Christmas 2012

To all of you out there who have not received a Christmas card from me 
- and that would be ...everyone, since I didn't send any this year
...this is it. 

As a nurse, I've had to work my share of Christmas shifts but it's what I have chosen as my profession and I'm good with it. Actually, I've always considered myself to be one of the lucky ones. Especially at Christmas-time.

It always been so easy for me to get caught up and into the hype of the holiday season - You know the drill...

• Get the house decorated
• Plan Christmas Dinner
• Bake
• Shopping
• Gift Wrapping
• Clean the house
• etc.

But what I am most grateful for is the regular dose of 'reality-check' that I get from going to work. It  helps keep me grounded.

A couple of weeks ago, my elderly patient happened to be blind. She had lost her vision completely, three years before. As I was feeding her dinner, the story on the evening news was all about New York City's Rockefeller Center Christmas Tree. 

My patient said "Oh, how I wish I could see a Christmas tree one more time".

I described the tree to her as colorfully as I could. 

Since that night, I have paid a little more attention to the beauty and detail of the Christmas season.

I consider myself to be one of the lucky ones.

Wishing you all a 

Very Merry Christmas, 

Happy Kwanzaa, 

Happy Hanukkah 

and a

Great New Year!

Munchausen's Syndrome

Baron von Munchausen

I was first introduced to the psychiatric malady known as 'Munchausen's Syndrome' back in the late 80's. I understand it's name comes from Baron von Munchausen, a widely travelled adventurer who would regale those who would listen of his fantastical experiences...

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Munchausen's Syndrome: "A chronic factitious disorder with physical symptoms.", "A plausible presentation of factitious physical symptomatology of such a degree that he is able to obtain and sustain multiple hospitalizations. The frequency of hospitalizations will be so extensive that the individual spends the majority of his days either seeking or maintaining hospitalization". 1.

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A dishevelled young man, I'll call 'Joshua', approached the E.R. triage desk with a complaint of moderate abdominal pain subsequent to an approximate 15ft  fall from the roof of a house. He was carrying a bag and a down-filled coat. It was August. In Texas. My inner "Bullshit Detector Alarm" sounded. Loudly.

But, having a high index of suspicion of possible internal injuries, our patient was efficiently triaged. During the primary assessment, he began to complain of sudden, excrutiating diffuse abdominal pain. Drawing up his legs and guarding his abdomen from further examination, his level of acuity was immediately cranked up a notch or two and our walk-in-fall-injury became a high level trauma patient with all the necessary bells and whistles... Trauma Team activated.

• Oxygen 100% via non-rebreather mask
• C Collar/Backboard
• 2 large bore IV's w/NS
• Multiple diagnostic labs including Type and Cross for 4 units of blood on hold.
• Heavy duty narcotics
• Stat CT Scan - abdomen & pelvis.
• Nasogastric tube (NGT) to low suction.
• Foley catheter.

Your basic Trauma Team

Before I go on, for those of you not in the health care biz, there are two tubes most people really don't like....

1. Nasogastric tubes (NGT)
2. Foley catheters

Why?

1. NGT are long tubes that are inserted into your nostril and advanced until they reach your stomach.
2. Foley catheters are placed into your urethra and are advanced until they reach your bladder.

'nuff said.

'Joshua' was a champ. Submitting to the barrage of tubes and needles coming his way simultaneously, he sucked it up and "took it like a man", so to speak. I was impressed. Even our drugged and/or drunken patients have a hard time with the NGT. He was stoic.

Now stable, vital signs within normal limits, Joshua and I went to CT.

It was upon his exit from the CT Scanner that he had the first of his many "seizures".

I had been an ER Nurse for about 10 years at this point and had seen my share of seizure activity. And although this was by far the best seizure performance I had ever witnessed, my "Bullshit Detector" alarmed yet again.


I shared my skeptism with the ER doc.

He shrugged.

