Disenchanted

Tuesday, December 23, 2008

Work 6p-8a--155.5#

A year or so ago, I met a young lady in her mid-teens in the ER shortly after she had been diagnosed with type 2 diabetes, what not so long ago was known as adult onset diabetes. Since then, I have seen her several times, almost always because her blood sugar is out of control. Here lately, it has been more out of control than in, often running in the 400's to 500's. Someone's initial response to this might be to blame her, accuse her of eating poorly and not caring for herself. Someone's initial response would be wrong.

This little gal is smart and kind, and, I believe, good. She's a senior in high school, works at Wal-mart and pretty much takes care of herself, all the while aspiring to go to college next year. And she truly wants to know how to care for this disease that is trying so desperately to defeat her. When she comes in, I try to talk to her to see what her primary care doc and her endocrinologist are doing to try to fix the problems she is having. Most of the time, the answer is nothing. Most of the time, it seems they just tell her to take more insulin when her sugar is up. At no point has anyone really sat down and taught her how to care for herself including how to eat and how to exercise or what to do when presented with a diabetes related problem. It's not that she doesn't listen or that she doesn't ask questions. She does. Her questions are intelligent and appropriate, but they are met with a deaf ear and apathy, and she leaves the visit with her doctors knowing no more than she did when she got there. Even her visit to the dietician was fruitless. On the surface, this would seem like the common denominator is the girl, but I know without a shadow of a doubt she is not the weak link in this chain. I know because when we interact she listens to what I suggest and asks questions and listens to what I say in answer. I know because last night she came to see me at one in the morning to ask more questions and show me her food journal to see what feedback I could give her.

This whole experience has left me even further disenchanted with my colleagues. I often find myself frustrated with either their lack of knowledge or their poor bedside manner or their apathy. Occasionally I'm disappointed by all of the above. But seeing this girl so neglected leaves me embarassed to be even remotely associated with the profession. I just want to throttle her doctors for not taking or having the time to help teach her what she needs to know and her mother who is a nurse for not placing more focus on her child who needs her. And I'm embarassed because I know this is the rule in healthcare rather than the exception, a fact that is driven by a broken healthcare system and a public who by-and-large just wants a pill or a quick-fix.

This young lady gives me hope, though. She reminds me why I went into medicine. She brought me a card (that's it in the picture) and a gift when she came last night. She thanked me for taking the time to try to help. She'll never know how so often I limp along in this ER feeling like I'm just throwing band-aids over situations that I have little power to fix because the patients choose not to work to help themselves or how much that card means to me and how it'll join the short little stack of notes or cards I've gotten over the years that I go back to time and again to remind myself that sometimes I might make just a teeny bit of a difference to someone.

WORKOUT: Today was my first day back after 8 off. It was going to be yesterday, but I jacked up the alarm and would have missed work if the hubbie hadn't realized something was awry. I had hoped I would go bounding into this workout blowing the top off of everything, but I didn't. Honestly, it was a weak workout. I just didn't feel strong, or coordinated for that matter. As I pondered the situation during my breaks, I think at lease some of that might have been a factor of dehydration. I think I probably was drinking about a liter less water per day over that last week because I wasn't working out.

5 rounds of the following:

30 sec of green band assisted pull-ups

30 sec of pushups

30 sec of box jumps--I just did this on the first round and changed it to burpees with a knee to chest jump on the subsequent rounds because I think my wierd modified box jumps might be part of my knee problem. There is NOWHERE to do real box jumps, so I've been flat-footed jumping over some stuff as my box jumps.

30 sec of plank

assisted pistol 1/1 x 2

rest 1 min

20kg TGU 1/1 x 2

20kg Tabata swing.

