Tales From The Nightshift

So, TINS©, TIWFDASL© one night in The Maternal State, years and years and years ago. My father had taken ill, and of the three of us boys (the attorney, the contractor, and me, the nurse), it seemed that I was the best fit for the job of helping Mom take care of our Dad.

Well, that, and I was the one who did not have a family.

So, in order to keep my house and my vehicle, my creditors agreed that it would be nice if I were to continue receiving a paycheck, while I was 800 miles from home, and taking a voluntary leave of absence from my employment. So, I became a travel nurse!

This one night, I was working midnights at Some Suburban Megalopolis Hospital’s ED. It was way, way late, and we had cleared all the souls from our beds, and were engaging in my favorite slack time occupation, Story Hour.

So, one nurse was recounting how her boyfriend was failing to meet performance/behavioral expectations in one way or another. The other nurses (all women) responded, in a sort of choir, with murmurs of affirmation for the reporter. Except for one particular nurse.

This woman’s speech was rich with the cadence and harmonies of Da Islands, with a Caribbean note permeating her pronouncements.

“Aw, naw, ghurl! Ya no haveta put up with dem shenanigans! He gotta go, out de doah!”

The chorus affirmed this pronouncement.

The protagonist in our little Greek tragedy continued with her lamentations of Mr. Unworthy’s misdeeds, and our Caribbean Correspondent again provided her assessment: “Out de doah!”

Again, the call of more misdeeds, again the response from the congregation: “Oh, naw! Out De Doah!”

It devolved into a documentary of The Misdeeds Of Men, and along about that time, I found something I ought to be doing. At the other end of the department.

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“Warn-A-Brutha”, in action.

So, TINS©, TIWFDASL©, and my MA, let us call her Maryann, exited the room that she had entered, shortly before, to assess and obtain vitals on a child.

“Reltney, this child here is working kind of hard to breathe, and he is coughing a lot: it seems to interfere with his taking a breath!”

I entered the room, and noted a child coughing approx every 10 seconds (and I mean a full throated cough, not some modest little “harrumph!” kind of thing), and, as I observed his breathing, noted a rate of around 60 breaths a minute.

Not so good.

We administered a breathing treatment, and he had kind of, sort of, maybe improved just a little bit.

I finished my assessment, and went to chart, intending to return and re assess him once my (generally 4-7 minute) charting was completed.

I did so, and noted that his breathing had dis-improved (is that really a word?). I invited the physician with whom I was working to lay eyes upon him, briefing her upon my observations and actions thus far.

Once she had assessed him, she was not favorably impressed. She, also, thought he was working kind of hard to breath. She, also, wondered if this was fixing to run him out beyond the end of his reserves, whereupon he would crash, likely biggly, and become a no shit emergency. She wondered if sending him to emergency, prior to that happening, might not be more wise than waiting until he did, indeed, crash.

I agreed.

I wrapped up my charting, once the child was safely on the way, and hunted up Maryann. I congratulated her. “You did good. Your prompt assessment that this child was not breathing right, set in motion events necessary to get him to the appropriate level of care, in a timely manner. Well done!”

The Heinlein Rule

Perhaps, I ought to initiate another tag, “The Heinlein Rule”. As Heinlein said, “Take a look around you. There never were enough bosses to check up on all that work. From Independence Hall to the Grand Coulee Dam, these things were built level and square by craftsmen who were honest in their bones.” (https://thisibelieve.org/essay/16630/)

I have spoken of Eloise in another post, as well as one particularly heads-up MA and how each of them, professional in their bones, acted on their own initiative and decisively to protect patients.

So, one day, TINS©, TIWFDASL©, when the registrar meandered back to the nurses’ station.

She opened her conversation, “Just checking. This woman reports that she is bleeding, and 3 days out from her delivery. You *DO* want her to go to emergency, right?”

Before I could contribute anything, my MA asked, “Does she look dizzy, or pale? Did she walk straight? Anything else going on?”

The registrar replied, “She looks pink, not sweaty, walked straight, no other complaints when I asked about any.”

My MA stated, “Please direct her to emergency.”

The registrar looked at me. I stated, “What she said. Does she have transport?”

