have crepitus for other reasons which do not creep me out so I am not discussing those types). I am talking about bone crepitus.

My 2006 almost-faint-during-procedure was in Whistler where we dealt with countless fractures that required skill at removing ski-boots/snowboard boots/bib-pants/long-underwear etc. Contrary to media portrayal we *do not* cut clothes off people most of the time, especially there when a pair of good ski pants can run you over $500! So you've got to hold on to the crunchy, floppy, limb while a colleague pulls the fabric or boot off. This I am borderline ok with most of the time but sometimes during reductions or casting it makes me get all sweaty and pale. The worst one occurred was while I was holding traction on a 4 year old boy who had broken his leg. I still remember that purple cast and the wave of nausea taking over me as I felt those little bones shift under my fingers."Don't faint! DO NOT FAINT" was my mantra for the entire task.

Bones in general freak me out actually. The feeling of ribs cracking when doing CPR is really unsettling, seeing ribs cut during autopsy also makes me almost hit the floor. Though strangely, compound fractures (i.e the bone sticking out of the skin) don't bother me. There is no rhyme or reason to these aversions.  But I suppose this eliminates 'orthopod' from future residency options.

3) Pseudomonas. Once you smell it you'll remember it for life. The best way that I can describe it is a putrefied, sickly-sweet, heavy, rotten smell. And I swear---with no scientific evidence whatsoever to back this statement---that the odor molecules from this microbe are larger and stickier than any other. Once you breathe it in it seems like the odor attaches itself to your nasal passages for days. Days, people! I am not exaggerating. You're riding your bike or eating dinner or watching a movie, you inhale and BAM!! it's there again, like you're face is right in a giant petri dish of the stuff. When a patient has an infection of this flavor I need to put a little clove oil under my nose to make it through the shift, or a dab of friars balsam on the neck of my scrub top. Trust me, it's bad.

Those are probably my top three shudder-inducers. I always find it interesting to poll my medical colleagues as to what theirs are, and often it is not what you'd think. It's almost never the big things that jump to mind as the offensive bodily fluids. It's almost always bizarre and random phobias. I have co-workers whose 'achilles' is a thing like: knees (they don't want to touch them, especially if there is something wrong with them), or suctioning sputum (spit), touching feet, seeing greasy hair, assessing rashes, etc. Some of them I can understand but others (knees?) are beyond me.

To work in places like the emergency department or an operating theater I suppose it is adaptive that we aren't disturbed by the usual suspects, otherwise we couldn't do our jobs. But it is funny how certain aversions (or phobias) still manage to leak out and remind us that we are not bullet proof to the bodily aspect of the human condition.

What gets you?


EMT GFP said...

Bone saws, mine is definitely bone saws, ribs cracking, and eyes. Can't say I have cracked anyone's ribs with CPR yet but I still can't even stand it when I do it to a mouse. Oddly, one of the few times I have seen a bone saw in action on a live patient, I was so busy/distracted with other things that the whole chest cracking thing didn't bother me as much as I thought it would have. Then again, I missed most of it too. I thankfully have never had to deal with an eye injury yet but the day I do will be very interesting. You just shouldn't have things wrong with your eyes!!!

OMDG said...

Watching someone else do an I&D. I can do it myself, no problem, but watching? I almost passed out the last time I had to do that.

I've never seen one, but I think an amputation would be pretty tough to take for me as well.

Albinoblackbear said...

EMT--Ok so I am not alone in my bone and rib phobia! Hahaha.

I actually have never been around for a chest cracking procedure on a living person (thank heavens) but can hope that when I am, I too will be too busy to get the heebies from it.

Eyes...yes! I forgot, that is another one for a lot of people. Most of the eye presentations I've seen have not been isolated injuries (that is, there was a lot of other skull related problems that grabbed my attention). So I could be an eye person too. Heh.

OMDG--I am that way with suturing. Watching sometimes irks me but doing never never does (except when it involves suturing a nail, of course). :)

Yeah...I think amputation would be a procedure I could miss on my "things to see before being done medical school" list.

