A high school Christmas party

What: Christmas PICU party
How: High School Prom Theme

Maybe the best slide show I've seen about work. Then and now pictures of colleagues. And then there was the results of the voting ...

Class Flirt ~ Farmhand
Most Likely To Do Compressions ~ Topper
Most Spirited ~ Sansalicious
Best Dressed ~ Baldy Metro
Prom Queen ~ Franny-poo
Prom King ~ Tan Shaggy

It was fun to see everyone dressed up. Some in evening dress. Some dressed like they did in high school. Case in point, Mr and Mrs Nine Yards came in jeans and t-shirts. Schmitty came in his letterman jacket (40+ years old). Jace and boyfriend came in 80's mod jackets and bolo ties. Hurricane R dressed as a Material Girl. Topper came in a hideously funny turquoise polka-dotted dress. And JoNG came in a tshirt printed with a tuxeda pattern.

Ahhh ... the people I work with know how to party. Some, like Tan Shaggy party a little too hard. But we're like a big, happy, occassionally dysfunctional, but highly productive family.

Rush Bloggingg: ECMO end

They decannulated the ECMO patient yesterday, and he expired soon after, being held in the arms of his family. I found out today. I hope they can find peace. The child was so ill, there really was nothing we could have done to save his diseased lungs.

It now remains to be seen what will happen with pediatric EMCO at my hospital

Rush Blogging: Extra ECMO

Of the past seven days, I've worked six days. One totally extra day. One 16 hour shift. And four regular 12 hour shifts. I'm exhausted. When T called me while I was in Raleigh to see if I wanted to pick up a shif last week for ECMO, I thought she was joking. I'dd come to expect that we would never again do ECMO on the PICU again. But, the call came from anotehr PICU, was referred to us by a prior fellow, and the attending on-duty was ECMO-friendly. So it was that we took the first ECMO patient on the unit (there have been others in the NICU and CTICU) in 18 months.

There were several saving graces.

First, it was Dr. Metro and Tan Shaggy on. They are my favorite attending-fellow team to work with. They are smart, good communicators, skilled, and fun to be with. The nurses don't ahve to worry about questioning the fellow's judgement, or worrying that the attending's disposition is going to be off-kilter.

Second, the mother was studying to be a nurse. She was very interested in everything we did, but not in an instrusive way. When I started talking to her, we got along very well, she asked intelligent questions, understood much of what was said, and was always grateful for however we could include her in her chid's care. She was also very realistic about the potential outcomes for her child. It seemed as if the rest of the family was in denial about how sick the patient was, despite all the many high level interventions.

Third, the whole EMCO team rallied. The ECMO coordinator was able to pitch in a lot to help us run the circuit, and relieve us for breaks. Many of the PICU ECMO team members who had quit the team got recerted quickly and came back to work either with the patient or the pump. And there was a lot of support from the other ICU's in providing the second nurse needed to take care of the patient and pump.

We'll have to see what happens next with the PICU ECMO team.

Flags and nuts

Driving to work this morning, there was more environmentally-minded coverage of Russia planting a flag to claim seas under the north pole. And I was suddenly reminded of one my favorite Eddie Izzard clips ... "Do you have a flag?". I'll bet that Peter MacKay, Canada's prime minister, had no idea that he was echoing the standup comedy of a british transvestite of the executive persuasion.

Work today wasn't bad. At least at first.

But by 1300, we'd transferred two patients out, I'd given up my patient to someone else, and had taken over a doozy of a new admit, we'd had one child code and die, admitted two post-op patients, and taken another really sick heme-onc-er from the floor. It was ugly.

The patient I took over was a doozy, as I've said before. Late teen. Congenital hydrocephalus, ventriculo-peritoneal shunt with multiple revisions, and concerning mental changes overnight. They brought her down, and a neurosurgeon placed a ventriculostomy to monitor pressure within the brain, and drain exra cerebrospinal fluid. I took over just as he was finishing. Besides all the blood, the patient was just starting to wake up from the propofol infusion she'd been getting during the procedure ... and she was totally psycho. Speech was garbled. Wasn't oriented to time or place. Repeatedly asked for people who weren't in the room, despite being reoriented. Combative in bed. Agitated. Crying. Intracranial pressures in the 40-80's. Bullied the ICU docs (who were concentrating on the sick admit from heme-onc) into giving her sedation and pain meds. But still she didn't calm down for another hour or so.

When she eventually attained a restful state, I hd a little quiet time to catch up on her orders. Had to get the resident to change all her oral medicine to IV, since she was very lethargic, and wasn't following commands.

Then had to take my patient down for a CT scan.

Got back, and she went all nuts again. And really, I don't mind taking care of really sick patients. Actuslly, I relish it. But I am just not wired right to take care of patients with psychotic issues, the mentally disturbed, or gerontic patients.

CT results came back. Catheter not in an optimal position. ICU fellows wrote for a CT-guided angio. Luckily (for me, at least), there was already a procedure going on, and my patient would have to wait until after change of shift.

All in all, a brutal day. Had had plans to go out with some co-workers that night, but I totally bailed.

Instead, I came home and de-stressed by finding some of my other favorite Eddie clips available on-line. Caution, some of these clips are a bit more linguistically colorful ...
Religion
Evil Giraffe
Covered in bees

It's tough being the Fearless Leader

Did charge today ... ideal, because I wasn't as hindered by my ridiculous gimped up ankle. Also, it's a Saturday, which means no admissions for scheduled surgeries, and no patients that have to travel for special prcedures, and less physician traffic for consults and follow-ups. And, as a bonus, I had TS as team leader ... or unit slave, as the position is more colloquially called.

Wasn't a bad day. Sent one patient directly home from the unit. Transferred three patients to the floor. Admitted one non-ICU patient to start nightly BIPAP. Got three sick calls, which wasn't ideal. And had to deal with one family crisis.

I've been thinking a lot about our really sick, chronic patients. Partially due to this post on DS and this other post on a child who had an in utero CMV infection. We see a wide variety of chronically sick patients, mostly in the winter time. In the PICU, summer is trauma season, and winter is respiratory season. So, in the winter, we see a lot of chronically ill patients, who suffer from a variety of congenital or chromosomal disorders. We see kids who are very much loved and well-cared for, and those who have been institutionalized because their parents lack the desire or ability to care for them. We see families who rally around a sick child, and those that unravel with chronic illness. We see those who put the best interests of the child above any other consideration, and those who prolong a child's suffering for their own needs. It's thorny, to say the least.

