Monday’s Musing 7/25/22-Literary medicine

It’s not a secret that I love to read. I am an equal opportunity book devourer; westerns are a little hard to get down but I’m game. One of my very favorite genres is medical. Fiction, non-fiction, it’s all the same to me. I’ve been reading it since I first read House of God by Samuel Shem in high school. But isn’t that a busman’s holiday? No, not really. These books have situations and patients in them that I will never experience but if I learn about an avenue to treatment I can utilize it in the future. The following is a section of my favorite medical reads, fiction and non-fiction.

House of God by Samuel Shem. This book was published in 1978. I consider this book required reading for all who want to go into healthcare. It is also where many of the phrases that are still used today come from. And when I use phrases from the book, I get a blank stare in response. To name a few is O-sign, that is a patient asleep on their back, with their mouth open. Q-sign, that is a patient asleep on their back their mouth open with their tongue hanging out. Buff the chart is to make the chart pretty so that a different department will accept the patient. Neuro or Orthopedic height refers to how high the bed or operating room table is. This means that a fall from that height will be a neuro consult because of a head injury, or an orthopedic consult because of a fracture. GOMER, which I know is still used today refers to get out of my emergency room, or a patient who may be malingering. LOL and LOLNAD does not mean laugh out loud, it means little old lady, and LOLNAD means little old lady in no additional distress. The original text speak is medicine because we love our shortcuts. Entire conversations can be had in letters. And my favorite phrase from the book is that there isn’t a body cavity that can’t be reached by a 14-gauge needle and a good strong arm. This is a sexist book, written in a sexist time, but I can read past that. In fact, I am due for my annual rereading, and I will definitely be packing it for the plane ride.

Walk on Water by Michael Ruhlman. This book was published in 2003 and opened my eyes to pediatric cardiology, which was a service line I had/have no experience in. There can be devastating birth defects that were a death sentence for the infant in years past. This is a powerful book. There is a scene where the primary surgeon, the resident, and medical student, and the scrub nurse are all hunched over a teeny tiny baby when suddenly there are graham cracker crumbs in the field. That the medical student, as I recall, had been eating in the lounge prior to the case with his mask dangling from his ears and under his chin. This scene made me change my own nursing process and I now remove my mask anytime I am eating.

Intensive Care: The Story of a Nurse by Echo Heron. Upon reviewing publication dates I was surprised that this was published in 1987 as it feels quite modern. The issues that nursing staff deal with have not changed; sick, sick patients, doctors who don’t really know what they are ordering, lack of higher up support. This book could be written today. Echo Heron is a nurse in San Francisco in the early 1980s, attendant with the AIDS crisis. She writes with compassion about nursing and the patients.

This is Going to Hurt by Adam Kay. This was published in 2017 and I read it in 2018. This is about a doctor in England under their system and deals with the punishing pace that doctors must train under. I reread it before the BBC miniseries came out and it was just as stunning this past year as the first time I read it.

Complications by Atul Gawande. This was published in 2002 and is about an MD and life on the wards. He is a surgeon specializing in endocrine and general surgery. In this book he explores the limits of medicine and what a doctor can do and cannot do. This was recommended to me several times since and each time I have to say that I read it when it came out and his subsequent books as well. The Checklist Manifesto, published in 2009, is a companion book I would argue, and speaks to using a checklist, much like an airplane pilot, to drive decision making and ensuring that all important steps are taken. The World Health Organization published the pre-operative checklist in 2008, which is funny because I distinctly remember using a prototype in California as early as 2005. Both are solid reads and worth a reread.

The Immortal life of Henrietta Lacks by Rebecca Skloot. This was published in 2010 and was very splashy at the time. Henrietta Lacks had cervical cancer and the cells that were biopsied went on to drive medical innovation and much of the processes that medicine uses today. She died in 1951 and her cells live on, multiplying and being used for medical research. This is the book that made me think that research might be a good fit for me.

Nurse by Peggy Anderson. Although this was published in 1990 the stories are from the 1970s. And they tell of a different time and place, where nurses were required to give up their chairs to doctors. I got my copy before the graduated high school at the used bookstore (shout out to Paperbacks Unlimited in Santa Rosa, CA). My mom graduated in the 1970s and this book made me feel closer to her college days. And how different life is now on the wards with the quick discharge of patients, both to make room for more patients, and to decrease the cost of hospitalization. Definitely will be reread in the near future because I still have my copy.

