Spidey-sense

I was having an interesting conversation with a resident earlier (and actually, gasp, enjoyed it) about how to know when to intubate a patient that looks like poop, but has a relatively normal blood gas. It was interesting in the sense that he really was looking for my opinion/experience on the matter. We bounced ideas back and forth and came to a few major points to look over. 

1. What does the patient look like? Labored, sweaty, pale, jaundiced, only awake when aroused, old/young? 

2. Are they oriented to time/place (sans hypercapnia)? (ie could they anticipate vomiting and warn someone about it?) 

3. What disease process(es)/history is causing this? Someone with ESRD can usually be fixed with bridge bipap/dialysis, whereas a stage 4 met lung CA patient is terminally ill and will succumb to the disease eventually.

4. What are the other vital signs/labs? Basically, are they about to code b/c their BP is labile and HR is jumping from 120's to 180's with a few pvcs thrown in there? 

5. Does the patient/family want aggressive care? Code status and the patient's wishes should always be respected if they are of sound mind (medical power of attorney plays a role, too)

6. Spidey-sense? This one is just something I've acquired over time. Call it intuition, my experiences in the ED, ICU or pre-coding patients on the floor... I just can tell when a patient is coming up close to needing life support. 

Those are just some good starting points (no particular order) in making a call on those borderline patients. I feel like one of the most obvious green lights for intubation on airway protection is status epilepticus that won't respond to benzos/barbituates (also taking into account respiratory drive depression from those drugs as well). Flash pulmonary edema in extreme cases, epiglottis (this is an absolute), hemoptisis, unstable NSTEMI going to cath lab, drug overdose, and history of very difficult airway in resp distress are the other big ones that I would push for intubation. 

Personally, I tend to go with that if the patient is exhibiting at least 3 of the 6 points I brought up, I will voice my opinion. Now, most of the time I don't make that call, but at least I can put forth my two cents (whether it's taken seriously depends on the boss man in charge). I do find it hard to swallow some days when I can see an intubation coming from a mile away, but no one will listen to my plea because abcdefg reasons.

I know I have more to elaborate on this subject, but it's late and I have another long long shift coming forth tomorrow. 

I hope you are all enjoying the lovely fall weather :) 

feeling feelings

So. Lots to discuss, but not enough desire to bore you with all of it. Just enough to keep up with the changing tides.

Work is a constant evolution of face palms. 1. work load. 2. computer systems changing at the same time as 3. annual check offs that are convoluted and weird 4. the suits and their obvious  and completely horrific displays of favoritism 5. being sick, triggered from work load 6. breaking bad is over and I no longer have something to small-talk my manager about 7. i dont like the new set of residents because one of them ordered an abg & electrolytes on a dnr/dni patient just to check a k+ level that should have been tacked on in morning labs that THIS RESIDENT FORGOT TO ORDER. And wanted me to help them put in the a-line. At 10:30 at night. Noooooope.

Anyway. Perfect segue into reasoning behind going back to school...

Apparently... a university system hospital that is of a "public service" entity,such as the finest university system hospital I am currently employed (hopefully to stay thus), reaches the bracket of loan exemption. Listen up kids, this is important. So, if I make 170 qualifying payments to my stafford loans (about 10 yrs give or take with some wiggle room), I can qualify for student loan forgiveness. Breaking it down...

Let's just say I have less than 20K in loans now. If I keep paying, go back to school and finish up prereqs for PA school, keep paying on loans through the PA program (which would be optional), exit said program with a price tag of 140K, and meet the criteria for loan forgiveness upon graduation and re-hire from current hospital employed....

Deep breath. Sigh. Could it be? Education that doesn't completely rape your bank account for the rest of your life? This all seemed too good to be true. Maybe it will all change someday soon, but for now I would suggest peeking into the current gov loan forgiveness program. I've let student loans deter me from going back to school for 2+ years, and I'm no longer letting the fear of repayment keep me from achieving my goals.

So the decision has been made. I'll start chipping away at classes over the next few years with the over-all goal in mind. Deep breaths again. It all begins in January.

