When You Assume...

In my experience, toddler illnesses are often like episodes of the Simpsons. You know how you can never tell what a Simpsons is going to be about at the beginning? Never a truly great Simpsons scholar, I'm afraid I can't give you any actual examples. But there's definitely this thing that they do where the opening scenes seem to be heading the plot in one direction, and then at some point about five minutes in, things veer off in another direction entirely. Say the first five minutes is about, I don't know, Bart getting his first B+ or something, and then you think that the whole episode is going to be about Bart and school, but then Marge and Homer decide to celebrate by taking the kids to an amusement park, and the actual plot turns out to be all about the amusement park. That's a lame example, but I imagine you know what I mean.

And so it is in the world of infectious disease in the under-4 set. The first signs of illness are crankiness and vomitting, and it turns out to be... strep throat. Or the first signs of illness are a fever and clinginess, and it turns out to be... an ear infection so bad it bursts the eardrum. And so it was this time, as Cassie's symptoms leading me to think of a bacterial infection, probably bladder, turned out to be... well, viral, anyway. Quite possibly Coxsackie virus (a.k.a. hand-foot-and-mouth disease), which gives you nasty painful ulcerative sores... in your mouth and throat. The bladder thing is looking now like a total red herring.

So, well, whatever. At least we don't have to figure out ways to get antibiotics into her several times a day. And her fever's gone, or nearly so.

The unfortunate thing (well, besides my having to miss clinical yesterday) is that this is the weekend that Cassie got to bring home Buzz Junior Teddy. BJT is a silver-clad astronaut bear who goes home for the weekend with each preschooler in turn, and gets his adventures documented with photos and narrative in the notebook that comes with him. Cassie's mentioned this whole thing several times in the past, and I think it's kind of a big deal to her. And we just have not been showing little Buzz a very good time. At least I had the presence of mind to take the traveling bear and our camera to the pediatrician's office yesterday, and got a shot of him on Cassie's lap as the doctor listened to her lungs, and then another one of Buzz posed nicely next to the glass jars of cotton balls and tongue depressors. Rather arty.

We hope to be able to go to the art museum tomorrow, if Cassie's well enough. Our friend Lucine would come along, and Buzz could look at the mummies, and a good time might be had by all. I'm keeping my fingers crossed.

Let Me Call You Sweetbladder

Cassie got sent home from day care this afternoon as per Center policy because her temperature went over 100.5 (it was actually 101.3 by the time Pete got there). Also, Cassie told Paula, Center Director and acting preschool room teacher, that her "heart hurt," which, as Pete said, "freaked the bejeezus out of Paula." Fortunately, on further interrogation when I got home, Cassie indicated that her "heart" was at the bottom of her abdomen, with pain radiating to her vulva.

It seemed like whatever she had going on was probably bacterial, because even at the peak of her ibuprofen, her temp was still 100.8 around 9:30 pm. She woke again crying around 3:15 am, but her temp was now down to 99.9. So who knows what's going on. I'll call her pediatrician in the morning to see if we can go in and get a urine dipped.

The thing is, tomorrow was going to be a little catch-up day for me. I have clinical 3P-11P, so I planned not to go in at all to my temp job. And with Cassie in school, I was going to get to answer e-mails and study about oncologic emergencies a little (at the suggestion of my preceptor) and clean the downstairs toilet and do a load of laundry. You know? Well, as Roseanne Rosannadanna's grandmother always used to say...

3rd Day

It seems not to be until the next day that the exhaustion of a 12+-hour shift hits me. My limbs feel heavy, and my whole body feels kind of depleted, and I just feel like lying very, very still. During the shift, though, and when I get home at night, I'm mostly all peppy and bouncy, except that my feet just start to hurt. I'm all revved up on adrenaline and this uncanny cheerfulness.

I also hate to even think about my varicose veins. I haven't been able to bring myself to wear support hose in July. But I really, really will once it's September. Or, you know, October. I'm not really claustrophobic, but my legs seem to be. They hate the thought of being closed in the tight grip of an industrial-strength sheath of nylon and lycra. "No! no! no!" they cry out piteously in their squeaky little leg voices, "Air! Air!"

