Sunday, August 31, 2008


Imagine being a recently married young woman and coming home from a night shift at a fast food restaurant to find your husband sitting in bed covered in poo and not able to remember anything or answer any questions.

 Yeah, I'd be a little concerned, too.

Such was the patient that I had last week. And a strange presentation it was, too. He could remember his wife's name and his birthday, but he would get easily confused and answer questions inappropriately. Grips were equal, no nuchal rigidity was noted, and I couldn't elicit a positive Kernig's sign (although later I realised that I don't think I did it properly), pupils reacted as expected, sensation was intact (in fact as we were cleaning the poo off his feet, he was complaining about it tickling). He was oriented to place - kind of (he could state that he was in an ER, but not the city or country. He could say his full name, but with a question in his voice each time. He had no concept of time. But then there were the signs that maybe he was faking it (although it would take a really devoted faker to lay in poo), such as the times when he would seem totally lucid, like when I would explain what was going to happen next. His medical history was unremarkable except that he had been complaining of bad headaches over the past 10 or so days. The wife said that she hadn't brought him in because they didn't want to pay for an ER visit and she thought it was "one of those things that you just sleep off."

After the requisite Head CT and chest xray and EKG and labs, the doc got set up to do a lumbar puncture, but got nowhere with it, because he would alternately be cooperative and oriented and then confused and combative. Ultimately he was sent down to radiology for a fluoro guided LP.

The doc and I had a little debate about what it could be because the presentation didn't fit any diagnosis very well. The vice-grip headaches for days preceding his arrival seemed to point to meningitis, but with no fever, photophobia or nuchal rigidity, we were skeptical. The AMS in an otherwise healthy young man indicated possible head bleed or tumor, but there were no hematological changes and his CT came back clear. His tox screen was negative and according to the wife he didn't drink or do drugs anyway. He denied any pain the entire time he was with us. It was unlikely to be a drug reaction or serotonin syndrome as he took no home medicaions. And finally, he had no known psychiatric history.

So we waited.

I took advantage of some time to get away from the room to go answer the urgent call of my 19 year old nausea patient who was kind enough to put away her cell phone and Doritos long enough to tell me that she wanted to go home because she'd been here forever (3 hours) and I hadn't even been in her room to see her in the past hour. I resisted the urge to go medieval on her heinie and lecture her about the 75 year old AMS (turned out to be from low blood-sugar) I had next door and the young man I've been talking about, both of which rank significantly higher on my list of priorities than a 19 year old princess with an attitude who has demonstrated no actual sign of disease, and who would eventually be discharged with a diagnosis from the doctor of "there's a bug going around." But at least she took up a room and kept me from getting anything more demanding while I tried to sort my real patients' problems out.

Finally, we got word from the lab on the CSF studies: Meningitis... not bacterial or viral; but fungal. Yeah, fungal. I've looked around a little since, and found some information on it, but I have to say that neither I nor any of the other nurses I was working with had ever even heard of meningitis caused by a fungus.

I took time the next day to go up to his room and see how he was doing, expecting to see him looking and feeling better. I have to say I was quite disappointed to find essentially the same person that I had last seen 24 hours earlier. For his wife's sake I tried not to let my surprise show, but it was there nonetheless. Fungii can be hard to treat. For his sake, I hope they didn't wait too long to come in.

Tuesday, August 26, 2008

Disappointed Excitement

Excitement because I found out from my neurologist today that I don't need to worry about all the scary things that she was testing me for.

Disappointment because I still have all the symptoms, but with no explanation.

So on to the next steps: EEG and referral to Neuropsychiatrist (that sounds scary!).

Bed Sports

So I had a really nice couple today and the wife was a little anxious, so she got a small dose of Ativan that seemed to do the trick fairly well (c'mon, when does Ativan not do the trick?).

As the husband walked her out to the car, he said, "it is time to go do some horizontal sports in bed."

