Sunday, July 31, 2011

Coming Home

After spending over a decade away from the itsy bitsy town in which I grew up, I'm still not accustomed to the small world that it is.

I still get a fleeting thrill when I see a local license plate before I remember that I'm actually home and they're more than common.

Last night, a nurse floated to our unit and, because it was relatively quiet, we got to chatting. She had just moved from Atlanta but, like me, grew up here. Oh, we went to the same high school! 84?, I graduated in 96. Did you know ___? What's your last name? Howe?!!! You're Franny's granddaughter?! Kathy's daughter!???

It turns out her father was a close friend of my grandpa's and my mom used to babysit her. We both, in our giddy, not-used-to-small-town-relations way, laughed and shared anecdotes all night until, like a pin in our bubble, two of the other nurses related how they discovered that they were cousins in an amazing story of medical drama and common relatives.

Humphh. Small towns.

Saturday, July 30, 2011

Nighttime Events

Yesterday, because of the construction, the census on U8 was low and I was expecting to get called off. Rather, another unit needed an aide so I floated down to the JD Rehab Center, a subacute care wing of the hospital.

I arrived to find Andrea, an ICU nurse, had been borrowed too. Andrea and I have worked together many times and have become friends. We laughed together as the night began because it was a vacation; most of her patients didn't even take medications and many of mine were independent.

Ironically, I wasn't allowed to do anything but task, no charting, testing glucose or vitals because I'm not a certified nursing assistant. So my responsibilities were minimal. After the last few months of juggling both the responsibilities of an aide and unit secretary, this was refreshing. Andrea teased incessantly, tickled by my certification limitations. She thought it was a riot and would demand proof that I was qualified to carry a dinner tray or empty linen carts.

The night dragged painfully though. After what would have been a double upstairs, the clock read only 3 hours into the shift on JDR.

Then the fall occurred. Apparently, the family of Grandma Smith* had unplugged her bed alarm while they were visiting. Its shrill beep was annoying to them. After they left without resetting it, 94yr Granny Smith decided to go to the bathroom to change. We found her crying for help in a pool of blood and vomit.

Andrea and I kicked into gear like Emil Fischer's lock and key enzymes. She checked vitals and stabilized her head while I went to the desk to call a rapid response team and the ED for a lift board, cervical collar and stretcher.

The nursing staff on JDR is amazing. They're friendly, good with patients and very good at their job. They don't have many medical emergencies there though and so seemed grateful to step back to let Andrea and I take control.

The residents, newly minted PGY1 and PGY2, examined her pupils, spoke with their attending and down we went to CT. I stayed at Gran's head, pushing the stretcher with one hand and holding the emesis basin with the other. When she would get sick, I would stop the stretcher, we would slowly angle the lift board and let her vomit on her side. Her wide eyes locked with mine and she held my hand tightly. I know that she was frightened by the fall and the rapid conversations flying over her head. I wasn't really needed in the medical part of the emergency other than as a strong back so I tried to keep a constant gentle flow of words to only her to give her something to focus on. I explained everything that they were doing before they did it and her breathing slowed and deepened.

We took her to CT, then XRAY and back to her room. She settled in quickly. Andrea dressed the wound on the back of her head and I swabbed her mouth out, washed the blood and vomit off her face and shoulders and changed her gown. She even laughed at some of my lame jokes. "What did one snowman say to the other?**" Then I stepped aside and let the CNA test her blood sugar.

*not Mrs. Smith real name. Also many details have been changed to protect her, or his?, identity and the identity of my medical institution.

**answer to really lame joke: "do you smell carrots?"

Friday, July 29, 2011


After a long day, nothing relaxes me like a cup of matcha. I like to brew mine in milk -sacrilege! I know!- instead of water; it cuts through the bitterness better.

Thursday, July 28, 2011


The hospital is undergoing renovations. Last night, the construction workers were on our unit. They taped up little tents and began asbestos cleaning under the ceiling tiles. They were being cautious. They had even put up double drop doors in their tents to prevent any contamination when they entered or left.

Partway through the effort, I walked into the little kitchenette where we keep snacks/ice/drinks for the patients only to find one of the workers rinsing his vacuum canister in the sink. Dude.