We had three patients on Friday. There was good old Mr. B, who said that the fireworks were, indeed, quite impressive from his hospital room window on the 4th--the best he'd ever seen, even. He looked kind of terrible, somnolent and stubbled and diminished-looking. He said he was feeling incredibly fatigued and sleepy, and I could tell it was kind of freaking him out. So then I started feeling anxious about it too. But Julie, my preceptor, said that at this point in his course (2 days after his bone marrow transplant, after more than a week of nasty-ass chemotherapy), that kind of misery was, unfortunately, pretty well expected, but we'd keep a close eye on him in case he had anything cooking. His temperature actually did get up to 99.3 mid-afternoon (and for somebody with essentially no white blood cells, any little bit above normal is considered a real fever), but to my relief it came back down again promptly. He also got a unit of blood, since his hematocrit had dropped below 25, and we were hoping that might pep him up a little, but it really didn't. His friendly family--wife and two teenagers, a daughter and a son--came in the afternoon, all wearing green shirts for some reason and looked like a doting matched set, but after a little while they just left so he could sleep more, which was all he felt like doing.

Then there was Mrs. R. She'd been needing a sitter because she'd been delirious and trying to get out of bed unaided, and I guess that a couple days before that, she'd been pulling out her lines. The night nurse gave us report, though, and said that overnight, she'd mostly been quiet, sleeping on and off, and that the sitter hadn't had to do anything. And for our 12 hours, she was absolutely the picture of lucidity--thoughtful, wryly funny, gentle. Her very short hair (still growing in after chemo?) was messy from her being mostly bedbound, but ended up looking rather downtown and stylishly tousled, and was remarkably soft to the touch. She had wide, striking eyes in a pale, pale face. She was in her 70s, and her breast cancer had recurred, widely metastatic now. She had had terrible belly pain and vomiting from the tumor invading her small bowel and causing an obstruction, but they'd managed to place a stent to hold open her duodenum, and at least her GI symptoms were now largely resolved. The physicians talked together about having the conversation with her and her family: we think that it's time to stop trying for a cure and shift care to "CMO" (an acronym I actually hadn't heard before but from context could tell must mean "Comfort Measures Only"). The conversation didn't happen Friday, though. I couldn't tell whether they were stalling, or whether their given reason (to wait to talk to the consulting specialists to have the whole picture) was real.

In the afternoon, somebody brought Mrs. R two perfect peony stems--one a full-blown dark magenta bloom with a ring-shaped golden yellow center, and one a plump pink bud ready to open at any moment. She was terribly hoarse, and could barely do more than whisper, but she managed to ask me if we could do something with them. I was the only one in the room, and so I said I thought that unfortunately, since this was an oncology ward, we might not be able to have them in water in the room, but I would check. "Or just put them somewhere!" she said. I think she just wanted to make sure that such beautiful flowers would be enjoyed by somebody. I asked Julie, my preceptor, though, and it turned out that Mrs. R's white counts were fine, and her roommate had just been made a hospice patient that morning, so the peonies could stay in the room. I peered into the locked clean utility room (I don't have an OFH ID to swipe in, so I have to ask a staff member to let me in when necessary) to try to figure out something we could use as a makeshift vase, but the water pitchers were kind of too squat (and distinctly unlovely), and the only other thing that seemed like it might work was the white plastic urinal bottle for male patients. It was the right size, and even had kind of a graceful shape, but I couldn't bring myself to subject the flowers to the indignity. Finally I took a couple more swallows from my 2/3-full Diet Coke and poured the rest out, rinsed the bottle, tore off the label, and brought it in to Mrs. R's room. It was just right.

Finally there was Mrs. T, coming in under her own power, for a carboplatin desensitization. She'd had a possible allergic reaction to it before, at an earlier point in her treatment for ovarian cancer, but other therapies had failed, and the tumor was growing in her belly again, making her feel bloated and achy and taking away her appetite. So now it was time to try the carboplatin again, which meant following an elaborate and very carefully paced protocol to reintroduce it while monitoring her closely. Mrs. T, too, had very short hair ("When I had chemo, all of my hair fell out..." [significant pause, raised eyebrow] "All of it."), which suited her nicely. She was dressed in casually preppy clothes and seemed remarkably relaxed and cheerful for someone who was in to receive a flow of a medication she might be allergic to directly into her bloodstream (for the purpose of treating her recurrent potentially lethal cancer). She explained, though, that her symptoms had been bugging her so much lately that all she wanted to do was get the show on the road and start getting more chemo. She'd even talked her doctor into squeezing her in so she could get it a week earlier than originally scheduled.

