Cold Bore Shot

I had intended on writing a long involved post with lots of pictures. But then the kids refused to take naps. Well, LittleXY did sleep...for all of 35 minutes. LittleXX's nap was a total wash--she probably also woke up her little brother by opening and closing her door.

So this, my lovely readers, is what you get instead.

This is a picture of a target from when I went to the gun range this past Friday.

Yeah, I know, I draw cute little aliens, right? If we are ever overrun by aliens with 4" high floating heads, you should feel much safer, because I've been practicin'.

Anyway, the group of holes at the top is a 3 shot group taken at 200m. I didn't get the calipers out, but it measures out roughly smaller than 1/2". It's been a lot of hard work on my part to be able to put 3 projectiles in a 1/2" circle from 2 football fields away. Believe me I haven't always shot this well, and I still have lots of room to improve. At this point, my weapon is still way more capable than I am.

But that nice little cluster isn't what I'd like to draw your attention to. I want to talk about the impact just to the right of the alien's nose. Those of you who shoot will understand when I tell you that's my cold bore shot. Essentially a cold bore shot is the first shot taken from a completely cold rifle--often the point of impact is different than all subsequent shots. There is some debate over whether this phenomenon actually exists, but the idea is that the cold action and cold (or clean) barrel will shoot differently than one that's warmed to operating temp (or already fouled). Some say it's merely psychological and have run bench tests that seem to say it is.

Regardless of whether the cause is shooter-based or equipment-based, if there is a significant shift in your point of impact, this could spell trouble. Especially if your first shot is the one that matters. Think police sniper in a hostage situation. Think soldier on the battlefield where a missed shot alerts the enemy to your presence and a second shot, if taken, allows your hide to be compromised and your location discovered.

What about in the nursing field?

What if your patient is coding and you need access NOW. Unfortunately the patient is a long time IV drug user, and has scarred, thrombosed veins, everywhere you look. You're reduced to looking for the fun sites, like in the scalp, or under the scrotum, maybe even the dang EJ. You find one juicy vein, pull out your 18 gauge catheter and...

Cold bore shot.

Got to have it. The first time.

Oh sure, you can always just go intra-osseous, but that's not without complications in and of itself. And it's certainly not preferred given the necrotizing tendencies of some of the drugs you'd be administering.

So what do you do? Do you take the shot? Do you hand off the catheter?

How do you prepare when you have to make a cold bore shot?

Trauma Moulage

I recently volunteered as a moulage patient for an ATLS course at a local Level I trauma center. The nursing coordinator of the course happened to be a guest lecturer in my critical care class this past semester, so she took the opportunity to solicit volunteers. There were only 4 of us from a class of over 100 that agreed to help. Pretty poor showing in my opinion, but whatever. It turned out later that that we were actually paid $50 for helping out, a detail she purposely neglected to mention.

When I arrived at the hospital, I was immediately whisked off into make-up. They applied white theatrical makeup to my face and hands to simulate pallor, and some blue around my lips and fingertips to simulate cyanosis. Then a stab wound was constructed under my left arm, complete with copious fake blood.

I was then given my scenario to read over so I could effectively play the part of the victim. I was to play a young male whose wife had stabbed him with a large butcher knife. Immediately I recognized a problem--the wound was supposed to have been in the 3rd intercostal space at the mid-clavicular line, but they'd placed it under my arm, so it was more like the 6th or 7th intercostal space at the mid-axillary line. Enter the magic migrating wound, and after they'd already cut a hole in the side of my t-shirt!

As I read through the scenario I worked out in my head what my priorities for treatment would be for the patient--or rather I suppose, what I would anticipate the physician to order for the patient. I was pleasantly surprised to discover I pretty much nailed the scenario when I read through the answers at the end.

Essentially I would arrive at the hospital with a BP of 40/palp and a HR of 170 bpm. Additionally the EMT's were reporting a sucking chest wound and JVD. Given the wound location, my mind immediately leaped to three possible causes of the above symptom set--a tension pneumo, a hemo-thorax, or cardiac tamponade. I was most concerned about tamponade, but the other two aren't pretty either, and based on the basic ABC's they'd get addressed first. It turns out my thoughts were correct, and the patient (me) did indeed have all three issues.

When I got into the room for the testing phase of the seminar, I quickly realized that the docs taking the course were the brand-new, freshly minted first year residents coming on board starting July 1st. And that's when things got interesting, and a little scary.

I died the first 4 times.

Usually it was because an over eager doc stuffed an ET tube down my throat and hooked me up to a vent...with a tension pneumo. Once it was because the doc stood around and said, "Um..." a whole lot.

