Friday, June 27, 2008

Diagnosis ??x??

My vacation has been lovely. Although I only spent 2 1/2 days in Philadelphia, I got to catch up with L, can't believe it'd been a year since I last saw her; went out with G, interesting developments there; got to spend 2 fabulous days with R &J; and now I'm back in NYC trying to tie up all sorts of loose ends. And by loose ends I mean dealing with my inured hip.

About 2 weeks ago, I finished a 13 miler. It was great. I felt strong, my splits were right on target, and I was really looking forward to my week off to get in some long outdoor runs. NOT SO MUCH. My left groin was a little sore after I finished the run, but I had one of my trainers stretch me out and I iced it when I got home. I was bummed when I couldn't run the next day, still sore, but I figured I just overworked it and I'd give it a few days.

After a week of seeing no improvement, actually the pain was worse at times, I decided to go check get acupuncture. I know, I know...I'm a nurse, I'm supposed to put all my eggs in the Western Medicine basket, but I swear, acupuncture works. I used it when I inured my knee 4 years ago, and again last year when I hurt my foot. Okay, after treatment #1, minor relief, still not enough to run. Then I left for Philly. Pain was getting worse. Maybe I shouldn’t have run around on the playground, but what fun is that? In a rather frantic panic, I managed to find a sports medicine orthopedist that specializes in running injuries. I called and said that I was a new patient. They said, "How about July 7th?." I laughed, said, "how about for an acute injury?", and they said, "How's tomorrow 3:30, be here at 2:30." I took it! I told the lady she could have told me I needed to be there at noon and I would have taken the appointment. I guess she didn't find that funny, but I was relieved. I've got a post coming about my fun times in PA, but for the sake of this post, we'll flash forward to me taking the 6:50 train home. After hauling my luggage on the subway and then to my apartment, it was hard to walk by the time I made it to my apartment.

The following day I went to the orthopod. My stomach was all fluttery, I was nervous....feeling of impending doom. Before the doctor even saw me, they sent me to x-ray. The kid who took my x-rays blushed when he asked me if I was pregnant. He must be new...working in the medical field you quickly grow accustomed to naming body parts and talking about their functions (or malfunctions) like second nature. Case in point, I held a candid discussion with a 50 year old patient of mine about if he didn't get out of bed and move, he would continue to remain constipated, the swelling in his scrotum wouldn't go away, and one of his last options was an enema with possible manual disimpaction....clearly the reason I became a nurse.. Oh yeah, so after my x-rays I went back to the waiting room and they called my name. I was led into a bright exam room with an entire wall of articles written by Dr. M on sports injuries. I knew I felt doom for a reason, I picked up the article on hip/groin pain.

I wasn't even 1/2 way through the article when Dr. M, and crew of residents, waltzed in. I gave him the history, told him a bit about my background (I have low bone density related to amenorrhea), and he pursed his lips. He asked me to take off my flip flops (which he then told me I shouldn't be wearing) and hop on each foot. Mission failed!

"From what you are describing and what I'm seeing, I'm 99% sure you have a stress fracture on the neck of your femur.

Even though you cant see anything on the x-ray, that's common with a stress fracture." He explained the mechanics and occurrence of stress fractures: increase in physical activity (apparently 55 miles a week qualifies), bone density (get on board that calcium boat), and body mechanics (hello grandma orthodics!).

WTF, I'm 23 years old! Broken hips are for old ladies, not marathon training nurses.
"I want to send you for an MRI. I'm away next week, so hopefully we can get this done before I go. I'm going to fir your for orthodics, but until we have a definite diagnosis, no running, take it easy. Turn around time with these kind of injuries is about 4-6 weeks. Are you in a calcium supplement? "
"Yes, with Vitamin D."
"Good. Okay. Here's my card, email me with any questions. Great to meet you Kel" (Love how we are already BFF's, right? haha)

I thanked him and sat there, baffled. This sucks ass. I dressed and made my way out to the reception area. The secretary told me that they had to call my insurance to get approval for the MRI, but they'd call me to schedule an appointment.

