Elopement and a Cuppa Joe

Perry, a Mental Health Specialist (the folks who do a ton of the patient care work around the hospital) comes to me Monday morning as I'm finishing up a discharge and asks if I've seen Curt, one of our new patients. Perry was doing rounds and saw Curt on 15" checks at 10:45, but now it was about 11:05 and he couldn't find him anywhere.

I call "Staff!" to alert the other MHS's that I'd like to have some help, and I get a reasonably good response. "Perry can't find Curt - can we all look?". Sometimes staffers doing rounds can't find a person because they're in the shower or sleeping in another patient's bed by accident or maybe just hiding in a corner somewhere. We spread out and do a thorough sweep. No Curt.

Somehow Psych Doc ends up at the end of the hallway and pushes one of the fire exit doors and no alarm sounds - the door pushes open just like *that*. Staff can use the doors by keying them open, but we're not supposed to because sometimes patients can go out if you're not watching carefully. The doors work a certain way to remain safe yet patients can't escape through them easily unless someone leaves one open.

I jogged down the stairs wondering if I'd catch a glimpse of Curt but no luck. Outside there is a reasonably high fence in a courtyard that will not open without a key. I found a piece of wood leaned up against the fence where he must have climbed over.

I came back inside and called the police. They usually locate patients who get out in a matter of minutes - some more easily than others. Curt was wearing a hospital gown, a yellow wristband, and was sans pants.

He was down the street at a coffee stand having a "free" coffee as the owner of the stand called us. From what I understand, the espresso stand owner motioned him over (believing him to be one of ours) and said "Hey buddy, free coffee today - under new management!!", sat the patient down in a patio chair on the deck, gave him a cup of coffee, and called us.

We've got some great neighbors.

Oh, and we checked the video and one of the utility guys had gone out the door. Looks like Curt caught the door and kept it from closing all the way, and then snuck out after the utility guy had gone around the corner.



(All names in this completely fictional story have been changed. In fact, it never happened. That's the ticket.) :)

Songs

Well, this weekend was a washout for blogging! Good job, as Kim has frequently pointed out, not too many people read blogs on the weekend.

In the meantime, Neonatal Doc has tagged me with the "Songs of the Moment" meme. Some of these aren't terribly current:

1. Snow Patrol, Chasing Cars.

If I lay here
If I just lay here
Would you lie with me and just forget the world?

Apparently this one was on Gray's Anatomy. They've been playing it here a bit, coinciding with a difficult week it seemed to speak volumes.

2. The Martinis, Free.

Omniprescent phrase in my mind
Spoken word I've heard one million times
Who are you to tell me that I'll always be this way
I close my eyes and I turn around
Leave it all behind

Sometimes simple is best.

3. Red Hot Chili Peppers, Soul to Squeeze.

I got a bad disease
Up from my brain is where I bleed
Insanity it seems
It's got me by my soul to squeeze

4. Goldenhorse, Dark Forest.

Underground the roots are your hair
And the leaves, leaves are your hair
Behind your changing face

Many times we try
Caught there by the tide
We walked into the light
But we couldn't find her
We didn't find her

Fantastic New Zealand band, do yourself a favour and check these guys out. Off-beat melodic pop.

5. The Muttonbirds, Anchor Me

Another classic from the land of the long white cloud. This is a Don McGlashan song that was covered by a group of artists recently for the anniversary of the sinking of the Rainbow Warrior.

How many was I supposed to do? Bugger it, I'll finish this later. The last of the sun is shining outside!

Change of Shift 7

KT Living hosts this edition.

Belated Grand Rounds pointer: at Tundra Medicine Dreams.

Today's lesson in medical equipment management: if an oxygen bottle is on your desk with a note taped to it saying "Can't turn on!", try turning the valve in the other direction. Nine times out of ten, it was already on...

Call for Nominations: October NBOTM

Now, with HypnoKitten in the throes of buying and moving into her new home (everybody know what that's like? You do? Any questions? Didn't think so!) the Nurse Blog of the Month award has been on hiatus. This will not do! Therefore I'm taking the liberty of stepping in and calling for nominations for October.

In fact, it's the award for March, April, May, June, July, August, and September combined; a very prestigious honour!

Although we love Third Degree Nurse, we probably won't be putting a big permalink to her blog at the top of our site forever. It's somebody else's turn... feel free to nominate the blogger that inspires you, educates you, makes you laugh... it's also absolutely fine to self-nominate. The only restriction: their site must carry the NurseBlogs logo, and must contain recent posts.

Nominations in the comments section of this post please.

(Attempting to maintain a daily posting schedule, figured this was a good way to start ;)

Called

Lately I've been reticent.

I think about what I want to say, and then about what my colleagues would think of it. What the wry and acidic anaesthetic consultant would say if he knew I thought this way. How nurses on the floor, many of whom are already a bit sceptical about me, would react. I pause, and don't write anything at all. We're such good censors of ourselves, aren't we? It's insidious.

Then last night I--well, to do this right I have to go back a few days.