Notes on Nursing by Florence Nightingale. The OG nursing book was published in 1859 and concerned care of the soldier during the Crimean War. Things that we do today can be traced back to this book. Cleanliness, fresh air, antiseptic practices, this book has it all. In 1847 Ignaz Semmelweiss was discovering that going from cadaver work straight to delivering a baby was probably not the best practice. I can believe that Florence Nightingale was aware of Semmelweiss and hand hygiene’s impact on survival rates or it may have been convergent evolution of ideas. It remains one of the bestselling nursing books to this day.

Seven books that still inform and impact my nursing career. Are all of these worth a reread? Absolutely. I think I will get started.

Sunday Post-it 7/24/22- Nursing mantra

The gown card reads ‘owning your personal empowerment through personal mantra’.

Because, really, the only person who can empower you is you. And if a personal mantra gets the job done, find a phrase that speaks to what nursing is to you and why should you continue on, despite setbacks and pressure to quit.

Not gonna lie. Sometimes the pressure to quit is internal. Because our brains love to lie to us, to get us to follow the easy path.

When I was running, I decided on a mantra that would keep me going. Because running is hard and is never the easy path. I decided on right foot, left foot. This signified more than just the act of running to me. It is also telling myself to keep going, despite my lungs and my legs and my brain all screaming at me to stop.

As an operating room nurse, this mantra reminds me that there will be an end. It may be the end of the case, the end of the shift, the end of the day, but there is an end. I just have to keep going in a forward manner.

Right foot, left foot.

On toward the next rest.

Right foot, left foot.

There is a famous WWI poem by Wilfred Owen “Dulce et Decorum Est’.

‘Towards our distant rest we began to trudge. Men marched asleep. Many had lost their boots, but limped on. Drunk with fatigue.’ This poem is about a troop marching in the midst of the carnage. They are battered, they are lame, they are tired but to stop means certain death.

Remind you of a certain healthcare circumstance that we are still in. I’ll wait.

These are selected lines about sleep and going toward rest.

Right foot, left foot.

And my secondary mantra that those words spawned in my head, but with almost the same meaning ‘the only way out is through’. I tell myself this when I am starting a new semester, when I am starting a forever taking case, when I am starting something I’d really rather not do. To get to the goal, the only way out is through. The case, the degree, the never ending shift; the only way out is through. By using the first mantra.

Right foot, left foot.

Mantras can be powerful reminders to keep going. To goad us to continue to work, and do something we’d really not care to. But in healthcare there is a person depending on us. We tell ourselves mantras to keep going in the face of difficulty. Because we’ve got this and the patient who is depending on us.

I have a third mantra that will be explored at another time. It doesn’t really fit into the somber theme of today’s post-it. Or rather, the somber feeling of my personal mantras 1 and 2 that I use to keep going.

And mantra number 3 is ‘Do no harm, take no shit’.

But for now, especially with school starting in 12 days, right foot, left foot.

What is your mantra?

Bright ideas, on the hook

Do you know what happens when you get a group of nurses together?

They come up with bright ideas.

Ideas about all sorts of things.

Things that need to be fixed.

And how to fix them.

Things that need to be retired.

And how to replace them.

Things that cheer other up.

And how to do them.

There is something relaxing and freeing when you get a group of nurses together and allow them time to talk while they are waiting for the speaker who is running late.

It’s like talking to my mom.

But multiplied by 20 other nurses.

Today I shared the crochet group I belong to with a group of nurses.

The Random Act of Crochet Kindness that is on Facebook. This is a British group that advocates creating little makes. This is gaining steam in part of the US. I’m doing my little part.

By makes I mean little crochet dolls, or octopi, or hearts, or butterflies, or whatever the crochet artist is feeling like making in the moment. I think that this has to potential to be a big morale booster.

The makes are then bagged up with a little poem saying they are not lost, but if it makes you smile to take it home.

And that’s it.

My grandmother taught me to crochet. I know all the stitches. I just can’t read a pattern. But I can follow along with someone on YouTube. As long as I can rewind. To that end I am doing a free crochet class at the library. Hopefully someone has some tips on how to read a pattern.

