Clearly I am Not the Only One Frustrated

Hadlington sent me this link and I enjoyed my morning coffee while reading it.

It's funny cuz it's true, as they say.

Conversations I am Tired of Having (Or Don't Have Time to Have) at Triage

Forgive me, this is more of an "I am triage, hear me vent" sort of a post and will likely not be very cogent because I am sleep deprived and trying to figure out how I am going to scrounge my first tuition payment due in August ($ 64 000 CDN--thanks for asking).

I have often felt that ER departments are the final resting place for all the crap that runs downhill in the health care system. Public health programs get less and less funding (and harm reduction programs just get canned altogether) so people aren't getting the education/programs/information there. They are sicker and know less about how to manage it. So they go to their local walk in clinic (because no one seems to actually have a GP anymore). Or better yet, they just wander down to the local ER on a Sunday evening.

My favorite quotes from last night:

"well I saw a doctor already and had an xray and was told it isn't broken, but it still hurts"
--did you take any tylenol or advil for pain?
"no, I don't like taking pills"

and

--how long has Junior had the earache for?
"oh about 2 h"
--did you give him anything for pain?
"no"
--are his 3rd year immunizations up to date?
"we don't immunize our children"

and

"I saw my doctor and he started me on this antibiotic...but it isn't working"
--how many doses have you had? (my inside voice finishing the sentence with--'for your virus')
"1 dose this morning"

The medical floors are understaffed so they can't take more of our inpatients, therefore these patients are stuck in the ED which means that we have fewer actual beds to see the incoming emerg patients. This pushes the backlog to the waiting rooms, which is where it gets ugly.

Voila. The crap comes to a halt, just at the final threshold of the hospital...the emergency waiting room door. Let me clarify, when I say 'crap' I mean the policy, the lack of funding, the shortage of staff, the health care CRISIS if you will, finally stops rolling and is allowed to show itself in all its glory.

The urgent and will-never-be-urgent are squeezed together in a tiny place, clamoring for their moment with the triage nurse.

One woman with diarrhea threatened to call 911 from the waiting room to get an ambulance so she could be triaged faster. I know this isn't a new tactic but last night it seemed particularly poignant as

a)the ambulance service is on strike right now and there have been code 3 calls that have had to be dispatched to cars over 100kms away because of the dirth of running cars right now

b) I was the triage nurse but was also looking after the inpatients and the IV therapy patients which meant that I didn't even have TIME to address this threat or give any direction to patients as to WHY they are waiting and what other strategies they could use to access health care or gain relief from their chief complaints.

I felt like imposing the triage method described to me by the South African doctor I was working with last night:

ask everyone in the waiting room to stand up

whoever stands up is told they are not sick enough to require ER services and is told to leave.

Ok so maybe a little Draconian, but...I was so incredibly frustrated at that point it almost seemed reasonable. If she had called 911 then an ambulance would have been dispatched, and could have possibly been sent from anywhere in a 100km radius...thus removing that car from it's region and putting REAL emergency patients at risk...you know those pesky time-sensitive things like heart attacks, traumas, strokes, allergic reactions, etc.

Am I done venting?

Almost.

We were simply lucky last night that we had no codes or REALLY sick folks in the department because things could have gone south very fast. Short 2 nurses in an ED is dangerous. There is no other word for it. And I know this is the case all over the country. It seems every emerg doc or nurse I know has similar 'flying by the seat of our pants' stories from their departments.

Here's to saving lives on a shoestring.

Celebrate Good Times C'Mon!

So after 5 days of nail biting and fielding the q 3 hourly calls from my mother seeking "updates" I finally broke down and called the admissions office. I spoke with one of the directors whom I met when I was in Toronto for my interview. He said, "is there a drum roll in the background?"

"Let me see if you are on the regrets list...hmmm...no no I don't see you on the regrets list...Congratulations! They are offering you a seat!"

I was unconvinced, "Double check and make sure I am not on the list by my first instead of last name".

He laughed, "No no, I just opened the offers list and here I see your name in capital letters!"

And with that I realised my goal. It has been literally years and years in the making.