Little known fact: Many nurses beat themselves up for thinking bad thoughts about people. I was no different. The poor guy was traumatized physically and emotionally. Here I was thinking it was all B.S. What kind a a nurse was I anyway? Had I become jaded? One of those crusty, old, acerbic ER nurses who could care less about you or the horse you rode in on?

All of Joshua's lab and radiology reports came back within normal limits. He was being kept in the hospital for further observation as his level of consciousness was deteriorating. At the change of shift I began reporting off to the oncoming night shift nurse..."This is Joshua X, patient of Dr. Y's, chief complaint; fall injury...." she interrupted me. "That's not Joshua X, that's Tony B. - I took care of him last month after he fell off of an escalator."; "He's faking".  Suddenly, upon hearing our report, and as if by divine intervention, 'Tony', my 'semi-conscious' trauma patient sat up, pulled out his NGT and demanded to be discharged.

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"Features associated with this disorder, as described by Sussman and Hyler include pathological
lying, extensive knowledge of medical terminology and hospital routines, demanding and disruptive behavior, substance abuse, shifting complaints and symptoms, equanimity regarding invasive procedures and operations, wandering, discharge against medical advice, deception regarding identity, evidence of prior treatment, and intermittent time in jail or psychiatric hospitals." 2.

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A few months later our ER doc recieved a call from another hospital's ER asking if we knew a "Tony B." Apparently, he had been 'found down' after reportedly falling down a staircase at the mall. He was unsconscious but had a card in his wallet from our ER...

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"Although the precise motivation for Munchausen's syndrome is unknown, several explanations
have been offered, such as underlying organic problem, substance abuse, resentment of physicians,
childhood deprivation and rejection, subintentional death wishes, castration fantasies, relief of aggression and guilt through operations, and seeing the physician as a father figure. It is currently
believed that different motives operate in different patients and even in the same patients on
separate occasions." 3.

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Reflecting back on Joshua/Tony, I wonder where he might be today? I guess it would be a safe bet to think (unless he has had extensive psychiatric treatment), he's occupying an ER stretcher somewhere, messing with the minds of his health care team.

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References;

1. Committee on Statistics and Nomenclature. Diagnostic and Statistical Manual of Mental Disorders,  3rd   ed.American Psychiatric Association, Washington, DC, 1980.
 
2. Sussman N, Hyler SE. Factitious Disorders. In: Comprehensive Textbook of Psychiatry, 3rd ed. Kaplan H,Freedman A, Sadock B, eds. Baltimore: Williams & Wilkins,1980.
 
3. Howe, G.L. Munchausen's Syndrome or Chronic Factitious Illness: A Review and Case Presentation. Journal of The National Medical Association, Vol. 75, No. 2, 1983.  

ER 101

In 1983, a doctor that I had worked with suggested I transfer to the Emergency Room at Baylor. I had planned a lengthy tour of Europe and would be gone for a couple of months, so transferring sounded like a good idea. I secured my transfer to the E.R. before leaving for my trip.

When I reported to the E.R. for my first day of duty, I was all bright-eyed and bushy-tailed (so to speak) and didn't get why the E.R. staff weren't exactly thrilled when introduced to me by the nurse educator. I certainly didn't miss the subtle eye roll and yawn when they were told about my (non-ER) nursing experience and I was blown away by the blatant rudeness of a more experienced E.R. nurse when she snapped "get me a real nurse" after I had entered the room where a patient wasn't doing so well.

In the eighties, nursing academics began discussing how ‘nurses eat their young’, a phrase used to describe an epidemic of how many times 'seasoned' nurses would not be kind or helpful to new or young nurses but rather, teach through intimidation, fear and bullying. Believe me, those nurses were most definitely in the ER and gave me a new understanding into the naming of 'nurse sharks'. That being said, without any ER experience, the truth of the matter was that I knew I had to ‘prove’ myself and that I needed them more than they needed me. Fortunately, the practice of 'nurses eating their young' has gone by the wayside. Nurses are generally more supportive and helpful to the newbies.