Later that day my phone rang and it was the MRI suite calling to book my appointment. I managed to snag an appointment for 7pm Thursday. I went and got acupuncture again Wednesday night and spent a lovely night out with friends at a house party. Thursday rolled around and I was a mess. I didn't sleep at all Wednesday night and it showed.

One issue complicating my need for an MRI was my belly button ring. I've had it over 7 years, but never changed it and consequently couldn't get it out. So I searched online and found this tattoo/piercing place in the East Village that seemed decent and had great reviews. Usually my trips to either side of the village involve a taxi ride because they involve dinners and drinks, lots of drinks (some of the best bars around!) but seeing as I was sober as a soldier, I thought I'd take the bus right down 2nd avenue.....big mistake. One hour and 15 minutes later, I arrived at 3rd and 2nd. I I weren't on "activity restriction" I certainly would have walked, you all know my thoughts on public transportation....

I walked in and pleaded my rather obscure request...I didn't want anything pierced or inked, I just wanted help taking something out.
Of course from the second I walked in, I got "the look." Oops, sometimes my preppy, clean cut looks just doesn't work...I certainly looked out of place. Nevertheless, I took a seat and 2 minutes later this guy called my name and introduced himself, "Colby." Hmm, aside from the tattoos from his neck to finer tips, and the huge plugs in his ears, he was sort of cute, great personality too. He easily took out my ring, helped me pick out a new one and told me to come back the next day and he'd put it back in. H even wished me luck on my test before I left. You know what, never judge a person by their means of personal expression...hey, the didn't shun me for being a perky, J.Cr*w plaid wearing girl. I left and limped up a few blocks and wandered around the Union$quare farmers market. I bought some fresh NJ cherries, strawberries, and tomatoes. They may be known as the "Dirty 'Jerz, but there's something in that dirty soil that makes splendid produce, right O?)

Flash forward to that evening. The MRI suite was located in the hospital, only a 5 minute walk from my apartment (no, not my hospital, but the orthopedic specialty hospital we are attached to and affiliated with). I arrived, 15 minutes early, registered and waited. They called me at 7:05, had be changed into a gown and put on the awful hospital socks. I locked my belongings in a locker and waited. The MRI tech led me into the room and I lied down. Good God, this certainly wasn't my idea of a good time. They tape your legs together so you don't move, strap these cameras to you (you sit on one as well), he covered me with a sheet and rattled off my music choices asked me what kind of music I preferred to hear during this test. I think I nearly shocked him when I said, "The Be@tles." I guess he was thinking that someone of my age would declare some sort of rap or hip hop, but I wanted something comforting and listening to the Be@tles reminds me of jamming with my dad in the car, at the beach, working in the yard, washing the car, etc.

The MRI machine makes so much banging and clanging, glad the guy warned me, haha. 75 minutes later, I emerged from the tube and was freed. I sat up and it looked like I peed myself. I had sweated so much my entire back was wet. Gross.

I thanked the man and got dressed. He told me that the turn around time was 2 business days, but after explaining that my doctor was going away, and batting my baby blues at him, he promised that my results would be expedited and that the radiologist would have them read by noon on Friday. I left and called my mom, she was supportive, but no matter what she said, she couldn’t take away my angst and frustration. I went home, talked to M and G on the phone and went to sleep with a little help from my dear friend Ben A Dryl.

Despite the help from my the little friend Ben, I didn't sleep much. I called Dr. M's office at 9:30 Friday morning to get an appointment for later in the day. Well, well, well....the secretary certainly had something up her a$$. She was so rude and despite my calmly explaining the situation about how Dr.M had expressed that he wanted to see me before he left and how I was unsure about my activity restriction especially seeing as I am returning to work this weekend. She told me to email him and say it's urgent. I calmly told her that I already had emailed him and that he hadn't responded. She told me to do it again and that was the best she cold offer. WTF lady, would it kill you to give the man a phone message?
Don't get my wrong, I work in healthcare, I know that patients will say anything to see the doctor (oh the stories and lies I could recite to you) but even if he wouldn't see me, I really just wanted to speak to him. Instead of getting mad, that gets you no where, I calmly hung up and then burst into tears. I typed an email, request a return receipt, flagged it as urgent, put my phone number in it, and hit send. Too much? Maybe.
I ventured back down to the east village to visit my friend Colby and get my belly button ring put back in. I took the subway this time. and had to walk a few blocks, but it sure as hell beat the bus ride! To my surprise when I walked in and asked for Colby, he came out and immediately asked me how my test was. Nice guy, seriously. If you are ever in New York and find yourself in need of piercing or inking, please go visit Colby at ADORNED.
I got home and checked my email, this is what I found:

Hi Kel!
Nothing that hurts, no running, ok?

