ok, here's a scenario ...see if you have the same suspicions i have (or any reasonable person would have smile emoticon )

13 month old comes into urgent care with reported "seizures", somnolent. Hospitalist decides he has increased ICP, so he gets mannnitol and 3% saline in our PICU. (now usually it is necessary to actually determine what the cause is before treating this way, usually needs invasive monitoring,multiple head ct's, not just : "he must have increased intracranial pressure" before using these treatments.
No tox screen done on admission because it 'isn't necessary".

2 days of nurses pushing for more eval, and a CT scan and bone scan shows a parietal skull fracture.
In the mean time, Mom insists on only feeding him the formula from home,("he hates eating food, he only eats this formula") and nurses continue to report very odd interactions with family and family with baby.

CYFD and police are finally involved. Dad skips just before they arrive thanks to a cousin who works in another unit who has been accessing the electronic record and probably warned him.

Picking up all the possessions left in room, we discover bags full of boxes of nonsterile gloves, boxes of face masks, a bag of syringes, and two boxes of aluminum foil from the cafeteria.
Pediatrician agrees that hair analysis for drugs or toxins "might" be worthwhile.

In the meantime, kid wakes up, eats real food, begins to smile and interact with staff.
DUH

"You should probably brace yourself for some light vomiting followed by life altering hallucinations."

Grace and Frankie makes me happy.  As I look around at my fairy lights and my paper lampshade globes and my crystal bowls and my strings of garlic and collections of essential oils, I also clearly need a labyrinth. Of course I need all that emotionally in addition to my deep appreciation for and dependence upon the scientific method. I work in a field that is based in real science, albeit imbued by lots of lovely fuzzy stuff like compassion and love. We save lives with science and passion, both.

50 years ago, I was 14, and attending a really nice little prep school in a tiny town in Maine. Even there, we knew  that things were changing, and many of us have gone on to make changes in our world, inspired by the chaos of that time.

But now, at 64 years old, I find myself wondering when and how our kind and compassionate hippy approach to the world somehow destroyed logical thought and respect for research and scientific thought. Yes, my generation made huge changes  in the world and in global consciousness. But it feels to me right now that somehow many of us may have fallen down on the job...even as we made huge changes in our personal lives, good changes, that we believed manifested in the greater world.
Individually, we meditate, we do yoga, we respect others no matter who they are, how they manifest; we donate to humanitarian causes; we recycle and have compost heaps; we eat clean because we actually  kinda invented co-ops and organic foods . We foster kids, we adopt kids, we give money and time to our transgender and gay kids and friends, we celebrate diversity in our schools. We practice compassion.

But somehow, we seem to have become complacent over the decades, and we stopped being outraged and effectively effective  about things that were happening in the political and judicial sphere.  We didn't rise up and protest when the automatic weapons ban expired in 2004. We forgot to rise up and protest when the Supreme Court narrowly allowed Citizens United to let corporations donate money as though they were equal to individual voter. We didn't rise up when congress allowed our rights to privacy to be devastated post 9-11.
We have allowed education to elide over real history, and to allow kids to graduate from high school unable to differentiate between the National Enquirer and actual science. I'm sorry. I am honestly very sorry. i thought my personal satoris were enough. Somehow we've missed the piece that radical compassion ALSO requires action in the real world, commitment to change. We all need to be obnoxious in telling our stories, and sharing our beliefs. There is a caveat: we need to make sure that our opinions are backed up by fact, not just nifty memes. It may well piss people off; it will undoubtedly trim down our nice friends lists on Facebook. No biggie, I can live with that. And I am planning to support the newest entrants into our great tradition of protestors against the big money that is working against all of us who are not billionaires. The teen survivors of Parkland are the ones who are saying, loud and clear, "the Emperor has no clothes!" The system is corrupt. We need their energy. It behooves us to support them in every way we can. They are our future, our hope and our chance to keep on doing the things we have always believed in. https://www.theatlantic.com/photo/2018/01/50-years-ago-in-photos-a-look-back-at-1968/550208/

I seriously don't want to be one of those old farts talking about how much harder it was in 'my day" of nursing, critical care. I don't want to bore the crap out of people I share with, yet at the same time , I do believe I have some perspective to offer, both personally and historically.

I'm going to park this Face book post here until I work on it and deepen the historical parts.

There are some interesting things about having been in healthcare for a few decades+ .
I'll skip my frustrations and anger about the politics and finance of caring for humans, and look at positives.

The things we can do to save lives are far more effective and nuanced than they were even in the 80's. We have better equipment...better monitors , better ventilators, more specific testing modalities, better understanding of many diseases, even though it is surely a work in progress. There is so much we are only now barely beginning to discover about autoimmune diseases, for instance, about how to tailor care very specifically to individual genomes.

I no longer need to carry my own tiny screwdriver to adjust the gain on a cardiac monitor. The advances in imaging and digital manipulation are extraordinary...(I honest to god remember crying when I took a patient into our first MRI and saw the gorgeous pictures of his tumor....and what we can see now is hundreds of iterations more accurate and clear)
it is possible to develop 3d pictures that allow surgeons to visualize up front what they will encounter in real life. Very soon, we'll be able to grow body parts. Really.

