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6/26 WILTW: Littlefinger's smirk makes me feel violated

Specializes in critical care.

IXCHEL IN DA HOWWWWSSSSEEE!!!!

Okay, not entirely since my back still sucks, but still... I've gotten my lazy brain wrapped around hosting this shindig for a good go-'round. How are you all this week?

It's been a weird few weeks. Well, to be fair, it's been a weird few months, but for the purposes of the here and now, WEEKS. Brexit googling, Scotland succession, and the Donald re-establishing that Americans can still win the "who can look more ridiculous" contest. The best episode of anything ever in existence came on HBO last Sunday at 9 pm, and the memes that resulted were actually disappointing. (Except for one of a pile of dog poo alluding to a character returning in season 7.) I got a mosquito bite on the bottom of my foot. (Might be the worst spot ever.) What have I learned???

Well...

Boy Child got Rocky Mountain Spotted Fever (RMSF).

A pediatric hospitalist made me realize that if I ever travel outside my geographic area and provide care to patients, I should learn the epidemiological trends of that area.

Never, EVER ignore petechiae on the feet. It is relevant to the differential, especially on a child.

RMSF is reportable to the CDC, and from 2000-2010, there were 2,000 total cases reported per year.

The typical presentation of RMSF is fever, then rash, with a recent tick bite (1-2 weeks prior). The rash will be flat, pink spots, and sometimes blanchable. It will begin in limbs and move toward the trunk. Later in rash development, petechiae will appear on the hands, feet and ankles. If the petechial rash develops, it's typically several days (up to a week) after fever onset.

RMSF attacks vital organs, including the heart and brain. Boy Child's first BAM! symptom was syncope. I did't see the petechiae on his feet until we were at the hospital. There, we also noted sinus tachycardia and alterations in mental status.

Unfortunately, not everyone gets the rash.

In the 1940s, around 28% of those who contracted RMSF died. In the 2010 data, 0.5%. (Doxy is a helluva drug!)

In other news...

Post op after spinal fusion requires more patience and endurance than I think I have.

I don't know how to make my pool water clear.

The sun burns shock off a small pool way too quickly.

I miss work, but I don't know if I'm actually recovered enough to go back.

Littlefinger is still a creepy *****.

If AN ever decides to censor ***, ******, *****, or *****, I will be a sad, sad ixchel.

I added the link at the bottom of this days ago and can't remember what it is. We'll be learning this together.

Edited by dianah
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ixchel

Specializes in critical care.

Ahhhhhhhhh YAAAASSSSSSSS!!!!!! I love Zachary Quinto so damn much!

AJJKRN

Specializes in Medical-Surgical/Float Pool/Stepdown. Has 6+ years experience.

Hope your son has a quick, safe, and un-eventful turn around!

OrganizedChaos, LVN

Specializes in M/S, LTC, Corrections, PDN & drug rehab. Has 10 years experience.

I have been sick. First I had the migraine of all migraines for a whole week. Then if that wasn't bad enough I got the mother of all UTIs. I haven't had a migraine or UTIs in so long & both were the most painful things I ever experienced. Child birth wasn't that bad compared to my migraine & the UTI.

I am still trying to get better. I'm still exhausted from being sick & a little nauseated. I don't wish that migraine or UTI on anyone.

LadyFree28, BSN, RN

Specializes in Pediatrics, Rehab, Trauma. Has 10 years experience.

I learned:

I still get triggered but can handle any DV, or PTSD pts; being proactive in their journey by educating, supporting and giving resources about the "experience", while not putting myself in their shoes and self-preserving and remaining in the clinician role while empowering, is exhausting and all in the same night will make me wake up with some form of an emotional hangover...I only expect it to get better.

I am moving forward with support on my education subject that I'm undertaking...the support is awesome, although the subject is overwhelming, it is suggested to not get overwhelmed. :laugh:

I'm putting my feelers out to work per-diem in Adult ERs; I learned I like PediER, but want to at least dabble in the AdultED experience; it will help when we get a adult dumping special at our Ambulance Bay, and give a little variety (and extra cash) without having to do the mandatory hours, and mandatory holidays. I hope all goes well! :up:

ixchel

Specializes in critical care.

You don't want AN to be come ineffable? :D

How about a compromise: AN remains effable, while its posters remain ineffable.

ixchel

Specializes in critical care.

Hope your son has a quick, safe, and un-eventful turn around!