I’m just not sure what I want my first makes to be. I know that I will be dropping them off at the hospital. Because everyone in the place, staff, patient, doctors, need a reason to smile. Because the staffing crunch is real. As is the bed crunch. As is the supply crunch.

And it is exhausting.

Cookie Thursday 7/21/22- fruit cake bites

The July theme of If You Want Women to the in the 18th Century so Badly… continues.

The bake of the week is fruit cake. I will be cutting the cake into small bites to increase the yield. As always one batch serves the entire OR.

Fruitcake was actually developed in ancient Rome as a way to get dense calories and nutrition into soldiers who were at war. The first fruitcakes were made up of a blend of mashed barley, pomegranate seeds, raisins, pine nuts, and honeyed wine. This dessert, called Satura, was very shelf stable and able to be carried into battle and sustain the soldiers.

(Aside: life in the OR is a battle and the healthcare workers are soldiers in that battle. I’ve used that idea as a metaphor before and it continues. No idea how this idea keeps threading through the posts)

Women also struggled during ancient Rome for rights. You see the connection. Or do i have to draw you a picture?

Fruitcake as we know it evolved and was brought to America by the colonists before the Revolution. The recipe used today has things that an 18th century kitchen would have: eggs, sour milk or buttermilk, flour, and sugar. Fun fact, sodium bicarbonate, or baking soda, was not discovered until the late 18th century, and use of it as a leavening agent was not until around then. Bakers sometimes used ash from trees as a leavening agent. Ash is basic and when combined with the acidic sour milk produces carbon dioxide gas which is a leavener and lifts up the dough (sorry, I couldn’t resist). Dried fruit is added to the batter and the dough is baked, yielding fruitcake. Of course, sodium bicarb is sometimes taken as a treatment for sour stomach, or indigestion. Indigestions may be caused by too much gastric juices, or acid. The sodium bicarb neutralizes the overproduction of stomach acid.

Neat little circle.

As always, OR nurses have to be able to think quickly and see solutions to obstacles and problems in the cases. The recipe for fruitcake didn’t spell out specific dried fruits to use and I used what I had in the baking pantry. This fruitcake is made with dried raspberries, dried blueberries, and dried cranberries.

As Cookie Thursday is a Thing is about experimentation let’s see how this goes. Of course, what is considered traditional fruitcake is baked in November and “fed” brandy every week until Christmas. I am sure I will be disappointing some of my coworkers by denying them that.

Forever stretching myself to learn more

There is always something to learn in healthcare. Especially in the OR, and in surgical services.

There is always some new gadget, or technique, or new surgeon.

When I started the call position I was told that I would be functioning as the second PACU nurse after cases, as long as there wasn’t a to follow case. Cool, I like learning things. And I functioned in this capacity in California, and at times in my current hospital. And there needs to be 2 PACU nurses, there until the patient is either admitted or discharged home. I agreed.

One of the reasons they stared the call positions was to decrease called back times for the hourly employees. That, and people hate call. Okay, more call for me.

I can be the second PACU nurse and learn more about EPIC. And patient care, and how to care for a post-op patient. Absolutely.

While I am doing that, I am also doing education. To keep my hand in prior to school starting in TWO weeks.

I think one you get in the habit of learning, it is important to continue, not to stop.

Yes, I am that nurse.

The education has to come from subject matter experts in the field.

I have a dry erase board above my desk that has all the seminars and education things listed on it for the month. And all the cool stuff I want to learn. But more on that on Friday.

There was a request from the AORN chapter I belong to regarding leading one of the seminars.

Oh, good. Another thing to learn.

Oh, no. They’re going to be looking at me.

They want to me to give a presentation on IUSS. Or immediate use steam sterilization. And how my OR went to near zero incidence of it. I am working on collecting the data now so there can be CEUs attached.

I’ve given this presentation before. I had a poster presentation at 2021 AORN conference. This is just more formal. Okay, I can do this.

An educator I had way back when referred to skills that every nurse learns as arrows in the quiver. Or tools in the toolbox. It is important to always be adding to the arrows and the tools.

Or, in Latin, semper doctrina. And now I need that on a tee shirt.

