Two Years in the Making

Every fall I have added new bulbs to the existing ones slumbering in the flowerbeds around my house. I often forget where and what I have buried. For the past year, there have been prominent green leaves next to the front steps. I could not remember what kind of flower they were, but given the size of the leaves, I had great expectations.

A few weeks ago, giant iris blooms appeared out of nowhere that were so heavy that the stalks tipped over to the ground. I guess it takes two years to make an iris, but I think that they are worth the wait.

Humble Pie

It has been a rough week for me procedure-wise. The other day I saw a septic patient. He had a fever, diarrhea, a heart-rate twice normal, and a soft blood pressure. So, we did all of the usual things, and then I got called to his room because there was a problem getting IV access. No problem-- time to put in a central line (an IV placed into one of the larger veins in the body- internal jugular, subclavian, or femoral veins). I didn't want to access his neck because he'd been shot there recently and there was a lot of scar tissue, a retained bullet and bone fragments. I didn't want to access his groin because of the diarrhea issue and with him being paraplegic it seemed like it would be easily contaminated. So, I settled on the chest. The needle connected with the vein and I had no problems floating the catheter in over the wire. However, when I went to check the ports, I drew back air instead of blood. Uh-oh.


At this point, the patient's father came in the room and said that central lines wouldn't work on his son (which doesn't make sense) and that he would have to have a PICC line (large catheter placed into one of the arm veins). So, we abandoned the procedure, and called for the PICC team.


And that's when the patient decompensated. He went from a heart rate of 120 to 160 to 200. The monitors get very angry when one's heart rate is 200... that's a whole lot of beeping! I had already had a sinking feeling about my failed procedure, but this just confirmed it. A quick portable x-ray showed it all: the patient now had a pneumothorax.


There was no time to wait for a PICC line. This guy needed fluids, antibiotics and was heading towards needing a pressor. Quickly, I put in a femoral line while the ICU was called. The ICU resident automatically called the cardiothoracic surgeon and that's how I ended up creating business for my least-favorite surgeon. The treatment for a pneumothorax is to put in a chest tube to decompress the air and reinflate the dropped lung. I'm capable of doing a chest tube on my own, but by that point surgery was involved and it was too late to uninvolve them.

I talked to the patient and his father and let them know what had happened. Apparently, the exact same situation had happened when a subclavian was attempted when the patient was shot several months ago. My attending was pretty cool about the whole thing, shrugging it off with "Well, they say you haven't done enough subclavians if you haven't dropped a lung." However, I think I am going to be more than a little gun shy about doing them in the future. As for the patient, he did well and went home a few days later.

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And then there was the patient that walked out of an ICU against medical advice a few days ago. The nurse called me immediately into her room and there I found a heavy older woman only able to speak 2-words at a time. She said the other hospital called her at home and told her to come in immediately or else they would send the police to her home to escort her to the hospital. (This story doesn't quite make sense because the patient appeared to be completely capable of decision-making to me, but that was her story.)

Anyway, the woman was in respiratory failure and had asthma and COPD. Not a good combo. She refused any IVs, and said she had a DNR (Do Not Resuscitate order) "somewhere" and did not want to be intubated. So now I have a patient in respiratory failure that's tying my hands behind my back as far as letting me help her.

We started breathing treatments. She had already taken oral steroids at home.

She got worse.

She agreed to let me give her one shot of something, so we drew up some terbutaline.

She got worse.

She agreed to an IV finally, and medication-wise I threw everything I could think of at her.

She got worse.

We tried non-invasive ventilation.

She got worse.

Finally, she said she wanted to be put to sleep. I confirmed that she meant she wanted a breathing tube, and to be put on the ventilator. I then called her neighbor and made sure there was someone to take care of her dog. Apparently, that was why she left the other hospital in the first place and didn't want to come in today.

We set up for intubation. She was difficult, but the tube passed easily, good color change, breath sounds. Fine. Before we could confirm it with a chest x-ray she desats and turns purple. I pulled the tube, but now I can't get it back again. I can see just a hint of where I need to put the tube but it's not going in. I try to use a different tool, but it doesn't work either. Finally, a colleague steps in and is able to get it. The patient went off to the ICU. She got extubated two days later, and is still in-house, but at least she's been moved out of the unit.

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So it hasn't been the greatest of weeks. Two big blows to my confidence. Everyone has bad days, but it is kind of poor timing as I am about to start working part-time at another hospital without an attending to be my safety net.

13.1

Thirteen miles is a long way to run. I ran a half marathon last Sunday (Yes, I also called my father!). I ended up finishing much better than I thought, at 2:30. For some reason, I had it in my head that it would take me 3 hours to finish. I did walk about a quarter of a mile of the race because I got a bit overheated, but overall I'm pretty happy with how I did.

This particular race has only been around for about 4 years, so while there was also a full marathon and a four-person relay marathon going on, it didn't attract athletes as competitive as in the 10-mile race I did earlier this year. The fastest marathoner came in at 2:50.