Thank you so very much! He managed to tolerate the doxy very well. All signs of rash gone. No fevers or body aches. He's back to torturing Girl Child. (That last part is not so nice. :\)

ixchel

Specializes in critical care.

I have been sick. First I had the migraine of all migraines for a whole week. Then if that wasn't bad enough I got the mother of all UTIs. I haven't had a migraine or UTIs in so long & both were the most painful things I ever experienced. Child birth wasn't that bad compared to my migraine & the UTI.

I am still trying to get better. I'm still exhausted from being sick & a little nauseated. I don't wish that migraine or UTI on anyone.

I hope you get better quickly, Cheerios!

Sorry Ixchel - I hope that your son recovers quickly and that you make progress after surgery ....

Most of my knowledge from the last week is related to palliative care.

Since palliative care is my work focus and I am passionate about sharing some knowledge I thought I write about it.

Recently, I had the pleasure of seeing Dr.Atul Gawande in person. He wrote the book Being Mortal: Medicine and What Matters in the End

which has become THE book about end of life care. He also writes for the New Yorker and is involved in other initiatives.

He said something that made total sense to me. It was along the lines of "if we realize that we are mortal, the quest is not to have a good death but to have a good life". Having said that - how do we spend our life when we get sicker or seriously ill? How do we spend the time we have left when we are seriously ill?

This blog has an excerpt from the book:

End of life medical decisions: Atul Gawande book excerpt on no risky chances.

The way we take care of seriously ill patients and patient at the end of their lives is often not congruent with their wishes or reflects quality of life. So - to figure out what kind of care people would want when they become seriously sick, it is important to talk about goals and values.

Example to make it easier to understand: If a patient with metastatic disease says that their goal is to spend as much time as possible with family at home, not in pain and not hooked up to machines in the hospital - but instead sitting in the living room watching sports and have a cold beer - shouldn't the care plan reflect this wish??? Patient-centered care?

Here an article about this topic:

http://www.conversationsofalifetime.org/downloads/Article-CommunicationAboutSeriousIllnessCareGoals.pdf

Here is a "guide" about how conversations in the outpatient setting should happen with patients who have serious illness. A structured way, checklist format, that walks the clinician through the questions that will lead to relevant information. Please note - "giving a diagnosis and prognosis" is not the scope of a nurse .... this guide is for MDs / NPs but a nurse can be involved in other parts of the discussion and it is important to know about the concept.

https://www.ariadnelabs.org/wp-content/uploads/sites/2/2015/08/Serious-Illness-Conversation-Guide-5.22.15.pdf

So - this is all still "pretty new" but I m sure that it will become best practice soon. Ideally, the PCP or specialist would have those conversations with anybody who has a serious illness and again after certain "trigger" events like re-hospitalization and document in a way that it can be found by other professionals. So that way, if Mrs COPD stage4 comes into the hospital it is clear what her goals and wishes are, she might have advanced directives, her family/HCP knows about her wishes, and she had conversations about her illness. Unfortunately the way it goes now a lot is "what??? you mean I cannot live forever? COPD stage 4 can kill me? I might not be able to get off a ventilator? What do you mean - Chest compressions most likely won't be successful ?? as witnessed when physicians have this kind of conversation with patients.

Our society seems to think that "dying is optional" and it seems that we need to normalize that getting sick and even death is also part of life.

If you have made it until here and are interested in another article about "overkill" please look here:

Overkill - The New Yorker

I also learned some more about errors in healthcare, risk management and micro systems.

System thinking is essential when we want to put processes in place to prevent errors. Just looking at the front line worker and blame that person for an error without looking at the system and how that design contributes to the mistake is not a successful strategy.

If you want to learn more about designing microsystems and have a lot of time or interest - I found this pdf helpful (but long...):

http://clinicalmicrosystem.org/wp-content/uploads/2014/07/CMAG040104.pdf

I continue to struggle with my diet efforts as my appetite with replacement hormones is just not normal. I swear that I do not feel satiety at all. I tried the Mayo clinic diet but gained weight with it. I looked into low carb but that somehow does not really work for me either. To be honest - at this point I just want some kind of magic wand ... I even changed from doing mostly weights and little bit cardio to fitness kickboxing several times a week for 30 minutes. But fact is that I sit a lot with school and work plus really LIKE to eat (which never happened to me before replacement hormones). I tried without hormones but the hot flashes were basically killing me and I was not sleeping - NO quality of life - which is really not what a palliative care nurse who focuses on quality of life wants...