I think he was genuinely surprised at all the gaping-mouthed expressions around the nurses' station.

"I meant snoring!"


* What Would Sigmund Freud Think?

Friday, August 22, 2008

Change of Shift

I'm a day late, but the Change of Shift is up over at Kim's place. For anybody who reads my blog and doesn't already read hers (there might be one of you out there...), go check it out, yo.

Click picture above for link.

Experiment Results

Well, thank you to all those who participated in my experiment from a few days ago. The results are nothing short of amazing.

I saw a rise in actual visitors to the page that was truly stunning to behold.

On the first day after my request to have people visit the site, I had 2 more people than the previous day.

Stunning, I know.

On the second day, I had 5 less.


But seriously, thanks to all those who commented. I appreciate the nice comments and it is good to know that I have regular readers hanging on my every word. I'll try to do you justice.


Tuesday, August 19, 2008

Help Me With a Little Experiment the number of visitors to my site skyrocketed after I hosted the Change of Shift a couple months ago (thanks Kim!), then it made a slow and steady decline to a point that it has held steady for nearly a month now. I thought it was because I don't always put deodorant on before I blog, but then I realized that while the number of visitors to my blog has declined, the number of people subscribing to my blog in Google Reader (and, I would assume, other feed readers that I don't know how to measure) has gone steadily up.

There are now 50 people who read my blog on Google Reader and many others who use other services, and since I have my blog set to publish the entire text - even when it is long and rambling like this one is starting to be - there is no incentive for you to actually click the link and go visit my actual webpage. I'm not about to change that, because the great thing about a feed reader is that - gasp - you can actually read the feed and not just get teased by a few lines that you then have to click a link to go read the rest. About the only blog that I let get away with such attrocities and still maintain my regular patronage (was that a sentence?) is Crass Polination (please note that there is onlly 1 l in polination, because everybody knows that you shouldn't add a second l. That would just be sily, and would probablly keep you from getting publlished on the littlle side bar of your favorite nurse who is llike totally your homey but who judges you based on simplle speling mistakes. No, I'm not bitter. Why do you ask?)

Anyway, if you skipped all that to find out what my experiment is, then you are probably an ER Nurse who has learned to ignore most of what a patient says until they finally get to the point. Congratulations. Here it is:


Those of you who read my blog in a feed reader, please click on this post to actually bring the blog up in your browser today. It will just take a second and think about how much you are benefitting humanity by doing so. If you want to be even cooler, leave a comment.


Your Humblle Correspondent and all-around good speler

Sunday, August 17, 2008


Overheard after a frustrated nurse couldn't understand an Ativan-induced mumble:

"Does anybody speak Ativan?"

Best Compliment of the Day

While SVN was in progress and Solu-Medrol was being pushed in the IV line, the doc comes in and listens to the patient's lungs:

"Well, you sound better, but you still sound crappy."

Can You Connect the Dots?

What do the following have in common (no, they are not new diseases that I have recently come down with):

Periorbital blowout fracture
Blunt abdominal trauma with early symptoms of shock
Spontaneous pneumothorax
Intractable nausea and vomiting
Peritonsilar Abscess
Severe lower back pain with abdominal distension

Stay tuned

Friday, August 15, 2008

Whatever you do, be careful!

I got this in my inbox this morning:
Dear Braden

We are pleased to inform you that your new @#$$%!@# order Has been carefully packaged and shipped via USPS.

I'm so glad to know that it was carefully packaged and not just randomly thrown in a box. I'll let you know just how carefully it arrives.

It is also quite reassuring to know that the people who will be carefully packaging my shipment have also carefully left the word "Has" capitalized and very carefully left two spaces between "shipped" and "via".

Thursday, August 14, 2008

Thank You For Your Urine among the gaggle of tests ordered by my neurologist was a 24 hour urine collection to look for heavy metals ("We're sorry, Braden but it appears you have Panteritis with a slightly elevated Megadeathicus level").

