Substituted Judgment

An interesting article, provided me by The Partner, describes the application of suspended judgment among first-year medical students, wherein patient self-determination is preserved in the face of loss of ability in autonomous decision making via appropriate, designated surrogate. The results are very interesting and an important consideration for all health care providers. It's the conundrum of best interest of the patient, medical judgment or family wishes placed against patient self-determination. As a nurse and 'patient advocate', you think you know what you would do, don't you? It's worth rethinking because it's a very tricky ethical dilemma.

The Reader

A classmate saw me reading before class this week and asked, "How can you find time to read?"
I just shrugged, because that's the polite thing to do, but I felt my brow furrow as I thought, "How can you not?"


The photograph is by Jennifer Zwick and is titled The Reader.

More Noir

This week's film recommendation:
Night and the City.
Wonderfully bleak.

Surgeons are Super

Surgeons have some of the most amazing writing skills I have yet to read. They are keen observers, excellent historians, and duly self-reflective. This observation is based on notes about a patient that I had this week, one Ms. L., suffering from pancreatic pseudocysts, who suddenly and unexpectedly began vomiting copious[1] amounts of bright red blood[2]. She was in absolutely critical condition by the time we got her to the ICU. Because I followed her there and participated in hanging her blood and plasma for transfusion, watched the endotracheal intubation, etc., and since she and I had been chatting and laughing all morning before the incident, I was anxious to follow-up with her the next day. She apparently underwent surgery early Friday morning and the surgery notes represent a unique literary form that I wish would be published as general interest material. I'd quote from it, but that is not HIPAA compliant, so let me just say to you students out there, if you want to learn in amazing detail and narrative about disease and anatomy, read your patient's surgeon's notes. Absolutely the best tool for learning I have been presented with thus far. (It will probably also be somewhat humbling in terms of differentiating the role of nurse from doctor. I'm just being honest.)

[1] 1000mLs* in about 60 minutes * class II blood loss at 1 hour.
[2] blood that would coagulate before we had time to rinse the basin.

Cello Scrotum, Revealed

And just in time for The Kid to start his cello lessons.
Hearing the Baroness Murphy's telling is definitely worthwhile.

The photo is of the amazing Ernst Reijseger. If you get the chance, have a listen.

Fillmore Will

Bonnie "Prince" Billy at the Fillmore.
March 30th, 2009 - 8pm.
Tickets are for sale and still available.

First Do No Harm

The Kid is reading, among other things, The Fortean Times Book of Strange Deaths. He said to me last night after my first med-surg exam, over which I was having mild to massive anxiety, "Mom, you'd better read this; I don't want you to make the same mistake."

"A newborn baby in a Chicago hospital came to an abrupt end when someone accidentally connected the child's heart monitor cables attached to electrodes on the chest and abdomen directly to the mains. Twelve day old Stratton Vasilakos died instantly. Apparently this was caused by a design fault which had resulted in several previous accidents but was supposed to have been corrected."

Somehow that wasn't really the anxiety relief, nor the vote of confidence, I was looking for.

By the way, did you know that "Primum no nocere" is not even in the Hippocratic Oath? I'm no doctor so it doesn't really matter. Interesting, nonetheless. It's actually attributed to the Roman physician, Galen.

Unbroken Circle

On Sunday we went to Tennessee Valley and not only happened upon such a large bobcat that we initially mistook it for a mountain lion, but a beautiful great horned owl. Perhaps foreshadowed by the latter, we were also confronted with a body on the shore. Given the position of Tennessee beach and the tides off of the Marin Headlands, it was pretty likely a jumper.

This was, The Kid pointed out, the closest he'd ever been to a corpse -- which is to say not too close, but close enough to tell us, aided by binoculars, what the man was wearing. There weren't many passers-by that day. Who knows the reason. So we were lone hikers when the coroner's van came by. Once the body was in, and the van passed, The Kid and The Partner both decided it was time to break into song. I scolded them both, unnecessarily imparting the significance of respect for the dead.

"But Mom, we are respecting him," said The Kid."We are singing because we don't know if the circle will be unbroken... we're singing because we wonder if he's a father."

And this was the moment The Kid began to grapple with human mortality. We learned thereafter that when we die he's going to keep a lock of hair from each of our heads in a locket around his neck, and The Partner's umbrella will be forever preserved in a pine box in The Kid's living room -- somewhat like the dog's ashes, which still sit in a tiny box next to his bed, bearing the words, in red sharpied child scrawl: "SAMMY RIP".

When Words Fail

For a class in Effective Communication this past week, we watched the opening scene from The Diving Bell and the Butterfly. I, aghast and somewhat stunned, learned that no one, not one, of forty-some people had read the book. I hadn't seen the movie, pretty much because I fail to see how such a profound experience can be turned into something so banal, and because I generally lack appreciation for Julian Schnabel's love of French cleavage. While I see the point in the exercise (for us to have the experience of the patient's perspective), I wonder how such an amazing document (aka: 132 pages written with the blink of a single eye!) doesn't have more power than some crappy, post-modern cinematic reenactment. Super sad social commentary for a Wednesday afternoon.

