F O U R
Patient walked into the ER, and within an hour, fell down, went boom, and landed himself in the ICU with FIVE maxed-out pressors, cooling blanket, CVVHD....everything but a head bolt.
Think about that: ejection fraction of F O U R.
When his heart beats, it spurts out 4% of the blood volume that sits in his heart while it is at rest. How many cc's you suppose that is? If his heart has 100cc at rest (possible, but probably more), it would pump out 4cc at systole.
I can spit more than that.
Jeez, if I'm sleepin good, I can DROOL more than that.
And what does it mean to max out dobutamine and dopamine on a heart with an EF of FOUR? Dobutamine, dopamine, levophed, epinephrine and vasopressin.
The frustrating thing to me is that I don't get to find out what the hell happened to this guy (other than the obvious cardiogenic shock...*why* the cardiogenic shock, I won't know.)
EF of 4. New record for my personal little observations.
Saturday, May 2, 2009
Tuesday, April 21, 2009
The conscience clause.
This may be one of my last posts to Sinus. But I’d like to get involved in one more nurseblog debate on the conscience clause and the discussion as to whether Obama should work to undo this legislation.
Namely, Emergiblog Kim’s initial post here
And subsequent ‘rebuttals’ (if you will):
Duncan Cross wrote.
And Manchmedic wrote.
I agree with Manchmedic.
I think that the government has no place regulating …as part of a state Constitution (much less Federal)…what private American worker should do as part of their job description for a private employer. Legal precedent exists to protect workplace safety (OSHA, child labor, harassment). The government can direct a soldier to war, because that soldier enlisted for that job description. (I don’t like the draft, either.) There are laws about taxation on income, and discrimination.
But this conscience clause is about driving contractual details (i.e. job description and responsibiities) between private corporations (i.e. non-VA hospitals) who hire citizens as employees.
Despite the fact that all civilized people believe that workplaces should be equal opportunity, the need for actual LAWS within a state or federal constitution that direct how workplace equality is to take place is still debated.
California nurse to patient ratio laws are new. Some CA nurses have said that their ratios are better, and they've lost ancillary staff and charge roles as hospitals even out the bottom line. That the ER's overflow. Government with good intent is slower than private enterprise. Perhaps not the optimal solution.
In my opinion, Dubya confused church and state and understood neither. Our founding fathers were very clear on this whole church-state separation thing. This issue is not about God, or beliefs, or hot-button Roe v. Wade.
It’s about what your employer expects that you do for them.
Do you really want the state constitution getting involved in that?
On this ground, I think the clause is a horrible idea and should be un-done.
****
There’s a secondary reason why I disagree with the conscience clause.
I believe with every molecule comprising my body that every human being should be treated that way when they leave. That they should be treated in a way that THEY direct. That we should do the utmost to provide for THEIR needs. That they are free of pain. That they are treated with dignity and respect. That we do everything we can to alleviate the other horrible undignified ‘symptoms’ of the dying process: nausea, vomiting, incontinence, wakeful coughing, clinical anxiety. And in the best situations, people are surrounded by love. The reality is that not everybody’s gonna get that. But I believe it’s what we need to aim for.
Some nurses like sunrises. I like sunsets.
Babies are great, fun, joyful. When I am the best nurse I'm capable of being, it's often with a patient who has made a decision that they're ready for their next big adventure. I am a rabid advocate for pain and symptom management.
I don’t believe in flogging bodies through endless complex procedures that have poor chances for positive outcomes. But sometimes I do it. I'm dialysis, for chrissakes.
There are many situations where I have participated in medical care that violates my humanist beliefs in the right for a patient's dignity and self-direction. Every ICU nurse has participated in cases that have gone before ethics boards. The young person who is HIV+ and after long, protracted illness, wishes to die. A parent wants everything done. Ethics board decides to go for the gusto. Dialyze!
A patient whose family has such financial interest in keeping patient alive that they are able to get him declared mentally incompetent under suspicious circumstances. When clinical psychiatrist, after thorough evaluation of patient, finds patient (to no surprise from staff) to be not only sound, but erudite and thoughtful about his own care, lawsuit by family ensues.
The dialysis patient who is a social work nightmare who becomes pregnant…the highest risk pregnancy I have ever seen. Patient has multiple hospital readmissions since the birth. Have we done that child any favors? Will the child become president or did we bring a human being into terrible suffering and adversity?
I find it morally reprehensible to paralyze a patient with vecuronium and provide no pain medication. I have done so and charted the hell out of the calls to the cardiovascular (bastard) surgeon who had me perform this odious torture. I advocated for my patient in much gentler ways through the family (uneducated in such medications) as well.
I have NOT given blood to a Jehovah’s Witness with a hemoglobin of 5, because the patient does not want that intervention. The patient understood that a lot of physical suffering could be alleviated. To the patient, the spiritual suffering would have been worse.
At no point in time did it ever occur to me to refuse to care for any of these patients. My point here isn’t that any good nurse would not have provided the same care. My point is that a pro-lifer's moral difficulties with abortion are very like my moral difficulties with the 92 year old CABGx5.
But here’s the rub:
IT’S NOT ABOUT ME.
If I don’t want to do the job, I can find a different job. There are nursing jobs that will not put me into a situation that violates my humanist values. My chosen nursing path so far is one of the least morally obstacle free I could have chosen for myself: critical care and dialysis.
However, if I am not going to choose to get a different job where I find such tasks ‘morally repugnant’, I choose to be a professional. You do your job. You prolong the life, you give the person comfort AND advanced intervention of Western medicine. Chemo. Or dialysis. Or intubation. Or surgery. Whatever.
It is not for me to decide whether or not a woman should have an abortion, or a 92 year old should undergo a cardiac bypass graft times five. It’s not for me to decide a crack addict has any business going home with her premature baby. It’s not for me to refuse to take care of an critically ill withdrawing alcoholic/any-other-substance-abuser because I think alcoholism/substance is ‘bad’. Or whatever.
I volunteered at a health fair today and a man asked me which substance be more 'okay' for his heart condition: cocaine, marijuana, alcohol or speed? I answered his question indirectly: cocaine and speed will kill you. No, I don't want him to go smokin pot.
It is for me to provide the best clinical and compassionate care for the patient that I can. I’m not giving up my personal rights as a nurse. Nobody’s asking me to have open heart surgery. Or do anything with my body. Or take up heroin. If I find somebody else’s medical choices to be repugnant, that is entirely my problem.