We weighed her and measured her, drew another chem panel to verify that her creatinine continued to look great (which it did), pre-medicated her per protocol with Claritin and Benadryl and some other meds I'm forgetting. She'd taken some stuff the night before and that morning, too. And then Julie (clad fetchingly in the brilliant blue gown and special purple gloves used to protect nurses giving chemo) started the carboplatin infusion. Fortunately, it went great. Mrs. T decided to keep her own clothes on, so she was sitting there on the hospital bed as if in Chemo Cafe, in her jeans and blue and white striped button-down (unbuttoned a bit so we had could have access to the Port-a-cath in her chest), reading glasses on her nose, sedately flipping through the newspaper and making pleasant conversation with us when we came in to check on her or hang the next bag of stuff. Her vital signs stayed steady as Gibraltar, and she had no complaints besides a bit of boredom (we developed a running joke that the next time Julie and I came in, we'd do a song-and-dance routine for her). Would that chemo were always so uneventful.

And me, well, I had some more moments of feeling overwhelmed and ridiculously inept, but I think maybe I'm starting to get a little bit inured to the feeling, because it didn't bother me quite as much. And Julie is so very nice about it. Toward the end of the shift, she apologized for being scattered and then (apparently having been looking at my resume again, which was sent to her when she agreed to precept) said something about how even though I hadn't done hospital nursing, I'd done so many high-level nursing things. "You could have come in with a real attitude, with all the things you've done," she said, and gave me to believe that she's seen some real attitudes in her time, "but you're so humble!" I was kind of floored. It hadn't really occurred to me to give myself points for humility, which feels, I must say, very well earned. But I'm grateful and relieved that she sees it that way.

The hardest part now is going back to my dumb temp job. As I get going with clinical, I find have less and less patience for mindless clerical tasks (well, actually I guess I have some patience for the truly mindless stuff, because then I can at least think about something interesting--what's truly killer is the deeply tedious clerical tasks that nonetheless require attention and thought). I get so antsy sometimes I have to get up and walk around a little so I can stay in my skin. And refrain from yelling "WHO CARES?!" at my computer screen.

FUO

I can't sleep.

It's probably the fault of the cup of coffee I had around ten this morning. We went to visit Pete's parents this weekend, and I forgot to take my antidepressant with me, and I think I revert back to my old caffeine-intolerant self when I haven't had the 'zac in a few days. (Fully medicated, I am able to drink an entire cup of coffee with no ill effects, which is a lovely little thing.)

Rather than lie on the dumb bed and listen to my mind chatter away, which was getting to be a little irritating, I thought I'd come let it chatter at the computer for a while instead. This insomniac mind has, oh gosh, just lots of tedious things to say, let me tell you. Well, I suppose it might have some interesting things to say too, except they're kind of getting lost in all the noise. With a hundred tiny thoughts rattling around like dried beans in an empty Crisco can, no one thought has any more value or weight than any other.

I've been running a low-grade fever for no apparent reason. I had this once before, when I was working as a geriatrics clinic nurse and absolutely running myself into the ground with work and stress. I saw a couple doctors, and as near as we could figure, it was just a different kind of manifestation of my chronic fatigue syndrome. The Infectious Disease doc thought it had something to do with an overproduction of cytokines. In the afternoons, my temp used to get as high as 101.5. I haven't measured in the afternoon this time around. An hour or so ago, it was only 99. But I've felt unpleasantly warm all day. Pink-cheeked. Febrile. It's annoying, but way better than the other kind of CFS times, because fever is the only symptom.

I got a wristwatch finally because if you're a hospital nurse, it's generally considered good form to actually be able to take pulses and respiratory rates. It was $20 at Filene's Basement. It has a metal band, which even with the maximum number of links removed is kind of loose, like a bracelet. I've always before had leather bands, so when I look down, it looks like I put on somebody else's arm by mistake. It makes me feel kind of chic and nonchalant and elegant. I remember when I was an adolescent, I really liked those few times when I'd be at a friend's house and end up having to wear her clothes for some reason (like maybe I'd sleep over when I hadn't been planning to). I felt so un-self-conscious in somebody else's clothes. Like I didn't have to bear the whole weight of my own geeky awkwardness if I wasn't in my own clothes, which, being mine, had become fully saturated with the unforgiveable essence of me.