I have felt kind of nostalgic tonight. Whether it's just been from writing on this blog, getting out there and having my adventure fun times, or just relationships (friendships and relationships alike), that are keeping me on edge...slightly. I feel like I've let some good people slip through the cracks. I wish some of my exs had just been friends, and nothing more. I can see now that I should never have held such amazing characters up to my fine-tip comb of my inadequacies.

As far as the ever-stimulating game of dating is concerned, I met someone. A person that's pretty important, and sees the bigger picture. We shall see how it evolves.

1 a.m.

Oh. So you can turn off a ventilator (and subsequently a brain/person...but let's not get so philosophical now) in a second... so why is it 1 a.m. and I still can't turn my brain off? Oh yeah, irony.

I think we all have a limit of bullshit we will put up with. I guess I just hit the wall today. Hard. My left eye has been twitching constantly for the last 7 hrs. And you know what? The only thing that made it stop was a heavy pour of red, red, wine. There's your advice for the evening. If you are considering a career in RT, please keep in mind you might become an alcoholic if every day in the hospital turns into the one I had today. I think I drank most of my caloric intake today based on that I had a 20 minute break once in a 12 hr shift. I was lucky for even that.

I really don't see how women can work full time, keep a house in check, kids alive, food on table, schedules organized, shower/grooming,  and still have time to turn their brains off/sleep at the end of the day. It takes me forever to unwind and all I have to worry about is a job, a dog, and a house. I think I could do a better job at allocating time and energy for projects around the house, but seriously my backyard it out of control. Yard work is not one of my stronger characteristics, and it has basically rained all summer in GA. I have had such a lovely time trying to get the outside weeds/responsibilities under control. My neighbors really don't help, either. I've gotten passive aggressive messages from both of them (to the left and right) and I swear, if they even try to question my methods after I spent 10 hrs out there on Sunday I will just tell them to go call the yard police. I need a cabana boy/toy/man-that-knows-yard stuff/looks good with a shirt off...I'll stop there.

I really don't like pulling the I-work-in-critical-care-and-have-lives-on-the-line card when I need space, but sometimes you just throw that one down to keep you in the game of poker. They will never know if you are bluffing (most evidently if they aren't in healthcare). Just mumble something about blood pressure being too low, abg kits that you started with have all been used, poop/smells, tracheal stenosis caused by trach x2 history and they are in resp distress, a lactate that's on par of the number of socks I wear in a month, mini BAL with no sedation orders, maxed pressors, a nurse that calls you constantly for a vent alarm that is only correlated to lack of sedation, no of full o2 tanks on the transport vent with a crit pt with 100% and 15+ peep, and no help when you could really use it. Some of that's true, some of that's false. Poker face, prn.

I donated platelets last week for the first time. If you have some form of ADD I would suggest that you never do this. It basically amounts to laying both arms out, palms up with two non-disposable 18 gauge needles in both arms (that will ruin your world if you bend your elbow at any time), and a superb attention span to watch your IV bag fill up with plasma. I guess the upside is that you have 2 hrs of uninterrupted time to watch a movie, and have someone at your call to scratch a mosquito bite on your ankle. I take what I can get.

I have my annual competency review tomorrow first thing.

And that's when I call it. Good night all.  Listen to the song, Breathe Me by Sia.

On writing

... In tonight's program we will feature the amazing writing of The Dirty Poet in, Emergency Room Wrestling.

"i stick in a nasal trumpet
i stick in an oral airway
i stick a suction catheter up his nose
triggering a vast bubble of yellow bile out his mouth
step back! i shoutthe room screams"

I haven't finished it all quite yet. I don't want it to end. A page a day. Such a good think in moderation. 

I've written a lot of poetry before. Some of it I've let fall away into the back of my mind, but this book had kind of made me want to try my hand at it again. I think writing is quite possibly the only thing that has saved me time in and time out in my life. It's most poignant when I'm travelling. Or, I should say when I have enough free time to be alone and be compelled to pick the pen or laptop.

Well. Work is changing. I'll report more on the through analysis in coming weeks. 