“Yep, She is here with some family member.”

“Outstanding. She should be on her way, please.”

The Lord blesses me with partners who play “Heads UP!” ball.

Smoking is Bad, M’kay?

Several times a week I get the opportunity to “cheerlead” one soul or another along the path that ends with not smoking. Some folks are receptive, and they get the full orchestration. Others, not so much, and they get the admonition, “So, smoking is not health promoting behavior, is it? There, I’m done yelling at you about smoking!”

Those who appear receptive get told, among other things, that The Plaintiff smokes, She is a nurse, so it cannot be that she does not know the effects of smoking. And, if you ignore the fact that she married ME, and divorced me, well, ignoring those two errors of judgment, she is pretty smart. Finally, she has never been any sort of shrinking violet. As a mother, I enthusiastically applaud that sort of strength of character.

As The Plaintiff, well, not so much.

I move on to observe that this set of facts (see previous paragraph) tells me that stopping smoking is a monumental task, complex and demanding much of those who would make that journey.

Then, I observe that I worked, full time, in my Nursing school years. Spent two years on around 2 hours sleep a day, in my AD program.

Pretty worthwhile. Mighty difficult.

I conclude by observing that worthwhile things are seldom easy (cf. Raising children), and that easy things are seldom worthwhile (see: video games).

Occasionally, I will see some soul who was on the receiving end of that spiel, several months later, and some of those folks will tell me”I have really cut down, and am trying to finally quit, because of what you told me!”

Sometimes, you get to think that you have, indeed, made a difference!

Nursing School Lessons

NURSING SCHOOL LESSONS

So, TINS, TIWFDASL, years and years and years ago. I was in nursing school clinicals, and working for EMS in Da City. This was so long ago, that HIV/AIDS was not even on the horizon.

One day in clinicals, I was cleaning up an incontinent patient, and my instructor motioned me outside once I was done and the patient tucked in to a nice clean bed, and he, himself, was clean and dry and in a clean gown.

She began: “Mr. McFee, You did very well keeping the patient covered so that he would not get chilled as you bathed him. There is, however, one item I ought to call to your attention.”

“Yes, ma’am? What is that?”

“I noticed that you were wearing gloves. That concerns me, because your patient might feel insulted at your wearing gloves for personal care.”

I responded, “So, you are telling me that the fact that I am wearing gloves to clean a patient who has been incontinent, of stool at that, might be seen as insulting?”

“Yes, Mr. McFee, that is exactly what I am telling you.”

“Well, ma’am, I worked last night, on the ambulance. I spent the night crawling in and out of cars, and over broken glass, removing injured people. I probably have a thousand little cuts on my hands alone. I am pretty certain that any patient of mine will get over their hurt feelings way before I recover from Hepatitis B. But, you are the instructor, and I am the student. Let’s write down your directions for me in this matter, and make a couple of copies. We’ll both sign each copy. That way you will have a copy, establishing what you directed me to do, I will have a copy and therefore cannot claim that you never told me to do what you told me, and there will be no questions moving forward what I am to do.”

She looked aghast. “I am not going to write that down! No way!”

I smiled. “Thanks for the counseling session. I will certainly keep your words in mind, moving forward!”

SNIPPETS V

STORY THE FIRST

So, TINS, TIWFDASL, just a couple of weeks ago, and, as I entered the room, I was greeted by the younger of the two women seated in the exam room. “There he is! You saved my mother’s life!”

While that certainly was a welcome greeting, I admitted that I was confused. The younger woman, evidently the daughter, filled in the missing pieces. Several weeks previously, she (the narrator) had accompanied her mother (the other soul in the room while we conversed) to a visit to our clinic. She (the mother) had been having a cough of some sort, and I had felt that something in the experience did not sound right. After some assessment in clinic, I had sent the mother to ED, and those worthies had identified a 100% occlusion of one of mom’s coronary arteries (the arteries feeding the heart). Mother had received a stent, and been sent home, and was still among us. Indeed, she was here, today, due to another cough.

Thankfully, today’s cough appeared uncomplicated, and I recommended my usual measures to ameliorate the post nasal drip that seemed to be the source of the cough.