I never really believed that I would ever be capable of getting accepted. It took me 9 years to get up the courage to try those pre requisite courses again, after dropping out of chem and physics in my second year of university. I can still vividly remember being on the pay phone with my mother after my devastating physics midterm, crying and telling her I'd never be a doctor all because of physics--and feeling sooo frustrated and that the world was completely unjust as a result of that fact.

That memory makes me smile now.

So Jerry and I began drinking bubbly at about 1600h. We lounged around and went for dinner at this wonderful restaurant in town which uses as many local ingredients as possible--spectacular food. He told our server what we were celebrating and when the black forest cake (my absolute favorite dessert in the world because it was my birthday cake every year when I was a child) arrived there was the scrawled "Congratulations" on the plate. I had to take a photo, Jerry wouldn't let me use my camera so I did it a bit more stealthily with my phone (no flash). I couldn't resist!

It was pretty much a perfect day.

Refresh...Pace...Refresh...Pace

Admissions committee's are such teases. They are like the really hot single interesting person you met at that dinner party who said they'd call you 'early in the week'.

What does 'early in the week' mean exactly? Before Friday? Tomorrow is Thursday and I will be driving through the mountains all day with intermittent phone reception. ARGHGH I just want to KNOW already! It's been a couple of years now of being in limbo and these past few days have stretched to eternity-feeling status.

I have hit 'refresh' on my email inbox so many times today I've worn a callus on my pointer finger.

Tough Day At the Storage Locker

Of course it was drizzling a bit this morning and cold. I was making trips back and forth to the storage locker all day, moving my things into AMG and Ryan's basement to get the goods on display for the "binge and purge" party.

Going through all of my boxes with a ruthless "am I going to want this in 10 years?" attitude was what kept the "for sale" piles much much more plentiful than the "going into storage in my mom's basement" pile. But every box I opened flooded so many memories back to me, from my stemless wine glasses to my flour crusted cook books to my tattered pink feather boa. I remembered what road trip I bought those engraved glasses on, what gig I wore that skirt for, what used bookstore I bought that Timothy Findley book in. Every piece has a story, a little part of my history, a little part of my life.

It was a tough day. There were a few times when I couldn't help the tears that welled up in my eyes as I stared at a handmade mug or a handful of arctic cotton that I had carefully wrapped up from Baffin Island. I couldn't help but wonder what I was doing, getting rid of all these little treasures. But the truth is, I'll be gone for at least the next 4 years and likely a residency in the US (which tacks on another 3-5 after that). And I know, it's only stuff, but it has taken me years to acquire and attain these things, some of them from many different corners of the world.

Soon my friends were stopping by and putting their bids on my various belongings. The buzz of activity jerked me out of my 'how sorry for myself can I feel as I get ready to embark on the adventure I've been hoping for for so long' reverie.

It ended up being quite the evening. Verena just kept saying "This is so weird! You're getting rid of all of your things! This is sooo weird!"

Small bidding wars have started over things like my retro dressers and Ikea lamps. Tomorrow we'll finish up the not-so-silent auction and I'll take whatever doesn't go to the second hand store, the bookstore, and the dump. The nostalgic bits are heading back to the storage locker and then to mom's basement (again).

AMG's contractions are now 1 minute apart and they are off to the hospital.

New beginnings all around.

Interview Post-Mortem

Just taking a few minutes to enjoy a hot beverage from my favorite world-dominating coffee distributor while I wait for my connecting flight...reflecting on the interview and the last couple of days.

I think, overall that the interview(s) went well. The group interview was, as suspected, somewhat frustrating and harrowing. We arrived first thing in the morning and were divided into groups of eight, assigned an evaluator (mine was the Dean of Medicine from the school) and sent off with a scenario. We were told to spend some time reviewing it and 'solving' the problem on our own and then we were to discuss our solution with the group and come up with a single, unified, answer.

I am not going to give away the problem on the blog as I don't really think the Uni would appreciate it, and I would hate to give someone else an unfair advantage (because I am sure that my readership includes at least dozens of pre-meds that will be interviewing for this school-ha!).