It has been, folks, a rough fortnight. Rough month, really. Our unit got worked. Everybody's tired. Things are just now starting to slow down this week, and I hesitate even to say that because they might speed up again!

Towards the end of the week I received an admission who coded on the ward. A few months old, disasterous medical history. As we worked to stabilise him, it became clear to us that this was not a child who would grow "to make old bones", as the saying goes.

It was one of the longest, hardest days I've had in recent times. One of those shifts where you're still catching up on documentation long after you should've been home. A fast, sad, taxing shift. I went home without much expectation that the infant would survive.

The next morning it was all absolutely clear: with a lactate above 30, terribly coagulopathic and on high ventilatory pressures, in fulminant liver failure, there was no going on. We withdrew care and he died.

I will leave the details out of this account. Suffice it to say I regard this as the hardest 'withdrawl' I've ever had to perform. Alone, in a single room, pulling out tubes and coping with the inevitable bleeding, managing analgesia and monitoring the patient, all amidst the loudest and most visceral outpouring of grief I have ever seen or heard.

I was beyond exhausted at the end of the day, and the weekend was rough. You do start to question whether or not you're in a sensible profession after all, that has these experiences in it. I don't know anybody in this city outside of work, so stewing in my apartment alone for two days didn't exactly help my frame of mind.

At the start of this week I met with our very smart psych who helps with debriefing after traumatic events on the unit, and talked it through. At the end of the day I went out of the hospital, down to the harbour and hopped a ferry across to one of our local beaches.

It was getting dark as I walked along the foreshore, and not the warmest of winter days. I was having trouble with the images: black deoxygenated blood oozing from central line sites and between my gloved fingers; the shock on the face of a young cousin, maybe three years old, eyes wide as he stared around the room at his crying relatives. Sometimes these images are addictive. It can be very hard to stop playing over them in your mind, once they get burned in there.

By the time I got to the end of the esplanade it was completely dark, and the wind was getting up. Lights flared on the ferries as they passed, making black waves. I said my goodbyes there, looking out over the water, told him I was sorry. A cold gust blew in across the sand, hit me in the face and I realised: this is what I was going to do for the rest of my life.

Suddenly I understood why people talk about their calling; why, in the face of difficulties that seem intolerable, with token pay and anti-social hours, they keep coming in to work. It's no longer cool to say it, but it has become inescapable for me... I feel the call. It is not just an occupation. It is a life's work.

I am where I am supposed to be.

The clarity of purpose I felt was astonishing. I can feel it now, surrounded by the distractions of the day. Perhaps my colleagues here would chuckle if they read this, but I reckon more than a few of them feel the same way, even the ones who would never admit it.

Is thirty-four years of age late to find your true calling?

9/11/06

They that love beyond the world cannot be separated by it.

Death cannot kill what never dies.

Nor can spirits ever be divided, that love and live in the same divine principle, the root and record of their friendship.

If absence be not death, neither is theirs.

Death is but crossing the world, as friends do the seas; they live in one another still.

For they must needs be present, that love and live in that whch is omnipresent.

In this divine glass they see face to face; and their converse is free, as well as pure.

This is the comfort of friends, that though they may be said to die, yet their friendship and society are, in the best sense, ever present, because immortal.

William Penn, from More Fruits of Solitude

Decommissioned

As I mentioned previously, I'm on a little 'sabbatical' from the PICU this month, filling in for the technician's position which involves looking after all our electronic and mechanical bits and pieces. The first week has gone well. I had to put quite a few hours in, but it was an enjoyable change of pace.

I actually fixed things! Me, who is not in the slightest bit 'handy'. A bed side was broken, I found a part for it, took it to pieces, figured out how it worked and put it back together again. Ok so it's not laparoscopic surgery but I felt an inordinate sense of pride at having contributed to the unit on such a basic level.


Then on Wednesday one of our baby warmers, an ancient and reliable frontline soldier in the PICU trenches, started alarming. "E0 13", it said. "E0 13". Nothing we did could convince it to stop shrieking, so we disconnected it and swapped it out for another warmer. I went to look up the manual. "E0 13," said the manual, "heater not turning off."

When things like this happen, we turn to our biomedical engineers. "Fix it," I said, "if you can do it quickly. Otherwise it was probably going to be the first one taken off the unit anyway." We have brand new warmers coming, so there isn't much point spending money on the old ones.

A few days later biomedical get back to me with the report that the warmer needs to go. "The wiring is all corroded inside," they say. "Too expensive to repair. You'll need to decommission it."

It turns out there are forms involved. Forms to be filled out and signed, in duplicate, and barcodes to be recorded, and approval to be sought. Has the equipment depreciated in value? Is it to be scrapped, salvaged, sold? Has it, in fact, been stolen? (If so, please attach copy of police report.)

For awhile I was amused by the image of a burglar trying to sneak out through the security doors and across the helipad pushing our baby warmer, hopefully sans baby. "Honest, officer, I was only road-testing it!"