I accepted the challenge of Emergency Nursing and did my best to present myself as a self confident, skilled and knowledgable nurse and made every effort to befriend even the most bloodthirsty of nurse sharks. Humor helped alot and I learned that when you swim with sharks you'd best not let them see you as bait.

The following are just a few of the new terms and phrases that I had to learn ...

ER Vocabulary

• ABC – Airway, Breathing, Circulation


• Biotel – a central communications center that is staffed with nurses, doctors and paramedics who communicate and advise with various ambulance services. They are also responsible for designating the hospital that receives the patient based upon predetermined criteria.


• Bat Phone – a red telephone in the ER that is a direct line to/from Biotel


• Blunt Trauma – hit with a baseball bat or crunched in a car wreck


• Code - normally a respiratory and/or cardiac arrest but there were many 'codes' used in the hospital. If someone "called a code" it could mean starting or ending CPR


• C-Collar – Cervical Immobilization Collar – neck brace


• DFD – Dallas Fire Department (and ambulance)
  Code 1 – lights only Code 4 – lights and sirens
  Priority 1 – easy Priority 4 – see train wreck


• ETOH – Blood Alcohol or just alcohol as in “ETOH abuser”


• FB – Foreign Body


• GCS – Glasgow Coma Scale


• Gomerade – 1 liter of Normal Saline with Multivitamin, Folic Acid and Vit B12 added – used for ETOH abusers (gomers) - Now the term is "Banana Bag" - much more politically correct.


• GSW – Gun shot wound


• LP – lumbar puncture (spinal tap)


• LOC – Level of Consciousness


• LOL/LOM – Little old lady/man


• MVA – Motor vehicle accident


• MVC – Motor vehicle collision/crash … around 1995 MVA was changed to MVC. According to the Board of Trauma Surgeons “There are no accidents. Every crash is preventable.”


• MCA/MCC – Motor Cycle Accident/Crash


• POPTA – passed out prior to arrival


• Pit – the ER


• PTA - Prior to arrival


• Penetrating Trauma – stab wound, projectile wound, gun shot wound, puncture wound etc.


• Ruptured triple A – see train wreck (ruptured abdominal aortic aneurysm)


• Ruptured ectopic – see train wreck (ruptured pregnancy gestating in a fallopian tube)


• SW – Stab Wound


• Thumper - A mechanism used to deliver chest compressions to a patient in cardiac arrest


• Train wreck – any really bad trauma or pt in really bad condition.


• Tox Screen – Blood or urine specimen to determine presence of opiates, amphetamines, cannabis etc.  

Knife & Gun Club - Part 1

Snakebite

It was in the early 90's and I was an ER nurse at Sunnybrook Health Sciences Center in Toronto, Canada.

Sitting at Triage early one Sunday morning, my mind dulled by inadequate sleep the night before, I was interrupted by a young man of the ‘skin-head persuasion’ who was in a panic. “Ya gotta help me!” he shouted. “I've been bitten by a Black Naja Cobra" He showed me his very swollen finger. A red bandana was tightly wrapped around his wrist as a tourniquet. I didn’t know a lot about snake bites back then and had no idea of what a "Black Naja Cobra" was, but I did know that if the bitten area has a gross local reaction, and the snake was called a "cobra" - you've got yourself a big problem.

As I was taking him back into the ER, I learned that ‘Randy’ raised “Black Naja Cobras” as pets and he was "helping" one of them to "him shed his skin" when he was bitten. He didn't happen to have any anti-venom as he procured these snakes illegally from Africa and the seller did not supply him with any. “You know how it is”, he said. I didn’t. I'm no snake expert but I would think snake-lovers everywhere should have some basic rules like Rule #1 - Do not help a venomous snake shed its skin - they 've being doing it for centuries alone. Rule #2 - If you own venomous snakes, and if you must help them shed their skin - have anti-venom available.

Supportive treatment was initiated including oxygen and IV Fluids. When I got the ER doc’s attention, orders for tons of blood work spewed - chemistry, hematology, clotting panels, bleeding studies and ABG’s. Black Naja Cobra…was its venom neurotoxic, hemotoxic, cardiotoxic or what?