Besides.
Nobody LIKES abortion. Think about it. Whether you’re pro-life or pro-choice, nobody thinks abortion sounds like a fun time, or something that’s really cool. Nobody says, “Hey! Let’s murder a fetus/baby (whichever you prefer) today!” No. Nobody wants to have one. Nobody wants their daughter to have one. We are all in agreement on this point.
The great thing is that we don’t have to agree on whether abortion should be available to women or not. Abortion is available to women by law and has been since Steely Dan was cool and I was still in diapers. In 2003, one method of abortion was made illegal, thanks to Dubya. Nobody is asking any of you nurses to ‘participate’ in that procedure, as no one is performing it in this country.
****
I don't need a clause in the constitution of my state to tell me that I can refuse to participate in a medical procedure.
If I have a problem doing my job, I can refresh my resume.
Namely, Emergiblog Kim’s initial post here
And subsequent ‘rebuttals’ (if you will):
Duncan Cross wrote.
And Manchmedic wrote.
I agree with Manchmedic.
I think that the government has no place regulating …as part of a state Constitution (much less Federal)…what private American worker should do as part of their job description for a private employer. Legal precedent exists to protect workplace safety (OSHA, child labor, harassment). The government can direct a soldier to war, because that soldier enlisted for that job description. (I don’t like the draft, either.) There are laws about taxation on income, and discrimination.
But this conscience clause is about driving contractual details (i.e. job description and responsibiities) between private corporations (i.e. non-VA hospitals) who hire citizens as employees.
Despite the fact that all civilized people believe that workplaces should be equal opportunity, the need for actual LAWS within a state or federal constitution that direct how workplace equality is to take place is still debated.
California nurse to patient ratio laws are new. Some CA nurses have said that their ratios are better, and they've lost ancillary staff and charge roles as hospitals even out the bottom line. That the ER's overflow. Government with good intent is slower than private enterprise. Perhaps not the optimal solution.
In my opinion, Dubya confused church and state and understood neither. Our founding fathers were very clear on this whole church-state separation thing. This issue is not about God, or beliefs, or hot-button Roe v. Wade.
It’s about what your employer expects that you do for them.
Do you really want the state constitution getting involved in that?
On this ground, I think the clause is a horrible idea and should be un-done.
****
There’s a secondary reason why I disagree with the conscience clause.
I believe with every molecule comprising my body that every human being should be treated that way when they leave. That they should be treated in a way that THEY direct. That we should do the utmost to provide for THEIR needs. That they are free of pain. That they are treated with dignity and respect. That we do everything we can to alleviate the other horrible undignified ‘symptoms’ of the dying process: nausea, vomiting, incontinence, wakeful coughing, clinical anxiety. And in the best situations, people are surrounded by love. The reality is that not everybody’s gonna get that. But I believe it’s what we need to aim for.
Some nurses like sunrises. I like sunsets.
Babies are great, fun, joyful. When I am the best nurse I'm capable of being, it's often with a patient who has made a decision that they're ready for their next big adventure. I am a rabid advocate for pain and symptom management.
I don’t believe in flogging bodies through endless complex procedures that have poor chances for positive outcomes. But sometimes I do it. I'm dialysis, for chrissakes.
There are many situations where I have participated in medical care that violates my humanist beliefs in the right for a patient's dignity and self-direction. Every ICU nurse has participated in cases that have gone before ethics boards. The young person who is HIV+ and after long, protracted illness, wishes to die. A parent wants everything done. Ethics board decides to go for the gusto. Dialyze!
A patient whose family has such financial interest in keeping patient alive that they are able to get him declared mentally incompetent under suspicious circumstances. When clinical psychiatrist, after thorough evaluation of patient, finds patient (to no surprise from staff) to be not only sound, but erudite and thoughtful about his own care, lawsuit by family ensues.
The dialysis patient who is a social work nightmare who becomes pregnant…the highest risk pregnancy I have ever seen. Patient has multiple hospital readmissions since the birth. Have we done that child any favors? Will the child become president or did we bring a human being into terrible suffering and adversity?
I find it morally reprehensible to paralyze a patient with vecuronium and provide no pain medication. I have done so and charted the hell out of the calls to the cardiovascular (bastard) surgeon who had me perform this odious torture. I advocated for my patient in much gentler ways through the family (uneducated in such medications) as well.
I have NOT given blood to a Jehovah’s Witness with a hemoglobin of 5, because the patient does not want that intervention. The patient understood that a lot of physical suffering could be alleviated. To the patient, the spiritual suffering would have been worse.
At no point in time did it ever occur to me to refuse to care for any of these patients. My point here isn’t that any good nurse would not have provided the same care. My point is that a pro-lifer's moral difficulties with abortion are very like my moral difficulties with the 92 year old CABGx5.
But here’s the rub:
IT’S NOT ABOUT ME.
If I don’t want to do the job, I can find a different job. There are nursing jobs that will not put me into a situation that violates my humanist values. My chosen nursing path so far is one of the least morally obstacle free I could have chosen for myself: critical care and dialysis.
However, if I am not going to choose to get a different job where I find such tasks ‘morally repugnant’, I choose to be a professional. You do your job. You prolong the life, you give the person comfort AND advanced intervention of Western medicine. Chemo. Or dialysis. Or intubation. Or surgery. Whatever.
It is not for me to decide whether or not a woman should have an abortion, or a 92 year old should undergo a cardiac bypass graft times five. It’s not for me to decide a crack addict has any business going home with her premature baby. It’s not for me to refuse to take care of an critically ill withdrawing alcoholic/any-other-substance-abuser because I think alcoholism/substance is ‘bad’. Or whatever.
I volunteered at a health fair today and a man asked me which substance be more 'okay' for his heart condition: cocaine, marijuana, alcohol or speed? I answered his question indirectly: cocaine and speed will kill you. No, I don't want him to go smokin pot.
It is for me to provide the best clinical and compassionate care for the patient that I can. I’m not giving up my personal rights as a nurse. Nobody’s asking me to have open heart surgery. Or do anything with my body. Or take up heroin. If I find somebody else’s medical choices to be repugnant, that is entirely my problem.
Besides.
Nobody LIKES abortion. Think about it. Whether you’re pro-life or pro-choice, nobody thinks abortion sounds like a fun time, or something that’s really cool. Nobody says, “Hey! Let’s murder a fetus/baby (whichever you prefer) today!” No. Nobody wants to have one. Nobody wants their daughter to have one. We are all in agreement on this point.