Today, I had one family that was in a lot of pain. An older couple, had been through years of fertility treatments to obtain their hearts' desire. Finally, their wish came true, but with a twist. Their eagerly anticipated baby had a non-hereditary syndrome that encompassed many congenital anomalies, affecting almost every organ system, with the outlook of a life filled with hospitalizations and surgical procedures. Added to this fact that the couple, although settled in the US, is from a first world country with socialized medicine.

I should have known that something was amiss when a consulting attending physician disrupted our unit attending rounds to speak with the attending on-call about this family, and their dissatisfaction with hospital medical staff. They had been presented with alternatingly rosy and gloomy outlooks on their child's prognosis. They had heard second-hand whisperings about physicians who reported not wanting to be involved in the case. They were put off by the brusque manners of specific doctors. The situation concerned me, but got lost in the hectic pace of the day.

(Aside: I might note that the day already had a white-rabbit-I'm-late quality to it. Morning rounds (with the fellows and the residents) hadn't finished until 1130, and the attending rounds had been delayed because of several mini-parent conferences regarding several very sick patients, and one not-sick-at-all child of a very pushy VIP. We didn't start attending rounds (with the attending, fellow, and charge nurse) until 1300.)

When we finally finished attending rounds, Half & Half came up to me and pulled me aside and described the situation ... the family was really upset, and wanted to meet with Nine Yards (the critical care and anesthesiology director). I groaned. I think I might have mentioned in several places how much I hate psych-social issues in nursing. But I knew that this had to be addressed today.

So, I gathered my thoughts and resolve, platered a gentle smile on my face, and knocked on the room and entered. I was unprepared. Instead of the angry and remonstrating parents I expected to meet, I met some lovely people. The parents were warm, clearly well-educated, and extremely reasonable. And as I listened to them, I could see that they needed me to be there.

Yes, they had been receiving very contradictory stories. Generally, the PICU physicians are really good at telling it like it is. Of course, some are more gentle and tactful than others. But they tend to give their expert opinion, based on the most current findings, and offer as many options are a possible. And, just as generally, many other services offer extremely rosy outlooks ... the oncology service comes to mind as one that is generally not realistic enough to benefit parents. The best solution for this mismatch of outlooks is best solved by a genuine parent conference, where the family is able to sit down with all the services involved in the child's care, hear all the opinions of the specialists, and have a chance to get their questions answered in a cohesive and understandable way.

The parents were further confused by the parade of physicians involved in their child's care. Not only are there mutliple services involved, but the attendings roate weeks on call. Then there are also the fellows in each service, and all the residents just in the PICU. The solution for this was to have one person overseeing the patient's care on an on-going basis ... someone the parents could meet with during office hours, who was available on a consistent basis, and not just on a by-the-week basis. The ideal solution would be to have a case manager keeping track of the patient's progress, to coordinate and be a support to the family.

The parents' unhappiness was compounded by the fact that there was a serious trend of miscommunication. When the physicians talked about the child's prognosis, all the parents could hear was that their child's life was intolerable and not worth living. I can emphatically state that this was never implied. Aside from cases of documented brain death or a DNR (do not resusitate) order, we do everything we can to restore and/or improve the health of our patients. Added to this was the fact that the parents had shut down when the physicians broached the subject of a tracheostomy. Apparently they had met a child who had the same syndrome, and who had a trach, and it became their worst fear. Clearly the parents needed someone to support them and facilitate communication with the healthcare team. Sadly, our unit social worker was on vacation, but I got the covering social worker to step in and start working with the parents.

And lastly, the parents wanted to speak with Nine Yards, which I agreed to arrange.

So, what did I do (besides try to keep my nervousness under wraps)? I practiced my reflective listening skills. Heard them out. Tried to reflect/rephrase their statements. Clarified when I could. Offered the above four ideas as a starting place. They were very appreciative, and I felt that I had helped de-fuse a potentially combustible situation.

When I left, I found an empty room and paged my on-call manager. And she listened to me. She took the responsibility to get a case manager involved. She informed me that Nine Yards was still on vacation. And advised me to broach the on-duty attending about what had transpired so that he was aware of the situation. She was a calm port amid the shrieking voices in my head.

Re-entered the unit and was immediately swept back into the business of being The Fearless Leader. Couldn't seem to get the on-duty attending alone for a minute ... demands on both his and my time. However, I finally got a quiet moment with him, and updated him on my conversation with the parents. Afterwhich I had to listen to him and help de-fuse some of his enfensive mechanisms. Afterwhich he calmed down, and was able to talk with the family to arrange for a conference. Afterwhich I approached the parents to follow up. We reviewed the goals of having the parent conference, getting a case manager, and involving the social worker. I told them that Nine Yards was on vacation, but that we would let them know when he returned and arrange a meeting.

My personal opinion? I think these parents will love their child with all their might. I think the child will be very well cared for. My hope is that they always put the best interests of the child ahead of their need to be parents.

With all this, you would think that I would be chomping at the bit to get home. If I wasn't gimping, I would have hightailed it to Pasadena for salsa dancing at Paseo Colorado, then blues dancing at One Colorado Courtyard. However, it wasn't even a possibiility ... and the night shift was short-staffed until 2300. So, I gave myself the smallest patient possible, gave report to the oncoming charge nurse, and stayed four more hours for the overtime pay, and to wind down from a rollercoaster of a day.

Get Gimpy

Up fairly early this morning, after having spent the wee hours of last night drowning my sorrow in watching every new tivo'd thing ... SYTYCD, Law and Order, Sex and the City (the tamed down version that Perky keeps saying should be renamed Heavy Petting in the City), and My Boys.

... and remembered that I had yet to put up a post over at the Exponent II blog. So, looking at my white board, I decided to put on hold the half-dozen ideas I've been contemplating, and post on how on-line LDS interactions translate into real-world interactions. You can see my ruminations here. Interestingly enough, the photo is actually of LDS women. Initially, I was hoping to get an interesting contemporary picture of multi-racial women. But when I typed "women" into google images, the picture showed up on the second page, as part of the Women's History Initiative, affiliated with the Joseph Fielding Smith Institute. Interesting also to note that 2004 saw the first Mormon Women's history class at BYU, co-taught by Jill Mulvay Derr, who I've heard speak at Miller-Eccles, and liked exceedingly.