At the time, our doctor could choose from text, microfiche or expert resources. He called The Metropolitan Toronto Zoo and knowing that the chances were slim anybody who knew anything about anything would be at the zoo on a Sunday morning, he explained the situation then asked the zoo operator to get a hold of the person in charge of exotic snakes. Within a few minutes, the 'snake person' called back and following a brief conversation, the appropriate anti-venom was secured and The Metro Toronto Police were alerted to deliver it to us.

I got pulled from Triage.

Randy’s blood work had come back and we found out that his pet's venom had a profound anticoagulant effect. His clotting mechanisms were failing rapidly.

When the anti-venom arrived, the ER doc turned to me and casually said, “OK, Joan, go for it." Trying to disguise the 'edge' in my response to that ridiculous statement, I said"How?"

Clueless on how to administer this stuff, we found the directions in the box.

Anti-venom or ‘anti-venin’, (as it was labeled on the packaging) was to be administered via IV drip and based on kilograms of body weight. The anti-venom was derived from various species of cobra. I clearly remember myself and another nurse having to draw up at least ten vials or so and mix them in 500 ml of NS. A skin test was to be performed first in order to check for a possible allergic reaction. “And if he's allergic...then what?’ I asked. The doc ordered steroids and benadryl and told me to skip the skin test as we would have to wait an additional twenty minutes for results to be read accurately. I began the drip. The anti-venom would infuse over thirty minutes and then repeat blood work would be collected.

The response to the anti-venom was truly remarkable. By the time the infusion was completed, Randy’s post anti-venom blood work had improved significantly and within a few hours, it had returned to normal limits. Unfortunately, his finger had become blackened and necrotic. I learned later that week that Randy had lost his hand secondary to gangrene. Plastic surgeons said that the tourniquet he had applied to his arm might possibly have slowed the transport of the venom but that it caused pooling of it in his arm and worsened the tissue damage.

That same day, as I was wheeling him out of the ER, Randy was repositioning himself on stretcher and that’s when I saw the back of his head. Although at first glance, his head appeared clean-shaven, it wasn’t until he sat up that I noticed the hair on the back of his head was shaped in the form of a cobra’s head.

Nice.

Coming to America 1

The Welcoming Committee:
I had completed the college requirements to be a Registered Nurse in Toronto Canada, and was looking forward to my first nursing position.

Unfortunately a hiring freeze was in effect for area hospitals and my graduating class was facing a bleak job market. I was nineteen and one of the youngest graduates in my class. A poor college student, I was ready to start making some cold, hard cash.

The light at the end of the tunnel appeared when a group of nurse recruiters from Fort Smith, Arkansas arrived at our nursing school. They regaled our graduating class with facts, figures and a slide presentation that showed nurses water skiing, disco dancing and sunbathing.

We were hooked.

The ‘sunbathing’ part was the biggest draw as we Canadian nurses typically spent six months of the year in snow and another three months in rain.

Twenty-six of us signed up to work at Sparks Regional Medical Center on the spot. We had no idea where Fort Smith was - but it was in “the states” and the weather had to be a whole lot better.

Our flight to Fort Smith was in August and included three airplane changes. I suppose that should have clued me into what could lay ahead of us but my nineteen-year-old “city-fied’ brain only had visions of handsome men in three piece suits, Wall Street, palm trees. Rodeo Drive and cocktails in fancy glasses.

As the plane was preparing to land in Fort Smith, we were looking out the window of our aircraft and could see nothing but trees. "What did we get ourselves into?” Stepping out of the airplane, the blanket of heat was like no other I’ve ever experienced.

We had never stepped onto a “tarmac” before and (for some unknown reason) really got a kick out of it.

Hospital representatives from Nursing, Dietary, Housekeeping, etc. were waiting for us and standing in a receiving line began introducing themselves. Soon, we were traveling with them to our new apartment complex, “The El Conquistador”.