The great thing is that we don’t have to agree on whether abortion should be available to women or not. Abortion is available to women by law and has been since Steely Dan was cool and I was still in diapers. In 2003, one method of abortion was made illegal, thanks to Dubya. Nobody is asking any of you nurses to ‘participate’ in that procedure, as no one is performing it in this country.
****
I don't need a clause in the constitution of my state to tell me that I can refuse to participate in a medical procedure.
If I have a problem doing my job, I can refresh my resume.
Wednesday, March 11, 2009
How do you blog when....
Eighteen hour day on Monday.
Today was 13.5.
Tomorrow I have SIX patients (typical = two to four) and I'm on call again.
....
It's a full moon today. It's been really obvious in hospitals everywhere, I imagine, and we're certainly feeling it. Everybody seems so damn touchy this week, too.
I think we need to pipe aerosol Xanax into the heat/air conditioning in the hospitals.
Relax.
Today was 13.5.
Tomorrow I have SIX patients (typical = two to four) and I'm on call again.
....
It's a full moon today. It's been really obvious in hospitals everywhere, I imagine, and we're certainly feeling it. Everybody seems so damn touchy this week, too.
I think we need to pipe aerosol Xanax into the heat/air conditioning in the hospitals.
Relax.
Friday, February 27, 2009
Compassion...
Found out today that I'd pissed off a patient and he managed to complain to my boss. Was yet another chronic, obese, bastard who didn't feel like going to his dialysis appointment one day. So a day later, c.o.b. goes into the ER of Suburban Luxury Resort That Has A Starbucks But No Water Hookups And Bills Medicare with chest pain.
I actually do understand that a life shackled to a dialysis clinic is a hard life. But the choice is to go or land in the hospital. I don't doubt that this is a painful thing. You will not garner sympathy by acting surprised at this turn of events, however.
I asked him, "Why didn't you go to dialysis on Wednesday?" He sniffs, "I wasn't feeling well." "Well, um, you're in the hospital now, how do you feel?" "Lousy." "I'm sorry you feel lousy. Why didn't you go to the ER yesterday?" "BECAUSE. I. WENT. TODAY."
Big fat duh. He's one of our frequent-flyers. He knows damn well how to work the system. He lives closer to one of the less luxurious hospitals, but he drives a half hour to the ER of Suburban Luxury blahblah because he knows they'll admit him. He finds me rude because I'm supposed to meekly treat him and not call him on the fact that he's milking Medicare for all its worth.
I was dialyzing the bastard at 10 o'clock at night while he was in his hardwood floor-ed single room watchin the flatscreen tv. He's got a free hotel room with predominantly twentysomething cute RNs to wipe his ass for him and a fresh cup of Starbucks every morning in his private room. He didn't like me and loudly told me so in those words. I said I was sorry to hear that, but my affect showed clearly I didn't care. I put his fistula needles in and I didn't do it gently. So he complained about me.
My boss asked what happened, heard the story, and then shrugged. "These patients are often ....difficult." Proceeded to tell me her favorite asshole patient story. "We just have to be mindful of our bad days, too." I nodded. Yeah, I know. C is a nurse too, and not a saint. We have "bad" days when we tell irresponsible people that they're irresponsible.
Which leads me to Head Nurse's blog about compassion. Head Nurse (also a Jo) was picked at for "not having compassion." She's defending a nurse's right to blog snarky.
The other day I dialyzed a Vietnam vet, who took high doses of daily methadone, smoker, chronic pain. He sounded like he had Tourette's, but I'm sure that wasn't a formal diagnosis. Everything f*ck this, d@mn that, sh!t this and that. I stretched his legs for a half hour. They were as tight as lawnmower belts. Slow, gentle plantar- and dorsi-flexion. It helped him. I just felt like doing it. Think I'm an angel and he's this poor, sad, sick man? When I was done with his legs, he told me his ass was hurting him. I just looked at him as if he knew better than that...and he did. "Sorry, I don't do ass massage." Sheepish, he nodded. "Well, thanks, that helped my calves a lot." "You're welcome."
I told my bf the first part of the story and he thought that was really "sweet of me" and "nice of me to do that". I told him the second part of the story and didn't know what to say at first. Because in the real world, I don't do nice, selfless acts for poor, suffering people. Or at least, it doesn't work that way most of the time.
The general public doesn't know what to do with nurses. There's is a greater stereotyping for nurses than there is for MDs. People expect docs to tell them what they want to hear, and to have Dr. Marcus Welby bedside manner, to be right all the time....but they also expect that docs be compensated well for this. Nurses are either dumb doctor-secretaries or saints/angels.
I'm none of those things. I have my own scope of practice that is collaborative with that of medical doctors. You don't want me diagnosing your weird condition, but you also don't want the majority of (non-surgical) MDs coming anywhere near you with needles or catheters. I don't do things to be saintly or angelic. I get paid to help treat patients to improve their health, to educate patients on their health/illness/diet/medications and to alleviate pain and suffering.
Yes. I get paid to do those things. I could get paid to do other things. But I choose to be a nurse.
If you're a patient and you're a dickhead to me, your expectation that I smile and sweetly take it is erroneous. I can stick really big f*cking needles into your fistula and I don't have to do it gently. If you're that stupid to verbally abuse a nurse that you KNOW has to put two 15 gauge needles into your arm, well...maybe you'll learn for next time. I can tell you bluntly what will happen to your body if you ignore medical advice. Take a swing at me and punch a pregnant nurse in the stomach and expect me to tie you down in leathers and I'll make it tight. Try to choke me, and I will put my hand around your throat until you let my throat go. Call me every name in the book and expect that pain medicine you want to not be my top priority.
I get paid to treat you. I don't get paid to be verbally or physically abused by you.
Why is that difficult for the general public, and for my patients?
I don't tend to blog about the gentle things I do. Thank you cards I've received from patients. Hugs and hand-holding. Times I've gone toe to toe with a doc on behalf of a patient. Can't even tell you the number of times I've shamed surgeons into giving pain medicine (aPALLing the number of times that's been necessary). Times I've helped to successfully treat patients, when my care over a shift has clinically improved the patient's outcome. When I've identified problems before the problem gets worse. All the preventative care I do, all the times I feel like a patient or a family member has come away understanding a disease process or medications or whatever because of the time I took to talk with them.
I don't do that cos I'm normal and I get paid to do a job, and like everyone else on in America, I gripe about what bugs me about my job.