He totally bypassed the closed/locked door with the sign on the front saying U8 staff only. (They have a master key to access all the rooms.) He was washing a disgusting greasy dusty cylinder in what was obviously a kitchen sink. I was horrified. I asked him what he was doing and then kicked him out of the kitchenette.

He claimed that he couldn't find another sink. I pointed to four sinks in the hallway and directed him to two different bathrooms, all closer to the work area than the kitchenette. Seriously, you couldn't have asked? *facepalm*

Wednesday, July 27, 2011

Cauliflower Quiche

I like to experiment with food. I often take random ingredients and try to combine unusual but complimentary flavors. This one was a winner.

3 eggs
1.5 cups grated cheddar cheese
.5 jalapeno pepper minced
lots of ginger
1/4 cup cream
1/4 cup water
1 package frozen cauliflower
handful of frozen spinach
handful of currants
salt/pepper to taste
bake in pie crust for 1+ hour (until firm) at 350*
garnish with currants and Italian parsley

Monday, July 25, 2011


My mother died last year and I've been trying to sell her house. It's a pain; the housing market in this area is incredibly depressed and mine is one of a dozen for sale in this neighborhood. I do what I can on a nursing assistant salary to maintain it. Spending hours weekly landscaping in the yard and tinkering in the house, I've become very handy. I've taught myself how to put up drywall, repair cupboards, fix burst pipes and paint/stain with the masters.

My neighbors are the same as when I was a child. I grew up with Krissy. We caught critters, played softball together and fantasized about pooling our money for a horse. The horse was to go in my backyard which I mistakenly convinced myself was zoned for farm animals. I think my father let me believe that, hoping that I would save money instead of spending it.

Krissy had a baby when she was a teenager and her parents, who live next door, often watch over him while she's at work. Over the years, particularly through my mom's extensive illness, Jack, Krissy's dad, has helped us tremendously. He mowed my mom's lawn, shoveled her drive, carried her groceries and brought in her mail when she was too weak to stand.

He was the very best neighbor anyone could have. Now he'll yell at me to be careful when I'm on the roof replacing shingles or painting ducts. He's always available in a pinch if I run out of gas or need an extra pair of hands.

His grandson, though, is a punk. Jerome is 12 now and the most disrespectful, destructive little brat I've ever had the misfortune to meet. We used to have a basketball hoop over our garage. I took it down after Jerome and his friends broke windows and cracked and shattered the vinyl siding along the garage wall.

I've come home to find shingles missing from the garage roof where they dive into the ground pool. The deck/pool is surrounded by lattice. I spent days painstakingly staining it only to find my efforts damaged from their rambunctious antics in the pool.

I've told Jack that I prefer the boys not come over without supervision. I've mentioned the damage but it has had no affect on curbing more wreckage.

I don't know what to do. Jack has been an amazing friend and neighbor over the years and I want to be able to extend open invitations to my parents' amenities. I just can't afford repairing all the destruction his grandson causes though. I've hinted that Jerome isn't welcome but it doesn't make any difference to his indulgent, doting grandparents.

This situation sucks. Any ideas out in blogland?

Sunday, July 24, 2011

Real Men Eat Quiche

Quiche is an awesome dish. Simple to make, easy to experiment with and impressive to serve. My burly manly-men cousins love quiche unabashedly, without exception, and will always stop by to help around the house if I have snacks handy. This quiche helped me get my refrigerator repaired in record time!
This is my twist on the classic Italian salad.

3 eggs
1.5 cups shredded cheddar
1/4 cup mozzarella (perline)
lots of fresh basil chopped
3 Roma tomatoes diced
1 jalapeno minced
1 cup milk
1 pie crust
1/2 cup whole wheat flour
salt/pepper to taste

Bake at 375* (until firm) and let sit 1/2 hour before serving. Garnish with fresh basil.

Juggling Thoughts

We have a nurse on our unit. John* is incredible with the patients and acutely intuitive about their well-being. He's saved several lives by noticing that a patient is 'off' and calling the appropriate people to take care of it.

He sucks at multitasking though. His medicines are always administered late and he can't give a decent concise report during shift change. We all, nurses and aides alike, dread following his group. There's always information missing and tons of catch-up to do before we can start our own assignments.

