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.

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?

Floating

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.

*sigh*

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.

Imagine:

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.

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.