Last week we practiced starting IVs. We each got assigned a hand with a wrist and brief stump of lower arm attached. The hands are cleverly made for just such an occasion, and come equipped with numerous plump, delicious, sproingy veins. When you take your little needle and access them and push in the IV catheter, they reward you with a nice "blood return" of red food coloring. We also tied one another's arms with tourniquets and cajoled out as many likely-seeming veins as we could, for practice, though we didn't then actually insert any pointy things into each other. My preceptor says that nurses on her unit start their own IVs. For the first time, I can kind of picture doing it myself. Well. You know. Sort of.

This week, our last two class days are devoted to EKG interpretation. My nursing school only offered that as an elective, and I took Nursing Theory instead (fun, if at times maddeningly dumb, and infinitely less practical). I went in this afternoon knowing pretty much nothing except normal sinus rhythm, and I walked out knowing more than that, so it was pretty satisfying. My favorites were atrial flutter (which I'd never before known was distinct from atrial fibrillation) and Grade 3 A-V block. In atrial flutter, there's this attractive regular rick-rack of atrial depolarizations (they call it "sawtooth," but I like my visual metaphor better) between the big ventricular jags. In A-V block, it's so wild because the atria and ventricles, instead of being tightly coordinated and in synch, are just going along, doing their own thing, entirely oblivious to each other. The atria can be contracting along 80 times per minute, and the ventricles can be doing their own independent plod at 25 times per minute, and they might as well be in different rooms rather than part of the self-same organ.

I've been writing out oncology drug profiles on little index cards so I can memorize them and show my preceptor that even if I'm terribly all-thumbs-ish when it comes to practical tasks, I care and am, you know, diligent and stuff. I'm also going to spend some serious quality time with my nursing procedure books and visualize myself doing dressing changes and spiking IV bags and stuff like that over and over again, so that maybe on Friday I can just go in and do some things smoothly.

Also, I have some more unsolicited product endorsements. Stain sticks (which you might think wouldn't actually work but really they do). Camisole/tank tops with shelf bras right in them. Steven Johnson's Mind Wide Open. Whole wheat tortillas. Extra-dark chocolate Petits Ecoliers.

Now that it's 1 am and therefore only 6 hours until I have to get up, I guess I'll try again to sleep. Maybe the noise in my brain will have died down by now.

2nd Day

13 hours, mostly on my feet. A low point around 11 am when I spent 15 minutes certain that I just could never be ready to be a staff nurse and I really might as well hang it up right now but oh no what would I do instead? But then it got good again. I broke sterility doing a dressing change and forgot to do Mr. B's vitals and then later forgot to check whether his Mesna had all run in or not, but I actually was getting to the point where I could be a tiny bit useful. Julie, my preceptor, also told me I was very smart and doing an impressively good job for just my second day, which cheered me up tremendously. I was feeling like such a dimwitted klutz.

They went back and forth about 5 times about whether or not they were going to send Mr. G back up to us from the MICU, and then they finally did, and he was kind of scarily unstable. They had just pulled out the pigtail catheter from the membrane around his heart (where fluid had been collecting, and starting to cause something they call tamponade, where the fluid builds up so much that the pressure of it impinges on the heart's actually beating. bad, bad news), and his wound kept oozing and oozing. And he was short of breath and wheezy. And then his heart started to go back into atrial fibrillation, which is a fluttering of the upper chambers of the heart, which makes it do its job much less well. And he was sometimes with it and sometimes not. He told his wife and me at one point that we should unload the stuff before the cops came. He referred to his patient-controlled analgesia button as the detonator. He was hooked up to a machine to constantly measure his blood pressure and pulse and oxygenation, and both his pulse and his oxygenation were wildly all over the place. His pulse was sometimes in the 90s, and sometimes in the 160s; his oxygen sats went from 65 to 100 and back again--all within the space of a minute or two. It still wasn't clear whether he was going to go back to the ICU by the time we signed out to the next nurse around 7:45.

Fortunately, Mr. B stayed steady as a rock. He didn't see much of us. I'd slip away periodically to check on him and do his vitals and stuff.

Now my feet hurt. But you know what? They had free nectarines in the cafeteria today.