Anyway, I got the urine collection container from the lab and she brought it out in a plastic bag that said "Thank You Thank You Thank You Thank You Thank You Thank You" on it. Seriously. 6 Thank You's down the side of the bag and then below that in small letters "for your patronage".

Umm... You're Welcome?

The Name of That Disease!

I posted a couple days ago about what could be the presenting complaint and ultimate diagnosis for the person receiving 7 kajillion tests, and it seems like people tended to coalesce around fibromyalgia or ETOH.

The initial presenting complaint was fatigue worsening over a period of a couple years and ultimately getting to the point of disrupting daily life. Also worsening over the past several months was difficulty focusing and worsening short-term memory. Incidental to that was paresthesias in both feet - worse at night.

I suppose it is a little misleading to have this on an ER blog, as the patient was never seen in an ER for these symptoms, but it's my blog and I can do what I want.

The patient presented to his PCP (with great encouragement from his wife) for the fatigue to see if there was anything beyond depression to explain what was going on. He had tried provigil a year or so before with great benefit but had long since run out. The doctor ordered a smattering of blood tests (TSH, CBC, CMP, B12, etc) and gave a couple samples of provigil. The Provigil helped a lot, but not as earth-shatteringly-lot as before. A week later, he got a letter saying that the B12 level was low - 212, and a follow up appt should be made. In the follow-up, the doctor re-ordered the B12 along with a couple of specific markers and a Folate, and prescribed weekly B12 injections. The new labs came back even worse than the originals - 189 - but the Folate and homocysteine/methymalonic acid were normal.

Enter referral number one to Hematology (one month later because that is the soonest to get in). At this point the fatigue has taken a back burner to the neuropathy because, though the fatigue persists, the neuropathy is becoming worse quickly. The Hematologist seems somewhat unconcerned about the B12 levels and thinks it is an incidental finding. He orders a repeat B12 to see how the shots are working, along with Anti-parietal cell antibody markers and anti-intrinsic factor markers, and refers the patient to the neurologist. week later, the patient is sitting in yet another new exam room when in walks the Neurologist with a big shotgun and KABLAM! fires away with every test known to man along with referrals to rheumatology and gastroenterology (which were politely refused).

So now here I am, a generally very healthy 28 year old, having my blood drawn regularly, seeing more Doctors in two months than in the past 2 years, and stuck on a regular diet of pills every day (okay not that many: Vitamin B12 tablets (grape flavored!!), Provigil (1/2 tab usually only on days I work evening or night shifts), Gabapentin (just at night to see if it helps with the neuropathy), and mouthfuls of ibuprofen and tylenol (the ER is killing my feet and back!!!)).

Now I tell you what tests have been ordered and you all jump to fibromyalgia. I just have one word for that: itbetternotbeflippingfibromyalgiamymotherinlawhasfibromyalgiaanditreallyreallysucks.

And somehow I think that ETOH problems are fairly low on the list of likely answers.

So what are the answers? It may end up being as simple as some depression causing the fatigue (although it really is very severe fatigue and the memory lapses and difficulty concentrating or staying focused is quite disconcerting. That, and while I find myself with low energy and difficulty finding impetus energy, I'm not actually sad or... you know... depressed) and maybe just muscle strain causing the neuropathy. But it could also be a bunch of other things, and looking at where that shotgun was aimed, it seems like the doctors are thinking of:

* Pernicious Anemia (though the neuropathy keeps getting worse even though my B12 levels are now back to normal)
* Diabetes (c'mon pregant peeps! That glucose tolerance test isn't anywhere near as bad as it gets made out to be)
* Mercury Poisoning
* Multiple Sclerosis (hence the MRIs)
* Systemic Lupus Erythematosis (I know almost nothing about this disease and I'm scared to learn about it)
* Rheumatoid Arthritis (Really? I'm 28. I thought it was just the LOL's who got that)
* Syphilis (what? You've gotta be kidding me. If it is syphilis, my wife has some splainin' to do)

One thing I'm fairly confident that it is NOT: A very drunk old man passed out and fell off a bar stool. And yes, Sean, you are a comment hog - but as an old cowboy once told me: "You're welcome at my campfire anytime."