I don't know else what we nurses need to do to fix these stupid perceptions. But we need to do somethin.
I actually do understand that a life shackled to a dialysis clinic is a hard life. But the choice is to go or land in the hospital. I don't doubt that this is a painful thing. You will not garner sympathy by acting surprised at this turn of events, however.
I asked him, "Why didn't you go to dialysis on Wednesday?" He sniffs, "I wasn't feeling well." "Well, um, you're in the hospital now, how do you feel?" "Lousy." "I'm sorry you feel lousy. Why didn't you go to the ER yesterday?" "BECAUSE. I. WENT. TODAY."
Big fat duh. He's one of our frequent-flyers. He knows damn well how to work the system. He lives closer to one of the less luxurious hospitals, but he drives a half hour to the ER of Suburban Luxury blahblah because he knows they'll admit him. He finds me rude because I'm supposed to meekly treat him and not call him on the fact that he's milking Medicare for all its worth.
I was dialyzing the bastard at 10 o'clock at night while he was in his hardwood floor-ed single room watchin the flatscreen tv. He's got a free hotel room with predominantly twentysomething cute RNs to wipe his ass for him and a fresh cup of Starbucks every morning in his private room. He didn't like me and loudly told me so in those words. I said I was sorry to hear that, but my affect showed clearly I didn't care. I put his fistula needles in and I didn't do it gently. So he complained about me. My boss asked what happened, heard the story, and then shrugged. "These patients are often ....difficult." Proceeded to tell me her favorite asshole patient story. "We just have to be mindful of our bad days, too." I nodded. Yeah, I know. C is a nurse too, and not a saint. We have "bad" days when we tell irresponsible people that they're irresponsible.
Which leads me to Head Nurse's blog about compassion. Head Nurse (also a Jo) was picked at for "not having compassion." She's defending a nurse's right to blog snarky.
The other day I dialyzed a Vietnam vet, who took high doses of daily methadone, smoker, chronic pain. He sounded like he had Tourette's, but I'm sure that wasn't a formal diagnosis. Everything f*ck this, d@mn that, sh!t this and that. I stretched his legs for a half hour. They were as tight as lawnmower belts. Slow, gentle plantar- and dorsi-flexion. It helped him. I just felt like doing it. Think I'm an angel and he's this poor, sad, sick man? When I was done with his legs, he told me his ass was hurting him. I just looked at him as if he knew better than that...and he did. "Sorry, I don't do ass massage." Sheepish, he nodded. "Well, thanks, that helped my calves a lot." "You're welcome."
I told my bf the first part of the story and he thought that was really "sweet of me" and "nice of me to do that". I told him the second part of the story and didn't know what to say at first. Because in the real world, I don't do nice, selfless acts for poor, suffering people. Or at least, it doesn't work that way most of the time.The general public doesn't know what to do with nurses. There's is a greater stereotyping for nurses than there is for MDs. People expect docs to tell them what they want to hear, and to have Dr. Marcus Welby bedside manner, to be right all the time....but they also expect that docs be compensated well for this. Nurses are either dumb doctor-secretaries or saints/angels.
I'm none of those things. I have my own scope of practice that is collaborative with that of medical doctors. You don't want me diagnosing your weird condition, but you also don't want the majority of (non-surgical) MDs coming anywhere near you with needles or catheters. I don't do things to be saintly or angelic. I get paid to help treat patients to improve their health, to educate patients on their health/illness/diet/medications and to alleviate pain and suffering.
Yes. I get paid to do those things. I could get paid to do other things. But I choose to be a nurse.
If you're a patient and you're a dickhead to me, your expectation that I smile and sweetly take it is erroneous. I can stick really big f*cking needles into your fistula and I don't have to do it gently. If you're that stupid to verbally abuse a nurse that you KNOW has to put two 15 gauge needles into your arm, well...maybe you'll learn for next time. I can tell you bluntly what will happen to your body if you ignore medical advice. Take a swing at me and punch a pregnant nurse in the stomach and expect me to tie you down in leathers and I'll make it tight. Try to choke me, and I will put my hand around your throat until you let my throat go. Call me every name in the book and expect that pain medicine you want to not be my top priority. I get paid to treat you. I don't get paid to be verbally or physically abused by you.
Why is that difficult for the general public, and for my patients?
I don't tend to blog about the gentle things I do. Thank you cards I've received from patients. Hugs and hand-holding. Times I've gone toe to toe with a doc on behalf of a patient. Can't even tell you the number of times I've shamed surgeons into giving pain medicine (aPALLing the number of times that's been necessary). Times I've helped to successfully treat patients, when my care over a shift has clinically improved the patient's outcome. When I've identified problems before the problem gets worse. All the preventative care I do, all the times I feel like a patient or a family member has come away understanding a disease process or medications or whatever because of the time I took to talk with them.
I don't do that cos I'm normal and I get paid to do a job, and like everyone else on in America, I gripe about what bugs me about my job.
I don't know else what we nurses need to do to fix these stupid perceptions. But we need to do somethin.
What I wish patients would do:
Lose 100 lbs. (The many that can afford to lose those pounds).
So Happy Hospitalist is a rabid anti-smoker and he lectures his patients on their smoking habits. That's good. I applaud that. Smoking gets under his skin, and it pisses him off that Medicare covers the serial intubations of smokers who continue to smoke. That pisses me off too.
What pisses me off is morbid obesity. Like smoking, morbid obesity is a choice. No, nobody did hold a funnel to your orifice. The argument that you don't have the emotional control means only that you need to be responsible and OBTAIN self-control. If you have an eating disorder, seek therapy, not my sympathy.
A full 37% of the American population is obese. Not 'overweight', not 'wish that damn 7 lbs would go away'....no....rolls of fat obese. Can't get oxygen into their bodies while sleeping because of obesity-induced sleep apnea.
I was at a hospital yesterday dialyzing a patient who is so obese, her bed needs to be constructed inside the room. She is unable to leave this room. There are TWO patients currently at that hospital that we dialyze this way. It's actually not uncommon anymore.
The patient barely spoke to me yesterday because she hates the whole dialysis process. She begrudgingly answered my questions and consented to do things like moving her arms so that I could get to her vascatheter. The one time she did speak to me was to complain about the bland food. "Your diet is killing you, Mrs. RollsOfAdipose." "You think I should eat that food?" "I think you are in the hospital because of your weight. You are unable to leave this room because you're eating yourself to death. You need to change your lifestyle or you will die here. A few vegetables might be what you have to do to get out of where you put yourself." She was mortified. And was infuriated at the suggestion that soon, she would need to actually leave the room to go down the hall to dialyze. "I can't sit in a chair for 4 hours."