Sometimes I get to think that I really do, from time to time, positively impact people’s lives. That’s nice to think.

STORY, THE SECOND.

Just the other day, I was shopping. Such is the life of a life saving, disease fighting, internet blogging champion (of sorts). As it develops, I am middling tall: 5-7 or so. It turns out that the pasta I was hunting for was on the top shelf, and several other people had purchased some, before me. THAT meant that I could just barely not reach the boxes. I had just realized that I, a tool using animal, could open my knife and extend my reach, tipping over the needed number of boxes, and add same to my cart. That is, I had just realized it, when a gentleman, taller than I, reached up, grabbed a box, and handed it to me, asking me if I needed more.

I requested two more, and thanked him, moving forward with my shopping.

A few aisles over I observed a woman attempting to retrieve an item from a shelf beyond her reach. Before I could respond, another (taller) gentleman stepped up, retrieved the sought item, and handed it to her.

Everyday, plain folks, acts of civility and kindness.

STORY, THE THIRD

We visited my wife’s sister, and her husband, recently. They live in rural Kentucky, and it is rather a change from their previous neighborhood in Metropolis. Indeed, it is a considerable change from my table-flat neighborhood of Un-Named Flyover State.

We arrived, following the directions provided, and noted that the terrain was, well, “hilly” does not really do it justice. As a consequence of that terrain, roadways tend to meander, circling around this hill, or weaving their way up to, over, and down that ridge.

We had spent something like 45 minutes meandering , as the road took us up in elevation, when I noted a sign ahead, announcing “Curves Ahead!”.

I turned to TDW-Mark II, and exclaimed, “Wait, what? THAT was the STRAIGHT part?”

STORY, THE FOURTH: OOPS!

So, TINS, TIWFDASL, and, well, things had come to a slow down. I was working with a physician, on this day at this clinic, and she had never handled an adrenalin autoinjector. We had one handy, and I handed it to her so she could examine it.

I was not quite quick enough, to admonish her to not remove the guard, nor to handle the trigger, on the one end of the device. Therefore, she did, successfully, remove the cap, and then trigger it, sending the needle into one of her fingers, along with some of the adrenalin therein.

The Good News was that, since she was youthful, she promptly withdrew her hand, and therefore only received a fractional dose. The bad news is that adrenalin is a very, very powerful vasoconstrictor, and therefore her affected finger became very, very white, and also burned. Oh, yes, it burned. I cast about, wondering if we had any phentolamine. (an alpha blocker: used to reverse the effects of, among others, adrenalin, when injected into an end capillary bed, Like you would find in your fingers.) Since ours was not an ICU, nor an ED, we did not have phentolamine, nor anything that would serve.

The good news, such as it was, is that due to her youthful age, good health habits (spelled n-o-t s-m-o-k-i-n-g) and the fractional dose of adrenalin she had received, well, after around 20 minutes, her finger regained it’s color, the burning pain faded, and she returned to normal, simply just a bit more shaky than previously.

Subsequently, I obtained, and CONSPICUOUSLY labeled a trainer, specifically intended to harmlessly teach folks how to handle and operate an adrenalin autoinjector. This one has no needle, and no drug.

STORY, THE FIFTH

So, TINS, TIWFDASL….well, okay. I was NOT FDASL, rather, I was off, and, having accomplished all my chores (or, such fraction of “all my chores” as I was going to accomplish that day), my step son (son of TDW-Mark II) called. I had spoken to him about a range day, and he was off work that day, I was off work that day, and it was off to the range we went.

I took my Garand, my .380 pistol, and my 9 mm pistol. Of course, I grabbed the ammo can labeled 30-06 (for the Garand), .380 (surprisingly enough, for the pistol in caliber .380), and the ammo can labeled “9 mm” for, no doubt surprising, the 9 mm pistol.

Now, recall that I have been an RN for, lo, these many yeas. That I have passed uncounted thousands upon thousands of doses of medications, and double checked myself each time, so as to accomplish the “5 rights” of med pass: right patient, right drug, right dose, right route, and at the proper time. This was effected by reading the order, the med container, comparing each with the other, and then, DOING SO AGAIN.

