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??

Bliss

I had a very long, very hot drive from Whistler to this...my 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 contract...bike 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 sky...it 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 well...at least my relationship with the North ended up being a little more long lasting.

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!

Religious Views Dictating Referrals?

Once upon a time I was working in a very small town. An isolated, small town. In this town there were no doctors accepting new patients and no walk in clinics. This left the people with only one option for accessing health care without driving to another town--the emergency department.

So I had to temper my usual growls about people coming in for 'ankle pain x 3 weeks', 'sore throat', and 'prescription refill'. I got used to the fact that I was essentially working as a glorified clinic nurse and attempted to enjoy a stress-free existence.

Over the long weekend I triaged a young woman who came in requesting a referral to the gynecologists office. The doc who was working that day saw her and found out that she was wanting a therapeutic abortion (T.A). Because it was a long weekend and he wasn't sure how to set this up when the office was closed he advised her to come back during the week and the referral/appointment could be booked. She left.

A few days later she returned and I triaged her again, I recognized her and asked why she was back--I wasn't aware that she hadn't been given the referral. She explained and I looked at the large stack of charts ahead of her to come in. It was going to be a wait.

After being in the waiting room for a couple of hours I was able to bring her into the cast room (the only spot in the department that actually has walls). I figured she deserved the privacy as she had to explain her situation again and this was a small town where everyone knew everyone in the department and waiting room.

I while later I saw her walking out with a small scrap of paper in hand. The doc dropped her chart on the d/c pile and grabbed the next chart. A while later as I was processing all the d/c charts I noticed what was written, "Pt requesting referral to gyne for T.A. Explained that I am morally opposed to same and will not provide referral. Given information re: adoption options."

I'm sorry...what?

It was a zoo in the department at that time as it was shift change and people were coming and going. I was totally shocked by the d/c note but didn't really know what to say or so about it. The patient was long gone by the time I saw what had been done.

That night I was off for a run and found myself thinking about this girl and her situation. I was upset with myself for not doing anything to help her. It's not that I am hard lined about abortion and being pro-choice. My personal beliefs on the matter do not come into play when I am at work. I know that is an easy cop out for me as I am not being asked to perform them. What I do believe in VERY strongly however--is rural access to healthcare. If this patient was in the lower mainland she could walk down the street to the next ER or a clinic and get what she wanted.

In this town, she had no other option.

The ER was her entry point to the system and being stonewalled there by the ER physicians meant she was being denied access to a service which she has a legal right to seek in this country.

I got more and more angry with myself for not speaking up.

The next day at work I brought up the scenario with the charge nurse to see what her opinion on the matter was and how or if I should proceed. She became quite angry that the patient was refused the referral and while we were discussing it the doctor who originally saw the patient over the weekend overheard and interjected;

"I was the one that saw her initially...was she not given a referral?"

"No, the doc that saw her refused based on her religious beliefs".

At this point he talked about his own religious convictions and his pro-life beliefs. BUT he said it wasn't his place to determine if the patient received the referral or not, saying it was within his responsibility to provide the option if requested. He was quite angry and the patient was sent away and said that the doc should have "put down the bible and practiced medicine that day".

Pretty strong statement in my mind, especially since he's not exactly an abortion supporter. He asked we pull the chart, wrote the referral to the gyne, and I called the patient to tell her. I said if she wanted to go through with her plan it was up to her to call the office and make the appointment, but the paperwork had been done on her behalf.

It made me chew my fingernails for a few days as it stirred up many considerations around the issue and the problems faced by rural practitioners/patients.

Where do health providers draw the line at 'responsibility'? Is it in the referral? The procedure?

And what happens to those that don't receive the services they want...dangerous home remedies? Do they have the unwanted child? Does that child become one of our abused, neglected children or does he/she become a loved and adopted child? Or is the patient relieved the abortion never happened and happily become a parent?

As I said, I know it is easy for me to feel comfortable in my personal resolve on the matter this time but I am not the one being asked to perform the procedure. Would I? Could I? I don't plan on ever becoming a gyne so hopefully I never have to answer those questions.

But then I think...what if (once I am a doctor) someone wanted me to perform a procedure that I felt morally opposed to...would I be able to justify not committing the act but providing the referral?