Monday’s Musings- Defeat of Roe one month later

This has been heavy on my head as I have read article, after article, after article, and watch video after video, after video of women being denied care as they stumble over the trigger laws that states put up as law to deny abortion to women.

I have read about the denial of care for a miscarriage which is losing a fetus before 20 weeks, and denial of care for an abortion, which is losing a fetus after 20 weeks. Or there is a miscarriage in process but the heart hasn’t stopped yet and nothing can be done to relieve women of carrying a doomed pregnancy. I mean the mental dissonance alone makes your head hurt.

Women are getting ill. There are infections that are sequelae (that means consequences) to carrying a dead baby that they are denied proper medical care for because doctors and hospitals are afraid of running afoul of the laws. And they should be, especially the laws that state that a layperson can sue for even the idea that a doctor helped a woman end a pregnancy and these laypeople are incentivized to do so by the $10,000 bounty on the doctors, or the driver who took a woman who was in pain and losing a pregnancy. This was a bad idea when Texas started it in September 2021 and other states have jumped on the bandwagon. Someone is making money off of someone else’s misery.

Got it.

Women are bleeding. I heard from another nurse that their patient had a hemoglobin of 6 and she was bleeding heavily and passing clots. And they were still denied treatment. Normal hemoglobin numbers for women are 12-15. At least half of the oxygen carrying cells of the woman’s blood were gone. These are cells that carry oxygen, which is something your organs cannot live without, to the organs and tissues of the body, and carry carbon dioxide from the organs and tissues of the bodies back to the lungs were it is exhaled. A hemoglobin of 6 is is a medical emergency, verging on the number that is not recoverable from for the woman.

Still others are being told that while there is a miscarriage in process after no cardiac activity is found during an ultrasound that nothing can be done without a second ultrasound to confirm there is no cardiac function, and a third to confirm again. And the women are left with this burden of a failed pregnancy, and have to go through a degrading ultrasound twice to confirm what it already known. This woman has to be told three times that the baby is dead before any action can be taken.

I mean, what the actual fuck?

And the infections can lead to a woman being unable to get pregnant, or carry a pregnancy. Where is the outrage about that? It is bad enough that we, as women, are told that our bodies are not our own and we can have no say over what happens to them. But women who very much want to get pregnant can have a miscarriage. And if they are in certain states they are not medically treated in a timely manner and this can lead to them being unable to every have a child.

And you are okay with that?

Women who have gone through this kangaroo court that we are all living in are suffering. And some of them are deciding not to have more children, or children at all, rather that go through this catastrophe again. And that is a compounding tragedy.

Next up on their docket of what they want not bound by laws will be gay marriage. Or maybe birth control so that they can have utter control over women. Because it is always and has always been about control. Someone, somewhere is doing something that a section of society doesn’t agree with and THEY MUST BE STOPPED!

I’m frightened and I am a married, white women in my late 40s.

It is unfathomable what others are going through.

Because a section of society doesn’t understand.

Can’t understand.

Won’t try to understand.

f you are not frightened, you should be.

Post-it Sunday 7/17/22-Patient>charting or phone.

The gown card reads ‘Treating the paperwork instead of the patient.’

Picture this: an OR that has all the lights on because this is an open case. The back table is full of instrumentation such as scissors, and pens, even replacement pages. There are electronic components carefully laid out. The “patient” on the table is a charting computer with its guts hanging out and a screen that has been blanked out. The surgeon snaps out ‘We’re losing it!’ as she frantically tries to stuff the electronics back into the computer.

You, the circulator, is sitting at the back of the room with the real patient and paying attention to their needs and wants.

I know I have written about this before, and it remains a serious judgement issue.

Some nurses are hell bent on getting their charting done and not paying attention to the field. They are chart first and let the field take care of itself. Um, they can’t, because they are sterile.

I find this especially true in nurses who have gone straight to the OR from college. For them, charting is the holy grail. After all, if you didn’t chart it, you didn’t do it has been bashed into their brains forever. I know. I had it bashed into my brain too and then I worked the floor for a year prior to being an OR nurse. And as a floor nurse, you have tasks to undertake and charting to do, but the tasks come first.

But which floor wants to train a nurse just to lose them to a specialty? It is expensive to train a nurse.

