What is That?!

We had a very pleasant trauma patient who needed to go to the CT scanner for a fall. I had adjusted the blanket on him and exposed him during the trauma exam to uncover a large metal ring around his genitals. Like this:

Between the nurses, techs, and doctors, none of us had ever seen a penile ring before, but we all kept extraordinarily professional faces and demeanors despite this fact.  As soon as people walked around the curtain, however, their faces changed into varying expressions of "What IS that?"

Finally, a male nurse mustered up the courage to ask, "so why do you wear it? What is the purpose of wearing one?"

"Purely decorative purposes." Mr. Cockring smiled. "I can remove it if you like."

He took our intrusion into his personal life with such a great sense of humor and grace.
It made for a good experience in the trauma room in face of the several homicides (shootings and stabbings) that also came in during the course of the night.

Also, because we had three extraordinarily good-looking male trauma nurses that day who did not want to be hit on, I helped Mr. Cockring with various tasks throughout the evening. We had a few inspirational conversations with his partner about their travels together around the world.  They were just really lovely, open-minded and intellectually curious people.

Then, I tried to troll the security officers by hiding the ring in the bag of valuables to be locked up, but they chased me out of their office.

S
http://en.wikipedia.org/wiki/Cock_ring
I looked it up later- apparently, they are also used as a sort of tourniquet to engorge the area even more
 so.  Interesting.

Health-Care Team

For whatever reason, all my patients tonight were extraordinarily ill.  Intubation after intubation, respiratory emergency after respiratory emergency, significant chest pains, intestinal blockages, internal bleeding, traumas, ingestions, you name it- we were swamped.

Mr. Cat-eyes, one of my regular drunks who is here at least 3x a week was a critical patient today.  Because he was unresponsive (and still drunk), we pumped his stomach and fed him activated charcoal through that same oral-gastric tube.  Activated charcoal is pretty gross. It got all over my gloves, then on my bare hand when I removed the gloves. It's thick, sludgy, and tastes terrible, so I hear, except for one girl who took the pediatric cherry-flavored charcoal and said it tasted like cookies.  He was sweating profusely (diaphoretically) so I wiped his familiar face several times with a towel.  He wasn't clean- streaks of yellow exudate covered my towel.  The respiratory therapist was a nice young man.  He actually wiped a spot I had missed on the other side of Mr. Cat-eyes' face.  When Mr. Cat-eyes went upstairs, I couldn't help but wonder what had made him this way today. :(

In the other room, a nice old gentleman had come in for difficulty breathing.  Throughout the day, his eyes were half-closed, but he was fully aware and answered questions appropriately.  It reminded me of when animals are sick. They don't vocalize, but lie there, panting and staring through half-closed, glassy eyes.  I felt so bad for him and made it a point to go to his room often to shut off the constantly ringing alarm on his monitor. Both his heart rate and breathing rate were extraordinarily high.  The same respiratory tberapist from before came to find me because my LOM asked said to him "I feel so tired, but I wonder if I fall asleep if I'll ever wake up again." He made me promise to check on him often, which I was doing already. It really touched me to know that someone else was caring for patients. Not "caring" in the cold, clinical sense, but caring in the way that you move a lock of hair from somebody's face, or tuck a blanket around someone's bare neck.  This therapist even did something that I normally do; he came back when he was about to go home, to check on this LOM once more, to reassure him that he was in good hands, and that we were going to take care of him.  I think that my faith in humanity jumped a few points today.

I did my own mitzvah today after seeing the respiratory therapist with my LOM. An older man had come in for syncope.  Apparently, he had been fasting all day for Yom Kippur and fainted dead away after a glass of wine.  He and his wife were lovely people and very grateful for my detailed attentions to them despite the craziness of 2 intubations in the rooms around them and several patients down the hallway screaming from PCP use.  It was worth the extra effort to me. They were kind people- you can tell from the way their bright eyes crinkled when they smiled. After I changed out of my scrubs, I stopped in to see them one last time and wish them luck. Luck would have it that they were being discharged at that very moment and as my final work-related action of the night, I removed his IV and sent the pair of them out into the warm autumn night.  Work felt good tonight... Can't wait for 12 hours of trauma drama-rama tomorrow!