But perspective:
One of my (many) grandfathers was an obstetrical surgeon. He graduated from Johns Hopkins Medical School in 1902, and went on to a very distinguished career including being an editor of the New England Journal of Medicine for a time.
(I think I might have learned to read by a combination of the NEJM and the obituaries from Henry Illinois, but that's a whole other story :) )

My step-grandfather Stephen was trained in a very different time: when one was expected to be able to read medical literature in different languages...in his case, Latin, Greek, Hebrew, German and French. A time when surgery was just developing and expanding ,when so often one could only offer comfort and common sense.

I can only imagine now how elated he must have been when antibiotics were discovered and made available in the 1930's, how his practice must have changed...how many women's lives were saved. Let's just think about that paradigm shift ...suddenly people no longer inevitably die from bacterial infections, but are miraculously saved with an injection of penicillin.
Hell, when he was in training, blood types were only just being discovered in1901!

Thanks to Abraar Quraishi for letting me meander around and reminisce while we were talking this evening.

I am reminded about why I keep working in critical care...it's so fascinating, and so much in flux. There is always something to learn. There are always resonances of the past, recognitions of how lucky we are, how recent our innovations and understandings, how hopeful we are for more paradigm shifts.

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55Catherine Mc Mahon, Quynh Truong and 53 others

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1h

I've only been sporadically able to write specifically towards my initial goal in  a writing course I'm enrolled in right now, but that's actually ok...I'm working on the things that block me.

Today, I got rid of the weeds and overgrown wanted plants growing over my steps and pathway out the front door. Because it's New Mexico, with iron hard dry dirt, it took a sharp pointed grub hoe and softening up with the hose. I found hidden cacti with spines while clearing, and had to stop for a bit to pull spines out of my gloves and hands.

I planted pansies and chrysanthemums in my outdoor pots, and then washed clear the kitchen window, the glass plant shelf and the crystal that throws morning rainbows.

Tomorrow I will finish rebuilding the gate in my fence. It was poorly built by a contractor, and has been pulling off its hinges, and dragging on the ground. The new gate will be true and trim, and is already painted a lovely turquoise blue.

This is a way to clear both the approach to my heart and egress to the world.

Crystal flash rainbows
illuminating the dust
covering my life

More later about how I think this new concept of using haibun can help me write what I want to. .

One of the very,very cool things about having worked in health care for so long, and in critical care especially for more than 30 years, is just how far we have come.

I was assisting a procedure a couple days ago with a colleague of my own vintage, and we were sharing some specifics:

I remember when chest tubes and chest tube drainage setups were 3 glass bottles..a suction chamber, a water seal chamber and a collection chamber. break one glass jar, and the whole set up was a recipe for disaster. Now we have these really nifty devices with all three chambers in one, which come complete with a prefilled syringe of sterile water to fill the water seal compartment, everything pre-marked for monitoring drainage, multiple sized connectors.

I remember a time when nurses actually mixed their own chemo infusions in the med room. All of our IV solutions came in glass bottles, too.

I remember actually carrying a tiny set of screwdrivers to adjust gain on the old HP cardiac monitors...and when a set of calipers was mandatory equipment to measure intervals on ECG printouts.

Monitoring internal heart functioning was a huge deal...Swan Ganz pulmonary artery catheters were kept in a locked cabinet in the pulmonary lab at Mary Hitchcock (now Dartmouth Hitchcock hospital), and inserting one was for a time a rare event. Then it was ubiquitous..every patient admitted to a critical care unit bought an arterial line and a "Swan". Now we use them for cardiac surgical patients, but with discretion.

Imaging: I actually remember when CT scanning was new, and remarkable,,,and then we had  MRI available. I literally cried when I saw my first MRI scan of a patient with a brain tumor...it was so incredibly clear and beautiful in all its detail.

Now we have MRI angios and catheter images that give us dynamnic, moving images of hearts; functional MRI's that show brains reacting in real time to stimuli; ultrasounds that give us not just black and white images but color images of blood flow, and 3d pictures of infants in utero.

Now we have 3d printers that can give surgeons actual forms of defects to hold in their hands and pracdtice with  before they operate. It is within the immediate future that we can see 3d printers provide scaffolding for building actual replacement valves and organs. Now, when I give report to the nurse coming on next shift I can pull up those images, and if it is a new, less experienced nurse that I am orienting, I can explain exactly what is going on with our common patient, why that baby is manifesting the particular physical symptoms we can verify and correlate by hands on.

We should not take these things for granted!

I started reading at a very early age...well before 4, and I was very blessed by parents who read omnivorously, so I was exposed to science fiction very early. And as it turns out lots of  the "hard science fiction" writers were then and still are, actual scientists ,who write speculative fiction because they are trying out ideas...ideas about possible things in their fields which have since become reality. The physicists and early immunologists and biomedical engineers and pharmacologists  and chemists and computer programmers who have created the equipment I work with every day now very probably were also inspired by
30 years ago, the idea of stem cell engineering was absolute science fiction, Now it is reality, and one which will save lives.