So, we arrived at the range, uncased the Garand, and set up targets. Several dozen rounds later, we placed the rifle in the case, put the ammunition away, and took out the .380 pistol. Fun times.

When it came time to take out, and shoot, the 9 mm pistol, well, I went to the “9 mm” ammo can, opened it, and beheld something like 200 rounds of RIFLE AMMUNITION.

For those in the studio audience who are unfamiliar with Things Firearm, well, 9 mm is a pistol round, and rifle rounds are (a) the wrong size overall, (b) with the wrong projectile (bullet), propelled by (c) an entirely wrong charge of powder, leading to (d) entirely way, way more pressure once the cartridge is set off, for any common pistol to contain, meaning (e) should, somehow, a rifle cartridge be forced into the pistol that I had before me, anyone firing it, should they survive the resulting explosion, would forever after be known as “Lefty”.

Not mentioning the emotional distress I would experience should this pistol, one of my favorites, be reduced to shrapnel.

Sigh. It appears that I had horribly failed the ammunition labeling process, leading to jovial kidding from my step son. Other than that, a good day at the range.

And, the ammunition got re-(and correctly)-labeled.

REDUNDANCY.

The other day, I was reading about everyday carry, and one writer was talking about how “two is one, and one is none”.

I recalled one night, nursing midnights in ICU. Now, every single hospital that I have ever worked at, has an emergency generator. These are equipped (or, at least, SUPPOSED to be equipped) with an automatic apparatus, that is intended to identify an interruption in the supply of power from the local power company, and start up the on site emergency generator, and then, once said generator is up to speed and functioning, disconnect the hospital from the shore power, and energize all “emergency” circuits from the generator.

As it developed, on this night, the power went out, and everything went black. We eagerly awaited the onset of generator power, but, alas, such was not to be.

Now, y’all may not know this, but in an ICU, there is an abundance of very, very sick folks. Indeed, several of them are dependent on ventilators to, well, ventilate them, since their illness renders them incapable of breathing adequately on their own.

With that thought in mind, it may not be a surprise that these life saving ventilators require an uninterrupted supply of several things, not the least of which is electricity, in order to function. When the power fails, and the emergency generators do NOT promptly start up, well, things get interesting.

While the ventilators, themselves, do NOT have battery backup, the alarms signaling malfunction, do. In order to respond to these alarms, the nurses, such as myself, need to alight from our chairs, walk around the nurse’s station, enter the room, and identify and remedy the fault eliciting the alarm.

(a) That is considerably easier to accomplish when you can see where the frack you are going, and identify trip-and-fall hazards, prior to, uh, tripping over said hazard, and falling upon your face.

(b) Should you have TWO ventilated patients, you are tasked with reaching each patient, disconnecting that soul from the (nonfunctioning) ventilator, and manually ventilating them employing the manual bag-valve resuscitator kept at bedside for just this sort of problem.

Except, you are one, non elasto-nurse, person.

As it developed, our ward clerk was in nursing school, was intelligent, and had paid attention. She ventilated my second patient, and the on-unit respiratory therapist ventilated Mary Sue’s second ventilated patient.

It only took a couple of minutes (…that seemed like hours!) before we regained power. But, I thereafter took to carrying a flashlight on my person.

Problem solved, right?

Not so right. A couple of weeks later, the power failed, again. The generator failed to generate, again, and I thought, “Voila! I’ll whip out my handy-dandy flashlight, and illuminate the area!”

Problem with that, is that the flashlight had somehow turned itself on, while on my belt, and was deader than disco. So, same cluster…er, hug (yeah! HUG!), same musical ventilation, and same subjective eternity until power came back on.

New! Improved! Plan, was a couple of flashlights, with a regularly (every other month) assessment of function and battery charged-ness. As well as additional flashlights squirreled about my person. So, presently, I have two flashlights on my belt, two in my shirt pocket (one Streamlight Stylus Pro, another that has been customized with a near UV emitter, so that I can use it as a Wood’s Lamp), one on my badge (one of the coin cell lights thrown in with my order from the folks selling me my CR 123 batteries), and one on my keyring (a Streamlight Nanolight). (none of these are any sort of freebie: I bought the Nanolight, and the Stylus, and then bought several more, at retail, because they perform for me what I need doing. Like, illuminate my way when nocturnal dogwalking, allowing me to avoid a dirt faceplant.)

