Above The Law

by Mr. Schnell

In the last few days I think I have heard about ten arguments by ten so called “legal scholars” as to what comprises “high crimes and misdemeanors”. Conclusion; none of them agree. Now let me get this straight, the US Constitution was written in Philadelphia between May 25th and September 17th 1787 and put into effect as the form of government of the United States after ratified by the ninth, and last needed state, New Hampshire on June 21st, 1788 and we are still trying to figure out what “High Crimes and Misdemeanors” references???!

232 years and we still don’t have a nonarbitrary, iron clad definition of “High Crimes and Misdemeanors”? Obviously something needs to be done to fix that oversight and lucky for us Donald J. Trump “To The Rescue“!

I am sure we can all agree Don is a man of few words.

Don is more a man of action. A Man’s Man…just ask Stormy D.

And in times of confusion, like today, and like we’ve experienced these last 232 years, actions definitely speak louder than words. We all agree on that. And that is great. Spank! Spank! It eliminates the need to split hairs trying to define confusing phrases and big words like “High Crimes and Misdemeanors”.

Take your time and look at the picture. They say a picture is worth a thousand words. See what Don is doing? No words necessary. Is this presidential or what???? Grunt Donnie Grunt! Push Donnie Push. No need to flush … Big Don saving water.

And when he isn’t denigrating Gold Star families and badmouthing the deceased Navy Fighter pilot, former POW and United States Republican Senator John McCain he is telling “Alternative Truths”. How many is he up to so far? I have lost count. Close to a million, right? (Ah, maybe not that many yet but surely working on it. He’ll get there if Moscow Mitch has any say on the matter and he does!)

Money means more than human life it seems. Snap Snap.

And what about that recent drone killing of Soleimani? Don was fresh off his victory lap from the Abu Bakr al-Baghdadi killing. Still tasting blood victory, on impulse Don belches confidently, “Let’s Do It Again!“. So they do. On foreign soil near Baghdad Airport Trump ordered a targeted strike on a convoy comprised of an Iraqi Commander, the Iranian general Soleimani, their drivers and passengers (collateral damage). But instead of praise and accolade he experienced criticism and backlash because the rest of the world feared he might very well have impulsively started World War III. Soiled jeans and dirty diapers world wide. Luckily!!! successful negotiations between Iran and the United States to save face were begun immediately. They came up with a brilliant plan. Iran needs to shoot a few missiles at a US base and we are even. Everybody is happy and no Armageddon. Don’t worry about the US servicemen (expendable Trump pawns purposely put in “Harms Way”) on those bases, we will warn them before firing missiles, providing plenty of time to take cover. Besides, we can always lie about casualties. Who’ll know?

Traumatic Limb Amputation, Brain Damage, Burns, Paralysis, Emergency Medivac: NO BIGGIE!

Another unnecessary crisis created and disaster averted. This calls for some martial bliss. Unfaithful fearless warrior and the loving embrace.

HOT NEGLIGEE!

We could go on and on. How on earth did the Donald make it this far?

In any other time Donald J. Trump would be the …

… BUT NOT TODAY. As long as we have a partisan, biased senate majority that puts “Party Before Country”, disregards the rule of law, and the US Constitution we are a nation that has lost it’s moral compass.

GOD SAVE THE KING

What It Means To Be American

by Mr. Schnell

There are Americans and there are republicans (always lower case “r”). Americans believe in America, our Constitution, our Bill of Rights, our rule of law. “r”epublicans believe in party only. “r”epublicans are not Americans.

Trump’s GOP

EVER BEEN NAKED?

by Effah Bin Newd, RN

Of course you have? We all have. But that is not what this post is about. The topic here is EBN. EVIDENCE-BASED NURSING; the sound-byte, catch phrase from our prestigious nursing “Think-Tank” universities. Those are the places where redundant nursing research studies are done that effect the way you practice bedside nursing by academic nurses that haven’t been at the bedside for centuries. Without this research you wouldn’t have a clue how to do your job at the bedside (please acknowledge the sarcasm implied). Don’t even get me started on the paperwork generated … I digress as I side track.

Back to EBN.