Tough As Nails

Today was a great day.

I grew up in the prairies, surrounded by farmers and ranchers. When older "Marlboro" men come in the department I get a twinge of familiarity that I get with no other population. It almost makes me a little nostalgic.

This older, eastern European farmer came in this morning after a tussle with a table saw. His right middle finger was lacerated in several places, including one long lac heading midline from the tip to the DIP joint. The nail was divided into one larger piece and several small flakes, the end of the finger was crushed to a pulp. His second finger had a 2 cm laceration to the lateral aspect, also from tip to DIP. I will admit that when I triaged him I looked at the finger wishing I'd get to be the one that got to repair it, but knew that it was way beyond my skill and experience in the land of sutures. Most of the docs I work with know of my expanded scope from working in the Arctic and thus let me do the straightforward sutures that come into the department.

Warning...if you are queasy about nails (Nature Nerd) you might want to stop reading now because I am going to go into the gory details on this one.

After he'd done the nerve block the middle finger the doc called me into the room and asked if I'd like to freeze the 2nd finger for suturing. I had never worked with this particular doc before but earlier had heard him asking one of the nurses why cardiac bloods had been ordered so I figured he was of the old school 'don't do it unless I order it first' mentality.

So I was pleasantly surprised when he asked me to inject the lido. He said he'd heard that I suture and asked if I'd also like to work through repairing the middle finger.

Inside voice: HELL YEAH! HOLY HOT TAMALE!! SWEET!

Outside voice: Yes, that would be great, if you don't mind walking me through it step by step.

The patient had already had his x-rays so we knew that the saw hadn't cut through the bone. He did the first adsorbable suture and then offered me the needle driver. Eeek! Hadn't done those before. I pieced together what I could inside the boggy tip.

After that we had to remove all of the bits of nail that were still attached. This meant essentially clamping the needle driver onto the end and pulling the nail off the bed. At first I couldn't get the technique but then saw how with rocking it back and forth eventually the nail just comes loose from the nail root and slips out. Feel free to shudder now.

*Shudder*

Then the nasty part which was separating the nail from the nail bed which was still attached. If you want to see a video showing how this is done...voila. Yeah. He did a couple passes under the nail with the scissors...that is correct...scraping the nail from the nail bed, then offered me the scissors.

Just...couldn't...do...it.

I was completely embarrassed but I was just concentrating on my breathing at that point.

I was getting that flushing feeling that comes over me just before I pass out...needed to breathe...did someone turn up the heat? Make the room smaller? Shine the light on my head?

I am blaming it on my low blood sugar but really it was just too much at that exact moment. I had just ripped off the other half of his nail for crying out loud! This was already a big day for me! I was starting to feel like a torturer in a Burmese prison.

Anyway, the sensation quickly passed (thank goodness--but not until after the patient joked that he hoped I wasn't planning on becoming a surgeon...har har). I was back at it to put in the sutures to close up the nail bed, the tip of the finger, and the rest of the laceration that went from the cuticle down to the first knuckle. Because the nail was so badly damaged and the patient didn't care if he ever regrew a nail, we did not reattach what remained.

So it was a nice close up to the nail bed, but it looked pretty hectic after that. To me, it was a thing of beauty! My first complicated laceration repair. I wanted to take a photo of it, but since I had no "before" to dazzle people with, I thought the "after" might leave some people wondering what I was so damn proud of.

I sutured the other finger, which was much more straight forward, though my first time ever going through the nail with a stitch. (Also super cool!)

Ahhh...it was so rewarding, and I learned so much during the procedure. Plus the doc was keen to teach and was very patient going through everything with me. The patient was really great about the procedure as well. He had actually apologised for coming into the department, telling us that it would have probably healed fine on it's own. He was sorry for bothering us.

We hastily reassured him that injuries like his are what ED are made for, and he could come in anytime without guilt with a chief complaint like that.

Sigh...salty old tough-as-nails farmers...gotta love 'em.

Fly Like A Butterfly...

Last night a mother came in with her 9 year old who had just been stung by a bee.

He had had allergic reactions to stings 3 times in the past and was already showing some hives on his face, neck and arms. Very mild swelling to his eyelids was also starting to appear.