When the discussion began it was as I predicted a bit of a gong show--people interrupting others, cutting applicants off mid-sentence, talking loudly over others...there was no bloodshed but a few claws definitely were bared. I sat back and listened for a while, watching the fur fly. Then realised that if I didn't start doing the same the group part would be over and I would have appeared like a shy wall flower to the Dean. Not good. So I jumped in. It was pretty stressful. Tough to be under the gun, trying to make yourself look good without strutting, while under a major time limitation (about 20 mins).

Finally it was over. I had 3 hours until my classic interview. Scampered back up to my hotel room, had lunch, then went and rode the bike in the gym downstairs for half an hour to settle my nerves. Re-ironed my suit. I think that was the best thing I could have done--the biking I mean, not the ironing.

I was interviewed by the Dean and a gastroenterology prof from one of our Canadian schools. It was only about 25 mins long and the conversation was actually pretty fun! I had done TONS of completely unnecessary prep--I could tell you all kinds of facts about everything from the rugby team to the major industries in the city...how long the school's been around, how the curriculum is organized, how many hours a day we are in class...Both of my interviewers were very congenial and pleasant. We chatted about my work in the North, my criticisms of problem based learning, my music background, and why I was choosing to make the leap from nursing to medicine. I felt I represented myself well and if I am not offered admission I can be comfortable with the belief that it wasn't because I choked during the interview.

So now I wait and try to decide what to do if offered a seat in Ireland.

I hit 'refresh' on my email inbox every 7 minutes or so (the offer comes out this week).

And wait.

And in the meantime give away most of my earthly possessions. Anyone want a full set of Paderno pots?

Eek! Interview Friday!

Just taking a quick procrastination break to say that I am cramming (I know, you'd think I'd have learned by now) for my Irish med school interview which is in two days.

The morning is a group interview which is totally stressing me out as I have no frame of reference for such an endeavor and the afternoon is for classic interviews. How to come across as a well rounded, smart, interesting, compassionate professional instead of a ADD, arrogant, conceited, emotionally unstable, domineering Captain of the Universe?

It shall be a fine line.

There isn't much I can find about group interviews online which is kind of frustrating...so I am prepping as I would for a classic and hope I don't fall flat on my face and say something inane like "because I want to help people" when they ask why I want to be a doctor.

Eeek! I am stressing.

On the plus side, my suit pants look better now that I've dropped the too-much-dahl-in-India poundage.

Look out world, I am on my way in baggy trousers!

I am Kind of a Big Deal You Know

So Jerry and I were discussing 'ego' last week. It seems to be a theme with our sushi meals of late. We tend to talk about it because he's Mr. Eastern Philosophy Guy and I quite enjoy getting a dose of the 'its not always about you' talk q weekly.

During dinner he told me about a dear elderly friend of his who had died years ago that had made the observation to him that just about every conversation can be distilled down to the speaker saying (cloaked in anecdotes, humor, facts, etc.):

"I am kinda a big deal you know"

The listeners replying in equally cloaked social niceties various responses ranging from:

"Yeah you are kinda a big deal, but I am a big deal too--this is why"

"Well, you are not really that big of a deal, but I know this guy--HE'S a big deal--this is why"

"I am a big deal, you are a big deal, that is why we get along so well"

"You were a big deal that one time, remember that time when I was a SUPER big deal?"

and so on.

Of course the hospital abounds with places to take part in/eavesdrop on conversations that will show this to be true time and time again. I was stifling a giggle last night as I heard it play out over and over again in comments such as

"Remember that time I told MD so-and-so that I wasn't a nurse to be messed with and he couldn't talk to me that way..."

"So then I was the one that picked up in NSTEMI when everyone else missed it..."

"Oh my computer wallpaper? Yeah, that is my new (insert car, motorbike, horse, boyfriend)..."

"Well, you know I worked (insert ICU/CCU/ER at Huge Tertiary Hospital) for years where we did countless (insert impressive procedure here)'s."

Honestly. It is true. And I know I am not immune. I catch (or don't catch) myself mid-sentence falling into the "I am kinda a big deal" statements all the time now and it makes me cringe.

Is that all the majority of our discussions are about? Posturing? Ego primping? Ego pimping?