I recently read Dr. Ofri's Lancet contribution and thought about John and then about my own future as a physician. My experience thus far has been relatively painless. There's a certain triage that people use when they multitask. Providing orange juice for a glucose reading of 56 trumps the coffee for a visitor in room 654. Occasionally, When I'm juggling 10-15 requests, I'll sometimes overlook one.

It scares me that I may forget something vital when I'm a physician. Will I remember to order a CBC on a patient with a GI bleed? How can I be smart enough to manage the care of so many patients when I can forget to bring someone a ginger ale?

Dr. Ofri's editorial has relived my mind (somewhat) in that I won't be the only doctor with these fears.

Poached Salmon and Bean salad

Last night, I made poached salmon with a garlic caper butter and a three bean salad.

Three Bean Salad:
l can black beans
l can red kidney beans
1 can white kidney beans
1 can corn
5 cloves garlic
1 bunch cilantro
3 plum tomatoes
2 large cucumbers
3 fresh limes squeezed
1 sweet onion
1 green pepper
2 jalapenos minced

Fragile Flower Syndrome

My grandmother has what she has denominated 'FFS'. It's a delicate balance to treat her hypertension, hyponatremia and Meniere's disease (for which she takes hydrochlorothiazide, a diuretic) and she'll often call me over to check her blood pressure.

The heat wave has hit her hard but she giggled today when I told her as I wrapped her arm with the cuff that she looked like a wilted daisy with her white hair and dark eyes.

Saturday, July 23, 2011


I have a cousin who is addicted to crack. Our family has struggled to understand how he could have made the choices that forced his life into a downward spiral. We discuss what approaches to take, limitations to set, anything to help Beck come back. But he doesn't want to. He lies, manipulates and steals, neglecting his children and watching his debt grow.

It's heartbreaking to see my aunt weep, grieving at the loss of her son and fearing for the welfare of her grandchildren. Their mother died of an overdose two years ago and Beck has sole custody. Though his house could be featured on an episode of Hoarders and his electricity and water are periodically shut off, he doesn't fall below the threshold of what is unacceptable to Social Services and so his children remain with him.

I see his jittery hyperactivity and the tracks on his arms when he comes to ask me for money; his electricity, water, phone etc are about to be shut off. I see the boy I played with as a child, catching snakes and salamanders, climbing trees and building forts.

My patient tonight, a woman with liver failure, is febrile and having seizures from alcohol withdrawal. Sedated, she didn't move when I took her vitals and washed her up. I was tender, reverent when I rolled her to her side to clean stool from her bottom and salve with protective ointment. Though she was alone, I could see the child that she was and the people who love her despite the abuse she gave to her own body. I hoped that my cousin would be treated gently when he crashes and is brought to a hospital unit like mine.

I swam tonight, alone in a crook of the river. I could feel the water against my body and the freedom of my limbs. I flew, buoyed by the water, unhindered by gravity. I love my body. It is the only house that the essence of me will have. I am amazed sometimes when I look at my arm, think about its function and then raise it purposefully, only to demonstrate to myself that my mind has control of it. I'm telekinetic with my own body. It does what my mind tells it to.

I could wax poetic, citing Descartes and his mind-body dichotomy, but I'm a Spinoza girl. I see the physical connection, calcium released and synapses firing, between my thoughts and the movement of my arm. It works beautifully and I don't want to mess it up.

I'll have a glass of wine with dinner and a scotch on special occasions. I love the taste, the dimension, the artistry that can be found with alcoholic beverages. I've even been happily intoxicated on occasion.

There's a turning point, a threshold that people pass when they immerse themselves completely into habits that destroy the function of their body.

I wash bodies for a living. Every day, I help someone to eat, walk, communicate or clean themselves. I hold reverence for their bodies and the function those bodies have in housing the special being that makes the individual. I'm gentle even when the patient is not. It's a gift to be there cushioning the body, encouraging someone to respect the majesty of their own body when they don't see it themselves.

I treat the open wounds of my patient tonight. I hope that she wakes from her sedation and recrosses that threshold into a place where she respects the gift of her body. I hope that my cousin rediscovers his own gift before he destroys it completely .