J***** ^. M**** MD
Sports Medicine
Hospital for $$
Phone (212) xxx-xxxx
Fax (212) xxx-xxxx

No Shit? You think ? So in the meantime, it's PT 3x/week, no running, no excess walking, no extra stairs, no non supportive shoes (are you kidding me? It's summer time!!)

Oh boy, time is going to crawl until July 10th.

Thursday, June 26, 2008

Back At It FFOF

So it's been a few weeks, but it's time to get back to the FFOF meme. Valmg's back to theme questions, here are this weeks:

#1. Name one cookbook, cooking website or food blog that you frequently use.
I love my whole foods cookbook

#2. Do you watch any cooking shows on tv? Which ones?
I'll watch anything on the food network, but I love TopChef on Bravo

#3. Are you in a cooking rut? Name a food or dish that you’d like to find a recipe for.
I'd love a recipe for a summer dessert. I feel like I always go for the standard variety of berries, angelfood cake, coolwhip, pudding

#4. Share a recipe created by somebody else that you haven’t tried but would like to.
This if from one of my favorite blogs, Fat Free Vegan Kitchen. She's so creative and these dishes hearilty satisfy meat eaters alike
Tofu and Vegetables with Lower-Fat Thai Peanut Sauce

14 ounces extra-firm tofu
1 tablespoon soy sauce
1 tablespoon vegetable broth
2 carrots
2 medium zucchini
1 pound broccoli
12 basil leaves (or to taste)
4 tablespoons natural creamy peanut butter
1/2-3/4 cup vegetable broth
1/4 cup soymilk (or other non-dairy milk)
1/8 teaspoon coconut extract (or use lite coconut milk instead of soymilk & extract)
1 tablespoon soy sauce
1-2 teaspoons Asian chili sauce (start with less and add more as needed)
1 tablespoon agave nectar
1 teaspoon lime juice

Cut the tofu into about 8 slices; then cut each slice into 4 triangles. Combine about 1 tablespoon soy sauce with 1 tablespoon vegetable broth, dip the tofu in it, coating all sides with marinade, and allow to soak while you preheat the oven to 400F. When the oven is hot, put the tofu triangles onto a non-stick baking sheet or silicone mat and bake for 15 minutes; turn the tofu over and bake for another 15 minutes. Remove from oven.

While the tofu is baking, prepare the vegetables and sauce. Slice the carrots on the diagonal, halve the zucchini lengthwise and cut into half-moons. Chop the broccoli into medium-sized florets. (Other vegetables may be used; aim for about 2-3 pounds total.) Place the vegetables into a large steamer and steam until tender-crisp. (Actually, stop just a little before you think they're done; they will continue to cook in the residual heat.) During the last minute of steaming, toss the basil leaves on top of the vegetables and steam just long enough to wilt.

To make the sauce, heat the peanut butter in a small saucepan over medium heat. Whisk in 1/2 cup vegetable broth. Add the soymilk, coconut extract, soy sauce, chili sauce, and agave nectar, and heat until bubbly. If the mixture seems too thick, add a little more vegetable broth. Add the lime juice just before removing from the heat and serving.

To assemble, place 1/4 of the vegetables on each plate. Top with 1/4 of the tofu and drizzle with 1/4 of the sauce. Garnish with fresh Thai basil if desired.

Tip: Reduce the fat and sodium by using reduced-fat tofu, low-sodium soy sauce, and fat-free soy milk.

Saturday, June 21, 2008

Difficult Questions

The burn unit is full of some sick patients right now, it's draining the staff. We go from very low acuity to very high acuity in literally minutes...all it takes is one spark and POOF! suddenly we are full.