The old....I'm so fat I can't sit up excuse.
In the meantime, I haul a half ton worth of machinery to her so that we can get all the damn potassium and protein wastes out of her blood so she doesn't die.
One nurse I respect told me a story that she was bathing an obese woman one time, and found a Twinkie in the woman's rolls. The woman giggled and told this nurse it was part of a game she and her husband play: find the food.
I don't actually make this stuff up.
If you're over 30 BMI (and you are neither very pregnant nor a bodybuilder), you need to stop the madness. Unless you're Mother Teresa or Albert Schweitzer, you don't deserve dessert every day. You need to eat some vegetables instead of Big Macs. You need to cut your portion sizes down by two-thirds. That's not debatable, much as you'd like that to be told to you in a more sugary sweet way. You're fat. You did it to yourself. You choose to stop, or you choose to die slowly, painfully in a medically protracted and undignified way. Period.
I have no sympathy for the 'helplessly' obese people that big. The vast majority don't have an eating disorder. They have Entitlementus Americanus Lazii. A lousy economy might be a partial cure for that.
I'm tired of my taxes going to paying for specialty beds to be built in your hospital room. My taxes pay for your insulin. They pay for your CPAP machines. Your weeks and weeks of inpatient hospitalizations. Your dialysis treatments, your heart surgeries. Worst investment my taxes ever made.
So Happy Hospitalist is a rabid anti-smoker and he lectures his patients on their smoking habits. That's good. I applaud that. Smoking gets under his skin, and it pisses him off that Medicare covers the serial intubations of smokers who continue to smoke. That pisses me off too.
What pisses me off is morbid obesity. Like smoking, morbid obesity is a choice. No, nobody did hold a funnel to your orifice. The argument that you don't have the emotional control means only that you need to be responsible and OBTAIN self-control. If you have an eating disorder, seek therapy, not my sympathy.
A full 37% of the American population is obese. Not 'overweight', not 'wish that damn 7 lbs would go away'....no....rolls of fat obese. Can't get oxygen into their bodies while sleeping because of obesity-induced sleep apnea.
I was at a hospital yesterday dialyzing a patient who is so obese, her bed needs to be constructed inside the room. She is unable to leave this room. There are TWO patients currently at that hospital that we dialyze this way. It's actually not uncommon anymore.
The patient barely spoke to me yesterday because she hates the whole dialysis process. She begrudgingly answered my questions and consented to do things like moving her arms so that I could get to her vascatheter. The one time she did speak to me was to complain about the bland food. "Your diet is killing you, Mrs. RollsOfAdipose." "You think I should eat that food?" "I think you are in the hospital because of your weight. You are unable to leave this room because you're eating yourself to death. You need to change your lifestyle or you will die here. A few vegetables might be what you have to do to get out of where you put yourself." She was mortified. And was infuriated at the suggestion that soon, she would need to actually leave the room to go down the hall to dialyze. "I can't sit in a chair for 4 hours."
The old....I'm so fat I can't sit up excuse.
In the meantime, I haul a half ton worth of machinery to her so that we can get all the damn potassium and protein wastes out of her blood so she doesn't die.
One nurse I respect told me a story that she was bathing an obese woman one time, and found a Twinkie in the woman's rolls. The woman giggled and told this nurse it was part of a game she and her husband play: find the food.
I don't actually make this stuff up.
If you're over 30 BMI (and you are neither very pregnant nor a bodybuilder), you need to stop the madness. Unless you're Mother Teresa or Albert Schweitzer, you don't deserve dessert every day. You need to eat some vegetables instead of Big Macs. You need to cut your portion sizes down by two-thirds. That's not debatable, much as you'd like that to be told to you in a more sugary sweet way. You're fat. You did it to yourself. You choose to stop, or you choose to die slowly, painfully in a medically protracted and undignified way. Period.
I have no sympathy for the 'helplessly' obese people that big. The vast majority don't have an eating disorder. They have Entitlementus Americanus Lazii. A lousy economy might be a partial cure for that.
I'm tired of my taxes going to paying for specialty beds to be built in your hospital room. My taxes pay for your insulin. They pay for your CPAP machines. Your weeks and weeks of inpatient hospitalizations. Your dialysis treatments, your heart surgeries. Worst investment my taxes ever made.
Friday, January 30, 2009
Dear MD, please write some orders for me. Thanks, your friendly RN
(Here's somethin you don't hear out of nurse blogs on a regular basis.)
Dear MD,
I did not go to medical school, nor did I do residency. I am not a doctor. I'm a nurse. I know a lot about health and medicine, pathophys and pharmacology. I can predict with a good degree of accuracy what drugs, doses, diagnostics and treatments make sense for a patient.
An MD should WANT me to be able to do this. We have a human-made and broken health care system and mistakes happen all the time. I am another clinician that helps protect patients by ensuring the drugs and treatments you want for our patient do what we both want them to do.
But the fact is that you have twice the amount of time, and a much more comprehensive training in the field. I don't diagnose. I don't prescribe. Yay for us both and for the patient. I have a good degree of accuracy....enough that I feel confident seeing a nurse practitioner for my general health stuff. But for my more complicated breathing stuff, I see a pulmonologist. I know the difference.
Here's my trouble: when I come to dialyze our patients, I get the name of a hospital, a last name, and sometimes a room number. I don't get any report on these individuals; I do not have the luxury of reading health and physical history, recent orders or even speaking to the patient before I get 75% of my dialysis treatment set up. I get some lab values, which allow me to predict the correct potassium prescription.
Let's go back to that sentance. I get some lab values and predict a potassium prescription (granted it's not that hard for dialysate) in a population with common comorbid cardiac issues.
What I ask of you is that you write me some orders for the treatment parameters. When I receive the chart, I often am going on orders you wrote for a dialysis treatment two weeks ago. Sometimes the patient gets two hours of a treatment I decide upon before you see them that day. Sometimes it's their first treatment and I am making those decisions until you arrive an hour or two into the treatment.
The good news is that I'm right most of the time. It is first grade math to subtract a serum potassium from seven.