Monday, December 8, 2008
Work 6p-8a--155#

I can't believe it's already Monday. The hubby's been in Florida for a couple of weeks, so I flew down to spend my four days off with him. We had a great time, but the days passed quickly and before I knew it, I was on my way home again. And already, I'm back in the ER. As I write, the nurses are taking my latest admission to the floor. He's a 5'9" 520# 26-year-old who lives in a nursing home because he's too damn big to take care of himself. To his credit, I'm not sure he's actually a hundred watt bulb. Maybe 80 watt. What I can't figure out is why the nursing home continues to feed him the tens of thousands of calories required to maintain those 500+ pounds. Maybe he steals food from the other residents.

I've got lots of pics to share. Some from this most recent trip to Florida. Some from Thanksgiving. Hopefully I'll get those up in the next week or so.

WORKOUT: 5 rounds of the following...
Pull-ups with the green band x 30 sec
pushups x 30 sec
box jumps x 30 sec
plank x 30 sec
pistols assisted with door jamb 2/2
Rest 1 min

These pull-ups with the green band felt really good. I couldn't go the whole 30 seconds, but the 4-6 that I did do felt good. I can finally begin to feel the mechanics of the pull-up kicking in.

Then... 20kg TGU 1/1 x 3

Ranting Randomness

Tuesday, November 18, 2008
Work 6p-8a--154#

Tonight's flavor in the ER has been stupidity--even more than usual. Or maybe I'm just grumpier than usual... You tell me.

EXAMPLES:
1. One of the nurses who is about 5'5" tall and probably weighs at least 260 pounds (I'm a really bad guess), of which at least 100 pounds of it is in her ass,was wearing $200 MBT shoes today. For some reason, some of the nurses here have decided that's what they need to help get their legs and back and butts in shape. They call them their "Make Butt Tight" shoes. Now even if those shoes make her butt tight, how in the hell is anybody going to see it for the 100 pounds of tabletop rear overlying it?!

2. 27-year-old white female came in complaining of fibromyalgia, lupus, Sjogren's syndrome, back aches, head aches, numbness in her fingers, memory loss, spells of cold sweaty hands coupled with a hot body, dizziness, nausea, cough, abdomenal pain from her left ovary, left ear pain, difficulty breathing, and panic attacks. Now this was all her complaints for tonight, what she wanted us to deal with tonight. Then she tells me, (read whiney tone here)"but I can't find a doctor who doesn't think I'm a hypochondriac." She wasn't having so much trouble breathing that she couldn't suck down a friggin' cigarette before she walked in!

3. 56-year-old white female with headache for 36 hours came in with a headache that's the worst one she's ever had, but it wasn't so bad she bothered to take any Tylenol, Motrin, BC powders, Alleve or any other over-the-counter medicine before she came. She just pranced on over to her friendly, neighborhood ER.

4. 28-year-old white male and female couple who together tip the scale at over 500 pounds decided that tonight was the night they just had to deal with this cough that they had had for the last month. It seems their usual provider, a nurse practitioner, has an office that is too "inconvenient" to get to. The good news is that they've cut down since they've been sick and are now only smoking 1/2 a pack a person a day. Unfortunately, I was unable to give him a work excuse for the three days last week that he took off from work but didn't bother to see his usual provider. They got a little miffed when I asked them, "Do you have any medical problems other than your weight?" Apparently, they don't see their weight as a problem...or their smoking...or their complete stupidity.

5. 32-year-old 5'1" 260# African American female came in at 0230 for left back pain, that she thought was "just a pulled muscle" which was going on for the last 3 days. It was just so bad tonight that she couldn't rest, so she decided to come to the ER. Apparently lifting her arms to take some pills and a drink of water exacerbated it too because she didn't bother doing that before she racked up several hundred dollars in ER bill.

I also had a 84-year-old white gentleman who is originally from Key West, and about whom I could almost bet money Jimmy Buffett wrote "I Wish I Had A Pencil-thin Mustache." His black, pencil-thin mustache was perfectly trimmed and colored black. That was just fun.

These are just the ones I thought to write down so I could remember and share. I'm sure there are more. And, honestly, interspersed amongst the insanity were some great people. The good news is unless I make a major league screw up, I guess I won't ever have to worry about being out of a job.