RH said...

I actually agree with your list except crepitus. I find that rather cool.

Nails needs to be extended to the entire foot too. Feet are disgusting, especially when they come through the ER - diabetics, homeless people who haven't changed there socks in six months, etc.

Bad GI bleeds can also make me a little dizzy (you know, the disgustingly, graphic ones that we won't discuss here!).

Albinoblackbear said...

RH--Head Nurse had a great post about nasty feet--including the idea of putting shaving cream in the blue booties then washing it off after a while.

It's true, feet in general can be really bad. Ohhh, how about the slippers that old bachelors wear into the ED--you know the ones with mouldy oatmeal and suspicious stains from years gone by? Ahhhhhhhh!

GI bleeds can be bad. The breath I find worse than the blood. And of course they are all NPO so you can't orally rehydrate them.

OMDG said...

Oh also, I did almost vomit once when I got a whiff of a necrotic foot ulcer. The BO undertones didn't help either.

Anonymous said...

The only thing that has ever made me faint is the thought of the responsibility. No joke, I spent my first day of clinicals in nursing school lying in an ICU bed with a juice box.

We had just gotten to the nurses station that morning and were getting our assignments when it hit me - I'd been a CNA for years, but now I would be the NURSE and I would be directly responsible for people's LIVES. I promptly slid to the floor.

It happened the next two times I went back. I managed to compensate by leaning up against stuff a lot and attempting remain inconspicuous. Finally I had a talk with myself - Self, You are going to do the absolute best that you can for your patients everyday, and you will be FINE. Been okay ever since.

Nothing else bothers. I'm always the one they send in to clean up vomit and trim the Ram's Horn toenails. There was one particularly disgusting incident as a CNA though when I was walking a resident to dinner and he Farmer blew a giant greenie onto my hand. I couldn't let go so I had to walk the entire length of the facility with that quivering green, blood-streaked thing clinging to my thumb just staring up at me. *Shudder*

Albinoblackbear said...

Ninja--Wow! 'Responsibility' is a new one!!

I mean, of all the phobias and aversions to have it makes the most sense. Everything else can pretty much be washed out or forgotten but patient responsibility is a little deeper.

I had a somewhat similar incident with my first asymptomatic (already diagnosed/on meds) a.fib patient in the Arctic. I was totally freaking out for no reason and the consultant doc in Iqaluit gave me the perfect perspective to shake me out of it. He asked me (this is all by phone and he's 4h away by plane): "if you had this patient in your tertiary center back home what would you want the doc to do?"


"Exactly. Do it."

I knew it and had seen hundreds of patients in a.fib who had a decent rate, who were on coumadin, with stable BP, no other symptoms, etc. but when it was *my* turn to make the call and send him home I was in a cold sweat.

Nurse J said...

gangrene, although that shouldn't really count. i mean, how often do you run into gangerene? we had a non-compliant diabetic who came in with a gangrenous leg. the surgeon came in to consult, and asked for a scalpel. he sliced off the botton of the guys foot, right there in the room! the smell was so bad, it permeated the WHOLE FLOOR. the guy, by the way, didn't feel a thing, so the doc kept slicing, cutting throught tendons and rotted muscle, then he squeezed from the top down to try and get as much of the puss and infection out as he could. mercifully, he stopped and finished the rest in surgery the next day. when i got him the next day, post-amputation, the smell still lingered, but the stories lived on.
the WORST smell for my, however, is the smell of my kids vomit. nothing NOTHING can make me wanna hurl like that smell. don't know why, but flesh of my flesh.......yeeesh.

Albinoblackbear said...

Nurse J--Yes, I have seen gangrene (similar patient story) as well. In fact in my first week of emergency nursing. It's like pseudomonas with the ability to linger in the nostrils. Gah. I would have fainted if I'd seen the cutting that followed. *SHUDDER*.

Vomit though...meh. Maybe if I ever spawn I'll change my tune! :P

RH said...