Please don’t misunderstand me, I was all for evidence based nursing in the beginning. I mean it too! I like to think my nursing practice was based on sound, tried, and true principles. I had no problem using whatever catch phrase the old girl’s came up with at those institutions of higher learning and thought. “Evidence-Based Nursing” sounds professional, even “educated” like smart people talk. And if I get tired of writing it out I can just use the abbreviation “EBN” and everyone in the “Smart People’s Club” knows what I am talking about (even if I don’t currently pay club dues).

But I did have a problem with all this research stuff. A trust problem. I had been in nursing a long time and experienced a lot. (I know, I know! Nurses are never given credit for their experience. You have to have paperwork proving you paid a ton of money, took a bunch of courses, passed them, and got a diploma to hang on your “Wall of Shame (as we called it in the military)” as proof. “On-the-job experience” and acquired expertise is never considered part of the equation and never certifiable. Whenever you change hospitals you are placed on the bottom of their totem pole and have to prove yourself all over again.)

This was my beef. It started when I read an article about “thalidomide” prescribed to pregnant women in the late 1950s and early 1960s (long before I became a nurse). It was prescribed as an off label use to prevent “morning sickness” which prevented pregnant women from getting rest and sleep because they were puking all night. Thalidomide was branded as an over the counter sleep aid safe even for pregnant women. It turned out not to be so safe causing severe deformities in the developing fetus. It affected over 10,000 newborns between 1956 and 1962. Doctors told their patients it was safe and so did the drug manufacturer. It was a nightmare for mothers and their newborns (but a medical malpractice gold mine for lawyers).

Throughout medical history there are more human guinea pig stories. Recall how they used to bleed patients in the old days. A doctor damn near bled George Washington to death. Nothing personal or political, it was merely the “standard of care” at the time.

Another example are the inhumane experiments the Nazi doctors carried out in the name of medical research and science. (As far as I know none of these Nazi doctors or their research findings are employed by today’s drug companies but the way things are going you wonder!)

Lets look at current medical research. How about that doctor at St. Luc’s Hospital in Montreal Canada back in the early 1990s. Dr. Roger Poisson falsified breast cancer research just so he could get published and also be eligible for more grant/research money. More recently, in Korea, Professor Woo-Suk Hwang, once thought to lead the field in stem cell research, falsified a mountain of his data.

Duke University had to pay a 112 million dollar fine for it’s research “misconduct”.

What about drug companies? The drug Vioxx was made by Merck. They pulled it off the market but not before thousands were affected. Turns out the drug company suppressed information and patients suffered.

In 2007, or there about, the drug Zyprexa was under investigation for illegal practices in marketing after they had 30 billion dollars in sales. They ended up paying 1.2 billion dollars in fines. The drug is still on the market and still being prescribed under a generic form called olanzapine. A major side effect is profound weight gain (up to 30 kg … 66 pounds) and diabetes.

For awhile there was controversy surrounding the heart drug Natrecor and drug eluding stents. The Natrecor issues were “resolved” and the stents are believed to cause a higher incidence of blood clots down the road.

What’s my point? All these examples involved medications and treatments that supposedly underwent mountains of research, studies, passed strict FDA guidelines and who knows what other “safety” standards in place. Your trusted doctor believed the data he/she was told and prescribed to you and what happened???? The medicine is some cases was just as bad or worse than the disease.

No one seems to really know what these drugs do or how they actually work. Is this blind trust? Are consumers nothing more than experimental guinea pigs? When drug companies make 30 billion dollars in sales and are only fined 1.2 million dollars the profits make the fine look like a mild admonishment and no deterrent at all.

This brings me back to Evidence-Based Nursing research. I ask: “Do I know the researcher? Are they honest? Where did they get their funding? Were their results objective or did they take money from a company and get results the company “paid” for? Are they living within their means? Do they have lots of debt? Are they abusing or addicted to drugs, alcohol, or gambling? Do they floss their teeth?

What I am getting at is that I don’t know these researchers from the man in the moon. In today’s greedy, “alternative truth” world it is INSANE to blindly trust anyone, let alone some unknown researcher trying to make a name for himself. To trust drug companies, when you know their bottom line is profit where monetary fines are easily accommodated and not a deterrent, is equally crazy. You have to trust someone (or else they call you paranoid …. dear God, not that!) so you trust your doctor. But what if he is fooled also (or getting kickbacks …. dear God, not that!)

It is all just downright scary.

When they asked me to base my practice on “Evidence-Based Research” I was weary. The scams in research created a trust issue for me. I had to go with tried and true years of experience and gut intuition. When you hang around nursing long enough you develop that “sixth sense” and you listen to it. I relied on it. I refused to blindly accept research.