Also, there is the renaissance of dry shampoo! I remember that it was sort of popular when I was a teenager for people who had problems washing their hair for whatever reason. But it left powdery residue on the scalp and I remember patients complaining of itching. Plus it was sort of sticky. Now it is popular again! I actually tried a sample I got and need to say that it was ok. In a pinch when late in the morning it is ok instead of washing my hair every morning...

I have been sick. First I had the migraine of all migraines for a whole week. Then if that wasn't bad enough I got the mother of all UTIs. I haven't had a migraine or UTIs in so long & both were the most painful things I ever experienced. Child birth wasn't that bad compared to my migraine & the UTI.

I am still trying to get better. I'm still exhausted from being sick & a little nauseated. I don't wish that migraine or UTI on anyone.

I hope you get better soon!!!

ixchel

Specializes in critical care.

I learned:

I still get triggered but can handle any DV, or PTSD pts; being proactive in their journey by educating, supporting and giving resources about the "experience", while not putting myself in their shoes and self-preserving and remaining in the clinician role while empowering, is exhausting and all in the same night will make me wake up with some form of an emotional hangover...I only expect it to get better.

I just want to hug you. I've come to realize in the last several months that I get triggered by DV/abuse/neglect patients, and I don't do well handling it. Adult inpatient, it is very rare I am able to impact a resolution to the situation. We send them back where they came from with no ability to do a single thing more. I'm working on it. Hopefully I can find a way back to the resilience I used to have, and then the ability to accept I can't do more.

Incidentally, tomorrow is National PTSD Awareness Day. For my sisters and brothers who are already so painfully aware, my heart is with you.

I learned:

I still get triggered but can handle any DV, or PTSD pts; being proactive in their journey by educating, supporting and giving resources about the "experience", while not putting myself in their shoes and self-preserving and remaining in the clinician role while empowering, is exhausting and all in the same night will make me wake up with some form of an emotional hangover...I only expect it to get better.

:up:

In my experience - it does get better.

I had some rough 10 years with PTSD that did not impact me too much at work back at that time. I worked critical care and felt very in control though emotionally distanced a lot due to PTSD.

After about 10 years things really started to fade and I hardly noticed it but got a significant PTSD flare up years later after some events triggered the PTSD stuff. With that flare up I started to struggle sometimes at work but also at home. I noticed the hyper vigilance and physical symptoms of PTSD and it was fairly uncomfortable at times. Things got better again and I do not notice much residue unless I get triggered significantly. Last year I had surgery and it triggered PTSD symptoms. I was out of work at that time because of surgery and saw a therapist for a couple of sessions to deal with that triggered aftermath from surgery and I am mostly in remission.

There is hope...

OrganizedChaos, LVN

Specializes in M/S, LTC, Corrections, PDN & drug rehab. Has 10 years experience.

Thank you for your well wishes everyone!

meanmaryjean, DNP, RN

Specializes in NICU, ICU, PICU, Academia. Has 40 years experience.

I learned this week that not everyone understands that you have to pay money for nursing home care. My 87 year old dad has reached the point where he is no longer safe to be at home (dementia, Parkinson's, falling multiple times per day), and it is no longer safe for my step-mother (or anyone else for that matter) to try and care for him in their condo.

She was shocked by the idea that she would have to pay for at least part of his care with the money they have saved for retirement.

In other news, I went to visit my former workplace, and realized that I do not miss bedside nursing even a little bit. That the work I'm doing in academia IS helping people / being a nurse.

I learned that Brexit may or may not be a bad thing, but that Bon Jovi/ direct TV commercial is much, much worse.

editingeyes

Specializes in Mental Health/Substance Abuse. Has 3 years experience.

My provider has been out of town last week and this upcoming week, so I learned just how much I am able to accomplish when I am not interrupted every 15 minutes trying to get vitals, answer questions, etc. However, it also puts more pressure on me as I am the only "medical" person in the office so everyone comes to me when a patient is in crisis mode.

I also learned that buying a house just doesn't seem to be in the cards for us right now. We've been looking for over two years and just haven't found what we want where we need it to be. If we could just move our location a little bit, I think we would be golden. However, between his job and kiddos, it just isn't possible. I keep telling myself "one day". I am getting crazy antsy though and need to either move houses or states (which isn't an option for the bf).