I'm so. so. so. so VERY tired of dating. I know I've said it once, but it needs to be repeated. My personal life hasn't been much discussed here recently. I guess it just changes so often. For now, single is what I will be. I  just can't keep forcing anything that isn't right. If you roam back to the ancient times of this-blog-past, you'd encounter the "boyfriend" posts. I loved this man so much. I had myself convinced he was my person. My whole world. And in one phone call it was all shattered. The wall I built up around my heart to protect it has become and obstacle no one could even try to scale. I feel like there's no more chemistry out there. And that makes me cry. 

For what it's worth, I'm still hopeful.

Good night for now. I have some hilarious stuff coming soon. 

Per request...

Here's an update:

I really really really dislike a particular micu that's a dump for ENT. I will not go into the atrocious details, but suffice to say that many integral parts of the patients faces are missing. And trachs. Not just your standard LTAC-type either. Fresh, oozy, bulb suctions abound, and quite miserable (and insanely needy) looking trachs. I have been isolated in this particular ICU for the better part of two weeks and tonight was the last straw. Vent checks take 2x longer just because the sky is blue, and orders that should have been put days ago exist only in verbal order limbo. I know this ICU is short staffed, but holding a morbidly obese leg up for a foley placement wasn't exactly covered in my critical care classes. So. There comes a point where you just sigh, and say to yourself that it has to be done, and you need to do it because you are there, and no one else isn't. Even if it isn't in your job description.

I wish I had time to look at patients admitting papers. I wish I had time to look over their most recent labs. I wish I could have talked to the family members just a little longer so they knew what was happening to grandma. I wish my charting and charging systems weren't on completely different applications. But, the main point I take away from tonight, was that the care that I could provide to keep patients alive, was all I could afford to give tonight.  I felt over-loaded to say the least, but an amazing co-worker was there to check on me periodically. I cannot even express the gratitude I have for this RT. He's an anomaly, and I could only aspire to be as smart, witty, balanced, humble and honest as he is. I'm very lucky to have such great friend.

They say that ICU delirium only affects patients...I disagree. I'm back to work on Saturday and I can only pray to little baby Jesus that I will have only floors. I need a break from critical care, although floors can turn into a perfect critical care mess in the turn of a corner.

But the crazy thing is that I love what I do. I like biology, and I like patient interaction. So, I will keep going, because I know I can recover on my day(s) off and come back fresh.

Enough of the work stuff. Here's some random thoughts I've had recently:
-I will never have beautiful legs. And I have no clue where the bruises come from
-I'm tired of dating, and just want to find my own puffin
-My house and dog are wonderful. I'm terrible at decorating though. And lawnmowers
-Trader Joe's kettle corn popcorn is crack cocaine
-It's been raining in Georgia for the. whole. entire. summer
-It does not impress me when boys have their shirts off at the climbing gym
-I need to change the title of this blog since I'm no longer a student
-Try not to get into serious discussions about bilevel/APRV when exceedingly tired


Enough for now. I need a bath and a few cuddles with my dog. Keep strong, my friends. I'm always around and I will try to be better about updating.

Keeping me awake

So. It's four am. I'm tired and it's not time for my last cup of coffee. Occasionally I'll sign up for these darn 16 hr shifts. You should have seen me earlier today. It was like I was a five year old begging not to have to take a bath when I had to leave to go to work. At least I can handle the 16 hr shift better when I don't know it is coming. Those random days I'll come into work at 3pm, thinking it's just a regular ole 8 hrs, and then there's a call out, and next thing you know I'm stocking up on redbull in the gift shop before it closes and holding on for 7am. They always say it's better if you don't know it's comin...

Four am seems to be the time that I start to get existential with my thoughts. Tonight I've generally been thinking about what it means to die gracefully. If you work in healthcare you know what I mean. Hospice vs. the full on code for an hour. Morphine vs. cracked ribs. Home comforts vs. crapping your bed minutes before you pass. I don't think it takes a genius to know where I stand on it, but yet, I'm still pushing tubes down 92 year old twigs and sticking an ailing man for serial ABGs because a new resident wants to have something to talk about at rounds tomorrow. Meh. I sound jaded. I know I do help some people every now and then. I think one of my biggest face-palms about this hospital is the ER. High rn turn over, docs I do not know very well, and a patient population as varied as any inner city hospital could be. I find it to be a very crude world, not to mention I'm the first one they call for ekgs. Monkeys can press buttons too.