The internet is full of examples. Google “falsified medical research” or “healthcare research scams”.

I don’t trust people or companies in healthcare today and I was in health care. We are “snakeoil salesmen” with magic elixirs and promote (false?) hope for profit. It is a business. Medicine doesn’t have a cure for everything but it does have a treatment for everything. It comes with a hefty price tag, can compound your suffering, make you go deep in debt, make you lose everything you earned over a lifetime, and in the end you are still sick. And broke.

That is the naked truth.

Let Me Show You Something

by Mr. Schnell

Every so often, on a regular basis, enough is enough. Time to get away. To sit and think. Alone.

Oh yeah, before we get to far…no cell phones.

There. Just ahead. See it?

The QUIET PLACE

In the clearing ahead. It is not Yosemite or the Grand Canyon but for me much more. Solitude. Sanctuary.

Have a seat.

Time to sit awhile. SHHHHhhhh. Hear that? No other humans around.

To the East

A robin landed above. A squirrel scampered across a pile of leaves then leaped onto the side of a tree. Can’t see him now but hear him climbing higher then silence.

To The West

They know I am here and have left. I have invaded their space but won’t stay long. Only long enough to recharge the battery. Rekindle the spirit.

To The South.

No computers, no cell phones, no electrical buzz. No other people. Only Quiet and Introvert heaven.

The Concrete Slab

In a clearing up ahead is “The Concrete Slab”. Don’t know where it came from or how it got here but there it is. When I leave I will sprinkle bird seed on it. When I return there won’t be any seeds. Where did they go? It is a mystery I choose not to ponder.

the last stop

This is the “Last Stop” before I leave my quiet place. I have carried a little cooler filled with shell corn to refill this basin. When I return I expect it will be empty again. Another mystery that makes me smile. I won’t ponder.

Mysteriously feeling better than earlier. I will go with that. Ahhh!

If This Art Line Comes Out

by Mister Schnell

We admitted this patient at three in the morning. She was an emergent open Abdominal Aortic Aneurysm repair; in hospital jargon “a triple A”. The procedure went fine. In and out of the operating room in record time. The decision was made to extubate then ship to the ICU.

They slice and dice, manhandle the bowel to get to the abdominal aortic aneurysm, put the scrambled gut back in place when done, close, allow the patient to wake up then extubate and transport!!! That has got to hurt and cold blooded if you ask me. At 3 AM there is no recovery room. The ICU is the recovery room.

The patient arrives in the unit screaming. Open aneurysm repairs are painful. She is hurting, agitated, combative and pulls out her radial art line. Apparently it wasn’t sutured in place. Art lines are nice to have to monitor and manage blood pressure when recovering aortic aneurysm repairs in the first 24 hours. High blood pressure can mess with the surgeon’s fine stitch work so I politely request of the surgeon, “Would you mind putting in another arterial line? The patient inadvertently pulled out the one she had placed in the operating room. It wasn’t sutured in.”

Oh was he pissed! He grudgingly put in a new line and while suturing this one he snarled at me, “If this comes out I’ll be back with a gun!

I was speechless. Did I hear what I thought I heard? I looked around the room, which was dead silent now. Yeah. We all heard it.

I looked at the surgeon. He is maybe 5’6″ at best. Pigeon legs. Weighs maybe 135 pounds. Bald with a few strands of comb over. Mid 50s I’d guess and threatening us with hand gestures indicating his high powered imaginary firearm. Bang Bang.

I am in my early 40s, 5’11”, 225 pounds, broad shoulders, full, thick head of hair, bushy beard (Charlie Manson style), stocky build. Hunted wild game all my life. Pretty good shot too, if I say so myself (but got my last deer with a bow a few years back). I am also a military veteran and on that day I have this scrawny, little, baldheaded twit threatening me with an imaginary gun at 3 am.

Next to me is another male nurse in his late 20s who was an Army ranger. A paratrooper. He used to shoot .50 caliber machine guns and throw hand grenades. Part of his training involved hand-to-hand combat and living off the land in alligator filled Georgia swamps. Did I mention he is a body builder too?

The only thought I had was, “What caliber gun, doc?”