The residents made the same silly mistake over and over again. When they checked for responsiveness, I was instructed to moan. This was to clue them in that I indeed have an airway, and it was intact. However they didn't pick up on that, rather interpreting my moaning as unresponsive, requiring a GCS assessment that ultimately led them to my needing to be intubated. Granted, I was in bad enough shape that I would eventually end up intubated. Unfortunately, they missed some cardinal danger signs like tracheal deviation, decreased/absent breath sounds on one side, and, oh I don't know, a sucking chest wound.

So the course of care should have included a dart or needle aspiration for the tension pneumo. When my condition didn't improve, and breath sounds didn't normalize, a chest tube was in order. And then when vitals again didn't improve, even though breath sounds were equal, the resident would need to diagnose the tamponade. The scenario was set in a small rural hospital, so the residents didn't have access to an ultrasound machine for a FAST, and would have to rely on performing a pericardiocentesis instead.

I do have more educational background than the average nursing student, especially in "big picture" assessment. But it seemed these docs were missing things that I as a nursing student had been taught to watch for, and to assess. Either I'm getting one hell of an education, or some of these residents were a little slow on the uptake.

In all fairness, the other half of the residents I tested with nailed the scenario. Although the majority of them had trouble re-diagnosing the tamponade when symptoms returned as the pericardial sack refilled with blood. And almost nobody thought to attach an EKG lead to the needle to avoid puncturing the heart itself during the pericardiocentesis. Also, surely these first year residents wouldn't be unleashed on the unsuspecting public without supervision...right?

All in all I enjoyed the experience. It was fun and educational. I look forward to auditing the course myself at some point.

Still Here

Well, the sun keeps on coming up, and so here I am.

Regarding my last post, thank you to all with supportive comments for my wife and I, they are appreciated. For those that were weirded out by the awkwardness, I don't blame you--in fact, I'm right there with you.

We've settled into somewhat of a working functional relationship by necessity. Family is in town to visit and we hosted small group at our house last night. Common goals and busyness makes it easier to avoid the real issues at hand. It's clear that we have a lot to work on. And there's time, seeing how out of pure practicality I couldn't establish a place of my own until I graduate and get a job that pays a living wage. Yes, I am incapable of financially supporting even myself at this point.

In other news we moved to the Week 3 workout of the C25K program yesterday. I was nervous since 3 minutes is twice as long as we've run at once before, and the running sessions were still winding me previously. I know how ridiculous that must sound, but 3 minutes is a long time to run for someone who's let themselves go as badly as I have. The good news is, the 3 minute sessions went extremely well and I was impressed with myself.

Right up until I managed to hit the STOP button on the treadmill. I hate that. It's so annoying. Everything just stops, and it takes a minimum of 30 seconds to do the math, get the workout parameters all setup in the treadmill, and get rolling again. I have to imagine that's how a lot of women in this country feel occasionally.

"Wait, you're stopping? You're done? I was just getting to the good part!"

As much as I hate the premature workout termination, the parallel may actually explain why there's so much PMS in this world...

I still have some nagging injuries, an ankle the hurts and swells with every workout, and a new hip-flexor pain that shows up at the end of my workout that makes it hard to even walk the cool down. But overall doing ok. Haven't weighed myself in a week--may get on the scale in a bit. I imagine we'll do Week 3 for two weeks also, Week 4 is a big step up.

Bir-Fath-a-Versary

As I alluded to in my previous post, all my personal holidays are grouped together. My birthday is on June 17, my anniversary is on June 18, and Father's Day is rarely less than a day or two away from the others. We jokingly call it my Bir-fath-a-versary. It's my most celebrated time of year, and my heart is full.

Full of anger, hurt, and despair this year.

I'm sure this breach of confidentiality will be added to my list of transgressions, but all these feelings have to go somewhere. And they been expressed verbally countless times to little or no avail.

In one instant we were all packed in the car for the trip to church this morning, and minutes later I was alone in my Jeep beginning the 850 mile journey to my parents house searching for escape from the strife-torn battlefield my home life has become.

I love to travel, and embarking on the trip to my parents house, (with harkening mountains and 20* cooler weather), usually fills me with excitement. But it just felt wrong to be leaving this time, so ultimately, I pulled over and turned around. I haven't gone home though. I'm sitting in Barnes & Noble watching the happy families heading to Father's Day lunches at the Cheesecake Factory next door. I find myself wondering if they're really as happy as they seem, or if they're just better at hiding the pain than I am?