I have a radical thought. In order to chart, a nurse actually has to engage with the patient and DO something.

Charting can wait. Especially when the field needs something.

Your phone can wait. I’ve been an OR nurse a long time, pre-smartphone supremacy (that means before 2007) and I will tell you that the biggest distractor in the room is not the charting, it is the smart phone.

Phone, charting. They both mean the same.

It means that the patient, who is the sole reason that the circulator is in the room and charting to begin with, is the loser in the attention wars.

Don’t let your patient become a casualty to not paying attention to the field.

988 mental health crisis phone line opens Saturday

988 is a new national number, similar to 911 which was implemented in 1968.

This has been such a great need for so long. Hopefully this will decrease the number to 911 for mental health crises that today lead to deaths because sometimes in crisis people can’t listen to directions. Cops are not trained to handle a mental crisis. When I was a volunteer for the local crisis line when I was in college, I had to undergo 180 hours of training in transactional analysis before I was allowed to take a call.

This was before the advent of cell phones as an everyday item. Some people had car phones but it was too expensive to talk to a person in crisis on them. Everyone I knew who worked on the volunteer line took their shift from their house. The people in need could call the number that was advertised, and the call would ring through to whoever was on call. Our personal numbers were never advertised.

Our local crisis line was staffed entirely volunteers who would take a shift to be available for calls to speak to whoever reached out. Mostly it was people who were lonely, I’m looking at you person who shan’t be named who just called in every shift to tie up the line for 4 hours at a time. But other people called with genuine need.

One day, in the middle of summer in the mid 1990s, I got a call from a suicidal person. They didn’t want to die but there was no other way to stop the pain. They had a knife and they called the crisis line instead of using it to harm themselves.

I remember telling them that I was so glad they called the crisis line and I would be happy to talk to them for as long as they needed. They just sobbed on the phone saying the mental pain had to stop and could I help them please. Leaning on my training, I ascertained whether or not they were alone, which they were. I asked if there was someone that could be contacted to come be with them. They panicked, thinking I was going to hang up the phone. I soothed, explaining that I had a neighbor who could call for them. I would just need a number. They mumbled a number, I wrote it down, along with a note that I needed them to call this number and alert who answered that they were needed at home because someone in their house could not be alone.

Still talking on my portable phone, I walked over to my neighbor’s apartment and banged on the door. He opened it and I thrust the note to him. As if we had practiced it, he read the note quickly, held up his hand in a call gesture and I nodded, mouthing please. It took less than a minute to convey the message. I went back across the hall, continuing to talk and listen. My neighbor gave me a thumbs up through the screen door. I smiled at him and mouthed thanks. And told the caller that their person was on the way to them.

The caller and I spent about an hour on the phone together, as they became more and more calm. We talked about whatever topic they wanted to talk about. I knew that the immediate crisis was ending but I didn’t want to hang up until someone else was with them. We talked about their plans for college in the fall, and which city had the better baseball team, about their job. We talked movies and television shows.

Every minute away from the acute crisis calmed them even more.

Finally, I could hear the doorbell through the phone. Their person was there.

Haltingly, they thanked me for my time and that they were feeling much better. I could tell they were becoming embarrassed about causing a scene and I rushed to remind them that is why I volunteered for the crisis line.

I did not give them any recommendations for treatment, that was not my role. My sole job was to listen and make gentle suggestions such as the have another person present and diffuse the acute crisis by being a listening ear when they needed one.

I am not sure that the crisis line still exists or if it has been enveloped by the mental health services for the county. But I was there when that person needed me, and that is all that matters.

Cookie Thursday 7/14/22- pound cake

The If You Want Women to be in the 18th Century so Badly… theme for July continues.

The bake of the week is pound cake.

Quick check in on my feelings. Yup. Still pissed.

Someone in the department asked what the theme written on the board meant. I had to adjust the board to add an appendix (Yes, this is a SCOTUS protest). No, not that kind of appendix.

In 1796 the first American cookbook was penned by Amelia Simmons. In a very literal title, it is called American Cookery. and it is fascinating.

It is a simple cookbook, with recipes that made use of what the people had. It is also written in the style of the time. The library copy of the cookbook that I read had the original recipe on the right page, and a modern translation on the left page. This meant that the modern translation of the words, not written in the script of the time was word for word with the original work. I found this fascinating.