I mean, honestly, he’s runt size even for an aging gnome, with smaller hands than Donald Trump. The kick from anything bigger than a BB gun would easily snap his hobbit size, tooth pick wrists.

Staff were staring at me. It was obvious they could read my mind and their eyes were pleading, BEGGING, “Don’t, please, PLEASE DON’T ASK THAT?”

Bowing to majority mental telepathy pressure and ignoring everything I ever learned in “The Bedside Jokester Book Of Clever Retorts” I suppressed the urge to engage and remained silent.

The sigh of relief was felt all the way to the hospital parking garage a bus shuttle away.

Why does this highly trained, talented surgeon have to be such a moody asshole? What he does for a living is amazing, prestigious, respected and rewarded. Could it be he is some how intimidated? Nah, surgeons are never intimidated. Maybe just tired? But that is a human quality uncharacteristic of his immortal stature. Does mentioning “a gun” win some kind of convoluted pissing contest for him? All of the above? Me thinks that be the case (pardon my grammar). Typical and expected. Something nurses deal with all the time.

We are an open heart, catch all surgery recovery unit. We deal with intubated patients, temperamental surgeons, and apparently, now, “gunslingers” around the clock. Leaving an abdominal aortic aneurysm intubated and sedated through the remainder of the night would have been nice and even humane. We would have allowed her to emerge from the anesthesia slowly, controlling her discomfort gently along the way. We would get her extubated like we do everyday with our post operative heart patients. But not tonight. Our sleep deprived munchkin is calling the shots (pun intended) and probably doesn’t want calls later (no one does).

Neither of us has ever worked with “Little Rambo” before and this is the middle of a night shift. Generally he is only around from 9 to 5. Must have been the on call surgeon tonight.

Anyway, we get this lady’s pain under control, make her comfortable, and settle her in. The new arterial line works wonderfully. We keep her blood pressure within parameters and use the line to draw blood work without disturbing her. The surgical stitch work is never stressed or compromised.

To our relief the arterial line stayed in and “little gnome Rambo” didn’t have to “come back with a gun”. The patient recovered without further incident and later that day I got a hair cut and trimmed my Charlie Manson beard while my Ranger coworker wrestled alligators at the local zoo.

A Walk In The Park

by Robert Schnell

The 54 year old male came to the hospital for an elective laparoscopic cholecystectomy. You know, gall bladder removal. Go in early morning, gall bladder out before noon, home before 5 PM, out bowling with friends that evening. A “walk in the park” procedure!

Yeah, right!

The patient goes to surgery. It takes 75 minutes, recovery room another 90 minutes, then post op surgery floor for observation.

Post op orders are written by the surgeon. Unknown to the surgeon the patient’s internal medicine doc, Dr. Moodswing, comes in and adds his two cents. He writes post op orders for anticoagulants. The order is sent to pharmacy and processed. A Medicine Administration Report (MAR) is generated and sent to the floor.

Meanwhile, the busy floor nurse with three other patients takes the new post-op “chole” admission after an “abbreviated” report from the recovery room nurse. No one really knows much history or anything else, for that matter, on this patient. He came from home that morning for the procedure. No post operative nurse has ever laid eyes on him let alone seen a history or done a physical assessment.

According to the new MAR, Lovenox (a power anticoagulant) is ordered. Subcutaneously. 140 milligrams. That’s odd. Normally you don’t give anticoagulants for 24 hours after any surgery but Moodswing ordered it. It’s given.

An hour later the patient has a heart rate of 140 and no blood pressure. He’s put on a Dopamine drip. He’s tachypnic, breathing at a rate of 35-40 breaths a minute and acidotic (pH 7.25) by blood gas determination. He is rushed to the ICU. The surgeon arrives seconds later while Dr. Moodswing is now at home enjoying a glass of wine, as is his habit.

The surgeon orders a unit of packed blood cells “STAT”.

Guess what? No pre-op type and screen or crossmatch was done. (A lap chole is a “walk in the park“, who needs emergency standby blood?!?) It will take at least an hour to type, screen, crossmatch and get the blood available and that is if you don’t detect antibodies (cross your fingers).

The patient needs the blood now! More fuel to the chaotic fire; the surgeon informs us the patient got Lovenox prior to the procedure. What??? That important tidbit of information was never passed along. He also received another 140 milligrams subcutaneously less than an hour ago, courtesy of Moodswing’s post op order.

