Friday, December 29, 2017

What was the most viewed post of 2017

This cold weather has induced a Winter brain freeze. I've been working on a post about old school trauma blankets, but  trouble with writer's block has slowed me down-if you could even call my foolishness writing!

I have zero insight about which of my posts are popular with readers. Sometimes my idea of a good post only comes up with a hundred views or less. Subjects that seem on the lame end of the spectrum end up with a thousand or more views. "Go figure," as I've heard youngsters exclaim when something doesn't make sense.

Drum roll...please. My  most viewed post of 2017 was this gem with about 2,200 views.  (Caution contains disturbing image.)  I did not have the appropriate insight and judgment when publishing this little gem to add the disturbing content disclaimer and this got me blacklisted on some referral sites. My bad (another expression I learned from you  clever youngsters,) and a thousand pardons for my crude behavior. I will try to contain my inherent barbarity in the future.

Wishing you the best New Year yet!

Thursday, December 21, 2017

Technology-The Perils of Early Adoption

When knowledge, experience and technology
fall into place concurrently amazing things happen.
Sometimes this takes time.

The latest and greatest in new technology provides contemporary hospitals health care entities with
ample fodder for advertisements and bragging rights.  Lack of experience and knowledge with technological capabilities can produce some unforeseen problems; antibiotics cure infections, but microorganisms fight back, X-ray treatments of enlarged thymus glands in children gave rise to cancer later in life, and bone marrow transplants for metastatic breast cancer were a big disappointment.

This is my personal tale of an encounter with a brain MRI done back in the good old days of the 1980's when these gigantic imaging machines were called NMRI-the "N" was short for nuclear. The neuro radiologists of today were likely in Kindergarten and ordinary run-of-the-mill radiologists interpreted these vintage scans.

After a fusillade of neuro problems including confusion, right upper extremity weakness, and visual field distortions I had one of those new fangled NMRI imaging studies performed. While I was reclined in the tight confines of that sewer pipe of a machine, I was aware of a commotion commencing in the procedure room. Turns out mine was one of the very first NMRIs that showed significant pathology at this facility and an audience had gathered to witness the premier event. I walked into the NMRI room and left on a Gurney for an acute neuro ward-not a good sign.  Here is the radiologist's interpretation.

The striking finding is an increase in T2 signal intensity in the right occipital area and to a somewhat lesser extent in the right frontal area. Differential might include CNS lymphoma, primary demyelinating process, encephlopathic or infectious etiology less likely. Correlation with clinical findings is suggested.

Now the real fun began. Neurosurgery was consulted and felt the scan was consistent with a glioma and a stereotactic biopsy would be necessary to determine the type. Alas, this was impossible because of the unavailability of a non-ferrous stereotactic head frame. Using the standard head frame would wind up with my head plastered to the magnet like a bug on a windshield. I remember thinking about calling Jack Kevorkian to see if he could squeeze me in as the prognosis seemed more grim as time passed, but there were many more consultants waiting in the wings so let's wait and see.

Next on the parade of consultants was a neurologist whose primary area of expertise was MS, of course he concluded that MS was the diagnosis and a spinal fluid study for monoclonal antibodies would be the confirmation. The studies later proved negative for monoclonal antibodies so the diagnosis was changed from MS to "demyelination syndrome," whatever that means.

Let's consult a clinical pharmacologist to get his opinion. I was taking Azulfidine for Crohns Disease and a review of the literature suggested an encephlopathic process could be a result of taking this drug. The final diagnosis: Azulfidine induced encephalopathy. Stopping the Azulfidine made no difference in my neuro status, but jump started the Crohns, not a pleasant situation.

I slowly recovered and started backing away from follow-up appointments, figuring that whatever it was would take its course. My  neurosurgeon died about 5 years ago and I started to marvel at my survival skills having outlived him. He had given me a prognosis of 5-7 years.

So 28 years after the original excitement  a  NMRI  MRI was scheduled and it was nothing like the old time days. The machine had a wide bore and I actually missed the intimacy of being stuffed in that old sewer pipe of an NMRI machine. The technician also insisted that I use ear plugs to muffle the signal generator. I missed the booming and banging. This time sure was different.