As we approached "El Con" - we couldn't help but notice the numbers of people lining the driveway with lawn chairs and beer coolers, ‘horseshoe’ games in full tilt. Apparently, they had been waiting for our arrival. They were all men and we were the attraction. Word had gotten out that twenty-six single Canadian nurses were arriving and it looked as though every single guy within a fifty-mile radius was there to check us out.  Part 2: The Welcoming Committee

Coming to America 2

It Could Be Worse...
The Welcoming Committee couldn’t have been nicer. Several of the guys came by our apartments with handwritten “business cards” detailing their names, addresses and phone numbers accompanied with offers to show us around town. The hospital had provided us with sheets and towels, a fruit basket and disposable cutlery and dishware. We were set.

None of us had cars so we became regulars with ‘The Razorback Cab Company’. A “Razorback” is the University of Arkansas’ mascot – a really big mean-looking red pig and oh my God, It gets worse. The pig was so popular that everyone (except for us) knew what ‘calling the hogs’ meant and ‘Pig-Calling Contests’ were fairly popular. ‘Calling the Hogs’ wasn’t very pretty but after a few drinks, it was easy. Ahem.

According to a University of Arkansas Website...."Although historians aren’t exactly sure of the exact date, a group of Arkansas football fans at some point during the 1920s are believed to have been the first to “call the Hogs” during a game. Spontaneous “hog calls” have been known to break out in airports, malls, restaurants and hotels all across the country. The words to the Hog call are simple: 'Woooooooooo, Pig! Sooie! “Woooooooooo, Pig! Sooie! “Woooooooooo, Pig! Sooie! Razorbacks!' Correctly calling the Hogs takes some practice. It starts with [a little alcohol and] both hands raised high into the air, fingers waving as the volume increases during the word Woooooooooo. The arms pump down on the word Pig and then back into the air on the word Sooie."
Speaking of drinking, I ran into a little snag when I first tried to gain entry into one of Fort Smith’s discos. For starters, it was law that you had to be a ‘member’ of any place that offered mixed drinks. For some reason, “Redneck Bars” were exempt. I guess it was because they only served beer. Secondly, the legal drinking age in Arkansas was twenty-one. I, being a Registered Nurse, responsible for the care of cardiac patients and licensed to administer narcotics had to provide fake I.D. to gain admission.

On our days off from work, we would hang out at the pool and/or go to ‘Central Mall” during the day, go disco dancing at night and drink ‘Wild Turkey’and coke. We were assimilating nicely to Fort Smith and soon started to make friends with native Arkansans. It was then that we learned of a few ‘peculiarities?’ I guess ‘squirrel-hunting’ was not peculiar to the natives but when you are raised in the city by a moose hunting Newfoundlander, I would think that those cute little squirrels would be completely obliterated with one rifle shot. When I asked a ‘squirrel-hunter’… “What is left of them after you shoot them?” He answered “Enough to make ‘Squirrel Chili”. Call me prissy but I have yet to eat a squirrel.

Considering the fact that we all spoke English, I noticed several differences. The expressions “Huh-uh and Uh-huh” were two very different things altogether. “Huh-uh means “No” and “Uh-huh” means “Yes” or if elongated “Uh-huhhhhh” means “You’re welcome”. ‘Fixin’ meant ‘preparing’, ‘coke’ was any kind of soft drink, as in…“I’m fixin’ to get me a Coke”. That same person would return with 7-Up. Despite our differences though, the people of Fort Smith will always hold a special place in my heart as they were so warm and welcoming to us, eh?  Part 3: Hang Around Fort Smith Awhile

Coming to America 4

Moving On...Snuff, chewing tobacco, rifle practice, horseshoes, squirrel killings, pick up trucks, “Wild turkey”, razorbacks and rednecks. A little over a year had passed since I arrived in Fort Smith. I had bought and learned to drive a car, ignorantly chewed ‘a plug’ of Redman” chewing tobacco (and promptly vomited), was getting pretty good at tossing Horseshoes and shot a rifle at some tin cans . It was about all I could take. I was not cut out for this. Several of my nursing class graduates had returned to Canada, one married an American and some traveled to other cities in the U.S. When my roommate announced she would be returning to Canada, I decided to move on.