This case is turning into a comedy of errors with no one laughing. Don’t these docs talk to each other? Does the right hand have any idea what the left hand is doing?

Two units of uncrossmatched blood are transfused. Dr. Moodswing keeps calling and interrupting while the nurses assist the surgeon placing lines. He shows up later only to get in the way. The patient crashes. Moodswing calls for anesthesia to intubate all the while badmouthing everyone from the unit clerk, charge nurse, to the blood bank. (He should have stayed home and finished that bottle of wine. Maybe he did! Would explain a lot!)

The patient later returned to surgery eventually needing 12 units of packed red blood cells, 6 units of fresh frozen plasma, and platelets. He ended up being hospitalized for 10 days (mostly in the ICU). He suffered a small heart attack from the hypovolemia caused by hemorrhaging but recovered and was eventually discharged home. No bowling with friends for awhile though.

Moral of the story: With any “walk in the park“, as everyone knows, there can be unforeseen events.

SHIT HAPPENS!

The Health Care Fortress

by Robert Schnell

(Disclaimer: The following post contains profanity, gallows humor, and graphic illustrations. No warm fuzzy today. Intensive Care Nursing is not a profession for the delicate and squeamish. Bedside professionalism always. Not the case in the break room or the local watering hole after work. You have been warned.)

How about the powerful, multi-billion dollar health care business? It is one of America’s money making sacred cows cloaked in altruism, sacrifice, respectability, knowledge, compassion, confidentiality, and concern. That is the message spread via high dollar advertising and propaganda anyway but remember Corporate Medicine squeezes maximum profit out of patient suffering, misfortune, injury, disease, medical travails and we can’t seem to get enough of it.

I was once informed by a career military relative that another relative had a rare and fatal disorder newly diagnosed. I read this via email after a particularly tough night in the ICU. My professional guard was down and replied emotionally via email admitting sadness and tears at this news. Three decades in the ICU I have seen the pain, suffering, and final end of many unfortunate patients. The rare disorder identified is particularly lethal and a painful way to go. My military relative replied, “Some people pray … some people send positive thoughts. That is what I ask for, either prayer or positive thoughts … whatever people are comfortable with. Empathy is okay … for a short time, sustained for too long becomes sympathetic and that presents as weakness. We cannot afford or allow that chink in our armor…. there is no room for tears right now.”

The relative survived this event and lived many years longer until ultimately deciding to become noncompliant with prescribed medications and therapeutic regimen. It is questionable if the original diagnosis I was told was actually the case. When I can’t assess a patient I have to rely on others with lesser expertise.

Many lessons learned here. 1) Don’t listen to lay person 2000 miles away. 2)Talk to medical staff directly. We speak the same language. 3) When talking to military people weaponize empathy, and compassion. Talk their language but also understand they are under stress, hurting and doing their best to “keep their shit together”. You can even say “keep your shit together” to them. They eat that macho facade up! OOOH-RAH!

For years I searched for the right words to describe what I do in the ICU. After that email the words came to me. My search was over.

(For 38 years I towed the corporate line but never weaponized health care like some nurse administrators, who left the bedside, did. It was nice to retire and take off the armor worn to fight those administrators so proper care could be provided. And to all you nonmedical people out there, when you tell a senior veteran ICU nurse a lethal diagnosis, chances are good we have seen and dealt with it. Automatically a mental nightmare is visualized and if our core has not turned to stone it still evokes strong emotion and that is never a weakness. It is our strength and guides the care given. You would want nothing less.)

By the end of my career we were getting so many “Article 15s” they became the rule instead of the exception.

The Last Twelve Days After Christmas

PROTECTED IN THE BUBBLE

From December 25th, 2019 to January 3rd, 2020, a mere ten days, we went from “Peace on Earth, Good Will to Man, Happy New Year” to a targeted drone assassination in a sovereign country on the other side of the world. It is now twelve days after Christmas and chants “Death to America” are reported on news stations around the world.

The world awaits Iranian reprisal, the collateral damage from Trump’s “decapitation strike”.

Reinforcement military personnel rushed to the Middle East before they even had a chance to say good bye to family and loved ones. Weren’t we supposed to be leaving the middle east?

GOP presidential re-election campaign strategy?

Weren’t Putin and that Iranian general buddies?

Is it true Don jr. and Eric are enlisting and volunteering for combat duty?

So many questions … so much unknown ….