Our healthcare system may well have deficits...and it does,huge deficits,  in terms of dealing with long term chronic disease, with funding, with equity, with dealing with the whole question of what is enough and the inevitability of death and how to be compassionate and ethical in extraordinary circumstances. And those are subjects for further writing, for sure.
But one of the reasons I am still hooked into, love what I do, is the recognition that a) what we did then was crude and elementary and is now better...and b) what we do is crude and elementary and we will do better. Very soon.

http://circ.ahajournals.org/content/117/18/2388.full
http://biomedical.materialise.com/cases/3d-printed-congenital-heart-defect-models-pre-surgical-planning

memories

Frootloops...
one of my nurse colleagues was eating them today, and I jokingly said " I remember when they were actually invented."
As it turns out... yup, I was right. 1963. I was 9 years old.

I also remember lots of things that we did as nurses in 1983 when I was 29 years old.

We were just beginning to switch out from written  (in pencil) Kardexes to very rudimentary computer systems . There was no information trail. When orders changed, we simply erased them, rewrote the Kardex.

We didn't have IV pumps so we had to calculate how fast an IV was running by counting drops...and it depended upon the tubing.

Moving to critical care was way cool. ..we had huge clunky  IV pumps that regulated how fast fluids and drugs were infused. We still had to calculate  the ultimate rate (and we do to this day) but it was no longer necessary to stand by the bedside and manipulate the clamp on the tubing.

I remember when chest tube set ups were made of series of glass bottles... one to modulate the suction, one to prevent back flow, one to measure output.

Actually, all our IV fluids came in glass bottles, and so did antibiotic "parfills"...such a mess when we dropped one accidentally!

I remember mixing my own chemotherapy in the med room.

I remember when we packed wounds with Dakins solution, a dilute chlorine solution that was certainly antimicrobial, but also incredibly painful. We used whole tubes of Vaseline around the wounds to hopefully keep the good flesh from being damaged.

I remember  when PALS was invented....it was a huge deal to have specific emergency care for kids codified  and taught. It was incredibly empowering.

I remember being part of  the first clinical trials for drugs for primary pulmonary hypertension ,and having to double and triple check the dosages of nanograms per kilogram per minute both with the study coordinator and the intensivist. I also clearly remember Lacey, the teen  we enrolled in our trials. She ultimately died after a heart transplant, and I believe so did her sister...they both had familial pulmonary hypertension.

I  remember things like the Circolectric bed and the Clintron bed (it looked like  a huge kitty litter pan, full of ceramic beads, with a tray at the bottom to collect drainage.)

I remember helping to  develop  scales to assess things like pain and sedation, often in response to using totally new drugs.

I remember not only carrying my own calipers to measure intervals on an ECG, but also carrying a set of screw drivers to adjust our monitors.

I actually remember when PA catheters and measuring pressures both actual and calculated of heart chambers and the pulmonary bed were very, very new concepts. I actually had  a job for several years teaching both nurses and doctors exactly how to interpret all those numbers.

I remember assisting at bedside to put in cranial bolts and then  later on, ventriculostomies to help manage brain swelling and prevent brain death in accident victims.

I remember actually crying the first time I saw the results of an MRI...it was so beautifully detailed.

What is very cool about all these memories is how my practice as a  nurse has changed, yet remained the same. We use different, improved technology to care for our patients, but the bottom line is that we use the tools we have at bedside to  do the best we can. Protocols may change as we learn more, but they also have the same goals.

Connections

I've expressed my frustration and disdain with CNN (and other "mainstream media channels" by extension) quite openly.

Once upon a time, when Ted Turner still owned it, CNN was a brilliant invention...a 24-7 channel with news available from around the world.

Now, it's just a game show of sorts, full of recursive, repetitive sound bites, "panels" of so-called experts who act out their dreams of 15 minutes of fame, over and over.

Arguably, in my own personal opinion, the uncensored repetition of all of Trump's rallies may well have added to his recognition value and his election.

But CNN on weekends actually does good stuff, things I recommend watching for lots of reasons.
And one of those things is Anthony Bourdain's  "Parts Unknown".

Bourdain is a celebrity chef, who became popular for his 2000 autobiographical book, Kitchen Confidential: Adventures in the Culinary Underbelly. it was rude, crude, and became a breakout best seller. Since then he's done several television series, mostly very interesting to foodies like myself because of the venues he filmed, as well as his bad boy persona.

Anthony Bourdain: Parts Unknown, however, is fascinating because he has taken his celebrity status to not just explore food around the world , but because of his very clear political stance, which is extraordinarily inclusive and global. He's been in Russia, and Iraq, and China and Vietnam, Somalia,  and  even American immigrant communities this last year, and he always asks the people he's eating with about how they see the global political perspective as well as how that fits with their traditions.
Basic premise: people are pretty much the same around the world. We want our kids to grow up safely , we want to be treated with respect and kindness, we want work which is meaningful,  we want to share with others; and food is one of the important vehicles with which we do share our common humanity. We all are far more alike than our political leaders and the news bites of every day would have us believe...

I highly recommend that if you can watch the 8 seasons available of the show that you do. It's on Netflix, and the 9th season will start in the next couple weeks on CNN.