The thought of returning to The Great White North didn’t interest me at all. I had become accustomed to sunshine and didn’t want to leave it behind so, I hopped in my Chevette and headed for Southwestern Bell Telephone Company (SWB). I presumed that SWB would have telephone books for most major U.S. cities (as this was way pre-internet). My research began and ended with The Yellow Pages for Dallas, Houston and New Orleans. I scribbled down the phone numbers of only those hospitals that displayed the largest ads.

The first hospital that returned my call was Baylor University Medical Center in Dallas, Texas. Baylor arranged for an interview, took care of my air and ground transportation to Dallas and provided a room for me at the Baylor Nursing School Residence. Following my interview, I was introduced to another Canadian nurse, who had been working at Baylor for a couple of years. She invited me out to dinner and brought me to the happening place at the time – TGI Fridays on Greenville Avenue. It was everything I had dreamed of … handsome guys in three-piece suits and cocktails in fancy glasses... Who could ask for more?  Part 5: A Friend in Dallas

Coming to America 7

Banking, American Style
Payday. I thought it would never get here. I didn’t have a bank account yet so I asked around and a couple of the new Filipino nurses told me that a banker had just given them a class on "American Banking". His bank was within walking distance of Baylor (a definite bonus) so they gave me his card.

That afternoon, I told my 'ride' not to wait for me as I planned on walking to the bank, opening an account and cashing my check. I would take a cab back home. When I made it to the bank, I couldn't find an entrance door for the life of me. Well crap, it was a 'drive-thru' bank. So, with my head held high and shoulders back, I walked up to a car bay and pressed the red 'call' button. "I would like to open an account" I said. The teller (who had to be stifling a laugh) said "I'm sorry ma'am, but this bank is a drive-thru only. If you would like to open an account, you will need to visit our bank office." There were two cars now, lining up behind me. I pretended not to notice. "Where might that be?" I asked. Trying my best not to sound sarcastic. "Just turn left on Hall then make a left on Elm. It's about 3/4 miles up on Elm" she said. - Easy for her to say, she was not the one walking alone in downtown Dallas.

That weekend, with cash in my handbag and a smile in my heart, I began my search for wheels. The used car section of The Dallas Morning News had pages of car ads and many dealerships were offering “No Money Down!” Perfect! I had no money to put down on a car anyway so, I’m thinking that this type of deal will work well for me. After calling several of the “No Money Down” dealerships, I soon learned that the “No Money Down” deals were for people who had an established credit history in Texas. My bubble burst. Was it a sign? Should I just pack up and go back to Canada?

On Monday, I contacted the banker whose card I had recieved earlier - 'Mr. Lou Bittner, Vice President, The Texas Bank'. I made an appointment to see him that afternoon "about a loan". The way I looked at it, if he was kind enough to help Filipino nurses learn the American banking system, maybe he would have a soft spot in his heart for a Canadian.

Mr. Bittner was a well-groomed, older man who looked very much the part of ‘the banker’. He invited me into his office and seemed genuinely interested in what I had to say. I took a deep breath and began my semi-rehearsed pitch… “Mr. Bittner, I am twenty years old, I am not an American citizen, I have no collateral and I have only been a nurse at Baylor for three weeks but I am trustworthy and could provide you with personal and professional references from Canada and Arkansas, I don't know anyone here. Anyway, I would like to apply for an unsecured loan to buy a car.” I had remembered being told by my dad that a loan without collateral was called an 'unsecured loan' and I thought that using 'banker-speak' would make me sound like I knew what I was talking about.

Mr. Bittner paused for a few seconds then looked at me intensely and said slowly, “I’ll tell you what... I will loan you $3,000.00. But first, you have to come up with $1000.00 on your own. When you do that, call me and you'll have your loan. Your car cannot amount to more than $4,000.00 including tax and title.”

We had ourselves a deal!   Part 8: Wheels!