After I'd negotiated the paper war, I cannibalised several attachments for spare parts. And then it was done; bereft of all trappings, it squatted in the middle of my office, waiting to be discarded. Although I tried to dismiss it, I couldn't help feeling unsettled as I stood there, thinking of all the infants who'd died in its perspex arms. The same mattress, used and cleaned over and over, exposed to blood and shit and Betadine and snot and tears, the same mattress for all of them. So many nurses hands on the cotsides, so many tired registrars trying to duck under the heater to intubate at 1 AM. Radiographers folding back the overhead to take xray after xray, irradiated over and over. Parents leaning on the edges, struggling to fit between the ventilator and the haemofilter.

History, on wheels.

It somehow seems wrong that it'll end up in a dump somewhere, a scrap yard, left to rust. But the newest Plastic Fantastic is on the way, and everything is disposable. On Monday I'll wheel it out of the unit and not give it another thought. Except to say to the designers, the engineers who gave it birth, the guys who tend not to get a whole lot of credit in medicine: you done good. It stood the test of time.

Zipredol

One of our nicer patients (who's still not quite oriented) visited me while I was passing out meds. With a shy smile he asked me if I could get the doc to prescribe "ZIP-red-ol" for him. "You know, that medicine that makes you not hostile".

"You don't seem hostile to me. In fact, you're quite nice."

"Oh, I know, but I've hear it's very good and I don't want to ever get hostile"

I've never heard of Zipredol - I imagine he was combining the names Zyprexa and Risperdal. I wish the patients that needed it the most would want it so badly...

:) Turn up your volume - this clip is a little old and you may have seen it before, but this scene reminded me of it.

Rounds

Grand Rounds 2:50.
Change of Shift 1:6.

Yes, I'm sorry he's gone

I wasn't a huge fan, but there's something about Steve Irwin that just made you want to watch. He seemed like someone with a good and true purpose, even if one didn't always agree with his methods, even if he became a caricature of himself at times. I'll miss him.


(I know I'm horrible, but when I first heard, I immediately thought -- wow, sting ray barb to the mediastinum. That'd make an interesting CT scan. Yes, I am an unfeeling monster. You may commence with the scathing comments.)

House

No, not the tv show :)

PaedsRN is right, I have been pretty busy lately - I just bought my first house!

Now I'm working on finding enough boxes. We've got a lot of stuff to move and we're not going to take any days off to do it. Closing date is October 2nd so we've got time to pack neatly and maybe have a garage sale before we go. I'm so excited! Finally I'll get to decorate and paint the way _I_ want to, and plant things and make a garden however I like rather than worry about what a landlord has to say.

It's a really cool house, too. I'll probably post pictures of it while I'm cleaning and painting.

Anyway, in case you missed me that's what I'm doing. ;)

-HK

GeekNurse Link Repair

I now realise when I shut down GN I also broke one of the links in the Grand Rounds archive. I've just rectified that by re-publishing GR 2 No 25.

That got me to reading through old posts again, which are no longer available for public browsing on the blog. There's some good stuff in there... some silly, but some worthwhile. I wish I knew which ones were found to be most offensive, and who felt threatened by them. Wish that people had come to me and discussed it openly, instead of hiding behind a manager. But turns out wishing ain't good for much except throwing money down wells.

Pitstop PICU

Great Ormond St have been in the news lately with their improvements to post-op logistics, which they credit to a collaboration with Ferrari pit crews. The parallel never even occurred to me, but it's an interesting one and something which I'm going to be thinking about over the next month or so.

The major restructuring of the patient handover procedure, resulting directly from the input of the F1 pit technicians, will soon be described in two scientific publications.

"It is not too early to say that, when we look at the number of critical instances we encounter, they have reduced markedly since we introduced the modified training protocol developed from what we have learned from Formula 1," said Prof Elliott.

The single A4 sheet of paper, which contained the flow diagram of Ferrari's pit procedure, became several pages of twice that size when Mr Stepney and his colleagues at Ferrari were confronted with the critical transfer from operating theatre to recovery room at Great Ormond Street.

"They were quite shocked at the complexity of what we did and the kind of kit we had at our disposal," said Prof Elliott. "They saw us operating on a solid table with the child under a heating or cooling blanket and all the vital connections to the various bits of equipment and then having to unplug everything and use a hand-operated ventilator as we took the patient out of the theatre, into the lift and along the corridor to intensive care."

I have a new job, at least for awhile--I'm filling in for the departing PICU technician until they find a replacement for him. It's an interesting line of work, though not something I'd consider doing full-time since there is little patient contact. Basically I get to look after all the machinery around the place, troubleshoot ventilators, pumps, monitors, make sure there's plenty of all the major stock items we use (ever run out of ventilator circuits at 9 PM on a Friday night? It's not pretty) and in general find solutions for many of the odd problems we encounter in the course of our work.

It will mean no night shifts for a month or so, and a chance to try something different. Plus I figure more familiarity with the 'gotchas' of the technology we use every shift couldn't hurt.

I believe HK is in the throes of buying a house at present, so she is probably undergoing considerable stress!