Telemedicine: Threat, or Menace?

One fine day, I was at work, FDASL, and received a text from my daughter, let’s call her Brenda. She related that her second child had developed what looked like pink eye, to Brenda’s assessment. She (Brenda) had contacted whoever, and that medical soul had video chatted/e-visited/virtually visited/some other bullshit with my grand daughter, and had prescribed an ophthalmic antibiotic.

Brenda was not altogether certain that this assessment was spot on, and wanted her clinician dad’s take on things.

As you may have surmised, MY take on non patient contact, not in the same room “visits”, is not filled with much enthusiasm. There is something to the gestalt of being in the physical presence of somebody, that provides you with clues that are neither evident, nor are they provided across a video screen of any sort. (Ever smell the fruity breath of diabetic ketoacidosis? Ever smell it over a phone?)

Placing that aside for a moment, I asked for some pix. (I am aware that this amounted to the very same thing I had just, 11 words ago, railed against. Wait for it.) My grandchild’s eye appeared red, and (uncommonly in pink eye), so did the tissue surrounding her eye.

I asked if this grandchild could move her gaze left and right, upwards and downwards, painlessly. Was there any change in her vision?

The response I received was that the vision in her affected eye was “blurry”, as well as “it hurts when she looks up”.

My response text, verbatim, was, “Who is going to see her in person, in the next half hour?”

Brenda took her child to our local urgent care, which clinician, to THIS clinician’s credit, is reported to have entered the room, taken one look at my grand daughter, and turned to her mother, and said “So, I’m not going to charge you for this visit. Do you know the way to Big City Referral Hospital? Good. Do not dawdle. Go directly there, now. Yes, I mean the emergency department. Thank you. Drive safely.”

THOSE folks examined her, CT’d her, and started an IV (a process that Grand Daughter did NOT approve of!), and IV antibiotics, and admitted her for several days. The CT had revealed a peri orbital cellulitis (mild, but, nonetheless…), which responded to the medication.

She is now home, sassy, and none the worse for the experience. Take home points: Brenda demonstrates many, many of the affirmative attributes of The Plaintiff: she is smart, decisive, has a finely calibrated and high functioning “shit don’t sound right” detector, and is a bulldog advocate for her children.

I loathe “telemedicine”.

Sometimes I am both blessed and lucky. This time, to the benefit of my grandchild.

KITTEN TAILS PART VI

So, TINS, TIWFDASL….we, uh, no, I was NOT Fighting Disease And Saving Lives, rather, I was at home while TDW-Mark II recovered from surgery. (Thankfully, minor. Well, “Minor” from my perspective. I’m pretty cure that, for whoever goes under anesthesia and awakens with sutures and re-arranged body parts, ain’t no such thing as “minor” surgery!)

In any event, on my multiple rounds on TDW, I noted that there appeared to be two, or three, cats perched upon the bed. Should one depart, one would take station. The others would eat, play, loll about: typical cat stuff. The two, or three, “on watch” all appeared to gaze upon her, that is, if they were not snuggled up against her. Just as if they were, indeed, “on watch”.

Olivia appeared to be the one constant watch-stander. She was perched upon TDW’s pillow, and did not seem to move. Others would appear to rotate in and out, but Olivia was pretty constantly there.

When she (TDW) was up and about the next day, she commented about it. “Every time I opened my eyes, one or more of the cats was there, looking at me. I felt as if I had a couple of private duty, furry little nurses!”

Then she reminisced. “remember that time you had your GI bleed? The two dogs, and all three cats (at one time, my cat crazy was under better control….) were settled in all around you! They would only leave to eat, drink, and go. Then, they were right back.”

At that time, we developed the McFee Critter Triage System: if one animal is sleeping with you, that’s normal stuff.

If two of them, well, likely normal, perhaps not.

If three of them, The Spouse needs to take a closer look at things: it ain’t raht!

Four? When is your doctor appointment?