WORKOUT:
I've been nursing the crud--a cough, sore throat, aches, etc. That and the medicine I'm taking for it has contributed to my oversleeping today and yesterday. Yesterday I felt bad enough that I decided the rest would do me better than the workout, and I believe it did. I did grease-the-groove with a bunch of assisted pistols at work, though. Today, I dragged my butt out of bed eventually and did all of the workout that I could. I'll do the rest in the morning before I go to sleep.
4 rounds of 4 of each:
Double 16kg C&P
Double 16kg Squat (these were just brutally hard today)
Double 16kg KB Burpees
Double 16kg Renegade Rows
Rest about 1.5 min--this is usually 1 min, but today it had to be longer. I'm trying to learn to listen to my body.
Then...4 rounds of 15 Double 16kg Swings with 30 sec rest b/w rounds.

When I get home, I'll do the Essentials test twice with the 12kg with a min or two of rest b/w rounds.

As a side note, my dad is scheduled for a heart cath today which scares me a little and makes me very sad. He's supposed to be Superman--even if he is 72. :)

Why Not To Drink and Drive

Sunday, September 14, 2008

Work 6p-8a

Off from workouts today.

Here's what a few beers will do to your 2008 Nissan Versa... The 58 year old man who did this is not an alcoholic or a derelict. He doesn't even drink on a regular basis. He was just out "having a few beers."

The guy walked away with ONE scratch on his right ear even though he was not wearing a seatbelt. All hale side curtain air bags! Yes, dude is now in jail.

You Are What You Eat

Monday, July 21, 2008
159.5#
Work 6p-8a
Slept 6 hours.

The human body is in a constant state of regeneration. Skin cells live only a month or so. Stomach cells only a couple of days. Colon cells 3-4 days. Red blood cells 4 months. White blood cells 10 days to a year, depending on the type. Every organ other than the brain is replacing itself one cell at a time. The skin, the gut, the liver, the pancreas, the heart, the blood vessels: they are all slowly repairing, building their replacements. The only building blocks the body has to form these new cells and the organs they form is the food that we eat and the fluids we drink. Really think about that for a minute. What have you eaten today? Is what you ate going to provide the appropriate building blocks for the cells your body is creating to form your new organs?

One meal couldn't possibly make that much difference in the grand scheme of things. Surely the average of our intake is what makes the greatest overall impact on the integrity of our health. After all, the entire vascular system does not regenerate in 24 hours' time. Ultimately, there is a great deal of truth in these statements. The overall picture matters more than any individual brush stroke, but each and every brush stroke is important. After just one meal high in saturated fats and carbohydrates, a person's risk of cardiovascular events increases as their body attempts to process all of those macronutrients and their resultant hormone cascades. The blood vessels actually become more likely to form a life-altering blockage during that time. (Just as for 30 minutes after taking the final puff of a cigarette, one's risk for heart attack and stroke is measurably increased.)

My last patient this morning provided me with an excellent illustration for how profoundly a day or two of extremely poor intake could affect the body. Keep in mind, this did not happen in a vaccum, and the details of why this was so dramatic are beyond what you want to hear. Regardless, the tube on the left is her blood. That on the right is "normal" blood. The layer of white fluid at the top of her tube is a layer of lipids--pure fat. When the blood came out of her arm, you could see the droplets of fat falling into the tube. NOTHING was added to or taken from this tube. A little more clear now how dramatically a few meals can affect a person, isn't it? Picture the insides of her blood vessels, the difficulty her lungs would have exchanging oxygen into that blood, the problems her brain, heart and other tissues would have getting oxygen and other nutrients from it. Dramatic, indeed.


TODAY'S WORKOUT: Finally, it felt STRONG! Don't get me wrong, I still didn't want to drag my butt out of bed this morning. And I stood looking at my toes for about 5 minutes before I made myself pick up a bell, but when I did, it didn't feel like I was picking up a small car. Today was the first time in over a week that my numbers of reps were back to normal and actually felt strong. Thank goodness!