Friday, July 22, 2011

Jalapeno, Tomato and Cabbage Slaw

1 small cabbage head shredded
2 large plum tomatoes diced
1 handful of chives chopped coarsely
1 large red jalapeno chopped finely
1/4 apple cider vinegar
1/4 honey
2 cloves garlic minced
and a tiny bit of ground ginger
squeeze 1/4 fresh lime

salt and pepper to taste...
The ginger adds some dimension to an uncomplicated dish.

The Fountain

People often ask me at work why I want to go into medicine instead of nursing. I often say in partial jest that I don't like poop. The other, non-jesting half raised it's head last night.

An elderly patient was admitted with a broken hip from a local nursing home yesterday morning. Throughout the day, XRAYs were taken, EKGs performed and Ike* was medically and cardiology cleared for surgery on Monday. It was an arduous exhausting day for the poor, confused man.

As the evening progressed, Ike began to become more confused. Sundowners syndrome is a common phenomenon with some disoriented elderly people. In Ike's case, he became spatially disoriented and lost control of his bowels.

His nurse, Tina and I noticed his incontinence and gathered the supplies needed to clean him up; washcloths and towels, bedclothes, a new gown and Proshield, a skin protectant. We rolled him to his unfractured side and I began the cleaning process.

Afraid that he was going to fall, Ike began howling and let his bowels loose. It was Old Faithful. For several long moments the stool shot up into the air, splattering the sheets, the bed rail and my shoes. I quickly grabbed the clean towel and, in a futile attempt to dike the flow, placed it against his backside.

After the fountain tapered off, I gingerly took the towel away and resumed my wiping. Whoosh, the geyser erupted again spraying the front of my shirt. I snatched the bedpad and all the washcloths and again tried to dampen the flying stool.

This cycled continued for at least 20 minutes, all the while Ike was howling, Tina was trying to reassure him and I was trying to trench the lake of poop. It was awful. Tina was rubbing his back, whispering to him and avoiding my eyes. She snickered a couple of times but for the most part, stalwartly restrained her laughter. I'm sure that I was a sight; covered from shoulder to toes in poop and frantically using anything handy to stop the pool from cascading to the floor.

Later, as I wiped the streak on my cheek away in the staff room shower, I couldn't think of any of my more noble reasons for preferring medicine to nursing.

*all names and details have been changed to protect the identities of anyone who may be totally embarrassed by the occurrences that I described.

Thursday, July 21, 2011

Egg Salad

Down to the dregs of my larder, I made up this little salad.

Boiled eggs
dash of salt and pepper
lots of fresh garlic
a little chopped sweet onion
frozen spinach
and dill to taste
a tiny bit of mayo to hold it together

It came out deliciously!

Ethics of Eating

There's a patient on the unit, a friendly undemanding young woman. Except for her diabetes and the cellulitis that brought her in, she has no other major medical issues. Which is surprising because she's beddridden due to obesity. She would need to lose over a hundred pounds to reach a BMI of 100. She's too heavy for any of our bariatric lift equipment and, though she rolls well in bed, two of our nursing staff have been hurt cleaning up her incontinence.

In his very first order set, the hospitalist requested Physical Therapy and Occupational Therapy to work with her 3x daily. The amazing strong gentlemen of our PT department were able to bring her to the edge of the bed (not an easy task for anyone on an airbed!) and do some ROM exercises with weights! We were so happy and proud of *Dolores. Then...

She refused. Every time someone would try to help her to the edge of the bed for meals, encourage her to use her little hand weights or ask her to try any form of exercise, she would become angry and uncooperative. She would throw the weights onto the floor and become unresponsive.

*Dolores is not this patient's name. All details have been modified to protect identities of both the patient and the hospital staff.

It's been six weeks since she arrived at the hospital. Her infection has cleared and she's medically well. The nursing home she came from no longer has a bed and other nursing homes/rehab centers won't accept her until she demonstrates some willingness to work on regaining functionality.

Our dietary service limits the concentrated sugars and carbohydrates she's served but her mother keeps her well supplied with candies and soda pop despite our requests that she not.