I know this is no new sociological discovery but still I have been finding it a fascinating exercise to be mindful of this pervasive theme and attempt to steer from it. The worst is it permeates every corner of our existence from the "I'm a big deal car" to "I'm a big deal handbag" to "I'm a big deal skis" to "I'm a big deal bookshelves" to "I'm a big deal snow pants".

Ack. Who am I kidding. Even my blogs are just one giant "I am kinda a big deal" exercise in internet pontification.

I hate that this is true and I loathe that I've been a sucker to it for so long. So now the question is how does one reprogram oneself? Or how long does it take to not notice again and keep playing along?

This Is Why We Do It

She was a beautiful woman in her late 40's. I was a disheveled and sweaty triage nurse. Our waiting room was overrun with people holding their bellies, foreheads, children's hands, and cell phones. There were no beds in the department. There was a large stack of charts waiting to be brought in, and still another chart buzzed through the printer.

I looked at the chief complaint: "food poisoning".

I called her to the triage station from the waiting room but she simply lifted her head, brown hair covering most of her face.

"Do you need a wheelchair?"

"Yeah."

I wheeled her in and looked at her flushed cheeks. She didn't look well, but then again, if she had food poisoning she probably had high velocity liquids coming out of her from all angles. I asked her what she had eaten, a hamburger and caesar salad. Ooooh. Hamburger. Not good. She had vomited once in the parking lot. No diarrhea. Her heart rate and oxygen were normal. Afebrile.

No meds, no allergies. She told me she had a history of hypertension but her doctor had recently taken her off her meds because she "needed to lose 10 lbs and then be reassessed". She only looked about 10 lbs overweight, if that. Her BP was 208/110. Umm...

"Do you have a headache?"

"Yeah a little bit."

"Visual disturbances? Double vision? Spots? Stars?"

"No."

"Chest pain?"

"No."

"Do you feel lightheaded? Dizzy?"

"Yeah."

Ok. Symptomatic HTN. No beds. Except for trauma bay. I asked the acute side nurse if she'd mind me popping this food poisoned lady into the trauma bay, just for a few minutes so I could get her on a monitor, get an EKG, and do a more thorough assessment. Her pressure was high and I was just not sure what was going on with her. "Do what you have to do" was the reply from the harried nurse who already had her hands full with a query stroke and 2 cardiac patients.

I wheeled the patient into the trauma bay, her repeat pressure was 168/78, HR 97, O2 98%. Now I was feeling sheepish for using our hallowed trauma bay for yet another puker and pooper. I asked her to turn from her side onto her back so I could hook the oxygen tubing behind her ears. I pulled the dark hair from her face. Her head turned in my direction, clear blue eyes stared up at me as she murmured, "I need to lay on my side for a minute". Her eyes rolled back in her head and she began to seize. Her face began to turned blue, first just around the mouth, then spreading up her cheeks, an unnatural mauve. Her husband used his body to keep her from rolling off the other side of the bed.

"I need some help in here!" as I pulled up the side rails and grabbed the bag valve mask for oxygen.

Within minutes two other nurses were at the bedside with a doctor in tow. Instantly we set about our duties.

An I.V is placed in her arm, valium goes in. No pulse. The OPA is inserted and we are bagging her. Her rhythm shows v.fib. The skin of her arms begins to mottle, and as I cut off her shirt I see that her chest is also mottled, no demarcation line though. I stick the quick look pads to her chest and charge the defibrillator.

When was the last time I hit the shock button? Why is this lady dying on us?

I see her husband standing with his eyes fixed on the head of the bed, mouth slack but eyes attentive, seeking. Just then another nurse offers to walk him outside, he agrees.

"I'm clear, everyone is clear. Shocking!"

And thus began the long hour of CPR. 13 shock deliveries, 8 doses of epi, a dose of magnesium sulphate (during a brief Toursades episode) and one dose of atropine.

We would get a rhythm, then a pulse, then back into v.fib. It was a roller coaster. We had no idea why this was happening--she could be a bleed--but was it hemorrhagic or ischemic? Was she an acute M.I? We had no labs so couldn't determine if it was her electrolytes. Pulmonary embolus?