As if the high acuity isn't enough, as the weather gets nicer more and more people are calling out "sick". Have I ever mentioned how much this urks me? I've been at my job almost a year and despite having 12 sick days to use, I've never called out. Sorry, I'm going off topic.

Back to my story. Last weekend I admitted a 74 year old man with a history of hypertension, diabetes, BPH, and end stage renal disease (ESRD). A few years ago, he agreed to having a fistula placed "just in case" he ever needed it. Why someone with ESRD didn't start dialysis, I'm not sure, but I wasn't there. We admitted him for a 4% 3rd degree burn to his left lower leg after he spilled hot water on his leg/foot. His diabetic neuropathy prevented him from realizing how bad the burn was and delayed seeking treatment until his family noticed his skin sloughing and oozing through his pants a few days later.

During his admission history, he seemed a bit foggy, slow to speak, and unsure of himself. The son and patent's sister accompanied him and they were very pushy and quick to answer for the patient. I kindly reminded them that I was asking the patient the questions, but that I would be happy to allow them to fill in the missing details at the end of history.

Come to find out the patient agreed to get the fistula, but the family persuaded him not to start dialysis because it wouldn't be convenient (for him? or them? WTF). I drew his baseline labs and inserted a nice fat IV into his right forearm (always a feeling of success!). When his labs came back, I was floored. His BUN and creatinine were sky high, no wonder this man was foggy mentally. I suggested to the fellow that we get a renal consult and we did. However, the family remained adamant that they didn't want the man to have dialysis. Normally, we would defer to the patient, but by the time he was seen by renal the following morning, he was lethargic and barely arousable.

Follow up labs showed even grimmer results; this man was in an acute flair of chronic renal failure. In 24 hours he had made only 100cc's or urine. As a baseline comparison, you and I make at least 1000cc's of urine a day. The patient was exuding a horrendous odor-acetone/uremic breath. Urine was essentially circulating throughout his body. My 3rd day taking care of the man, he was really decompensating. His leg needed to go to the operating room, the skin looked like this; however, until he was hemodynamicaly stable he wasn't going anywhere. To make matters worse, this mans lungs were filling up with fluid. He had coarse rales and crackles (click to listen). When the family finally arrived in the afternoon, it was the first time I saw even a glimmer of concern...maybe that's because he was gurgling, lethargic, and only responsive to pain.

I had already discussed with the attending surgeons and residents the need to possibly go though the ethics committee to get this man dialysis, but thankfully we didn't have to go there. The family agreed to emergent dialysis. We set up dialysis for that night. When I came back the following morning, the patient looked slightly longer gurgling, and was at least oriented to self. Apparently when dialysis is first initiated they like to complete 2 sessions in less than 24 hours, so less than 30 minutes into my shift, dialysis arrived and set up in the room. We figured that we'd take advantage of dialysis and transfuse the patient with 2 units of blood, seeing his hematacrit and hemoglobin were also alarmingly low, but we didn't want to give him excess volume. The blood arrived and we followed protocol to a "T". We performed the 2 RN check 3 ways confirming the patient, the donor, the type, the expiration....all set and ready to go!

Being that I work in an ICU, our patients are continuously hooked up the he monitors, but I still never wander far when they are receiving blood. I initiated the infusion protocol for vital signs. The patient remained stable throughout the first 65 minutes of the infusion. Just as the first unit of blood was finishing up, I noticed the patent's heart rate shoot up into the 140's, his systolic blood pressure was 190, and he was breathing at a rate of 45 breaths/min. The patient was minimally responsive and posturing, but not like what you would see with a seizure. His fists were clenched and he was rigoring.

I yelled for the resident to come in. I grabbed my stereoscope and listened to his lungs, immediately thinking that he might have threw a clot resulting in a pulmonary embolism, but his lungs sounds were no worse than before. We immediately stopped dialysis, I ran and got the EKG machine and did one STAT, we drew an ABG, got a chest xray, threw the patient on a 100% non-rebreather face mask. I ran and grabbed the intubation box and the code cart...wasn't quite sure where this one was going. We all remained in the room and stood by. We sent off STAT labs and waited. We were ready to intubate if the patient lost his airway, but within 7 minutes, his HR slowly decreased and his BP's creped back down. We avoided giving any medications to control the heart rate because we wanted to rule out MI. 20 minutes after the patients condition seemed to be resolving, I did a follow up EKG. It looked better than the first one, as that one showed some ST wave depression.