Every time I work with Dolores, I'm frustrated. As an aide, I have little autonomy in my work with her. I cannot refuse or limit her HS snack without a calorie restriction order. I cannot force her to use her weights or incentive spirometry. I cannot search through her mother's tote to prevent the mars bars or cherry coke from entering the room and Dolores' digestive system.

I've always adhered to Kant's categorical imperative (the second formulation). Shadows come though, as Kierkegaard predicted, because people are freakin' LAZY. Unchecked, people don't behave rationally. Dolores' laziness has become pathological.

Do we have a responsibility as healthcare givers, to set limits and enforce regimens on those who refuse to adhere? It becomes a catch-22 when someone refuses care but is too weak/ill to go home. What do we do when they're refusing care and refusing to leave?

Do we have the right to become enforcers, trumping their free will in these situations?

Monday, July 18, 2011


I'm glad to be off my unit today. Lately, I've had a hard time tolerating the young and, well, just young, attitudes/behaviors of my co-workers. The nurses are, for the most part, friendly but they can be callous and selfish in a way that only reflects their immaturity.

With more experience, most of them will probably develop into compassionate and wonderful caregivers but for now it's frustrating. With the patients, they can be dismissive of pain and fears, only noticing that the patient is inconveniencing them with 'petty stuff'.

Their own lives oscillate between two points: either everything is wonderful or it's awful. Calling in sick because their best friend's grandma had a heart attack, their parents' cat died or there's a power outage in their neighborhood is routine. In the last month, we've only had two shifts proceed without a call-in.

Today, I'm working on a telemetry floor. The staff is older and the shift is virtually tranquil despite the higher acuity. People are doing their jobs without histrionics or (much) complaining.

I can't help but wonder if the hospitalists realize how the differences in unit culture can impact the patient experiences and subsequently the HCAHPS and Press Ganey scores. Because of the future changes in insurance reimbursement policies, it's something that could really impact their livelihood.


Saturday, July 16, 2011

Dutch Tears

The first recorded example of tempered glass (1640s), these 'Dutch Tears' awesomely illustrate some key thermodynamic and physical concepts. The self-sustaining fracture waves have been measured at 1900m/s. (That's over 5 times the speed of sound!)

Prince Rupert, Duke of Bavaria, used to give them to his courtiers as a prank.


The candles flicker off jewels, lace and silk, and metallic embroidery as dancers move. A chassé opens the crowd and there is the King's cousin, brilliant soldier, artist and scientist and immensely powerful. He gestures toward you. After smoothing the silk mantua that your father could ill-afford, you're escorted forward. Your father's investment is coming to fruition; you've been noticed by royalty! Unheard platitudes are given, you smile modestly and then, then!, The duke gives you a lovely graceful droplet of glass. Oh! A gift! The honor! But as he slips it into your palm, it explodes into fine powder. You stare in horror at the dust sprinkled over the new pink ribboned rosette on your slipper. The shine, the glitter and noise has been muted. You're shamed! You hear nothing but the whisper of your future. "An old Maid is now..look'd on as the most calamitous Creature in nature." [Richard Allestree] But alas! Your senses slowly return and you become aware of the grins and snickers of the men surrounding you. The Prince brushes dust off the lace at his wrist, grins mischievously and walks away.

Thursday, July 14, 2011

My Narrow Room

In his sonnet, Nuns Fret Not at Their Convent's Narrow Room, Wordsworth describes the paradoxical liberation of having limits. The cells of a nun, though tiny, can still admit God just as the restrictive form of the sonnet can still accommodate the greatest imagination.

Likewise, my life started out at Versailles. I was overwhelmed with the need to open every door and look through every window. I traveled, wrote, acted, explored different careers and places to live. I studied poetry, literature, history, people and science. As I grew up, I gained the freedom to close doors behind me. I meandered through the palace, enjoying beautiful views and then fastening the windows.

I find myself at the end of a long winding corridor, looking into a small room. Of all the choices, careers and life paths, I chose medicine. This narrow chamber shines with light from a beautiful window and is large enough to fit and small enough to focus all the passion, curiosity and adventure I've found in life. I'm coming home to my narrow room and this blog is a chronicle of that journey.