The Feminist's Son

The Kid asked if I wanted to hear a little ditty some boys at school had created.
"Sure," I said.
"Well," says he, "It goes, I'll give you a nickle to tickle my pickle."
"Oh, that's not right..."
"I know," he replied, "I think it would be more like a hundred dollars."

Humble Pie

When I was a graduate student, I came to the realization that the more that I learned, the more I could see was out there to learn.
The more you know, the less you know kind of situation.
Now, as a nursing student, I know that I don't know much of anything. How's that for a healthy dose of humility?

The Pretender

Will Oldham transfigures American music.
by Kalefa Sanneh. Courtesy of The New Yorker, January 5, 2009.

Jacuzzi Exposure

I have never really liked jacuzzis. At the end of a long day of skiing, a favorite winter sport of choice in Montana was to get a bunch of people together to soak in the hot tub, jump into a snowbank, and then hop back into the tub. There are a lot of reasons why this didn't appeal to me, not the least of which is that I find jacuzzis, well, disgusting. Add freezing my ass off before jumping into a pool of germs - no thank you.

Thursday of this week I had a patient who had "bumped his shin", developed cellulitis which abscessed and subsequently turned into a stage III wound needing debridment, packing, possible plastic surgery. The medical interpretation of the cause of his abscess was "lower extremity trauma followed by jacuzzi exposure". Wondering if this is a common medical problem*, I did a little research and discovered another ailment known as hot tub rash (pseudomonis folliculitis), a bacterial infection of the hair follicles.

So, the next time you're thinking about your relaxing afternoon at the spa, think again.

It is a fairly common medical problem. Typically, people with compromised immune systems or poor circulation, or healthy people with an open sore, can be exposed to staph and other strange things in that large, steaming petri dish of relaxation. Professional athletes, fearful of MRSA, have began to take extra precautions around shared jacuzzis.

A Bonnie Preview

The new Bonnie 'Prince' Billy album, Beware, due out on March 17th, has a welcome preview and interview here. Enjoy it. The new song is called You Can't Hurt Me Now. He also performs Palace/Music/Songs/Brothers favorite The Brute Choir. So nice.

In response to his thoughts about being quoted by writer Graeme Thomson, Will talks not only about the utility of death in music, but a bit about death, generally, as he sees it: "Sometimes you just want something to end so that you can go on, go free."

The White Ape

Tarzan the Apeman is an action-packed adventure, circa 1932. And racy! Who knew that the implication of sex is far more sexy than the real thing? Elephant graveyards, juju, five-time Olympic gold medalist Johnny Weismuller, a super cute and hilarious chimp named Cheeta, actual ethnographic footage and weird allusions to colonialism make an evening with Tarzan worthwhile. Did I mention Johnny Weismuller?

Feminist theorists love this movie because Jane, woman, is given voice. It must be mentioned, but who even wants to go there? I'm much more satisfied sticking with the weird ethnography and loincloths. It may say more than the theory. Then again, it may not.

Germs, Germs Everywhere!

Note to self: when wounds are being debrided, wear protective gear over the face, because sterile water splashing off of a body covered with decubitus ulcers and positive for MRSA is no longer sterile and does not fall under the "universal precaution" umbrella in any way, shape or form. My mysophobia has multiplied ten-fold since the start of this quarter. Now I follow Nurse J. and take my scrubs home in a plastic bag for laundering. According to this article in the Wall Street Journal, shared with us by Nurse D., you should too.

Sinking Nurse

I know that the hospital is a lot less like television than we would like to think, nurses and docs madly rushing to save lives and falling in love all at the same time (mind you, I haven't had a television since about 1994 so this is all based on first season episodes of ER), but in the *actual* hospital, why can't everyone at least pretend to care what's happening to a 20 year-old patient found unconscious on the floor and desating... and why can't the doctors pretend that they think nurses are competent? We're not doctors, but we're also not dimwits. Seriously.

p.s. if you read this blog with any regularity you know that I defend docs to the hilt; I do so because I recognize that we are not doctors. Personally, I accept that I could never be and would never want to be socialized in that way. Still, experiencing the doctor/nurse dilemma first hand, not as a peer researcher, but as a nurse, was, frankly, a proverbial slap in the face. I'm still trying to understand what it means to follow that path. And that understanding is proving to be difficult.

thirtysomething

When I woke up at 4:30 for my clinical yesterday morning, The Partner said to me, "Happy Birthday. You're 35 years young today," which is one of those clever constructions used to reinforce that one is middle-aged. Ack!

Social Justice?

Reading Carolyn Chute. Finally, someone willing to talk about class. And I like that her husband's backyard target practice "keeps away the same old tired bohemian intelligentsia types."

Anyone up for target practice in my backyard?

Princess Leia: Post-Feminist Icon.

This review of Carrie Fisher's new book has perhaps the funniest quote I've read in a long time: "In a book full of weirdos, he [George Lucas] emerges as possibly the strangest of all. He wouldn’t let Ms. Fisher wear a bra under her Princess Leia shift because, as he patiently explained to her, there is no underwear in space: according to Lucas-physics, if you were to wear a bra in a weightless environment, your bra would strangle you." Fisher also claims that Lucas ruined her life.