Whew, good thing I wore my strong deodorant to work! Recognizing that this could have been a delayed reaction to the blood (delayed due to the dialysis) I drew repeat labs and sent them to the blood bank as well as filled out the possible reaction paperwork. Things settled down but I still watched this man like a hawk (did I mention that I had 2 other patients to care for?) The remainder of the afternoon was uneventful until the family showed up.

*Oh yeah, forgot to mention that when all of this was going down in the morning the son happened to call. When we asked him to clarify his fathers DNR/DNI status, he didn't even seen concerned. If you were told that you parent was possibly about to be intubated, wouldn't you try and come to the hospital or at least call and follow up? *

The family hadn't been there 10 minutes when the patient suddenly began gurgling and breathing very shallowly again: 7 breaths/min, 6 breaths/min....oh boy, I know where this is going. I stood by and roused the patient. He would breathe at a rate of 10-12. That's when one of the sisters called me out into the hallway, frantically, and asked the loaded question: "Are we loosing him?" The look of fear and dread in her face was immense. I wanted to look at her and yell, "Well if you hadn't been so selfish an let the poor man get dialysis, we could have avoided this!" I took in a slow deep breath, put my hand on her shoulder and said, "I wouldn't say that. Like most of the patients here, your brother is sick, but he's in the best place possible for someone with his condition. I understand that as his family, it must be very difficult to sit back and see your loved one look so helpless and sick. But this is our job, we do this everyday. I'm here to advocate for your brother, and make sure that he gets the best care possible. We will do whatever we need to provide him with the care h needs for the best possible outcome. I know it's scary, but we encourage you to remain active in the patients plan of care. We're not only here for the patient, but we're here for you as well."

I no sooner finished and thought, did that really just come out of my mouth? haha. I was amazed that I was able to set aside my anger with the family to remain professional.

The family seemed okay and I turned around to go check in on my other patients. However, before I could walk away, the charge nurse and resident came up to me and said, "Well done. you handled that like a veteran."

And that's how my day ended. It seems like I grow into my professional role more and more everyday. Less than a year ago, I was afraid to answer the phone at work, but in just 11 months I've come into my own and learned how to answer the much tougher stuff.

Thanks for reading!

Thursday, June 19, 2008

so much to do, no time to wait, i'm late! i'm late, i'm late!

I thought that working days would really free up my schedule...not so much.
Work has been busier than ever, not to mention some other developments in my life, good don't worry, but they are for another post. I have a good 5 posts that are still in their draft form, maybe this week I'll get around to polishing them. How will I do that? I'M ON VACATION THIS WEEK! Kicking the week off with a trip to Philly to some friends and of course spend a few days with the L's! Other than that, I'm planning on enjoying sleeping in, lounging in the park, reading some books, trying out some new recipes (my "to try" list is busting at the seams), and maybe get around to planning a winter vacation!

stay tuned, more good stuff to come!

Friday, June 06, 2008

Four Foods on Friday, # 32

It's that time of the week again...are you going to play this time? Pop on over to Valmg's blog and join in on the fun.

#1. What snacks do you eat at the movies? Do you buy them there or bring your own?I usually just bring along a sliced up apple and bottle of water. I love popcorn but hate how it makes me even hungrier! If I need something really sweet, I'll buy some raisinettes.

#2. What’s your favorite food movie, or movie that shows a lot of food? Never gave it much thought; however, as far as TV goes I love TOP CHEF on BRAVO.

#3. What food or meal do you wish was available at the movies and why?
It's sort of hard to eat a "meal" at the table + the dark + cramped quarters= recipe for disaster (well at least if you are me, haha). I'm pretty content with just having snacks, but I'd love some chocolate covered strawberries. yum!

#4. What’s your most favorite way to make popcorn? Hot, cold, buttered, air, microwave, chocolate, caramel, you get it.
Air popped, fresh, with a little bit of I Can't Believe It's Not Butter Spray and salt.