The bad news is that I do not have MD behind my name and you do. Please don't leave these decisions to me. Please don't grouse when I ask you to write me some orders for the treatment I'm halfway through completing. Please don't look at me as if I'm a moron who's asking to be told what to do when it's seemingly obvious what I should do.
It protects us both. It's best for the patient. I do not have any business deciding how much potassium to give a patient, how much Epogen, how fast to dialyze a new patient who's never had dialysis before. I know that. I also know you're busy and have 35 patients to see today. I get it. I also know most of the other nurses on the team do this all the time. But I think they allow this to continue because they interpret this possible laziness/busy-ness on your part to be a vote of confidence in them.
It doesn't take much to subtract from seven, yes. But what you may not know is that other physicians are altering other electrolytes through the treatment that are providing benefit to the patient. They're giving additional drugs that may be beneficial. They're even having me change the direction of my dialysate flow (something I need to know 35 minutes beFORE patient arrival), to reduce the risk of adverse outcomes on new patients.
That's not first grade stuff. And for treatments I 'prescribe', I don't do that. But maybe you should. Or maybe it goes through your head to consider, but you never get around to writing it down, so it never happens.
I respect what you know. This laziness is possibly a nod of confidence to me, or maybe you think any monkey can do what I do. Either way, I don't care. It isn't right and there are clear legal scope of practice boundaries, no matter how busy we are. These boundaries are for the best of the patient.
So just. Please, write me some orders.
Thanks
/jo
Dear MD,
I did not go to medical school, nor did I do residency. I am not a doctor. I'm a nurse. I know a lot about health and medicine, pathophys and pharmacology. I can predict with a good degree of accuracy what drugs, doses, diagnostics and treatments make sense for a patient.
An MD should WANT me to be able to do this. We have a human-made and broken health care system and mistakes happen all the time. I am another clinician that helps protect patients by ensuring the drugs and treatments you want for our patient do what we both want them to do.
But the fact is that you have twice the amount of time, and a much more comprehensive training in the field. I don't diagnose. I don't prescribe. Yay for us both and for the patient. I have a good degree of accuracy....enough that I feel confident seeing a nurse practitioner for my general health stuff. But for my more complicated breathing stuff, I see a pulmonologist. I know the difference.
Here's my trouble: when I come to dialyze our patients, I get the name of a hospital, a last name, and sometimes a room number. I don't get any report on these individuals; I do not have the luxury of reading health and physical history, recent orders or even speaking to the patient before I get 75% of my dialysis treatment set up. I get some lab values, which allow me to predict the correct potassium prescription.
Let's go back to that sentance. I get some lab values and predict a potassium prescription (granted it's not that hard for dialysate) in a population with common comorbid cardiac issues.
What I ask of you is that you write me some orders for the treatment parameters. When I receive the chart, I often am going on orders you wrote for a dialysis treatment two weeks ago. Sometimes the patient gets two hours of a treatment I decide upon before you see them that day. Sometimes it's their first treatment and I am making those decisions until you arrive an hour or two into the treatment.
The good news is that I'm right most of the time. It is first grade math to subtract a serum potassium from seven.
The bad news is that I do not have MD behind my name and you do. Please don't leave these decisions to me. Please don't grouse when I ask you to write me some orders for the treatment I'm halfway through completing. Please don't look at me as if I'm a moron who's asking to be told what to do when it's seemingly obvious what I should do.
It protects us both. It's best for the patient. I do not have any business deciding how much potassium to give a patient, how much Epogen, how fast to dialyze a new patient who's never had dialysis before. I know that. I also know you're busy and have 35 patients to see today. I get it. I also know most of the other nurses on the team do this all the time. But I think they allow this to continue because they interpret this possible laziness/busy-ness on your part to be a vote of confidence in them.
It doesn't take much to subtract from seven, yes. But what you may not know is that other physicians are altering other electrolytes through the treatment that are providing benefit to the patient. They're giving additional drugs that may be beneficial. They're even having me change the direction of my dialysate flow (something I need to know 35 minutes beFORE patient arrival), to reduce the risk of adverse outcomes on new patients.
That's not first grade stuff. And for treatments I 'prescribe', I don't do that. But maybe you should. Or maybe it goes through your head to consider, but you never get around to writing it down, so it never happens.
I respect what you know. This laziness is possibly a nod of confidence to me, or maybe you think any monkey can do what I do. Either way, I don't care. It isn't right and there are clear legal scope of practice boundaries, no matter how busy we are. These boundaries are for the best of the patient.
So just. Please, write me some orders.
Thanks
/jo
Thursday, January 15, 2009
Clinical case study du jour.
So I got a call at 17:00ish today to go to the Hilton Hospital of Suburban Growth Upon My City (you know, the one with the Starbucks). All I get is: "Go to HH of SGUMC, ICU bed 42, patient's name is Fritz and he just left a week ago. His K+ is 8."
(I was gonna name the patient something like Schwarzenpfluger but I decided that's too many letters to type repeatedly. I picked 'Fritz' instead, because it's a nice name and makes me think of nice schnauzers I have known.) (Why I'd think of schnauzers I don't know. It's been a longass day.) (Note: Patient is not of German heritage...Germany is just on the brain this week.)
So my first thought is that Fritz went home and then didn't go to his dialysis appointments, and then someone found him dead, called 911 and there you have it.
Patient is early-mid40s, alert, chatty, polite. He doesn't look like an end stage renal patient at all. He doesn't even look like he was dead a few hours ago. No apparent neurological residual...he's freakin texting somebody on his cell when you get in. (Can you imagine that text: Dude! Died today. Came back. Txt me when you get this.) ....but definitely not a chronic kidney....his skin is healthy, for one. He's not depressed, for two. Third, he's not watching either Jerry Springer or the Food Network, and I'm pretty sure that having kidney disease compels you to do one of those things.
"Hi Fritz, I'm JustCallMeJo and I'm here to dialyze you."
"Nice to meet you."
*boggle* Really? Did I get the right room? I address him by name to double-check. I set up my machines; I get Fritz's story.
(Also notice that the patient is on a nasal cannula only, so of course <_5L of O2, rhythm in a grossly normal-appearing sinus tach, satting well for altitude, with a normotensive blood pressure. Other assessment findings: c/o 6/10 pain, pericardial rub, pulses all palp and regular, wheezes post left lower lobe, bowel sounds hypoactive, 1+ edema BLE, two fentanyl patches on back of scapulae, permcath to R IJ and a #18 rather ugly field IV in the L AC, unmessy #20 R hand IV.)