So, got my post blogged, then headed over to work for the preceptee graduation. I thought about skipping it, but I wanted to be there to support E, and felt that since I'd already told her I would be there, I should be there. Ended up taking my crutches (that I got when I broke my ankle at my first snow-boarding attempt) along just in case. I ended up not having time to get flowers for E, but I've got a good idea for another gift that will do much better at a slightly later time. Was very glad to have brought the crutches along, as the swelling, soreness and stiffness in the demmed ankle was getting worse.

The graduation was nice. The class this time was small, just twenty preceptees for the whole hospital. In the fall, there will be seventy with six in the PICU! They showed the video set to With Arms Wide Open (good grief, could Scott Stapp be any sexier?). It's the second time I've seen it, and it still gets me a little misty. They show video clips of many patients ... critically ill, hooked up to life-support, in surgery, recovering, at clinic visits, playing in the gardens, interacting with staff doctors and nurses, etc etc.

The Chief Nursing Officer, and CEO spoke a few words.

The pain management nurse (who works hospital wide with a team) was the keynote speaker, and had a great presentation about how the preceptor program has changed and developed in the past decade. Of note, our program is so successful that it's being marketed and used across the nation.

The on-site childcare program kids came and sang for us. Image the "You Are My Sunshine" song. Except the lyrics go like this:

You are my angel, my only angel
You made me better when I get sick
YOu'll never know, nurse, how much I love you
Please don't ever change your career.

Totally brought the house down.

And then, the graduates were presented with certificates, etc. The PICU team got the most enthusiastic responses!

Afterwards, spoke with E for a few minutes, and congratulated her. Then hobbled back to my car. Called my PMD, and got an appointment for tomorrow afternoon, after which I expect to get some xrays done. Gimpy has had it ... and it's not even been 24 hours!

An unfortunate incident

Second day on, in one of the big rooms, with a fairly busy pair. And, I was in the room with E, who came off orientation early because we were so short-staffed. I could tell that she was a little nervous, but I reassured her that she would do fine, that she had all the skills do carry her through the day, and provide excellent care to her patients. I'm so proud that she'd been doing so well.

Day went well. Even managed to put in a substantial amount of time into getting the first version of the schedule finalized and printed. E did well,and volunteered to stay over until 2300, since nights was going to be a bit short. At some point I asked her if she was working the next day, and she said that she had the preceptor graduation. A good reminder, although I'd had it penned into my Franklin. Anyway, I told her that I would be there.

Finished work, and changed to go out dancing. Had originally taken a change of clothes to go to the Wed night summer series over in Santa Monica. However, after I read through my juno email accounts (I know, they're old, and not as user friendly as gmail, but I still keep those accounts for certain list-serves), I decided to go to Doug Silton's novice/intermediate west coast swing class, at a location not too far from my place. I've just really taken a liking to WCS, and would like to sharpen up my stylings for when I go to SLC in October.

The class was small, only two leads and two follows, which meant for a lot of personal attention, if not a good variety of leads. We worked on basic WCS styling, and a wide variety of pass-bys ... I liked the double turn ones the best, both in front and behind the leaders. Afterwards, we also worked on a move that they Int/Adv lindy class (which met just prior to the WCS lesson) had done the week previous ... which had a side by side forward movement, cross-handed turn, body stop, and an interesting lat-push by the leads that moved into side by side turns and a shoot-her-out-the-back second half of a whip. Take 5 minutes to describe, and 20 seconds to do. Really good class. Unforturnately, it looks like Doug won't be continuing the class, due to low attendnace.

Didn't change my shoes, but picked up my stuff, and was about to leave. Then, I felt bad about not saying goodbye to one of the leads (who I don't really like, but don't really dislike), so I turned around nad bade farewell just as I was walking through the door. Bad move. I should have listened to my first instinct and kept walking. Because, by turning my attention to the guy, I missed the low step down out of the door. My right foot turned under me as I collapsed, and I followed onto the ground. Ugh ... horrible horrible horrible. After laughing off the event, I slowly walked to my car, becoming surer and surer with each step that I'd badly sprained my ankle.

Got home, and RICE'd my ridiculous injury. Rest. Ice. Compression. Elevation. To which I added my customary dose of advil, for a little non-steroidal anti-inflammnatory action. This does not bode well for the rest of the summer.

There's a first time for everything ...

... even a disappointing night at Lindy Groove.

Work was harried. Unit was busy. I was in a big room, and had a pair. One little thing after another. One patient had a fever and needed to be pan-cultured. The other was pretty agitated, requiring lots of care, and additional pain and sedation meds. Feverish patient also had to get a thoracentesis, and have the fluid sent off for another battery of tests. New batch of residents who need to be broken in. Didn't take breakfast until 1100. Then, thoracentesis-boy had to go down for a hip CT ... since he couldn't fit into the MRI machine yesterday, due to the severe hip contractures that contort his body. Went down for that. When I got back, the resident complained that they hadn't read all of his comments, and we needed to go down for the pelvic CT. Ridiculous, since I think the resident ordered the CT wrong in the first place. Anyway, the fellow SS took a look at the CT on the computer (all of our radiology studies are digital ... I love it!), and said that the hip CT had captured the pelvic info they needed, and cancelled the second CT. Thank goodness!

Spent the rest of the afternoon catching up on thoracentesis boy's quadruple antibiotics (all given via a single lumen PICC line), and was grateful to report off the same nurse I had gotten report from in the morning.

Took a little nap in the staff lounge before heading up to LG. Have to say that it was a disappointing night. Every other year, the Thursday before Camp Hollywood has been fantastic, as all the out-of-towners have been so eager to ge in on the Lindy Groove action. However, I'd forgotten that this was the 10th anniversary of CH, and that they had planned a special event, with an instructor's jack and jill. Needless to say, the crowd at LG was thin. The number of people I wanted to dance with was small. Danced a few numbers with some guys who were eager to impress. Oh, they impressed all right, their thumbs into my forearms so much that the dance was more pain than pleasure! Whatever else it is, dancing should not be painful. I left much earlier than usual, and was glad to escape.