I was at triage and we were slammed but he was a priority so I whisked him into the department and poured some liquid diphenhydramine (benadryl) down his gullet before you could say "histamine response".

Mom was a nice, middle aged woman. We chatted about the risks of stings and the fact that she might want to look into an epi pen and liquid benadryl. Kid was sniffly and upset but not getting any worse. Mom told me last time he had a reaction it took 3 nurses to hold him down for the injection. I said he may not need one today depending on how the benadryl took effect (it seemed to be working).

Doc and med student saw him and he ordered an I.M injection of benadryl. I drew it up and went in the room to give it.

The child completely flipped out, running and hiding behind his mother, screaming, crying.

Mom just sits there with her hands folded in lap,

"oh Honey...the nurse is busy, let her give you the shot, remember we talked about where we will go eat after?"

Kid continues to freak out. I do not have time for this little episode...I walk away and tell mom to get him settled and I'll return with some more nurses. In the meantime I talk to the doc and see if we can give some oral ranitidine or maybe more oral benadryl...he is responding to the P.O meds so is an injection necessary? It is not going to be easy, I explain. But no, he says it will not absorb fast enough. Fine.

I come back with our male site leader and nursing student and ask them to hold with mom's help.

Mom continues to be useless at disciplining or calming child. The two other nurses are trying to hold him, I attempt to wrap him in a sheet which completely doesn't work.

Now kid is ballistic. Freaking out, screaming, kicking and punching as hard as he can. I am bent over trying to hold his hip still so I can give him the injection in the glute. In the process I get a kick to the abdomen (with shoes on, thanks) and punches/flailing arms to my upper body. My two colleagues are also getting kicked and punched by the child. Mom is the most impotent disciplinarian I have ever encountered. Her child is assaulting three health care professionals and all she's doing is saying, "oh, don't do that, stop it, come on....donnnn't...".

Finally I get the injection in after telling the kid to stop several times (and calling him a brat--I couldn't help myself). We walk out.

I was trying to mix some gentamycin up for a septecemia patient and my hands were shaking to the point I could hardly hold the vials. I have never been so furious at work in my life. Not only was I angry for being assaulted but I was also extremely upset that the mother didn't even apologise or discipline the child. Plus, the staff all just brushed the incident aside.

I was shocked at how upset I was actually. I was fighting tears over the whole thing and I couldn't figure out why I was so emotional after the event. When I had calmed down I returned to the room. Sat down and looked him in the eye. I apologised for calling him a brat. He evidently hadn't even heard me but accepted my apology anyway. He apologised for kicking and punching me. I offered, "friends?" and we shook on it.

I told him, sometimes at work people punch me, scratch me, kick me, even bite me.

"They BITE you???"

"Yes."

I went on to explain that we are nurses who are trying to do our jobs and it is very upsetting when the people we are trying to help are trying to hurt us. He said sorry again and said he wouldn't do it in the future. I walked out of the room, but have to admit, I couldn't bring myself to say what I wanted to the mother.

When I got home from my shift I took a long walk.

It was a beautiful night, just dark but still the warm air was hanging heavy. I was trying to unravel the nights events in my mind and look at my reaction to everything a little more objectively.

Why did only one co-worker ask me if I was alright?

Why did that mother not react to the way her child was acting?

Why is nursing the one job where being assaulted at work is an accepted job hazard?

I don't care that it was from a 9 year old. The whole event was unacceptable but I was unable to articulate it at the time. Or take the appropriate actions to deal with it. The "suck it up" mentality is very clear in nursing.

By the time I got home my lower back had completely seized up due to my poor body mechanics during the wrestling match avec needle. It's still very sore today despite my early morning hot yoga class in an attempt to work it out. I was in pain all day today at work but no, of course I didn't fill out any incident forms or make any complaints. Yeah, what am I going to say, "kicked and pulled by 9 year old, now suffering from lower back pain." Right.

To think about the monotonous regularity with which these events occur in the nursing profession makes me wince.

I just needed to vent a little.

Next time you see a nurse, give her hand a shake for all the sh*t we have to put up with. And then, when she sits down...give her a nice little shoulder rub (really get to those traps...).

Suddenly I feel Old

Why is the question, "how many years of school do you have to go back for?" always followed by "and how old are you?"

Irritating.

Irrelevant.