I always have been one to wear my heart on my sleeve. Some would say that it's a good thing--what you see is what you get with me. I have difficulty hiding my feelings at all; something that made growing up especially treacherous. With all the teasing and emotional assaults that dot the junior high landscape, any sign of weakness was usually quickly and brutally exploited. My sign of weakness was that every bully's taunt, every cruel joke, every barbed comment made a mark, and I didn't know how not to show that it bothered me. So "they" kept at it, and kept it up. Incessantly.

All this frank emotion also means I'm especially demonstrative. I like to show people I love them on a grand scale. Like "kidnapping" someone on their birthday, blindfolding them, and driving 3 hours away to visit their best childhood friend. Like arranging for a surprise trip to San Francisco, and then proposing from horseback in the middle of a Napa Valley vineyard. Like planning and arranging for Spring Break trips to New York City. Like listening carefully and working hard to get inside people's heads to buy gifts that are personal and significant to them. Like purposely trying to build up other weaknesses. Like expressing gratitude on a regular basis.

This same heart on the sleeve also means that when something hurts or upsets me, my mouth runs just as quickly. I tend to say things that are certainly pertinent to the present circumstances, but may have lasting consequences that I haven't always thought through.

Unfortunately, my expressions of love and concern are often passed off as empty grandiose acts, only a product of my overt emotionalism. Yet when the same fiery furnace spurns or criticizes, it's taken to heart and internalized. Counted and tallied; neatly noted on the scoreboard.

Talk about your double edged sword. In fact, live, and then die by the sword was never more fitting.

And so, with no more detail than that: right now, this moment, in this place, I want out of my marriage. One has to realize the gravity of me saying that out loud. It's my second marriage, I have 3 kids by 2 different women. The likelihood of finding someone I could love in the future who would also actually accept that kind of baggage is slim to none at very best. It may as well be the death knell of a life without loneliness.

I recently heard an extremely convicting and Biblically solid sermon on marriage. In the course of the message, the pastor explained that in his years as a marriage counselor he hears the same things over and over again.

He said the top two needs of a woman are, (a.) to be loved, and (b.) to be provided for. In regards to (b.), I've failed miserably. With the chiropractic school debacle I've been unable to provide for my family for years. Beyond what that's done to my own psyche, it means I've greatly failed my wife and family. I thought I was doing a pretty good job of (a.) but I've been told that I'm failing miserably there too. I have to take that at face value since that's what she tells me.

The pastor continued on and said the top two needs of a man are, (a.) respect, and (b.) affirmation of love through physical intimacy. Unfortunately it's become painfully clear that (a.) is not being met and has not been met for some time now. Again, thank you chiro school. And (b.) has been only minimally attended to.

The 4 top needs in our marriage are pictures of utter and complete failure. Who would want to stay?!

I don't know where to even begin, but I guess I'll start by getting in the Jeep and driving home.

Happy Father's Day everyone.

Miss Maggie

Well, Maggie came home yesterday, the perfect birthday/anniversary/Father's Day present for me. She's as sweet as can be, and great with the kids. I'd gotten so many warnings about how strong of a personality Scottie's have, and how we should think twice about getting one with children. So far she's been fantastic with them. I just don't see it being an issue. The kids know they're to be gentle with her, and she rewards them all with many kisses.
Last night she started the night in her crate, and did a really great job. She fell asleep and stayed quiet until about 2:30 am, when she woke up. I took her outside and she did her business like a big girl. When we came back in, she was much less of a fan of the crate. And being the militant hard-ass that I am, she ended up sleeping at the foot of the bed. Sacked out. Curled up against my legs. Oh, who am I kidding. I'm a huge softie, alright? What of it!
She's doing pretty well at potty training. She's had a couple of accidents which is to be expected, but she's been courteous enough to do it on the tile floor in our bathroom. Easy, easy clean up. We had our vet visit this morning, and it turns out she's got ear mites. Pretty common, and a fairly easy treatment. Ear drops every other day for 3 weeks to make sure we get all the eggs too. Other than that she's in perfect health it seems. The entire vet office staff fell in love with her.
Our contract with the breeder has a 72 hour return policy, so I asked the vet if there was any reason why I should return her. She said, "No, but if you decide to, call me first!" I don't think so, we love our Maggie-girl already!

MmmKay? Thanks

Dear Charge Nurse:

Maybe next time we should assign a nurse who actually believes the patient will survive to said patient. I understand he had a massive heart attack, is on a balloon pump, is in renal failure, is maxed on 3 pressors, and needs CRRT, but having a nurse with a positive outlook would be so much more beneficial for the patient. Then the nurse wouldn't say things like, "I'm not in a hurry to start the CRRT, it's not like it's going to matter." And then the overly large family (17 people crammed into one ICU room) won't pick up on her pessimism and become angry because they believe the patient is receiving substandard care--especially if 2 family members are physicians themselves.