Forth of four

At last! Finally doing my forth shift of four. It's rare that I do more than two in a row ... it just takes a large toll on the body. However, with trying to squeeze in babysitting, et had to be done. Anyway, after today, I'm off work until Monday!!! Sometimes I feel very lucky to have a rather bohemian work schedule. Then again, when I have to work on a weekend on a holiday, there is occassional grumbling. Good thing I'm getting higher on the seniority list, and getting bargained off weekends and holidays.

Went across the street to tour the new mockup rooms. Hospital has been undergoing lots of rennovations and rebuilding ... as is every hospital that's getting retrofitted for the latest earthquake safety codes. New area looks impressive. We'll have one nurses station for every 4 beds, a procedure light at every bedside, suspended rods for monitors, ventlators and IV pumps, and a family space at each bedside. New building is supposed to be finished by 2010, but I'm inclined to be skeptical.

After work, headed up to Paladino's for the first time in years. Paladino's is a dive bar up in Reseda ... famous for being the LA city that the Karate Kid moved to decades ago. Actually, since the remodel, it's not so dive-ey. However, the floor is still sticky and less than desirable. Why go, then? Well, it's where most of the good Hollywood dancers hang out. Dave and Kim still run a fun place ... good music, lessons before-hand, lots of special parties and treats, and good dancers. When I first started going to Paladino's, I was wearing all kinds of vintage and styling my hair in 40's rolls. Nowadays I'm more likely to be wearing pants and a t-shirt, with my hair pulled back and coiled, and it's just as good ... without the drycleaning bills.

Phase III

E has completed Phase II on nights, and came back to days to complete Phase III on days before coming on shift. I really like precepting during Phase III ... it's when all the hard work of teaching becomes most apparent. Now that E's mastered all the basics of routine care, we can talk more about physiology, disease process, treatment and management. Today we had a trauma kid with an ICP. Good review of increased intracranial pressure, Monroe-Kellie doctrine, ventriculostomy monitoring and drainage, treatment modalities, how to recognize signs and symptoms of Cushing's Triad, and what to do for impending herniation.

Didn't go to Lindy Groove tonight. Right ankle's feeling a little tender and bruised after I hit it against a dumbell. However, wore a brace today and my new, expensive, ugly shoes, and didn't have any trouble at work.

And now we'll take a little break for some screaming

WooooooooHoooooooo!

Yeeeeeeaaaaaaahhhhh!

Haaaaaahahahahahahaha!

Wootwoot-can-I-hear-a-wootwoot!

Ahem ...

Yes. This morning I took and passed the American Association of Critical-Care Nurses CCRN pediatric critical care exam. And PASSED! (Repeat first four lines above).

Took a review course at my work a few years ago, and freaked out at the amount and intricacy of the material covered by the test. Didn't take the exam ... pushed it to the back of my mind and let it simmer. But I've lately had more incentive to bring the pot to a full boil.

My hospital is now applying for Magnet status. There's been a huge surge to improve the nursing staff and conditions ... lots of multidisciplinary committees, pushes to increase education, more nursing research projects, and encouragement to get additional certifications. So, my unit started a display in the hall with all the names of the CCRN nurses. So far there are about ten names. Now there will be eleven. And yes, while I don't generally like to admit to being that competitive and that petty that I'd rush to get my name on before a lot of others, I freely admit it in this instance.

Stopped posting on Exponent Blog to concentrate on studying (albeit ofttimes lackadaisically). Took half of the review course again. Sat for a practice exam. Listened to review mp3's until I thought I'd scream. And took this week off work to get in the last little bits of nitty gritty before the exam and my annual trip to Arrowhead.

Thoughts on the test? They're all given via computer at authorized testing centers. Like FK suggested, as soon as I stepped to my desk, I started jotting down notes on the provided scratch paper: ABG interpretation tips, heart chamber/vessel pressures, normal CSF test values, etc. The test was difficult. But that's really the point, isn't it? Found that I hate taking multiple choice tests on computer ... when it came to those questions where we had to choose the best answer out of several correct ones, I had to literally write down ABCD on my scratch paper and cross out the ones I was able to eliminate. I had difficulty with the cardio section because there were so many questions on cardiothoracic pre- and post-op patients ... which we rarely see because they go to the CTICU and not the PICU. However, I did really well in the Pulmonary, GI, Renal, Multisystem and Professional/Synery areas.

When I got my results, I uttered an elated "Yes!" under my breath. This swelled to a normal voice when I stepped outside the office. And became full on screaming when I got into my car! Turned up the radio loud (ahh ... my long lost friend the radio ... I can't wait to be reunited with NPR morning news), and alternatingly head bopped, screamed and laughed for about ten minutes. I think I stopped because the oxygen in my car ran out. The guy in the next car was pretty amused.

Got an hour Thai massage on the way home to celebrate.

And then, watched SYTYCD tonight. I LOVE THIS SHOW. I don't really want anyone to go home. Thoughts on the show (during which I indeed laughed, gasped and occassionally screamed):

Jessi and Pasha (jazz) ~ He is such a comic, and moves so well. Loved how he completes movements, like continuing his hand down her arm after the music finished. They were both sinuous and staccato per the wonderful choreography.

Sabra and Dominic (contemporary) ~ Amazing choreography paired with amazing partnering. When she did that foot pull, it looked like she actually slid him across the floor, eventhough he was really pushing with his arms. Such intricate, innovative and powerful movements. I was in awe.

Lacey and Kameron (Broadway) ~ The routine was okay. However, Lacey is really good at emoting while dancing, at least on the two choreographed pieces she's been on so far. I agree that he moue-ing during the auditions wasn't attractive. And, as much as I think Kameron's beautiful and is a good partner to Lacey, he doesn't seem to move as well when he's on his own. Plus, his shirt was ridiculous. They should have had him wear a vest.

Anya and Danny (Viennese waltz) ~ That reverse attitude spin was truly amazing. Anya is such a lovely dancer. I'm interested in seeing her do hiphop and contemporary. Didn't like the slapdash slashing of shiny material on her costume, but I guess it's less expensive than sewing on sequins just where they want them. Danny has such beautiful lines, but sometimes he just looks stiff and unnatural. Plus, as Wonder Woman astutely pointed out, he seems really cold.

Sara and Jesus (paso doble) ~ Thought the ballroom dance set to contemporary music was genius. His posture was a lot better than hers.

And even Neil (hip hop) and Jaimie (samba) stepped it up by performing so well out of their genres.