S

Patient Patients

It's one thing to wait for 8-10 hours in a room for care and entirely another to wait in the bustling hallway, watching the nurses, techs, doctors walk by quickly, be on the computer, make inappropriate jokes. You can observe who is taking care of patients and who is waiting for a paycheck.  Ms. Alone was feeling terribly sick. Graying hair in a tangle, she was slumped over, totally forgotten for several hours at a time. Every two hours, she would patiently stick out her arm for me to take her blood pressure and open her mouth for me to take her temperature.  She had a low-grade fever, so I grabbed her another blanket and let the nurse know, in hopes that she would come help the lonely old lady soon.  Instead, the nurse asked the intern if he wanted to practice drawing blood.  The intern was thrilled, but he missed her veins several times.  Without complaint, she let us stick her multiple times. Finally, the intern asked me, abashed, to draw the final tube.  She did not complain, but smiled at and me and thanked me for taking good care of her as I pulled off multiple gauze pads off both arms to find a vein.  Sweet lady of good temper, I wonder what happened to you to make you so patient with us.

S

Old Country Manners

Mr. Right-Handed had been a carpenter for the last 40 or so years before he had an accident one morning that split his dominant thumb in half lengthwise, cutting several tendons and causing him a lot of pain. He kept apologizing for not speaking English very well, though I understood him perfectly.  His deep blue eyes searched my face and crinkled into a smile. He trusted me to take good care of him.  His daughter sat in the background, distant and businesslike.

A stoic man, Mr. RH, didn't want to admit to pain at first, but as he got to know me through his many hour stay, he began to let me see the grimaces and such. He refused almost all the pain medication, however, and I stopped in many times to grab him another pillow or ice-pack.

When the surgeon finally took the bandages off, I was fascinated. The jagged cut went clear to the bone. It was then that Mr. RH finally agreed to have some morphine as the surgeon cleaned and stitched the wound up for evaluation the next morning. He asked me to stay with him, and I distracted him by making conversation through the bloody procedure, though the numbing medication was wearing off quickly.  We got along really well- he told me about his family and about his love for his profession, making customized handiwork for clients.  Occasionally, he would wince and I would hold his good hand.  My father is the same way about pain- he would never admit having any. I notified his nurse, and Mr. RH received some more morphine, but will eventually need surgery to re-attach the tendon.

10 Hours after I first met him in which he wasn't allowed anything to eat or drink, I sent him off with some juice and a sandwich box.  As he stood up, he thanked me, then remarked with a grin, "it looks like after alcohol" as he left on his daughter's steady arm.

S

I Would Love to Go to England if the People Were All Like Him

26 Hours of interrupted sleep later, I think I've recovered somewhat from the splitting headache and nausea all through yesterday.  Whew.  I rarely get headaches and forgot how hard it is to get rid of them! Just imagining the pounding behind my temples makes me nauseous again. The mixed-up dreams and fitful sleep were the worst part though.

The good part of this experience is that I have refilled my empathy pool for people with headaches.    At work, I can generally tell if a patient is legitimately compromised, so I would turn off the lights and let a nurse know about the state of the patient. Other times, I might receive a surly or hopeful demand for that "drug that begins with a d", in which case, I just backpedal quickly out of the room and alert the nurse about the narcotic request.

The other day, I had the most delightful old man. I walked in to see Mr. Dickens lying on his back, a large bleeding "egg" over his left eye. Ever so polite, he brought out my good humor with his mild British accent and tongue-in-cheek charm.