MmmKay? Thanks.

And while I'm on the subject, dear family members who happen to be physicians: You, of all people, should know that 17 people don't fit in an ICU room with a balloon pump, a CRRT machine and 2 trees of Alaris pumps maxed on modules. What would happen if we had to, say, code the patient and we couldn't get the crash cart, let alone the required staff, through the door and to the patient? It's an ICU room, not a freaking clown car.

MmmKay? Thanks.

Dear 184kg (404lbs!!!!) woman: Maybe you should seek medical attention for your massive cellulitis in your leg long before you've had it for the 12 months that you claim. Maybe then you won't end up in the ICU for emergency surgery for a wound that started as a blister from a bad pair of shoes. And, PS: When you weigh 404 lbs and it takes 3 of us to hold back the fat rolls so we can place a foley, you don't get to fuss about the procedure being embarrassing.

MmmKay? Thanks.

Dear 144kg (317lbs!!!) man: Maybe you should let your nurse know that you haven't pooped in 12 days (even if it is "normal" for you) BEFORE we give you kayexalate for a potassium of 6.9 (because your kidneys have shut down because you're in cardiogenic shock because your fat ass ejection fraction is a whopping 15%.) They don't make chucks big enough for 12 days of poop, so a little heads up would have been nice. And please don't say things like, "What do you think of my 'organ'?" while we're cleaning your junk up for the 4th time of the day. It's creepy and weird. "Looks about like every other one I've seen today."

MmmKay? Thanks.

Dear 94 y/o little old lady: We typically like to see more than one QRS per monitor screen so, maybe you could bring your heartrate up into at least the 30s for us? And maybe if you'd shut up with the small talk, your heart might actually have the energy to beat more often. I don't really enjoy "little old lady" CPR, you LOLs make too many popping sounds--and that's coming from an ex-chiropractor.

MmmKay? Thanks.

So yeah, kind of a busy 2 days at work.

Several days off now--Mmmkay? Thanks!

Guilty Pleasure

One great way I've found to release some tension and make a lot of noise is to head to the gun range. I truly enjoy the mental aspects of long range shooting. To do it well one must clear the mind, control one's breathing, and even deliberately slow one's heartbeat. At 600+ meters, even the pulse of the subclavian/brachial arteries can be seen in the sight picture through the scope.



There is comfort in adhering to the rigid code of conduct around firearms. Safety is paramount, and a breach in form can be deadly. It's rewarding to reside within absolutes and to be so deliberate in one's actions. When I'm on the range I think of little else, but the task at hand.



I hand-built the rifle myself. I started with a Howa 1500 heavy barreled action, and dropped it into a Bell & Carlson Medalist Tactical vertical grip stock. I skim bedded the action with MarineTex to help with repeatability and accuracy. A Badger Ordnance 20MOA base and Burris Xtreme Tactical 35mm rings cradle the IOR 3-18x42mm FFP scope. A 3 color Rhodesian camo paint job dresses it all up.



Just thought I'd share. Any other shooters out there?

Embrace Life

This was just too good not to pass on.



My favorite comments from the YouTube page itself:

"This had more character development, emotion and cinematic value then most of the sh*t Hollywood is putting out right now."

-and-

"Full of glitter covered emotional WIN!"

As I Lay Dying

I'm a big William Faulkner fan. Have been since we read his novel As I Lay Dying my freshman year. But that's not what this post is about.

Earlier this week at work we had a patient who was actively dying. Being around things like this is just part of working in an ICU. Being around things like this is just a part of nursing in general I guess. Nursing is all about beginnings and endings, and we only hope we make a difference and affect the things that happen in the middle.

The patient was being cared for by a nurse I don't normally associate with when I'm at work. You see, there are extern-friendly nurses, and then there are...well, the others. I'm only lucky to be in complete control over when I work, as well as who I work with when I choose to be at my job.

Sometime in the course of the day, the patient started to brady down. She dropped into the 40s, and since this particular nurse's stunning communication skills meant that she declined to inform the rest of the unit her patient was actively dying and was a DNR, several of us showed up inside the patient room ready to code the patient.

The patient was an old woman with a mane of beautiful white hair. With her face turned toward the window and head half-raised to heaven, the look in her eyes made it easy to tell she wasn't long for this world. At her side she had a brace of sturdy Southern sons who had each clearly gotten something in their eyes judging from the tears that wet their cheeks.