And lastly, although it didn't involve any screaming whatsoever, I went to the book club sponsored by my unit at work. It was held at FB's house, which was one of the major motivations, since she's just wonderful. And, Phillip Hawley, Jr, the author of Stigma was going to attend. It was really interesting to hear him talk about his writing process, and how the book eventually got published. Amazingly, Stigma is Hawley's debut book. Wrote it in his spare time. Had a friend look at it, who had another friend look at it, and two years later, it's published and selling at Costco (not that Costco is a purveyor of fine literature, but the book was just that promising). And so it is that a practicing pediatrician now has a contract with a major publishing house. Fabulous. And I have the autographed book to prove it.

Just beneath the surface

Small talk. One of my less favorite things to do in the world. My standard answer to the ubiquitous question, "So, what's new with you?" is pretty standard: work and dancing. Really, that's it. Not even any international travel plans this year.

But dig a little deeper, and there's tons going on.

At work this past week, I took care of a patient with his guts in a sac outside his body. I've taken care of patients with opened chests, where the heart is visible under a transparent betadine patch, but I don't think I've ever taken care of a patient with a surgically extruded organ. Bizarre. Anyway, eight year old patient with a malrotation and volvulus. MD Spaniard, came back with the patient from the OR and said that they couldn't close the abdomen because of the major swelling of the entire small intestine, so they piled the small intestines onto the abdomen, covered it with a plastic sheet, and sutured the sheet to the edges of the incision. It looked like a six inch, bloody stack of cd's on his belly. Good thing I'd put the egg crate on the bed before they took it to pick up the patient, because we weren't even allowed to turn the patient ... which could have kinked off parts of the already injured bowel.

The next day, they took the kid back to surgery to see if they could salvage any of the small intestines, but it was a no-go. They had to resect all of it, leaving only a small portion of the duodenem to save the insertion site of the head of the pancreas. Poor kid will need a small bowel transplant, and maybe even a liver and pancreas if they can get it.

Another day, I taught NM how to work the hemofiltration machine. Hemofiltration is like hemodialysis, except slower. What dialysis does in a matter of hours, filtration does over days. Filtration is gentler, and a better choice for unstable pediatric patients who have temporary renal issues. We've had a run on renal failures lately. Lots of kids on hemofiltration, peritoneal dialysis and even those who get bedside hemodialysis. We're only missing the kidney transplants, which is a shame, since I really like those types of cases. Anyway, it was lucky that my (different) patient needed a circuit change that very day. We'd discontinued the hemofiltration earlier in the day to trial the patient off in preparation for dialysis, but the patient became too unstable, and the lytes were going crazy. So, the didactic class instructors were able to have the class prime and initiate a new circuit. Good timing, since sometimes it can be months between hemofiltration cases, by which time the class members have lost a lot of the info they learned in class.

So, I taught NM how to run the circuit. After the first two hours, she was able to assume total patient care, and used me as a backup. Busy kid. Some baseline neuro-cognitive deficits that will be exacerbated by the lithium overdose that bought her to the hospital in the first place. Nasty stuff, lithium. They had to start her on hemofiltration to remove the lithium. When her levels got down to below detectable, they took her off the circuit. But since lithium is stored in the tissue, her levels shot up after a few hours. The neurology team is pretty certain that she will have some permanent functional deficits after her acute symptoms resolve. At least she will be followed by our team from now on, not the crackpot local team that had her on too many antipsychotics in the first place.

ECMO staff meeting the other week. We may be starting use of a new pump specifically for the post-op heart patients. Which will mean cross-training for the CTICU and PICU ECMO nurses.

And, dancing ...

Wonderful night of dancing at Lindy Groove. An almost perfect dance with StretchJ. He really excells at the faster tempos, which I tend not to like. But, there are songs that are just at the higher end of my tolerance, and at the lower end of his, where our dancing is just superb.

A great, break-laden song with Sociologist. He uses a lot of weight behind many of his crazy lock-turns, etc. And I love those moves because he maintains firm-but-painless connection. And because he especially loves doing those moves with me because he likes the way I counterbalance. So good, especially if the music is more moderately tempo'ed.

And lastly, my favorite new leader of the night, D-Roca. Really, he looks like Mo Rocca (who I find adorable), except with a really bushy head of hair. D-Roca was celebrating his birthday this week, and his style was so funky that I had to jump in on his birthday dance. Later, we grooved a little to some alt-swing music, and it was a blast. Finding new, danceable leads is such an A-Ha/discovery moment.

And, more dancing ...

Tivo failed to record SYTYCD on Wed and Thu. What a tragic disappointment. Spent Friday morning scavenging info and dance clips on the net to appease my inner demons. In the process, I decided that, instead of swing or salsa, that I would teach Nightclub Two Step for the mid-singles FHE in July. I just can't stand teaching east coast swing anymore. Besides, NCTW is super easy, and much better suited for contemporary music. And, I found this clip of Jeremy and Monica doing NCTS. Jeremy is one of my favorite leads to dance with in Utah, and it made me curiously happy to see him dancing NCTS and West Coast Swing. In the WCS clip, Jeremy even does those he-goes-she-goes travelling turns that he's so good at leading. Utah is a long way to go for NCTS and WCS, but I generally can't make it out for WCS on Thursday because I go to Lindy Groove, or Sundays, when there's dancing at Memories, but I choose to stay home. Anyway, seeing people at the Murray Arts Center made me realize how much I miss dancing there.

Incidentally, Jeremy reminds me of His Vickness. Neither are flashy dancers. They don't stand out because of crowd-pleasing moves. They stand out because they are fantastic leads that interpret the music well, are very ogranized and clear in their lead, and allow the follow to just relax and enjoy the dance.

So, I've decided to teach NCTS, and am putting together a lesson, and I've recruited a friend to help me teach. Fun!

Also, there's just a ton of dancing during the summer! The LA and SM YSA's are doing a summer dance series on Wed nights. Dancing Under the Stars in Pasadena on Fridays and Saturdays starting in July. Camp Hollwood at the end of July. And Paladino's in open every Tuesday in the summer. I feel like dancing all summer!

Yes, there's really only work and dancing occupying me nowadays. But there's plenty going on just below the surface.