"So did you get that shiner from a fall or a fight, Mr. Dickens?" I asked.
"Oh, I fell, definitely not a fight," he chortled. "Excuse, me, but if you get a chance, I was wondering, I've been here all day and was hoping to get something to eat."
"You know, I will have to check with your doctor about that- if you have to get a surgery, then you can't be eating."
"Oh yes, miss, I understand that they told me they are reconsidering the need for surgery."

I went out of my way to find a vegetarian option for this LOM, and when I presented him with an egg salad sandwich, he was delighted, using all the cutlery gingerly and politely.  It suddenly hit me how often I've seen patients wolf down their food and appreciated little Mr. Dickens ever the more.

"So what was your profession, Mr. Dickens?"
"Well, back in England many years ago, I was a professional voice recorder for books on tape."
"How wonderful! I used to read a lot of Dickens, Thackeray..."
"Dickens is delightful, isn't he? You sound like you like a lot of the Victorian literature."
"Yes, I do, indeed. What an interesting career you must have had."
"Yes, it definitely was."

I gingerly cleaned all the blood still draining from his eye, which was puffed shut. I had to rub out with peroxide what had dried and settled in his gray hair.  He was patient with my gentle and didn't say he felt any pain when I asked, though his eye was puffy with bleeding.  His accent was charming and conversation nuanced.  It's not every day I could gush over classical literature with someone.

Oh, Mr. Dickens, you made my day so much better, though you probably thought you were being fussy and making me busy.  Wishing you well.

S

It Could Be Worse

I walked into the room to take vital signs on a very thin young man. He was very calm, his mother was an anxious ball of nerves.  She was so worried about her son.

After introducing myself, I immediately got a good vibe from him.  Polite, easy-going, he spoke softly and acquiesced to all my requests and questions with good humor.

S: "Do you feel any pain?"
Young man: "Not at the moment, thank you for asking."
S: "Ah, well that's good to hear!"
Young man: "Yes, I suppose so."
S: "If you don't mind me asking, what did you come in for?"
Young man: "Well, I have renal failure and have had type I diabetes since I was 3 years old. I'm waiting for the transplant team to come talk to me."
S: "Oh, I am so sorry! That sounds terrible."
"Well," he shrugged and smiled, "it could be worse."

Really? Life could be worse than having renal failure and living half your life in the hospital? He was right, of course- I've seen worse... But he is still so young.  I tried to imagine what it was like to go through dialysis every week, to be on the transplant list, to be on anti-rejection medication on top of all the diabetic worries, insulin shots, controlled diet... I can only thank my lucky stars.  He is tough and a down-to-earth.  He is not bitter, as far as I can tell. He exuded a peaceful acceptance of his conditions and thankfulness for having all his wits, limbs, and other functions intact.

I appreciate a good person when I find one, so I stopped by his room several times to just to ask how he was and if I could do anything to make him more comfortable.  He never required anything, though each time I came in, his mother would start asking me questions.  Poor lady.

S

Contracture Conjecture

Imagine waking up in the morning and having a stitch or something in your neck. Try as you might, you can't move yourself just right to get rid of it. In fact, you can barely move, maybe your arms will flutter stupidly as you try to grasp the railing on the side of your bed, but they won't work, stupid things.  The nurse will come in to see that you've wakened and give you your morning medications. You try to say something to her, but all that comes out is stuttery nonsense. You take a deep breath and try again.  "I...I...I'm m m m huun huh huhhn...g gr gry." "Ok, honey," she will say off-handedly and arranges the bedding, "We have to do a bunch of things. We will have to shift you first."

You can't move because your legs are twisted up so tight from contracture that they are half-crossed up to your chest and you can't even pee.  It's like being curled up tight in fetal position- forever.

http://en.wikipedia.org/wiki/Contracture
http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/articles/health_tools/dupuytrens_contracture_slideshow/PRinc_rm_photo_of_dupuytrens_contracture.jpg (Imagine this, but with your hip flexion...)