3 min 12kg warm-up just keeping the bell off the ground.

4 rounds of
16 kg snatch 30 sec R, 30 sec L, rest 1 min. I consistently got 10 per side each round.

10 rounds of
12kg Snatch R 30 sec
Rest 30 sec
12kg Snatch L 30 sec
Rest 30 sec
I consistently got 12 reps during the 30 sec.

"Gardeners Beware" or "Why I Occasionally Love My Job"

Thursday, May 22, 2008
7w5d--163#
Work 6p-8a
Slept 5.5. hours (I just realized today that I have been forgetting to put this on my posts. Not much use to everyone else, but it's helpful to me.)

Last week I saw the most dramatic thing I've ever seen in 6 years of working in emergency departments.

As usual, the department was ramping up to its comfortable level of chaos, and I was in seeing a gentleman who had been waiting 30 minutes or so to see me. (I take pride in seeing patients as quickly as possible.) As I was looking at his open left arm fracture from a dog bite, one of my nurses poked her head around the corner, rolled her eyes, and said, "They're bringin' in a little girl with a tomato cage on her head," implying that I should go to see her right then. Instantly at least a hundred thoughts flew through my brain, and I started to walk to the front of the department. "Hmmph, how did this kid get a damn tomato cage stuck on her head? Are they bringing her in by ambulance? What the F*%$!" About that moment, I rounded the corner and saw a father calmly pushing his 11-year-old daughter through the er as she held in front of her the 3 foot wire conical cage intended to guide tomato plants in their growth. The three large guage (think pencil) wires that formed the point of the cone were embedded in the skin of her forehead and temple. "Damn, that's gonna suck trying to get that sombitch outta there," I thought to myself as I thought about the hundreds of embedded fishhooks I've removed over the years. I just knew those wires were bent between the skin of her forehead and her skull. So I went to talk to her to see how she was doing (no that's not rhetorical) and get a better look at that forehead.

My nurses and I guided the father and daughter pair into a room, and I asked her if she were hurting. "A little," she said, calmly holding the cage and rolling her eyes to watch the flurry of activity around her. To each question, "Are you sick to your stomach? How's your vision? Why is your nose bleeding? How did you get this stuck on your head?" she gave quick, pointed answers in a voice that was astonishingly calm. I was amazed. Even when the wire cutters wouldn't budge the cage, and we had to get a huge, scary pair of bolt-cutters to cut away the biggest portion of the cage, she was unbelievably calm, and not in a way that made me fear she was in shock. As we were cutting the cage away, I realized that the wires were not just floating between the skin and bone. At least two of them were embedded in bone. My brain would just not let me believe that the wires had actually gone through the skull into her brain, but I knew that I had to work with that assumption, so I ordered a CT scan to see inside her head.

While the little girl was in CT, I went to talk to the mother, the other individual most directly involved in the accident, because I was just not understanding the mechanism of injury. Her mother was hysterical. She was wise enough, however, to understand that her hysteria would hinder the process of helping her child, so she stayed in the conference room and out of the way unless she was needed. After some unintelligable sobbing replies, I finally began to understand that she had been cleaning the tomato cages and was slinging them to shake the mud off when she lost her grip on one and it flung through the air, coming to rest in her daughter's head. Think as I might, I still cannot understand how so much force was generated by that single act.

At least able to picture what happened, I went to reexamine the girl on her return from radiology. She was still calm, only minimally in pain, and now a little nauseated. She could still talk to me, could still see, and was overall doing well, so I went to the Xray computer to see the films. All I could think was, "Holy Crap!" One of the wires not only had penetrated her skull but transversed a sinus, her eye socket, and the boney floor of the eye socket and come to rest at the back wall of her head, missing her eyeball, pinning her optic nerve and missing her carotid artery by less than a millimeter. The second wire penetrated the temple, went under the frontal lobe, crossed the skull and came to rest within a centimeter of the brainstem. The third simply skirted the outside of the skull between it and the overlying skin. The 11-year-old lying in my ER had two large wires running directly through her cranial vault.