Somnambulist

Up at 0630. Did the bare minimum morning routine and dragged myself into work for ECMO recert. I do enjoy being on the ECMO (extracorporeal membranous oxygenation ~ like a heart-lung machine) team. The patients are so sick, and the balancing act is much more nurse driven than anything else I do. The physicians set the parameters, but the nurses are the ones who juggle the balls and decide which drips to titrate and how, and how to adjus the machine to maintain the patient. They've come up with a new protocol for the Cardiothoracic ICU to prevent the excessive bleeding from their post-op hearts. I'm excited to see the figures. Also, they're considering getting new pumps for the short-term post-op hearts. This will mean cross-training for the CTICU and the PICU.

We also got to work on a practice pump. Walking the raceway within 40 seconds. Repairing the raceway. Reparing the bladder. Removing air from the circuit.

Then we had a discussion about what our worst EMCO nightmare would be, and how to deal with it. Personally, I would freak out if the cannulas dislodged. Blood spurting, patient decompensating, machine beeping like a banshee. I've never had it happen to me, but it's known to happen when surgeons aren't careful, when moving the patient, or even spontaneously. If it ever happened, I'd have to apply pressure to the cannula sites to prevent a bleed-out, and yell for help. Someone else would have to maximize the ventilator settings, go up on the pressors (making sure that they were actually connected to the patient and not to the circuit), administer volume (saline, then someone drawing up the blood or FFP we keep at the bedside), get the crashcarts in position and start drawing up code meds, while someone calls the surgeons to come stat and replace the cannulas. It would be especially bad if this happened on a post-op heart patient, because their cannulas are generally inserted directly into the heart, the chest is left open, and an iodine patch is left in place. If the patient accidentally decannulated, there wouldn't be a place to effectively apply pressure.

And on that happy note, ECMO recert was finished.

Went and got a Thai massage. My calves were a little sore from getting used to my new Aris Allen shoes. The masseuse really worked me over. So good, even though there were a couple times that I yelped. T Diddy would have laughed.

For some reason, I didn't end up taking the nap I sorely needed. Instead, I ended up going to see Pirates of the Carribean II with Boss and a couple of his friends. Not normally a movie I would have chosen to see (at all, even less in the theatre). However, it was good to connect with Boss and chat a bit. He's a hard guy to get a read on. A little closed off. But I respect his opinion.

After the movie (I saw #1, but didn't see #2 because of the awful reviews), everyone gathered in the vestibule. Someone asked me what I thought of the movie. Trying to be diplomatic (because I didn't want to be the one to say, "Whoever wanted to pay $10 to see this in the theatre has no taste or sense of proportion.") I said that it was a good movie to see in the theatre because of the special effects. Then, everyone started trashing the movie. Ha!

I decided not to go to dinner with the crowd. Afterall, there was dancing at Do Something Blue to attend. Stopped by at Borders to get a copy of Stigma. The author is a pediatrician, and knows one of my managers. Frannie is having the bookclub at her house in June, and Hawley will be attending. I haven't been to my work bookclub in a while. Mostly because they are on nights when I have other things planned, but also because of some of the flops they've chosen to read. Now, Running With Scizzors and A Million Little Pieces aren't flops in the conventional sense, but I stopped reading and threw them away because they just made me feel *icky.*

Anyway, as I was standing in line, I read the back cover, and had to keep myself from laughing out loud. Either the book is really bad, or the publisher needs to hire a new backcover writer. It was that bad.

After walking back to my place, I decided to take a nap before heading out for dancing. Dancing would go until 0200. Drank a diet coke just to make sure I didn't sleep too deeply.

When I finally woke up, the clock read 0300. Bummer. Turned over and slept until the morning.

Craziness of Being in Charge

In charge today. Came prepared. Large quantities of chips and salsa to appease the villagers (staff on the unit). If, as Mary Poppins postulated, a little bit of sugar helps the medicine go down, then snacks in the back help the staff bear their burdens easier!

Day wasn't too bad. Little fires here and there. Tranferred one of four possible patients to the floor. Had little alert for possible admission calls from the OR . One nurse had to go home sick. I went to lunch feeling good, and even managed to take a 20 minute nap. Then I came back and was accosted.

Clinic patient had to be admitted because there wasn't an appropriate bed on the floor. Had to staff for a liver transplant admission. Two trauma calls from the ED. One night nurse called in sick. One unexpected post-op admission. One transport from another hospital for a surgical consult.

Ended up taking the clinic patient, eventhough it was later discovered that she was in the middle of a chemo regimen. Was able to staff for a team leader to admit the liver tranplant later in the night shift. Trauma calls ended up being stable enough for the floor. Took the post-op. And our ICU team ended up postponing the transport when I explained the staffing difficulty.

At the end of the shift, I was able to give report to Fearless Leader (one of the core charge nurses, and probably the most knowledgeable and capable nurses working in my unit). And I escaped to Lindy Groove.

Of course, I stayed later than I should have.

Mr. Little was back from San Diego for his second summer law internship. He's short and skinny, but he's a fabulous lead. He's got this interesting styling ... pulling back and twisting his right shoulder during a whip that no one else does. He also reminded me that SYTYCD was starting tonight. I hope it's still going to record since I haven't touched the tivo programming on it since last year.

His Vickness and Evincerator. Love these guys.

CaucasianStretchJ and I talked about Yosemite, where he is going this weekend. Reminds me that I need to condition and make at least one more trip and make it up to the top of Half Dome. Up the Rainbow path (past the waterfalls), and down the backside (with all the switchbacks), armed with my camelback and trekking poles. And hopefully no thunder like last time.

Darring showed me a new Charleston angle-shifting movement. Very easy and smooth. I can't even remember how he did it, but that just shows what a good lead he can be.

Left at about 2330. Got home and checked to see if SYTYCD had recorded. It had. And I WATCHED THE WHOLE THING! Nuts. I'm so nuts.

Work horse

What a week! I have been at work every single day this week, and I'm exhausted.

Monday I was put in charge because the core charge nurse called in sick. Craziness. We were well-staffed, but 2W was trying to steal one of our nurses so that they could take a post-op, and 4W was trying to sneak one of their patients in. Plus, we had a lot of preceptees. Insane. Luckily, I had Tso as my team leader, and she helped get people out on breaks and was able to coordinate patients travelling to procedures so that we didn't fall behind.