But enough of that ole woe is me rant. Things could be way worse for me. I just have to make it through this weekend of work and I'm off on vacation. I shall not tell you where, as not to elicit any pangs of jealous this would undoubtedly cause you. You are most welcome.


Well. I see I've now killed forty five minutes. Now just to figure out what to do with the last two hours of work. I could go roam the hospital, but I'm le tired and I've noticed creepy individuals in certain staircases late at night. So I'll sign out for now, and maybe go have a chat with one of the hospitalists about Game of Thrones.

Chhhh ch ch ch changes

Turn and face the truth.


Well damn. Every time I log back into blogger they go and change the format and make me lose my bearings for a minute. It's ok, I've recovered.

I have some advice for the general public after working in a hospital for two years:
1. Don't drink Drano.
2. If you're going to develop a disease, go with ESRD. You get 9 lives.
3. There's no such thing as needle rape. You did tell me I could stick you for an ABG
4. You can over dose on Girl Scout cookies
5. I don't think your God(s) will save you. Medicine might. Maybe put faith in that.
6. Go to the gym. Quit smoking. Quit eating shitty food. Quit binge drinking (as I drink wine...)


Just a little humor for the fun people out there. Horray for a new post!!


June will make my second anniversary at.... that hospital that I work. It's been a wild ride so far and I just can't see myself moving anywhere else. It's had it's ups and downs, but ultimately I enjoy where I am. The friends I've made a long the way are absolutely priceless and I heart every one of them.

So work stuff aside, I just bought a new house. It's been absolutely fantastic to have a real home. I NEVER have to move again if I don't want to. It's basically adjacent to a big park here in Atlanta, and every week I've been running through said park, and eyeballing the Zoo that I will undoubtedly become a member of (mostly to stare at the otters).

Picked up rock climbing as a hobby. Scratch that. Obsession. It started so innocently. Oh, there's a fun thing to do with a boy. Ok, that boy sucks, but man I sure did have fun at the climbing gym. Wow those muscles hurt... It's a good distraction that keeps me focused on things outside of work and stress. I can listen to music and let myself go on a climb. I highly recommend it.

And that's right about where my life is right now. I'm finally coming into my adulthood without stressing about which direction to take. I'm doing what is making me happy and keeping me healthy. It's probably the first time in YEARS since I've been happy on a daily basis without it having to do with which relationship I'm in. So I'm celebrating that milestone by keeping with the trend and just being single.

Okay it's bed time. I have a date with my pillow and an early morning aimed at doing laundry, spray painting things, putting the hammock up on the porch, climbing gym, running and then  packing my suit case for a fun snowboarding trip in a matter of days...

Oooof. Blogger just updated it's format and I'm a little disoriented.

Well we are now in a new year. Everyone rejoice for 2013! I hope everyone had a lovely slingshot through the holidays. I was pretty busy with work and getting ready to buy a house. I know, I know. I'm a real adult now. Shhh don't tell the 23 year old that still lives in my body.

Packing has been such a slow process. I'm mostly just trying to organize everything right now, but I'm sure it will just come down to a few days before I move with me throwing stuff in boxes and just hoping I remember where everything goes.

I just started rock climbing. It's helped a lot with my upper body strength. I'm still on a modified diet too, which has helped me maintain my goal weight of 120lbs. I really stopped eating meat all together and tend to stick to fruits and veggies. I have been horribly lazy at training for the half marathon too, so I expect I'll be walking most of it. Hah. At least with climbing I have been exposed to a new circle of people in the city. It has kept me occupied after splitting with the BF last fall.

Work has just been work. I've spent a good bit of time in the ER during this "winter." I don't mind it so much as long as I still get rotated to other ICU's too. I had a shit day at work last week where I did a billion useless breathing treatments, and the ONLY thing that I did to actually help a patient was get them a blanket out of the warmer. Seriously.

Anyway. So those are my updates for now. I'm dragging a little, so it's time for some coffee.