They had to drill a hole in your suprapubic area and insert a catheter directly into your bladder.  The contortion isn't painful, per se, but staying in one position will make the bones from your spine and pelvis bore into your skin.  Sometimes, this might cause sores. Depending on the stage, the sore can vary from just a red and tender patch of skin to terrifyingly open, ulcerous, boring caverns.  Luckily, you have people who love you and take care of you 24/7.  It's impossible to even imagine what you would do without them.

Today, however, your catheter seems to have been pulled or something- and urine is leaking out of the hole.  It's time for another trip to the Emergency Room, where so many nice nurses, doctors, and techs know you by name.  Luckily, it's not serious today- you've been here for this before and you don't even feel pain.  The inexperienced nurses will have no idea what to do with you, and will baby-talk and condescend, but the urology resident will greet you warmly.  He does a great job and that technician that held your hand earlier and had trouble prying your legs open for the procedure, she was nice too. She was really worried that she was hurting you, but it was fine, nothing you haven't experienced before.

That technician came in a lot of times to take vital signs. She chatted with you like you were anybody else and didn't use the sickly sweet voice.  You were glad she was the one to take you back downstairs to get taken home by the ambulance, and she was nice enough that you decided to take a chance and ask.

Ms. Bedbound: I-I-I-I w-was - w-w-won-d-dering g- - -if--you c-c-could---do--- a f-f- f -favor -for m me.
S: Of course, what can I do for you?
Ms. Bedbound:  D-d-d-don't-t-t g-g-get ma-ma-ma-d.
I couldn't even fathom where that came from. I felt so sick that she would think I would get mad.
Ms. Bedbound: C-c-c-could... -I -I -I- c-c-could-d- - -have- - a sn-sn-n n-ack-k?
S: Do you like graham crackers?
Ms. Bedbound smiled widely and nodded: C-cr-c-r-crack-kers-s w-would -b b-be n-n-nnice.
S: Do you want peanut butter?
Her eyes widened and she shook her head no. Her hands fluttered and hit the railing several times before she got a grasp on the two little packages I gave her.
Ms. Bedbound: Th-th-th-th-thank you!
S: No problem. Are we all set to go?
Yes, but Ms. Bedbound was agitated and was trying hard to say something I couldn't understand. I paused to look at her and she took several deep breaths to try again.
Ms. Bedbound: I-I-I-I-I'm...s-so hap-p-p-py!

I felt a chill.  Maybe it was because my heart was warmed, but there was more than that.  I couldn't imagine what her life was like, to be utterly dependent on other for every detail of her life.  Of all the things that could go wrong, she had almost all of them, as a young girl about my age.  Immobile, infertile, incontinent, totally dependent. Yet, she could say she was happy and mean it. She looked in my eyes and there was something so childlike in her glee- she let me know that at that moment, she was truly happy.  The catheter tube problem was fixed, she was leaving the hospital, and she had graham crackers clutched tightly in her hand.

My problems are not problems compared to hers. Meeting her made me want to stretch out in the sun and bask in thanks for the life I have.

S

Humor in the Time of Overcrowding

"Do you have time for a short story?" Mr. Professor asked as I was pulling my nurse-on-a-stick vital signs machine out the door. I stopped, "sure."

"So on Good Morning America this morning, this is a true story, mind you, there was a guy who got his foot stuck in some machinery and had the strength of will to cut off all five of his toes. When he called the ambulance, his friend said to him, why did you call the ambulance? Why didn't you call the tow-truck?"

I laughed at him for being silly, but he insisted, it was a true story- how great it is to have a sense of humor like that in such a time. It's true- it's a sign of the just how deep the friendship was and how smart the guy had been to do what he could to make his friend feel slightly better about the situation. Mr. Professor quickly became my favorite patient of the day. A local college lecturer, he had been in the middle of a class when the room suddenly felt very warm. After a dizzy spell, he came in to visit us and we observed him for changes in troponin-levels- something that signifies damage to heart-muscle.