Tuesday I was scheduled to be in charge. Again with the craziness. No CNIII's ,since they were all at the meeting, so I had an interesting mix of new and moderate RN's. The 4W patient hadn't even been started on chemo, which was the reason she was sent to us. We had 6 patients travelling to MRI, CT, fluoro and dialysis. SaSo was the team leader, but she'd never even responded to a trauma page. I went with her the first time and showed her the ropes. I think we had a combined number of six trauma pages. Ridiculous. At least all of them looked good and didn't need to come to the PICU.

I forewent going to Paladino's on Tuesday night, eventhough I really wanted to see the old crowd.

Wednesday I went to CCRN review class for the cardic and respiratory content. Many good lectures. The cardiac defect and staged repair lecture was good ... the first one on this topic that I've really fully understood. It's just so far from my regular practice, since those patients all go to 2W. FK also gave a superb respiratory lecture. She wears so many hats ... respiratory therapist, RN, and recently passed the CCRN. A very good day.

Thursday I precepted EC again ... our last day for a couple months. We didn't get a pair, but were able to focus on a mildly critical patient, and she did fairly well. EC will be on nights for a couple months before she returns for her last stretch. I like her, and like precepting her, but it is tiring.

Thursday evening I went to Lindy Groove. Maybe I shouldn't have. But sometimes a little dance therapy is needed. Plus, I'd already skipped out on Tuesday.

Friday I again woke up early and went in for the CCRN practice test. Two years ago, when I took the full review course, I freaked out because I felt so unprepared. This time, eventhough I'd missed half of the review session, I passed with a few questions to spare. What a relief. I'm going to continue studying hard, but it's a huge relief to know that I'm on solid ground. Also, since this is a scored test, I'm shooting for top 10th percentile. We'll see.

There was a Do Something Blue event tonight, but I was so worn out that I skipped that too. Really, I hope to never have another week like this past one.

Doing something blue

(Darn it, the heads got cut off! Anyway, this is the logo for DSB.)

Went and got my hair done today. Marvelous and easy drive up to Glendale.

Afterwards drove out to San Marino for a Do Something Blue dance.

Tracy lead the lesson, with Melissa as the follow. Lots of really good information and technique. And I liked how Tracy kept reiterating that it was just a dance. Seems as if some new dancers get the feeling that because they are dancing with someone so closely, that their partners must necessarily feel some romantic attachment. Not that I deny that it can happen, but it's generally a good thing to talk to the person one has romantic feelings for, as opposed to stalk them on the dance floor.

During the lesson I danced a couple of times with That Tall Asian Guy. TTAG is tall, asian, slightly older, very stiff, and always creeps me out a bit. Maybe because he physically reminds me of my father. Maybe because he always comes on a little strong. Maybe it's the overpowering cologne. Maybe it's because I think he thinks he's better than he actually is. I don't know. For whatever reason, I don't really like to dance with him. Which is unfair, because, deep down, I do think that he means well, and is probably just insecure. And it's not like he's creepy in the blatant manner of Dead Fish Guy.

Did manage to get some dances in with Arthur and Arnold ... both amazing blues dancers. And talked some with LitheOne (who I met at Gwynn's party) and some other fun (and also little) asian girl. We commiserated about Dead Fish Guy. Creepy. Even more so now. Before, he usd to plaster his hair to his head in imitation of Nick. Now it seems as if he's decided that more is more, and is growing his locks out. But even more than the hair ... it's the inappropriateness of him. Inappropriate dips, drops, lifts and leans. Creepy hand gestures. Always searching for young asian women. And (per report) inappropriate touching. Creepy. I generally dance with anyone who asks, but whenever he's around, I always find something else to do to signify that I cant' dance the current song.

Also talked some with Sheri. Didn't know that she worked as a physical therapist. Turns out that she regularly works with one of the more spectacular patients that came through my work. When she mentioned the name, I immediately knew who it was, even though it's been almost five years since the admission. Will have to report back to the old-timers at work on the progress. Most of the time I eschew talking on the dance floor. Really, what can be said in a couple minutes that can be worth exploring when there's music blasting in the background? But everyonce in a while I click with a person or topic that merits going beneath the surface, and this was one of them.

The Payoff

Every once in a while, when I've had a not-very-stressful day at work, I do something crazy. Like agree to do a double or triple shift. Yesterday was one of those days. A couple of nurses had stayed over from the night before, and some came in early, in the afternoon, to help cover the unit ... every bed full, the ED back-logged, and OR cases being held in the PACU until we could move more patients to the floor. So I wasn't surprised when Mon asked for nurses to stay over. And I was prepared. Twenty hours. Mine had been a relatively easy day, although my assignment did double up after the first twelve hours. But that's fair, as I was earning double time plus the night-shift differential. More money in my pocket for Paris.

However, my pay-off came early. At about 0200, when I came back from break, a little droopy-eyed (and you thought this was impossible for Asians?), Topsy came over and donated a blissful ten minutes to dissolving the knots in my shoulders with her thumbs and elbows. Or at least I thought those were her elbows. Maybe she just has really strong thumbs. Pressure, but good pressure. Enough to move the chair a few inches. I wanted to swivel the chair around so that she could have better access, but I didn't want to disrupt the flow. Anyway, I felt the knots when she found them. Then I felt them pop and dissolve. And then I felt good.*

AC took report from me a little early. And so it was that I was on the road home at 0300, and in bed by 0330. Until I woke up at my customary 0600. And felt the knots ... again. Oh well. C'est la vie.

*Fred the Man continues to assert that PICU nursing is really stressfull. Not as stressful as managing a family restaurant in the Austrian Alps, but less stressful than managing a family restaurant in the Austrian Alps under the watchful gaze of family. I don't know. I don't think my work stresses me out unduly. It can be difficult, but I tend to leave work at work. Otherwise I write it up here and let it go. Maybe it's just that I realize that while I do good work, it isn't incumbent upon me to be there for good work to be done. I contribute a lot, but I'm not the lynchpin. Or rather, I don't feel guilty about taking a "mental health" day when I need it. Or just plain want it.