ABB-Yeah I've heard the shaving cream procedure before and tried it, but it doesn't always work.

Most GI Bleeds are fine, but the ones where there are fluids actively coming out of both ends that end of all over you (reason why I always carry a second pair of scrubs!)...well those just make me sick thinking about them.

ED PTSD I supose.

Jenn said...

I find that the worst thing for me is sensations.

Crepitus also gets to me... but the other kind, the air leaking into subcutaneous tissue kind. I worked with a man one night who was very sick, but when I had him the next week he had looked like he had gained 50 lbs. I mean the guy's face was so swollen that he couldn't open his eyes. But when I went to get his vital signs and had to put the BP cuff around his arm (I don't know if this even resulted in an accurate blood pressure... but whatever), I could feel it underneath his skin... ugh. Feels like rice crispies, but not in a cool way.

Also I was helping a nurse with a wet to dry dressing change on a stage III sacral decubitis. This man had recently had a rectal tube removed (because it gave him another sore... this one in the perineal area right under the rectum), but was still having uncontrollable bowel movements. I mean it was just continuously seeping out of him. Well, as you can imagine, it doesn't make for a very sterile field. So we'd start cleaning the sacral wound and have to stop to wipe. During one of these wipes my finger slipped into the sore under his rectum.... and I could feel undermining.


Like I said, the sensation thing...

Maha said...

Awesome post ABB!

My top 3 ED gross outs are;
1) Drunk homeless piss and shit soaked people. Especially in multiples. The old EtOH + rotting foot and BO + fermenting urine/feces is a combination that always drives to the edge of quitting nursing and health care forever. Sometimes I wake up in a cold sweat thinking that smell is lingering on me.

2) Colostomy/ileostomy bag poop. The normal rectal kind I can deal with. Even melena, I can deal with. But if it's contained in a bag and the patient even touches the bag, a part of my soul dies.

3) ANYTHING to do with sputum/suctioning. I love the RTs because if I had to do their job, I'd die a thousand times over choking on my own bile.

Oh and I'm firmly with you on the lingering stench of pseudomonas. If you get a run of those in a shift, you know you've done something wrong and karmic vengeance is riding your ass!

Nurse J said...

ah, Maha, i was waiting for a nurse to make an 'i-hate-boogers' comment. you know how to tell, right, if you should become an RT or an RN? i know so many nurses that HATE boogers-
in case you haven't heard it, i'll share it here.
stand up to your chin in poop, and then have somebody hock a loogey at you. if you duck, you should be a nurse. yeah.....

Albinoblackbear said...

RH--Yes. My ED PTSD manifests itself into wearing every form of protective equipment for all the sports I play.

All I can see when I'm skiing down an icy patch on the mountain or biking on single track--is flashes of the x-rays we'd see in Whistler, branches embedded in peoples thighs, blow-out facial fractures, missing teeth, etc. It makes me a massive wuss.

I would wear a helmet to the grocery store actually if it didn't cause my friends to stay far far away. *Full body shudder* That is just wrong. That would definitely cause me to skip lunch.

Maha--Thanks! You are hilarious.

Yesssss the ostomies can be a scary bunch but I get doubly freaked because I don't deal with them that much so I am always worried I am going to totally screw up changing the thing.

And yes, the combo of odors that can come in with some of the frequent flyers can be formidable. It makes me feel doubly bad for them.

I am with Nurse J on this one, I figured sputum would be a big contender.

Nurse J--LOVE THAT! I've never heard that before and will definitely use it in the future--hahahah. Nice.

GENOVEZ said...

suctioning sputum!!!... that particular sound!!! just creeps me out...:(

Albinoblackbear said...

I know this sounds weird but I *almost* like that sound because that means the gunk is coming out and I can only imagine how good that must feel.

Ok. I think I am alone on this one!


Keet said...

I'm a sputum gagger. And hepatic abscess gagger.

Otherwise, I seem okay.