Every time I came in, he would greet me warmly and I would open up and talk to him, tell him stories of what I had seen, including when I had a full half-hour's worth of one-sided conversation with a man who was completely deaf. He was surrounded by loving family who carefully and tenderly cared for him. A man with a great sense of humor and presence, who really made my night.

S

The Ones I Go Above and Beyond for

It makes a huge difference when you get a patient who is appreciative, understanding, and, well, patient. These are the ones that you wouldn't mind going on multiple little trips for, precisely because they wouldn't presume it is their right that you serve them hand to foot. Sarah was like this. She and her husband sat quietly in their room, concerned, but resigned to a long wait.

They were an attractive couple, middle-aged with young children. They took very good care of each other, politely introducing themselves and smiling genuinely when I did the same. Sarah was open to talking to me about her sudden-onset pain- like needle pricks all over body- that wasn't subsiding with tylenol or motrin. At first, the nurses thought they were drug-seeking, but she refused anything narcotic. Her husband made gentle wisecracks on the side to make her smile. The atmosphere was so pleasant and genuine; there was no denial nor despair, but his concern was obvious, despite his best efforts at hiding behind his jokes. I liked them so much, I poked my head in every hour or two to see if they were still comfortable.

After myriad tests, none of the blood work, CT scans, even MRI's came back with any conclusive results. She had an extensive family history of autoimmune disorders, so she sighed and said, I was fine but I guess it's all going to catch up with me now. Almost 8 hours after they first came in, the physician came in to explain that in the emergency setting, we couldn't perform in depth work-ups, but just wanted to make sure that the pain was not because of a life-threatening issue. Sometimes, he said, we have to send people out without a definitive diagnosis of what is wrong with them, and that can be very frustrating. She sighed.

I drew six more tubes of blood with obscure test names I have never drawn in the ER and helped send her on her way. She could barely walk, so I pushed her on a wheelchair all the way to the curb of the front entrance, stayed with her until her husband came with the car. Because they drove there separately, I ran to the other side of the hospital to ask valet if they would let her car stay in the garage. When I came back with the news that they would let the car stay in the valet parking zone despite a small fee, the husband shook my hand and thanked me for everything I had done, wishing me the best for my future. With that, they took off, both waving from the window. They told me they had a good visit, despite 8 hours of tests, waiting, not eating, and no definitive answers about what is hurting her.

Compare this with my trauma patient last night, breathalyzing .250, no effort, who gurgled and couldn't speak for all the slurring. Apparently, she fell several times and was walking headlong into oncoming traffic. She had a large bleeding laceration on the back of her head. She swung her fists at us, had to get held down by security while we did the trauma assessment. "Ma'am, we're trying to help you." "**** you." She calmed down, but only until we turned our backs, when she ripped her collar off and sat up, cursing (still slurring) and threatening to **** all of us up. She tried to stand up when security put her in 4 pt restraint and the collar went back on. She was on the point of spitting. For four more hours, she continued the struggle, cursing (no longer slurring) at us- I'm FINE. Get this ***** thing off me. **** you all. I can't wait to get my hands on all you **** ********. Hey, can I get a sandwich or something?? She calmed down at hour 5, when one restraint was taken off so she could eat the sandwich we brought her. Instead, she screamed. Get this ***** thing off me and used the open hand to take her collar off. At this point, I breathalyzed her again, she was .275. She was taken to a quiet place to calm down but still cursed anybody who walked by. In 4 point restraint, she still managed to twist her neck to get the collar off. She apparently didn't break her neck. Nevertheless, her head bled everywhere as she shook it. Seriously? We know you fell, we don't know if you've been hit by a car, and we can't even get you to stay still enough to stay on the CT or x-ray machine to figure it out. I bet she was there for a much longer time than if she had cooperated.

Sigh. Just another day in the life.
S