A genuine neuro radiologist interpreted this MRI and there was none of that old school beating around the bush. This lady knew what she was looking at, no bones about it. I certainly could have benefited from her expertise 28 years ago. Here is her impression.

abnormal foci of T2 hyperintensity within the subcortical and periventricular white matter are much greater in size and number in the right cerebral hemisphere compared to the left. There is a more confluent area of abnormal T2 hyperintensity posterior to the right lateral ventricle. The asymmetrical appearance of these lesions effectively rules out classic multiple sclerosis. This MRI is indicative of an acute disseminated encephalomyelitis.

It's nice to have a definitive diagnosis even though it required a 28 year wait. Some problems cure themselves if you can wait them out. Time is the most valuable commodity and the neuro Gods have cut me a break. I'm still vertical and my foolishness remains intact but sometimes I wonder about my cognitive abilities.

Thursday, December 14, 2017

Nursing Awards - Emmitt Knows Where They Belong

Proud winners of a nursing award. At least
their trophy has relevance-looks like a bath basin.
When Emmitt Smith, the hall of fame running back for the Dallas  Cowboys received the"Galloping Gobbler" award from John Madden, he knew what to do with it. No pretentious acceptance speeches or bubbly gratitude for a meaningless award.  When Emmitt thought he was off camera that pointless award was unceremoniously deposited in it's rightful place, the garbage can.

It's too bad that some nurses lack Emmitt's judgment and discretion regarding meaningless, phoney baloney awards worth their weight in wormwood. Hospitals of today often have a shrine-like  area where garish gold plaques are displayed honoring a select group of nurses. Nothing wrong with this concept if it gives recognition to deserving nurses who have honed their technical skills to help patients, but frequently the awarding entity is far removed from patient care and  has little insight into bedside nursing excellence or comforting patients. Physicians, administrative nurses (if you could even call them nurses,) insurance companies, and the nurse academic/ office sitter complex all have very minimal working knowledge of what makes a good bedside nurse. Doctors just love nurses who know their rightful place and never question orders or call them up in the middle of the night. Administrative types view nursing through the distorted lens of corporate goals and please don't get me started on office sitters of any permutation. Discretion is the better part of valor, I keep muttering to myself. Sometimes it's better to keep my foolish mouth shut.

We certainly had nothing like this when I was a nurse. Our instructors and mentors (if you could call them that) always stressed that the satisfaction of helping patients recover from injury or ailment had to come from within. If a trauma patient walked out the door or a patient's pain was relieved, you did a good job and that was your reward.  In their mind nursing was a calling and required self motivation which was also a good reason for paying nurses a poverty wage. If you are looking for good time Charley back slapping rewards or big money you are in the wrong profession.

As a public service the OFRN institute for nursing practice is going to separate the wheat from the chaff when it comes to awards for nurses. If you notice any of the following words or combination of words in the criteria or award title, its of  dubious distinction: influential, pinnacle, showcase,  emerging, distinguished, rising star, engagement, transformational, breakthrough,  paradigm, cameo, illustrious, or eminent. It's time to go above and beyond or even eschew these  nonsensical awards. It's time to take a lesson from Emmitt Smith and deposit these chucklehead awards in their rightful place.

Here are a few worthy nursing awards that have straightforward criteria and reflect nursing as it's clinically practiced, untainted from pie-in-the-sky bafflegab.

The Last Nurse Standing Award... An endurance award of sorts to the scrub nurse that can hang in there on one of those knee aching  surgeries that start before sunrise and end after sunset and I'm talking about Chicago - not the Arctic circle. My personal best is close to 8 hours on a complex trauma and that's not even worth mentioning because  my mentor Nancy went for close to 12 hours on a Whipple with complications. She deserves a standing ovation and a well deserved trip to the bathroom.

The Stink Finger Statue... Goes to the nurse who never shied away from any mess-you name the body excretion and this nurse gets down to business, sans gloves. I really admired this nurse because almost everyone has an Achilles heal when it comes to messes, mine was that gooey blood/bone chip slurry mess left on the floor of the ortho room after a long,  messy case. problem, bone problem, but mix them together and the resultant ooze-like  combo brought me to my knees every time. Thanks to Colleen and Gail for bailing me out on this one. You deserve this and remember to refrain from sniffing those fingers.