The next 30-45 minutes were spent arranging for a neurosurgeon to care for her and flying her to where they could do just that. The last 7 days have been spent trying to picture exactly how a tomato cage came to rest not only in her skull but more-or-less through her skull. I don't think I'll ever completely understand that.

Her mother called me yesterday on their way home from the hospital. My patient is not only alive, but she has no lasting effects. Sometimes I love my job.

WORKOUT:
12kg TGU 10/side-- AS I was doing these, I could tell my workout was not going to be the strongest in the world. I think the degree of difficulty of this workout on my fourth day of working out in a row makes this a little more harder than the workout on Monday. I also firmly believe that I have a mental block with this workout because of the thrusters. They are difficult enough that they play a mind game with me. I'm working on this, though.

5 rounds of the following with Double 12kg bells:
Snatch x 8
Thrusters x 8
High Pulls x 12
C&Px8
alternating rows /side
Swings x 20

Then... 12kg Snatches 25/25, 20/20, 15/15, 10/10, 5/5 separated by 90 seconds of jogging.
Whole thing took me 1hour and 32 minutes.

Flavor of the Day: Addicts and Crazies..and a bitch fest.

Friday, April 11, 2008

13w, 5d to pics 165.5#

Slept 6 hours. Work 5p-8a.

The emergency department has "flavors of the day." I may have talked about this at some point already, but it truly does. Today's flavor has been addicts and crazy people (that would be the highly technical medical term). Sometimes this flavor is entertaining. Tonight I have simply found it sad. At times I felt the futility of things weighing down my soul. There is no end to humankind's ability to abuse itself and all that surrounds it.

Perhaps I should have said that the flavor of the day is "futility" because come to think of it, I awakened this afternoon with that sense, a fact that no doubt has colored the way I look at each patient in the ER tonight. My mood being such that it is in light of the ER's flavor tonight is interesting, certainly makes some patients more difficult to deal with. Regardless, I was thinking as I got up and ready for work about what clothes I am going to pack to take on my next trip to the Sunshine State, and I had some realizations. I am in the same pair of jeans that I was so excited to buy in January. And I still cannot wear (without embarrassment) the pair of pants I bought slightly small in January in anticipation of being able to wear them in a month or so. I know my measurements are slightly smaller (1/2-3/4 of an inch) and my weight is about 4-5 pounds less, but I had genuinely hoped for more visual results by now. And I had really hoped for being a size smaller, too. This realization on the coattails of the 168 that showed up on the scale on Monday really jumpstarted my attitude today.

In light of these realizations, I have spent what little free moments my mind has had tonight thinking about what i need to be doing differently to accelerate change. My calories are in the 1500-1700 calorie range which I feel is appropriate, and David has said that he would like to see me in the 1600-1800 range. I should be good there. Just before I left for Florida last time and since I have gotten back, I have tried to follow his other advice which was to keep my carbohydrates below 100 and my protein above 120. That has been going quite well. Since coming back from Fl, Splenda has been cut out completely. I just don't think that cutting my calories any more would be productive. As hard as I'm pushing my body, it just can't be wise to eat much less than what I am. (Any thoughts?) That leaves kicking up the workouts. I just got my new series from David,and it has, indeed, increased in volume, so we'll see where that leads me. Any observations or ideas here would be appreciated.

WORKOUT: 12kg Workout B:REnegade Rows 5R/5L, 20 Swings, AMAP in 30 min--23=3 more than last time.

Artwork by Alexis: A friend's daughter drew this "portrait" of me the other day. Funny what a 6-year-old sees. I was proud to see that I am a rectangle, not a circle, and I have a smile on my face. My hair isn't quite long enough to reach my feet, though.