(Career) Woman Interrupted

I posted this over at X2 today. Some interesting responses so far. The thing is, I don't know how I would react to being a stay at home mother. Would I love it? Would I tear my hair out? Would working one day a week be enough to keep my sanity if I started to lose my grip? I don't know. And I'm not entirely convinced that I can know until I'm actually facing the situation head on. Of course, this is all academic. I'm still single. I have no children. And I seem to constantly be looking for ways to cut back on my hours at work. But I take comfort in the fact that there are many different answers to the question of how to balance family and work. And that even a man as traditional as my father was able to carefuly listen when my mother approached him with her issues, and that they were able to find a solution together.

I'm not warm or fuzzy ... or fuNNy

The other day a friend was upset that one of her bosses said that she wasn’t very warm. This was interesting to me, since I think of her as passionate and involved. However, her job is so demanding, that I can see how it would suck the ability to share warmth with others right out of her bones. Anyway, I told her not to worry about it too much. But maybe I’m biased, since I’ve gotten the same type of comment from the manager who does my yearly evaluations, although probably in a much gentler fashion.

I don’t get emotionally involved at work. I’m not one of those touchy-feely nurses who wants to sit and talk about feelings for hours on end. At work, I like to have really sick patients. And it I can’t have a really sick patient, I’ll settle for one who’s intubated and sedated. I especially don’t like to have patients whose parents are a mess. Which I understand is unfair. Any parent whose child is in the ICU would probably be a mess. However, when it gets to the point that I’m spending more time dealing with the parents’ emotional problems than the actual patient, is when I get really, really irritated. (BTW, I’d like to send a shoutout to the PICU social workers. Love them. Especially this week. Major interventions with two crazy families).

So, I don’t tend to get involved in my patients’ emotional lives. There are a couple of Extra Nice Nurse things I like to do … French braid the girls’ hair (those who have long hair, are mobile enough, and will be in bed for a long time), sing (when there’s no one else in the room), and hold fussy but consolable babies … but these are secondary to actually providing requisite care, and generally only happen when there is time to do such extras. My main concerns are making sure patients are stable, safe, comfortable and clean, and keeping the parents educated and informed.

Another not-really-related thing I’ve noticed … I’m not very funny, and I’m not very invested in fun.

I’m not a very funny person. I have a hard time telling jokes. Sometimes I don’t think other people’s jokes are very funny. I don’t like American stand-up comedy. In fact, I don’t like stand-up in general. Except Eddie Izzard. And only really in Dressed to Kill and Glorious (We went to see him live in LA a couple of years ago, but I was too astounded by the fake boobs and the crotch-high slit skirt to pay much attention to what was coming out of his mouth). Except that it’s mostly because he’s clever. Not to say that he’s not funny, but I like him because he’s clever and witty.

Which leads to me next point. I’m not very invested in fun, for fun’s sake. This may seem like splitting hairs, but I’m just not interested in just having fun. I like to do interesting and fulfilling things, and find a measure of fun in them. But I don’t do them because they’re fun … I do them because they’re interesting and/or fulfilling. Take iceskating. And no, I’m not very good at it (and it's been a while since I've been). However, I started doing it because I wanted to strengthen my ankle after the snowboarding accident (and no, I’m not good at snowboarding either). I continued with the iceskating because it got me out of the summer heat, and because I could feel how it strengthened my body in general. And because I liked finding ways to move to the music. Yes, it was fun, but that was the least of the draws.

And maybe what I’m really trying to say is that I don’t trust “fun.” I have many fun people in my life. And I enjoy them immensely. But when it comes down to getting things done, I generally can’t rely on the fun part of their nature to do those things. Or rather, I have to come up with fun angles to get them to do those things that need to be done.

So, I’m not fun. I can live with that. Now, let’s go out and have an interesting and fulfilling time.

On getting the snarkiness out

The past two days were icky ones. Really smelly patients. Hectic and annoyingly busy patients and parents. Three transfers cancelled … and that was just in the room of four that I worked in. Ick.

After work I had to wipe myself down just to get the ick off. Changed. Primped a little. And was on my way to Lindy Groove for some dance therapy. Was so sensory overloaded that I made the trip in total silence. Not even the voluptuous repetition of “Prepositions and Other Useful Words” in French.

Up at LG, I put my things away, and sat for a minute or two in the usual spot, chatting with PlumbCheery.

A woman sat next to me and said, “Excuse me, I need to get to my water bottle.” No problem, I thought. We all deposit our things along the periphery, and need to retrieve things once in a while. So, I started to turn so she could reach past me. At which point she maneuvered me out of my seat and took it over. I had to laugh, and I shot her an amused but questioning glance, which earned me the reply of, “Oh, I put my sweater here to mark my seat.”

To which I archly (and piquantly, as you may imagine) ruminated, “Oh, I didn’t realize we were reserving seats now.” And went off to dance with PC. It was rather bizarre. At LG, there are no “reserved seats.” There are people who tend to sit most of the night, but that really just defeats the purpose of going out to dance, now doesn’t it. There are tables for birthday celebrations (which are free, and which come with a grocery store cake), but even those usually devolve as the night wears on.

Anyway, as we were about to start dancing, I asked PC if I’d been really obnoxious. Actually, I stated, not asked. He gave me one of his cheery smiles and said, “Well, I understood why you said it.”

So, straight away after the song, I approached the woman (who is probably my own age … fancy that, I’m a woman) to make amends. Turns out that she comes from tango dancing, where seating is apparently more rigid. Seems she is relieved to be switching from milonga to lindyjam. We both laughingly made our apologies and parted with good will. Hopefully she won’t spend too much time in “her” seat.

I should probably note that tonight was LG’s first ever lindy competition. The first place couple (I don’t know their names) were good. Entertaining and good musicality. Even if I’m not a Savoy fan. Second place were Nick Williams and Kristin Sorci. And they are good dancers (for those in the know, they are the ones who trained the Dmitri and Donyelle for the lindy routine on SYTYCD), but didn’t really sparkle tonight. Personally, I would not have ranked them. And in third place were Jeremy Otth and Sarah Whatserbucket, who are not regular partners, and were entertaining, but not great. Really, Julius and Holly should have won. And they might have, if Julius hadn’t fallen on his tush while doing a slide drop. Even now I can’t help but giggle. Also of note were Katya (getting every break with a bang) and Gio and MaeLae (for the swivels with the lead slides … they were hot).

Got home and was still amped up. Watched Grey’s Anatomy and Men in Trees before I was relaxed enough to shower and climb in to bed … about 0300. Sometimes it just feels good to return to my nocturnal roots. And thus was the snarkiness expelled.