Turns out he has mediastinal cancer, which I would not wish upon Pol Pot. It's horrible, cruel and unusual. It metastasized to a kidney. To complicate things, his first round of high octane chemo caused acute tubular necrosis (as chemo sometimes does.) Acute kidney disease became chronic kidney disease, and he became dependent upon dialysis.
This all sucks in ways profound and deep. But this guy decides to choose life when life has handed him lemons laced with battery acid and prune juice. Amazingly, he's on board. He has GONE to his dialysis appointments as scheduled. He and his wife are asking me good questions about the renal diet, which IS genuinely confusing and difficult. One of his parents is present, and the parent asks me really detailed questions about kidney physiology and how the dialysis machine works. ("So, what are the filter fibers made of?") (What ARE the fibers made of? I have never been asked that.) (I'm explaining finer points of ultrafiltration, diffusion, osmosis and molecule size of creatinine to people who are ASKING about it. I mean, nobody but ME likes that stuff.)
Point is, this is a guy that intends to live. This is a guy that will do whatever sucky things life is requiring him to do. This is not my usual patient at ALL.
So.
This morning, his wife finds him down, unresponsive, foaming at the mouth. She does CPR. For real. Jane Anybody calls 911, does CPR ...and this woman saved her husband's life. (I just think that's amazing.) EMTs arrive, intubate him, lights and sirens to the HH of SGUMC. Upon arrival, he codes again. They find his potassium to be 7.3. During the code, they did glucose, insulin, bicarb and calcium. No Kayexalate, no Narcan, no Romazicon. Some intensivist decides to call the nephrologist in to evaluate for stat dialysis. Meanwhile, as they're getting a nephrologist to come in urgently, who then has to see the patient, call the scheduler, who calls me, who drives through rush hour traffic, yadayda....the patient stabilizes and they decide to extubate the patient.
And then, I guess, he resumes text messaging his friends. And then he has chicken soup for dinner, which he says is too salty.
*******
Aren't there things that bug you about this picture?
....
So I'm thinkin it was a VT arrest, end of story. However, parent of Fritz is at bedside and parent asks aloud, "But what about all those drugs you're on? You took extra didn't you?" Parent obviously disapproves of narcotics. I ask patient what he's on. He gives me a litany of narcotics. It is enough to kill a herd of cattle, and maybe a few small rodents, too. I assure parent that the son has mediastinal cancer, which is very painful, and I explain the pathophys of narcotic tolerance. The difference between the patient's prescribed dose and the "extra" he took was a single tab of PO Dilaudid. I don't know the patient's pain and narc history, but I do know that it's possible that the "extra dose" is a drop in the bucket, equivalent to a glass of wine for me. Could one glass of wine, after enough on board, toss me over the edge? I suppose it could.
So.
There's a question in the patient's mind as well as with the physicians and nurses of what deadified him twice today: cardiac arrest (from the high K+) or respiratory arrest (from the narcs). But again, no Narcan was done, and the twelve lead EKG shows a wildly unremarkable sinus tach. On the flipside, the patient lives with a potassium of over 5, so who knows how much it would take to send his heart into an arrhythmia.
***********
I'm still thinkin cardiac because, well, if it looks like a duck and sounds like a duck.... I might be wrong. I have RN behind my name, not MD. My job is to treat, not to diagnose. There's a whole lot I am sure I am missing, particularly since I know squat about oncology.
I asked the nephrologist of course. He doesn't know for sure, yet. ("Come on, he doesn't look at ALL like a status post respiratory failure, this guy's had a cardiac event today, don't you think...?" "Yeah, I'm with you, but there's so much goin on with this guy. It feels like that, but it could just be a combination of both.") An hour later, he called me to ask me to change some things with the treatment. He's out supposed to be having fun at a party but he's checked out, thinkin about this patient.
I think the real mystery is: Why was his potassium that high?
* I can't imagine diet alone doing it. (His PO4 also elevated.) I suppose my imagination is limited, but if the potato famine didn't wipe out all of Ireland, I'm not sure diet alone is that efficient.
* He didn't skip dialysis treatments (and his hemo treatments are being done by a source that suggests extremely unlikely that he was dialyzed with an acid bath of 16 or something ridiculous like that.)
* He last bout of chemo (which might have caused mass lysis of cells, causing a flood of potassium into his bloodstream) was three weeks ago.
* His wbcs are low, but I've seen far worse. Infection? Leading to lysis? His lactate was elevated somewhat. ?
* I can't imagine it being so no-brainer as he's accidentally taking potassium pills. This patient has had his life upside down and entrails out for less than a year...he has a polypharmacy stash of narcotics. But I doubt he's like my 70something polypharmacy patient with old stashes of cardiac and diabetic meds that might get mixed up.
* Again with the....Less than twenty four hours post full four hour hemodialysis treatment. Even if the acid bath was wrong, it would have had to be dangerously, wildly, toxic, deadly wrong to produce a serum potassium of 7.3. (Can you even supersaturate an acid solution with that much KCl?) I just don't see a mechanism for that to have happened.
So what did happen?
....
....
I have four days off, which I'm delighted about. But I kinda am really curious about what happened to this patient today.
Mostly, I'm writing this down just to dump it outta my head so I can sleep. Sheesh, it's 0155 a.m. I'm off call in 4 hours. Yay for me.
...My day started at my Home Hospital with a nosepickin, Jerry Springer-watchin, morbidly obese patient who asked me "where the beauty salon is in this hospital." She "needs a cut."
For real.
But then on hospital #3 of the day, I got to Fritz. And people like Fritz, and his family, are the reason I do this stuff.
(I was gonna name the patient something like Schwarzenpfluger but I decided that's too many letters to type repeatedly. I picked 'Fritz' instead, because it's a nice name and makes me think of nice schnauzers I have known.) (Why I'd think of schnauzers I don't know. It's been a longass day.) (Note: Patient is not of German heritage...Germany is just on the brain this week.)
So my first thought is that Fritz went home and then didn't go to his dialysis appointments, and then someone found him dead, called 911 and there you have it.
Patient is early-mid40s, alert, chatty, polite. He doesn't look like an end stage renal patient at all. He doesn't even look like he was dead a few hours ago. No apparent neurological residual...he's freakin texting somebody on his cell when you get in. (Can you imagine that text: Dude! Died today. Came back. Txt me when you get this.) ....but definitely not a chronic kidney....his skin is healthy, for one. He's not depressed, for two. Third, he's not watching either Jerry Springer or the Food Network, and I'm pretty sure that having kidney disease compels you to do one of those things.