Both dogs, and all three cats? Call dispatch. It might take some explaining (“Ma’am? Did you just tell me that your emergency is that all five animals are sleeping on the bed with your husband? I…I..don’t understand..?”), but Bad Things are at hand. Do Not Dally.

Fortunately, TDW-Mark II recovered uneventfully.

KITTEN TAILS, PART THREE

Our Cat Farm grew, as Momma Kitty joined us. One autumn day, TDW-Mark II observed Momma Kitty come onto our porch, and eat the dry cat food we had been placing out for her. TDW opened the kitchen door, on this pleasant autumn day, and verbally invited Momma Kitty to enter, and get acquainted.

Much to our surprise, she promenaded into the kitchen. She next sat herself in one of the windows, and we could not convince her to move. TDW then retrieved our travel crate for the one dog, opened it, and Momma Kitty simply walked in, settled down on the dog bed, and looked at us as if to say, “Well? Do you think you are done?”

We secured the door of the crate, and realized that we now needed to find, and retrieve, her latest batch of kittens.

TDW (perhaps, by now, y’all have realized who is the brains of this operation. And, it’s not me, apparently.) had observed the dogs lingering over a particular potion of the porch, as surmised tha the kittens would likely be located underneath.

So, we accessed the underside of the porch, TDW entered, and passed out the two kittens she found therein. The first kitten, now know as Oliver, was a wee bit, and appeared to have a lesion of some sort on the back of his neck. (this later was identified by our vet as an abscess) The second kitten, now know as Trixie (due to the black and white, “cow camo” pattern of her fur, reminiscent of TDW’s pet cow from her childhood), appeared to have some sort of mucoid material from her one eye. We wondered if the litter had been larger initially, and suspected that the stimulus to bring Momma Kitty in might have been some predator (we have raccoons about) might have attempted to clean out the litter, and these two, and Momma, survived.

We cleaned them up, as a start, and arranged for vet assessment. Oliver got an antibiotic, and his abscess resolved. Trixie was another story.

The vet could not visualize her one eye, and voiced concern that this might be a viral conjunctivitis, and have a corneal ulcer associated with it. She wondered if this would, in fact, heal, or if, once healed, she would have no vision in that eye.

So, we became cat nurses. Trixie got her eye ointment twice a day. After several weeks, she improved. And, since curveballs seem to be my lot in life, one of the other cats appeared to develop pink eye as well.

Since conjunctivitis is wildly contagious, unsurprisingly the other cats developed it. To my surpirse, only 7 of our ten cat herd did so: the three oldest appeared to miss that fun. So, we drew a kitty MAR (medication administration record), and began twice a day sick call.

The bad news was that the biggest of the kittens Was Not Having the medication administration. That led to Sumo Cat “Parenting”, which is every bit as much fun as it sounds. Particularly for those of us who bleed freely. And do not have hind claws. Fortunately, TDW, wise in the ways of Catdom, determined that should we profit from the old aphorism “letting the cat out of the bag”, and place Reluctant Cat into a sack made of two retired pillowcases, his paws and claws would be neutralized, I could immobilize his head, and she could administer the eye medicine.

To Reluctant Cat’s credit, he either did not realize that he could readily gnaw the shit out of us, or else elected to let this insight pass by, unacted upon. In either event, he improved.

The good news is that, soon, we would corral Reluctant Cat, and his escape artist sister (previously referred to as the superball, or the furry bottle rocket), and medicate them.

That task accomplished, we would administer treats, in the form of canned cat food, which they seemed to very much enjoy. Then, we would open the bathroom door, to release them and seek the next contestants, only to find that there was a feline line up, and next two would walk in, apparently unworried.

We would shut the door, medicate (and chart) these two, and provide their reward/treat. Opening the door, those two would saunter out, and the next two would meander in. Shut the door, medicate cats, treat/reward cats, chart meds, open door, those two exit, and the next one would enter and be medicated, rewarded/treated, easy-peasy.

As the kittens became integrated into the pride, one adopted our older cat. (I told of Henrietta and Max in a previous note) We were surprised to see that, once Oliver was in the pack, he appeared to adopt Olivia, from the previous litter, as if he was her “pet kitten”.

The cuteness mounts!