Wednesday, June 04, 2008

Kitchen Mishap

When I couldn't sleep last night, I was blog lurking (so creepy, I know). I stumbled across Food Nerd and saw this contest that she's hosting. She wants to hear about your kitchen/cooking/baking mishaps. I thought I'd play along, so happy reading.

My mom comes from a family of five kids. To make the holidays easier, they rotate who hosts each holiday. Seven years ago my mom's younger brother (B) and his wife (D) were hosting thanksgiving. D is slightly anal retentive and type A (who does that remind you of?!?!) so holidays at their house always resembled something out of M*rth@ Stew@rt Living . They had recently redone with kitchen, gourmet and lovely, but there had been a problem with the oven. They had a cook top with a seperate oven, but somehow an oven-meant to be a wall mount, got installed. Picture this: really low to the ground, on the smaller side, not practical. That being said, it clearly wouldn't do for hosting a holiday for 25.

B & D's neighbors were away for the holiday and graciously offered up their ovens (they had a double wall mount). D took full advantage of this and sent the men (i.e. my dad and 3 uncles) over to their house to turn on the oven and put in the turkey. Not thinking much of it, she went about cooking. She used her oven to warm things like potatoes, pies, veggies, etc. She was very busy in her kitchen so she kept sending the guys over to baste the turkey, etc.

As the hours passed, then men kept drinking, D kept cooking, the crowd was getting hungry. About the time the turkey should have been done, D was putting the veggies and potatoes back into the oven to warm them up. That's when she got the call. D had sent my mom over to the house to get the turkey (the men were too engrossed in the football game). Then guys had turned on the top oven and put the turkey in the bottom oven. Now as I mentioned, the oven in D's kitchen was really low to the ground. She left the veggies and potatoes on the door to answer the phone and got a little distracted...actually I'm pretty sure she flew off the handle and this is what we heard, "B! What the F***. @&#$*$ $*$(#(#* $*$$)$$, You totally #&#(#$& this all up. " She no sooner stopped yelling, but then turned around to see the dog, devouring the veggies and potatoes off the oven door.

Words cannot describe her facial expression. I cannot comfortably repeat what she uttered. My dad fixed D a very dirty martini and we pulled out the takeout menus. Definitely the one and only time in my life, I've eaten Chinese food on Faberage China. Don't worry D, I don't think M@rtha reads this blog...she won't think any less of you.

If you want to share your tales of kitchen mishaps, go here and play.

Tuesday, June 03, 2008

In Memory

I still cannot believe she is gone. Her hearty, contagious laugh and effervescent spirit always set me at ease. She is the sole reason I didn't quit my nursing orientation, why I kept coming back for more despite wanting to turn and run the other way, the person who told me, "One day, about 9 months from' just going to click ,Kelly. It's all going to come together." I wish she were still here to read my post from last week.

Her name was Tara. She was 38 years old. She was my clinical nurse educator at my first real job. She died in her sleep Saturday night. She left behind a husband and four little kids under the age of 12. I got the dreaded phone call on Sunday night. My heart sank, my stomach dropped, I had to hold back the vomit. I last spoke with her on Thursday as she was frantically trying to get something up on the employee continuing education website. Weird, how you never think that a conversation with someone could be the last.

I'm going to the funeral on Thursday. However, I wish I had more time. I wish I could write her kids and husband a letter sharing with them, a side of Tara, that only those who worked so closely with her could know. Tara , usually running "a few" minutes late, would sit in front of the class, so casual (never formal or stuffy) with her half wrinkled lab coat because surely it had been thrown in the back of the SUV while she drover her kids back and fourth to hockey/dance/baseball/soccer/gymnastics/lacrosse/CCD, etc. She'd digress and get off topic, but those tangential lessons served us all well in life (i.e. I now know the best time of day to cross a bridge that is under construction). She was always sipping Coke from a straw, and 98% of the time would have one of her little girls pink or other bright colored scrunchie in her hair. She talked in her thick New York accent and always made us (and herself) laugh. She knew not to take anything to seriously. She was an avid believer in taking breaks, teaching what was relevant, and never putting anyone down. Tara loved everyone; Everyone loved Tara.

RIP Tara.
Thanks for everything.
Love and miss ya!