I ran with another couple from work. AG was there, but he didn't get to run because of a knee injury (healing well, but too soon to test it). Our race packets got mixed up, so I ended up accidentally running with his number and chip timer. When I crossed the finish line, they read off his name, took one look at me, and then tried pronouncing his first name a different way to make it sound more feminine! He was a great asset-- doing all the driving, calming my nerves, and just being great moral support.

While running the race, I decided that I would have to be crazy to attempt a full marathon at this point in my life. The running schedule for just a half marathon pretty much sucked up the majority of my free time these past couple of months. And to be honest, I didn't even run as much as I should have. So now with multi-hour runs off my schedule, I am once again a free woman... or at least free to focus on my academic projects, and doing stuff around the house. I would like to not completely blow off running entirely and do a couple 10-mile runs a month, but we'll see how well I maintain it.

Washington DC Day 2

Day 2 was another full day of walking, museums, and monuments.

International Spy Museum, which featured all sorts of mini cameras, a dog poo radio transmitter, a lipstick gun, and an emergency rectal tool kit (Unfortunately, I am not making that last one up!):

Recently built (2004) World War II Memorial:

The Washington Monument:

The Lincoln Memorial:

Korean War Memorial:

Statue next to Vietnam Memorial:

Statue honoring medics/nurses during wartime:

The Jefferson Memorial:

An inscription inside read:

I am not an advocate for frequent changes in laws and constitutions, but laws and institutions must go hand in hand with the progress of the human mind, as that becomes more developed, more enlightened. As new discoveries are made, new truths discovered, and manners and opinions change with the change of circumstances, institutions must advance also to keep pace with the times. We might as well require a man to wear still the coat which fitted him when a boy as civilized society to remain under the regimen of their barbarous ancestors.

We also squeezed in the Smithsonian Air and Space Museum, and attempted the Holocaust Museum, but they were closing up for the day. There are so many things to see and do there, that I would like to go back again sometime. It was fun having a weekend with AG to explore and ignore phone calls and email.

Washington DC Day 1

Some traditional and not-so-traditional sights found walking around Washington D.C.

I am still not sure what they meant by "Kiss & Ride" at the Metro Station:


No clue what building this is:

The Capital:

J. Edgar Hoover FBI Building:

The White House:

This was at the Smithsonian Museum of Natural History. The title of the display was something along the lines of "Man Taming a Goat". It cracked me up, because if I worked in a museum, I'm sure I would get bored with setting up traditional displays.

Roman tile mosaic:

Door detail from the Department of Justice building:

Arlington National Cemetary:

Changing of the guard at the Tomb of the Unknown Soldier:

That night, we had tickets to a murder mystery dinner. There were some strangely dressed people in the audience that we had originally thought were part of the cast, but it turned out that they were just bizarre people in the audience.

All the Pretty Horses

Last weekend AG and I went to Washington DC. I had never been there before. He did a summer internship during college at the FBI, so he was a great tour guide and helpful at navigating the Metro and figuring out where to stay inexpensively. We spent two full days cramming in every museum and memorial we could find. I quickly noticed that Washington DC seems to be a city in love with horses. AG was laughing at me as I went on a quest to capture every horse statue that I could find.

We found these while walking around town:

This one was at Arlington National Cemetary:


Behind the Lincoln Memorial:

Gremlins

AG came back last week. It is nice to be able to talk to him regularly on the phone, not to mention being able to put my arms around him! For once, we both had a three-day weekend off in common, so we seized the opportunity to jump in the car and make a break for it. Our trip was almost ruined before we even got to our destination. After stopping for dinner about 2 hours into the drive, we went back out to my car and it wouldn't start.

In fact, the key wouldn't even turn in the ignition.

I couldn't imagine what the problem could be as I had never had any problem with the key sticking before. We were in a small highway town in the middle of nowhere. There was no Saturn dealership for miles, and it was after-hours on a Friday night. Even if we could get into a dealer early on Saturday morning, our weekend would be wasted.

I was just about to throw up my hands in disgust and call a tow truck. However, tucked inside my wallet I had a roadside emergency key that came with the car in addition to the two sets of keys and remotes. My memory was that it was just a key to be used in the event that I locked my keys in the car, and it would only work in the doors, but not the ignition.

AG suggested we try it anyway, and wouldn't you know it: it worked! It was kind of clumsy to slip the key far enough out of its plastic sleeve to turn in the ignition, but it served us well the whole weekend.

When I got home on Monday, I tried my spare key, but it wouldn't turn in the ignition either. Tired and frustrated, I went in to work my evening shift-- which turned out to be crazy-- 3 GSW's and a bizarre ICU case.

On Tuesday, I got up early to take the car into the dealership. They checked the lock cylinder and said it was ok, that both keys had just gotten too worn down to work any more. The "spare" key was the one that I used almost exclusively for the first few years I had my car, until the remote battery died and I switched over to the second set. However, it worked perfectly fine the last time I used it.

It seems pretty odd to me that both keys would be worn down to an inoperable condition! However, I'll just blame it on Car Gremlins and be thankful that it wasn't a more expensive problem and that our weekend wasn't ruined (pictures later). Just the other day, I had considered removing the roadside key from my wallet because in the 6+ years I'd been carrying it around, I had never needed it. I guess now I will always keep a backup key around.