Working in plastics and ENT, and community homecare, I got/get plenty of rotting meat, pseudomonas, gangrene, nec fac, and all the yucky mucky legs and feet and nails I can handle, and it didn't bother me at all.

Its when I have to suction or clean a tracheostomy and the snot is flying I have to hum a little tune to stop the gag.

And the one time that the nurse/dr prior to me on gastroenterology had incorrectly closed the drain on the hepatic abscess drainage bag, and when i picked it up to see how much was in it, it all poured down my arm and front. I almost barfed directly onto the patient. I had to flee the room, (walking briskly and professionally) directly into the patient shower. Thank the lord for skin being so good at protecting us, because whatever was in that bag smelled like EVIL.
Once I was soaked and scrubbed and looking like a drowned nurse rat, I went back to the nursing station and told the charge nurse what had happened and she sent me for new scrubs, and went to deal with the patient. I went and apologized once i was freshly dressed. The poor kid said I wasn't the first nurse to pale and run out when draining it, but I was the first to take the drainage with me.

I now check drains are closed before lifting them.

Albinoblackbear said...

Keet--I vaguely remember you telling me that AGES ago but...I must admit it made my laugh my ass off to read it again.


I always enjoy the war stories from the front lines of healthcare.

Doctor D said...

I can handle any amount of puss, shit, and guts, but horrible mouth odor is the only thing a person's body can do that will make me nauseated.

Albinoblackbear said...

Dry mouth. Post GI bleed breath.


Post ETOH overdose dry mouth breath.

Yeah, it's a no gouda.

Gelfling said...

During my first rotation as a student nurse I took care of a woman with an active GI bleed... when I walked into the room in the morning, and the dark black/red gelatinous melena had run all the way down to her feet and was dripping off the edge of the bed. I was gagging, but got her cleaned up... and then did it 7 more times on my shift. At one point a classmate of mine was helping me change her, and she was rolled to her side facing me with my classmate on the other side of the bed washing her up. She passed gas. Loudly... and wetly. My classmate leapt back out of the way, I leaned over the trash can gagging... somehow our eyes met and we both started laughing hysterically. It was that defining moment of my nursing education where I had to make the choice to either a) throw up, and find a new career or b) laugh about it, hold my breath and do my job.

I now carry a little jar of Tiger Balm with me to work... a bit under the nose helps with melena, wet gangrene and psuedomonas (which to me smells like artificial grape flavoring... can't do the grape lollipops or popsicles anymore) and seems to last longer than essential oils alone.

Albinoblackbear said...

Gelf--GI bleeds seem to have struck a chord deep in our nursing souls, that is for sure!

Tiger balm?! Huh! I hadn't thought of that one. I just always went for the clove oil or friars. But I love the smell of tiger balm so it'd totally kill it for me! haha

VinceD said...

Injuries to nails are what get me, especially avulsions or anytime I assist with a suture where they go through the nail. Just yesterday we had a woman come in with a sewing needle that went through her nail and into her finger and broke off at the tip (flush with the nail surface, must have been a tough removal). *shudder*

Also, everytime I watch this commercial I want to curl up in the fetal position when "Digger" lifts up the toenail. Or when they dig into the nailbed. Or 15 seconds later when I think back again to the nail being ripped off.

Albinoblackbear said...

Vince--Gahhhhhhhh! Welcome to the nail club. Heh.

I am not going anywhere near the youtube link! Hahahha.

krystina said...

*gag* I can't believe I'm reliving my reviles.
1) bad breath-be it GIB's or general NPO for a few days, or ETOH withdrawal/sedation. I hate it. I hate it so much, that I have a hard time helping them with mouth care. I'd rather they keep their mouth closed and me stay away
2) the vomit that's just the saliva. It's got that smell *shudders* Give me food vomit any day--actually, don't, just-- you keep it all, I'm good, thanks
3) FEET!! I hate feet! and toenails! Nast-ay! of course, my baby's feet are adorable and yummy--but I'm sure once he reaches pre-pubescence, they'll hit that category too!