Interesting aside (because, frankly, if you have read this far, you are so invested in this post that I can pretty much say whatever I want now): both the anti-parietal and anti-intrinsic factor tests came back negative, meaning that my body should have no problem absorbing B12, and since I am not a vegan and I drink plenty of milk and my total lifetime alcohol consumption equals a couple of chocolates while I was living in France, that leaves us pretty much no idea why my B12 would be low.

Another interesting aside (why not, right?): Vitamin B12 in pill form is usually cyanocobalamin. Without a doubt this ranks among the coolest names for a medication, and it is much more fun to write cyanocobalamin on a history form at the doctor's office than boring old b-twelve.

Saturday, August 9, 2008

I'm Excited! at 7:30, I folded up my tent and sleeping bag and moved out of the ER for a few days.

In the 26 days since my wife left, I've worked 215 hours. That is an average of over 8 hours a day even including the days that I had off (of which I never had more than one in a row) and an average of almost 11 hours a day on the 20 days that I did work.

My back is killing me and my feet have officially fallen off.

I'm ready for a break.

But even more, I'm ready to have my wife and daughter back from their family reunion, and that is exactly what I'm about to do. It is amazing how energized I am given that I just finished my third 12 in a row.

You would be, too, if your family was as awesome as mine.

Friday, August 8, 2008

I Need to Say Goodbye to My Family

He handled an incredibly difficult tanking patient admirably well, but Dr. CF made one big mistake.

When your patient tells you that he is about to die, you don't tell him that he isn't.


Security! Please Escort God Off the Premisis

I heard a lot of yelling down the hall and so I walked over to the nursing station and looked over to the other side of the ER and I see a patient backing up, yelling at whoever is threatening him:

Patient: "Don't you know that I'm God?!?!?" I see our recently-returned-from-Iraq no-nonsense tough-guy PA marching straight at him with shoulders set and an angry look on his face:

PA toughguy: "Yeah, well you are about to meet Satan!"

Later while in the break room I was talking to him about it, and he said, "I was really hoping he would lay a hand on me so I could beat the hell out of him."

My response: "He's God. You can't beat the hell out of him, but maybe you could have beat the heaven out of him..."

and such is life in the ER.

Tuesday, August 5, 2008

Crass-Polination Blog Take 2

Well I tried once to get included on Nurse K's sidebar, so maybe i was just a little too subtle. Let's try again:

Nurse K Freaking Rocks!
Nurse K is the only blogger I know who successfully uses the word "purveyor" in an "about me" sidebar. How much more coolness could you possibly want?

Public Service Announcement

Despite it's rather benign appearance on the outside, if you happen to pass a building that has big letters on the outside that say "Castle" and underneath, "Knights and Damsels Welcome", you should know that despite your wife's protests to the contrary, it is not, in fact, a dinner theatre, and is also not necessarily an appropriate place for your 14 month old Damsel.

This has been a public service announcement.

PS - Don't click that link above.

Too Little, Too Late

She was in for vaginal bleeding and cramping. She was 8 or 9 weeks pregnant. She had been to the doctor at her Tribal Clinic the day before and been told that there was a "threatening miscarriage".

When I asked if she took any medications, she said, "yes, I started taking prenatal vitamins yesterday."

I truly am very sorry about your loss, young lady, and maybe there was nothing you could have done anyway, but seeking care and starting prenatal vitamins 8 weeks in is far too little, far too late.

Monday, August 4, 2008

And I Never Want To See You Again!

On a comment about pens, Prisca said:

"On my floor, stealing a pen from someone can end a friendship!"