I am excited to have the next week to get my office all caught up with everything that seems to get thrown in the "to do when I have free time" pile. I also learned that lots of staff are trying to leave my night/PRN gig and that makes me sad because I truly like my coworkers. Change is needed there, though, and unfortunately upper management isn't very in tune with that.

Ixchel - glad your kiddo is feeling better!

LadyFree28, BSN, RN

Specializes in Pediatrics, Rehab, Trauma. Has 10 years experience.

In my experience - it does get better.

I had some rough 10 years with PTSD that did not impact me too much at work back at that time. I worked critical care and felt very in control though emotionally distanced a lot due to PTSD.

After about 10 years things really started to fade and I hardly noticed it but got a significant PTSD flare up years later after some events triggered the PTSD stuff. With that flare up I started to struggle sometimes at work but also at home. I noticed the hyper vigilance and physical symptoms of PTSD and it was fairly uncomfortable at times. Things got better again and I do not notice much residue unless I get triggered significantly. Last year I had surgery and it triggered PTSD symptoms. I was out of work at that time because of surgery and saw a therapist for a couple of sessions to deal with that triggered aftermath from surgery and I am mostly in remission.

There is hope...

:yes:

I've had PTSD for 8 years; I have successfully been discharged from my trauma therapist since the beginning of May; I plan to do a few "checking in sessions" to help cope; I also still see a medication management psychiatry team, which is now a new team most likely the end of the summer...so I'll see how that goes.

My PTSD comes down to physical symptoms as well; I cave complex regional pain syndrome as well, so when I am triggered, it feels as though my CRPS symptoms can "flare up".

This is my second round in critical care; first in a PICU, and now in a PediED, so far I have been doing well, and this was the first time I felt exhausted and triggered. The best thing is being able to go to resources where I can talk about it freely (without mentioning PTSD) and actually have support. :yes:

Lauraingalls, BSN, RN

Specializes in OB. Has 4 years experience.

Well 10 days to Nclex.

I got a job offer for an L and D position that I wasn't expecting but am so happy to have.

My husband also got a job offer after being laid off for 3 months but in Dallas. (I am in AZ).

Trying to convince 3 teenagers that we will need to move is very hard.

The plan is for me to stay in AZ to gain a year of experience and then move.

So I will go from being a stay at home mom to a full time working single mom.

That terrifies me.

:yes:

I've had PTSD for 8 years; I have successfully been discharged from my trauma therapist since the beginning of May; I plan to do a few "checking in sessions" to help cope; I also still see a medication management psychiatry team, which is now a new team most likely the end of the summer...so I'll see how that goes.

My PTSD comes down to physical symptoms as well; I cave complex regional pain syndrome as well, so when I am triggered, it feels as though my CRPS symptoms can "flare up".

This is my second round in critical care; first in a PICU, and now in a PediED, so far I have been doing well, and this was the first time I felt exhausted and triggered. The best thing is being able to go to resources where I can talk about it freely (without mentioning PTSD) and actually have support. :yes:

I think it is just part of PTSD to know that it can flare up at any time and to have a strategy in place.

It is unrealistic to expect 100% cure or such but it is realistic to develop strategies to cope with triggers or a bad day. To be honest - when I realized I had PTSD (which was 30 years ago) I did not have much hope that it would get "better". I did a lot of research back at that time but there was not much out there at that time. With some common sense I developed my own plan and strategy, which worked just fine. And time does help.

When I had the rough patch 10 years ago there were much more resources out there. Therapy was not my number one thing but I did see somebody for a while. What helped me most was peer support ! Talking to another person who understands what you are going through and is supportive is price less in my opinion. Also, I found writing very helpful and did some "art" as a means of expression...

Sorry I've been so MIA. So here's what my last few weeks have looked like:

I stayed at my friend's empty apartment and helped him move when his lease ended. It substituted my workout for the week.

The retreat was amazing. I was blown away by the passion and energy my students had, and I was really humbled as well during the time I served. I feel exhausted and feel a cold coming on, but there's also a newfound sense of peace and confidence.

I applied and interview for a position in Oncology at a MI hospital. It was probably one of the interviews that I prepared the least for, but I did really well and clicked with the DON and charge RN I interviewed with. When I was asked a clinical question, the DON was really impressed by my answer, which is the complete opposite of what happened at my last interview. I'm expecting an offer, but who knows. Even so, I was thankful for the opportunity to hear about the DON's praises at this specific hospital. It gave me insight into how great changes are, even thought sometimes things might not work out the way you hoped or expected.

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