Beat by beat her heart rate climbed back into the 60s and the heavenly escort was waved off for only a touch-and-go for the time being. We all left the room and continued on with our day.

A couple of hours later, her pressures on the monitor started to dip precariously low--80s over 40s. When I got into the room I cycled the cuff again, and she was 70s over 30s. Her sons were not in the room. I hustled across to the nurse's other patient room and informed her that her patient's pressures were bottoming out.

She shrugged and said, "She's a DNR."

After I scooped my jaw up off the floor, I asked, "Where's the family? They aren't in the room?"

"I sent them out because visiting hours were over. Say, can you help me pull this patient up?"

I'm ashamed to say that I *did* help her pull the patient up in bed. I should have given her a death star glare, turned on my heel and marched right back to the dying patient's room.

But as soon as I was free, I did go into the room. I pulled up a chair, and sat down next to the patient.

And then I took her hand and quietly explained, "Ma'am, you can't let go just yet."

"Your sons aren't here just now," I whispered, "I'm so sorry, but they'll be back soon to see you off. Please hold on a little longer."

And she did.

When I came in the next morning, she was gone. Apparently shortly after shift change the night nurse brought the family back in, and the patient was gone within the hour.

I'm not saying that anything I did had anything to do with that. And I'm not saying that the nurse's other patient's care wasn't important. I don't know that in the practical sense that anything else could have happened.

But I do know this: As I Lay Dying, I don't want it to be in an empty room accompanied only by ringing monitor alarms.

I'd want someone to be there.

One Foot in Front of the Other

Week 3 of running and still going. We're progressing more slowly through the program than scheduled, doing our best to stay healthy by only moving on when it's very clear we're ready. We did the Week 1 program for 2 weeks, and we'll probably do the same with the Week 2 workouts. I feel comfortable doing that since a large portion of our workouts actually happen on days where at least one of us has worked also. When the primary barrier to full on running is fitness level, working a busy 12 hour shift doesn't leave much left over for a running workout. So far we've run at least 3 times a week as prescribed, and completed every workout.

We are starting to feel a little beat up though. Both of us are dealing with knees and ankles that are bothering us. I think mine are more of a nagging nature than my wife's, but they're sore nonetheless. We went to the chiropractor on Tuesday, and are scheduled to go again today.

This morning we broke down and got properly fitted for running shoes. Proper shoes are clearly an important part of healthy running, but it can also be $$expensive$$. Especially if you wear a size 14 like I do. Lucky for me they still had my size in last seasons models so my $140 shoes were on clearance for $83, while my wife's size 8's were only available in this season's shoes of course. Hello full retail price. I got a pair of Brooks Trance 8's, and my wife got some Aisics.

Anyway the running seems to be going pretty well. I don't hate it. I did actually have a great run last week immediately after work where I felt some of the euphoria that people describe, so that was encouraging. Right now we're supposed to be running for 90 seconds and walking for 2 minutes in between for a total of 20 minutes. Yesterday I was able to add another run session at the end of my 20 minutes, and increase the speed to a slightly faster pace. We're not running terribly fast--we start each new workout plan at a 10 minute mile pace. As we progress through the workouts I increase my speed until I hit about a 9 minute mile pace. Not exactly gold medal pace, but I'll keep plugging along.

I'm reluctant to get on the scale based on my recent attempts to lose weight that always start with me losing a bit of weight and then rebounding to my start weight, even though I continue to work out and not change my calorie intake. Regardless I'm down 6 lbs over 3 weeks from 279 to 273.

I feel better though. And it's been no small victory to do my workouts, even on days that I work.

Rejected, Officially

From my inbox:

Thank you for applying for the Summer 2010 Student Nurse Extern Program. We have filled all of our allotted positions and cannot accommodate you this summer. We appreciate your interest as well as your talent and skills. We had a record number of qualified applicants.

If you graduate December 2011 or later we would be glad to consider you for the program next summer.

Please keep in mind that [our hospital] has an excellent Graduate Nurse Intern Program. We train new graduate nurses in many pediatric specialty areas. We interview for this program in Feb/March for May graduates and October/November for December graduates. Please apply through our online application system during this open window.

Best wishes to you as you continue in your nursing program.

I have to say that while it is nice to finally get an official confirmation of my rejection, I had figured that out on my own given that the program started June 1st.

Just to be sure I understood that they didn't want me, they sent me the rejection email 3 times.

And yet, I'll probably still be applying for their "excellent Graduate Nurse Intern Program" in October. Sigh.

Meanwhile nurseXX's unit (my dream unit) just hired 5 GN's, NOT from their intern program. Double sigh.