This may be true of the ER as well. In addition, there are several other things that I've found can end a friendship:

* Taking somebody's WOW - even if they haven't used it for the past several hours.
* "Oops, was that your food that we just threw away? It wasn't labelled."
* "You are in triage... again."
* Putting a patient in somebody's room and then forgetting to tell them.
* Helping out by stopping an IV drip, taking a pt to the bathroom, emptying a commode, etc and then not charting it.

Any other ideas?

Sunday, August 3, 2008

Cruel Joke Revisited was just thinking: as long as we are having our ventilators play video game theme songs, why not just have downloadable ring tones?

The family members can choose from a list of thier favorite songs and assign them to the different alarms, so perhaps you could see some of the following options:

* If the tube is disconnected, we could get the theme from "Gone With the Wind"
* If the vent does not sense enough return of air, it could play "Waiting to Exhale"
* If the battery is running low, we could get Bryan Adams' "Can't Stop This Thing We Started"
* If the patient falls in too deep of a sleep, we could get Garth singing "The Thunder Rolls"
* Maybe if the ventilator senses several problems at once, we might hear "I'm Every Woman"

Any other ideas?

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Saturday, August 2, 2008

What's In Your Pocket?

Every nurse has their essential supplies. These are the items that are so important to you that you have to always have them with you as you do your job. It is interesting for me to see what some people have (do you really always need to have an 18g IV needle handy? What good is it if you don't also have a start kit and an extension?) and what some people don't have (stop asking if someone has an alcohol pad and start carrying a few around with you!).

That said, here is what I carry with me in the ER:

4-5 saline flushes
5-10 alcohol preps
Assessment forms (little 1/4 sheet of paper that I put together to remind me to cover everything as I do assessments - though I use them less now that I have started taking the WOW with me into the rooms and doing my assessment straight on the computer)
Pocket PC (currently I have PEPID installed because my Davis is 3 years out of date and my Tabers is the same)
I just bought some dry-erase markers with pen clips so that I can write names on the board of who's who.
Other: Sometimes I keep a couple 2x2s or some of my coveted nitrile gloves with me (so I don't have to use the crappy ones that are in most of the rooms). I used to do the hemostat-through-a-roll-of-tape-clipped-onto-scrub-top-made-into-a-makeshift-scissor-holder thing, but that just got in the way too much.

Well, know you know what's in my pocket; so what's in your pocket?

What a Nerd!

After work today (yay! my 60 hour week is over!) I stopped by Office Depot to buy more pens because I've finally run out of them after I bought two boxes last time.

It was while trying to explain to the salesman what I was looking for that I realized what a complete nerd I am. The pen can't have a big rubbery grip because then it doesn't fit in my pocket very well. It can't have a cheap plastic end piece (the little cone-shaped part) because those always slip down and make it hard to write. It has to be a click-pen because I would lose the cap off of a stick pen in about 2 hours. It has to be medium point because thicker than that turns into mud when I'm trying to squeeze a whole narrative into the two inch wide nurse charting section on our ER records and thinner just feels wimpy. It has to be a black pen because that's what nurses chart with in our ER. It can't be a gel pen because they don't transfer through to carbon copies very well. It can't be some crazy style or color because I tend to be very understated and conservative in my style (yup: plain, boring scrubs for me). It can't feel light because I need a good solid pen to write with.

The long-suffering salesman did his best to satisfy my needs, but in the end, nothing lived up to my standards. I realized halfway through that I was being picky about a freaking pen, but that didn't stop me from being picky. It is, after all, the item that I use the most often while working, so I have room to be fussy.

All I want is what I had before. Why do all pens have to suck now?

Oh, and I took care of some sick people and made them feel better and all that stuff...

Friday, August 1, 2008

Random Thought

Why do we use the phrase "stepping up to the plate" as some kind of heroic act?

Everyone in baseball steps up to the plate, and statistically speaking, only about 25% of the time do they get on base.