The original recipe for pound cake calls for 1 pound of sugar, 1 pound of butter, 1 pound of flour, 1 pound of eggs. Hence the name.

There are many other recipes that I found interesting. Carrot pudding. I hate carrots but this has potential. Game, or the meat source of the time, had several pages of recipes. It wasn’t as if you could pop out to the nearest supermarket when you have a hankering for chicken. And all parts of the animal are discussed in recipes. And variations are given for different recipes. There is a variation of the pound cake recipe with is the one I used. And there is also a brief explanation of what ingredients to add to make the pound cake into cookies in case you don’t have small tins to bake in.

The coolest thing was the last page, which was the corrections page. This means that the cookbook had been re-printed. I know that, but it is still very cool.

It is kind of like translating between the generations in the OR, just not as literal. Kind of like telling a millennial or a generation z that the reference number is pound sign123 and them looking at you like you are crazy. Until you remember that they have a different representation of that and you correct yourself hashtag123. Things get lost in translation. My favorite factoid is explaining where the word and came to be. From the ampersand, or the @ symbol on the keyboard. Blows people’s minds.

The recipe that I chose for this week is also very simple. There wasn’t a lot of different ingredients as we understand them available. There was no leavening agent to make the cake rise, instead it depends on adding the eggs to the creamed butter and sugar. There is no vanilla to flavor the cake, it depends on rosewater. Which I found really interesting, and I am going to explore this more in future Cookie Thursday is a Thing.

Experimentation is so much fun! And at the heart of Cookie Thursday is a Thing.

Covid update 7/12/22-AGAIN! AGAIN!

And here we are again.

Again.

There is a new alarming covid variant that is spreading rapidly.

Again.

For a very brief moment this spring my hospital’s covid cases dropped to zero. For less than a week. Something to be celebrated, yes, but it didn’t last long. I’ve been monitoring the covid hospitalization rate for what seems like forever, at least since testing and reporting became a thing.

The OG covid is Alpha, and then Beta didn’t do much of anything and certainly did not become the most widespread. I don’t remember Gamma at all. Must have been a flash in the pan. And then came delta in Summer/Fall 2021, followed by Omicron fast on its heels in November/December. And then the offspring variants of Omicron started showing up. Omicron BA.2, Omicron BA.4 were each more infectious than the last as the virus learned. Now we have Omicron BA.5. It is now the prevalent covid variant in the country, as 65% of all cases are sequenced as it.

Covid evolves quickly. That is 3 subvariants that are making inroads into the population in less than 7 months.

And then there another. BA.2.75. Arising from India. Some dude on Twitter named it Centaurus. And the name stuck. Naming your enemies is supposed to help them be defeated. Um, guys, I don’t think it is working like that.

These variants are all more and more infectious as they learn to step around immune response, either from prior infection or vaccination. This is known as immune escape and that was a phrase I never wanted to learn.

Some people are going to work sick with covid. I get it, you have to earn a living, but although you will likely survive, others you come in contact with may not be as lucky. At least you will save money on gas. (weak joke)

I read several articles that if you get sick, you should assume that it is covid. That is how widespread it is. Not that we’ll know for certain, unless you get tested. Because testing, has fallen out of vogue. I’m not sure if this like when my cat reaches for my pizza with her eyes closed, I think she is reasoning that if she can’t see me, I can’t see her. Or, to use a fable, the emperor has no clothes.

We are all sick of this merry go round. Trust me when I say that healthcare workers are the most disgusted of it of everyone.

It is like a round, why, why is this happening? Because of low vaccination rates, giving the virus plenty of time to evolve into something even more deadly. Just get the vaccination already. I can’t believe I am still writing about this.

The refrain: wear your mask, stay home if you are sick, get vaccinated and boosted if you have not. A 2nd booster is available to those over 50. If you of that population, get the second booster. You might still get sick, but it will not be as severe or deadly. And you might survive.

Wear your mask when you are out. I have read articles that the outside air may not be as noninfectious as last year. Reasons? Please see last two paragraphs.

The WHO came out with a warning that covid is nowhere near over. Despite the rosy misguided thinking of most people, but Americans most of all.