Venous Access King or Queen...goes to the best IV starter. Bring me your hypovolemic, phlebotic and sclerotic patient and I'll slide that angio cath in faster than you can say central line.

The Sailor Award...goes to the most fluent user of off color language. I usually avoided this one because it resulted in much childhood unpleasantness if caught uttering swearwords, but I  some how felt a sense of relief when others spouted out colorful descriptive language. Nurse  Felix deserves this award for coming up with the u;timate inclusive cuss word (sh++t,f**k.G++d**n it) all in one breath. What more can I say?

Most Likely to Cry...I always admired nurses that could do this. It's better than alcohol or drugs at diffusing sadness. The most I could come up with were a couple of stray tears, but at least I tried.

Most Kind nurse...We all know one of these. This nurse is nice to everyone and always sports an infectious smile that's even visible under a mask. As nurses age this trait seems to decline although I have met a couple of these angels in white who were well into their 60s. Rita you deserve this award if you can stop puffing on that Winston long enough to claim it.

The Walking Wounded...These tough nosed, hardened nurses can work through bone on bone hip joints, unremitting Crohns Disease, or even while on chemo for aggressive cancers. Tough as nails; the primary objective is to die at the bedside with their Clinic Shoes on. I did manage to scrub on a case one day after having impacted wisdom teeth removed and I was never so grateful that it did not involve oral surgery. The pain sharpened my senses, but I would not never,  ever want anyone to work for this award.

A really good nurse will do whatever it takes to help a patient in need not because it's about award procurement, but because it's the right thing to do. The fact that the obsessive pursuit of awards leaves profound deficits in other areas of direct  nursing care is a definite reality. Emmitt got it right.

Friday, December 8, 2017

Ahh-The Good Old days

I got sick and tired of viewing that  image of the traumatized (and that's putting it nicely) young man in my previous post. Kind of a foolish post and I should probably refrain from reading old posts.  My proof reading skills are lacking to the extent when I go back over my post to correct errors, I make it even worse. Paradoxical indeed!

I've had this picture floating around and could not come up with a post that equals what it illustrates. I catch myself staring at it and daydreaming of the old days before patients were customers and hospitals became health care centers. It's so much nicer than that previous traumatic  illustration. What was I thinking?

Caps, Rotary dial telephone, paper charts, and nurse attentively viewing a cathode ray tube monitor. I think I just heard that distinctive air bubble  gurgle from a vented glass IV bottle as it infuses. 

Tuesday, December 5, 2017

Who You Gonna Call?

I certainly hope for this young man's sake, that the  tattoo is prophetic, but who are we going to page to extricate that foreign body. Many decades ago, all it would have required was a quick page for my general surgeon hero, Dr. Slambow.  In the days before surgical protocols were  dreamed up by busy body office sitters,  limiting the scope of a surgeons intervention, general surgeons did it all. Amputations, setting bones, circulatory grafting, repairing lacerated livers, kidneys was their stock and trade. There were few "specialists" and no subspecialties.

Dr. Slambows treatment plan would be to anesthetize and "succ" the above patient and then simply yank that nasty blade out. "Standby...if there is bleeding we will have to go in and find the bleeder, lets hope for the best." Dr. Slambow always called the standing around and waiting routine, "masterful inactivity."

I can't imagine the number of specialties that might be consulted today for a case like this. Here is the conversation between two residents considering the various consults that might be indicated.

"We better get an occuloplastic surgeon to see this tattooed knife target. That wound is pretty near the eye."

"No..I'm calling the ENT man, that toad sticker is obviously impacting his maxillary sinus. Maybe an oral surgeon too."

"What about that hospital directive advising a neurosurgery consult for any wound to the head?....That's not his head, that's his face I' calling the chief plastic surgery resident on call."

The straightforward approach would be a call to Dr. Slambow to quickly resolve the problem while the others are pontificating and checking the patients insurance coverage.