We had intubated her successfully on 2nd attempt with a 6.5 after the 7.0 was a no go. With the intubation and bagging her sats remained 100% and we kept CPR going throughout. The numbers were running through my head...she'd been down now for over 60 minutes, she was getting 25% circulation of oxygenated blood thanks to the CPR, we'd given her enough joules of energy and epinephrine to power a leg of the Boston marathon and we still didn't know what was happening to her. What were we saving now? Would she be on a vent with severe brain damage the rest of her life? Would she even take to a vent? When do we call it? With enough epi on board I've seen PEA last for ages. After such a long time the heart is just twitching, it has no intention of ever beating again.

The lab attempted to do an EKG but due to mechanical interferance from the monitors and defib pads (which I was not about to remove any time soon) the print out was basically unreadable.

Her pupils were fixed and dilated. She is frighteningly cyanotic despite what our monitors were telling us.

She went into sinus rhythm. Tachycardic but sinus. We prayed that this time it would continue for longer than a few seconds.

It did.

The paramedics had arrived to take her to the Big Hospital. Her color began to improve, her cheeks no longer dusky. The mottling on her arms faded as they returned to a pale pink color. She was taking the odd breath against the tube.

We packed her into the ambulance, the doc and I at her side. We pulled out of the parking lot just as the respiratory tech pulled into the lot. Gotta love rural emerg. I attempted to fill in the gaping holes in the charting as the ambulance careened along the rainy streets. The paramedic student bagging her.

We arrived at Big Hospital and went through the usual song and dance with the dragon-lady triage nurse:

"Who is this patient? Where are you guys coming from?"

"We're from Small Hospital down the road, we talked to your ED doc who accepted her, this is the cardiac arrest we're bringing in..."

"I have never heard anything about this woman."

"Well, as you can see, she is intubated and unconscious. We've been working on her for over an hour. She needs a STAT CT among other things and time is of the essence, she could crash again at any moment before we know what is going on with her..."

*Large audible sigh from Dragon Lady.*

"Fine, roll her into trauma bay 1".

'Thanks."

We get her into the trauma bay, give report to the nice accepting ER doc in shorts and the cranky ER nurse with green streaks in her hair. The RT saunters in in his scrubs and PUMA's, looks at the tube and remarks, "the tube is too small". I stifle a remark about his genitals and point out that it has provided her with adequate oxygenation thankyouverymuch pointing out her color and sats. Asshole. I am so not in the mood.

Doc and I walk down the hall where our paramedics are anxious to get us back to our hospital before they go on another call. We see her husband and young son walk into the waiting room. Both Doc and I say goodbye to him. I shake his hand and say something about hoping for the best outcome for his wife. He walks in a daze to the quiet room with the teary eyed boy trailing behind.

We return to the department.

I call the CV-ICU everyday.

Day 1: She had been to the cath lab, showed a 30% occlusion in her LAD artery. She had had two stents put in, and was still in an induced hypothermic coma so neurological status was unknown. Outcome did not look good.

Day 2: Still intubated and in coma. Body temp not rising despite cooling protocol cessation.

Day 3: Still intubated but some periods of wakefulness, responding to voice.

Day 4: The nurse comes on the phone and I ask again how Mrs. D is doing. I explain that I was one of the nurses involved with her code at Small Hospital.


"Oh I am looking at her right now, sitting up and having coffee with her husband."

A sputter from my end of the phone comes as the reply.

"Yeah, none of her doctors can believe her recovery. She has no neurological deficits at all. Well, she has some amnesia from the night of the arrest. She remembers going to the movie but nothing about the dinner or afterward. But that is probably a blessing, who would want to remember any of that? You guys did great work on her out there at Small Hospital!"

I tell her she has no idea how much I needed that news this week, thank her and hang up. My eyes are filling with tears of joy and relief.

I am still stunned and thrilled at this outcome. I cannot remember the last time I was part of a successful resuscitation. Scenes from that night keep replaying in my head and all I can do is shake my head with gratitude that she is alive today.

This is why I love my job.

A Welcome Curveball

Some happy news this week...

I got an invitation to interview for an Irish medical school! April 10th to be exact.

Yay!

This both pleases me and complicates my life greatly.

My life is nothing if not unpredictable.