"Hi Fritz, I'm JustCallMeJo and I'm here to dialyze you."
"Nice to meet you."
*boggle* Really? Did I get the right room? I address him by name to double-check. I set up my machines; I get Fritz's story.
(Also notice that the patient is on a nasal cannula only, so of course <_5L of O2, rhythm in a grossly normal-appearing sinus tach, satting well for altitude, with a normotensive blood pressure. Other assessment findings: c/o 6/10 pain, pericardial rub, pulses all palp and regular, wheezes post left lower lobe, bowel sounds hypoactive, 1+ edema BLE, two fentanyl patches on back of scapulae, permcath to R IJ and a #18 rather ugly field IV in the L AC, unmessy #20 R hand IV.)
Turns out he has mediastinal cancer, which I would not wish upon Pol Pot. It's horrible, cruel and unusual. It metastasized to a kidney. To complicate things, his first round of high octane chemo caused acute tubular necrosis (as chemo sometimes does.) Acute kidney disease became chronic kidney disease, and he became dependent upon dialysis.
This all sucks in ways profound and deep. But this guy decides to choose life when life has handed him lemons laced with battery acid and prune juice. Amazingly, he's on board. He has GONE to his dialysis appointments as scheduled. He and his wife are asking me good questions about the renal diet, which IS genuinely confusing and difficult. One of his parents is present, and the parent asks me really detailed questions about kidney physiology and how the dialysis machine works. ("So, what are the filter fibers made of?") (What ARE the fibers made of? I have never been asked that.) (I'm explaining finer points of ultrafiltration, diffusion, osmosis and molecule size of creatinine to people who are ASKING about it. I mean, nobody but ME likes that stuff.)
Point is, this is a guy that intends to live. This is a guy that will do whatever sucky things life is requiring him to do. This is not my usual patient at ALL.
So.
This morning, his wife finds him down, unresponsive, foaming at the mouth. She does CPR. For real. Jane Anybody calls 911, does CPR ...and this woman saved her husband's life. (I just think that's amazing.) EMTs arrive, intubate him, lights and sirens to the HH of SGUMC. Upon arrival, he codes again. They find his potassium to be 7.3. During the code, they did glucose, insulin, bicarb and calcium. No Kayexalate, no Narcan, no Romazicon. Some intensivist decides to call the nephrologist in to evaluate for stat dialysis. Meanwhile, as they're getting a nephrologist to come in urgently, who then has to see the patient, call the scheduler, who calls me, who drives through rush hour traffic, yadayda....the patient stabilizes and they decide to extubate the patient.
And then, I guess, he resumes text messaging his friends. And then he has chicken soup for dinner, which he says is too salty.
*******
Aren't there things that bug you about this picture?
....
So I'm thinkin it was a VT arrest, end of story. However, parent of Fritz is at bedside and parent asks aloud, "But what about all those drugs you're on? You took extra didn't you?" Parent obviously disapproves of narcotics. I ask patient what he's on. He gives me a litany of narcotics. It is enough to kill a herd of cattle, and maybe a few small rodents, too. I assure parent that the son has mediastinal cancer, which is very painful, and I explain the pathophys of narcotic tolerance. The difference between the patient's prescribed dose and the "extra" he took was a single tab of PO Dilaudid. I don't know the patient's pain and narc history, but I do know that it's possible that the "extra dose" is a drop in the bucket, equivalent to a glass of wine for me. Could one glass of wine, after enough on board, toss me over the edge? I suppose it could.
So.
There's a question in the patient's mind as well as with the physicians and nurses of what deadified him twice today: cardiac arrest (from the high K+) or respiratory arrest (from the narcs). But again, no Narcan was done, and the twelve lead EKG shows a wildly unremarkable sinus tach. On the flipside, the patient lives with a potassium of over 5, so who knows how much it would take to send his heart into an arrhythmia.
***********
I'm still thinkin cardiac because, well, if it looks like a duck and sounds like a duck.... I might be wrong. I have RN behind my name, not MD. My job is to treat, not to diagnose. There's a whole lot I am sure I am missing, particularly since I know squat about oncology.
I asked the nephrologist of course. He doesn't know for sure, yet. ("Come on, he doesn't look at ALL like a status post respiratory failure, this guy's had a cardiac event today, don't you think...?" "Yeah, I'm with you, but there's so much goin on with this guy. It feels like that, but it could just be a combination of both.") An hour later, he called me to ask me to change some things with the treatment. He's out supposed to be having fun at a party but he's checked out, thinkin about this patient.
I think the real mystery is: Why was his potassium that high?
* I can't imagine diet alone doing it. (His PO4 also elevated.) I suppose my imagination is limited, but if the potato famine didn't wipe out all of Ireland, I'm not sure diet alone is that efficient.
* He didn't skip dialysis treatments (and his hemo treatments are being done by a source that suggests extremely unlikely that he was dialyzed with an acid bath of 16 or something ridiculous like that.)
* He last bout of chemo (which might have caused mass lysis of cells, causing a flood of potassium into his bloodstream) was three weeks ago.
* His wbcs are low, but I've seen far worse. Infection? Leading to lysis? His lactate was elevated somewhat. ?
* I can't imagine it being so no-brainer as he's accidentally taking potassium pills. This patient has had his life upside down and entrails out for less than a year...he has a polypharmacy stash of narcotics. But I doubt he's like my 70something polypharmacy patient with old stashes of cardiac and diabetic meds that might get mixed up.
* Again with the....Less than twenty four hours post full four hour hemodialysis treatment. Even if the acid bath was wrong, it would have had to be dangerously, wildly, toxic, deadly wrong to produce a serum potassium of 7.3. (Can you even supersaturate an acid solution with that much KCl?) I just don't see a mechanism for that to have happened.
So what did happen?
....
....
I have four days off, which I'm delighted about. But I kinda am really curious about what happened to this patient today.
Mostly, I'm writing this down just to dump it outta my head so I can sleep. Sheesh, it's 0155 a.m. I'm off call in 4 hours. Yay for me.
...My day started at my Home Hospital with a nosepickin, Jerry Springer-watchin, morbidly obese patient who asked me "where the beauty salon is in this hospital." She "needs a cut."
For real.
But then on hospital #3 of the day, I got to Fritz. And people like Fritz, and his family, are the reason I do this stuff.
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