Nerdy Nurse Tip of the Month

If you've ever had a spontaneous bloody nose, absent-mindedly scratched open a scab, or are generally accident prone like me, you've gotten blood on your clothes. Screw Martha Stewart, being in the ER, we nurses know the trick to getting it out fast. You don't have the time or the resources to pop it in the washer and even then sometimes that doesn't even do the job. The key?

Hydrogen peroxide.

As soon as you realize you'd messed up your clothes, saturate the area, dab it with a washcloth or papertowel you can throw away and poof! It's gone. Like it never even happened. HP dries quickly, doesn't smell, and doesn't leave a stain of it's own (to ensure it doesn't bleach your clothes, rinse or dab the area with cold water after you've removed the stain). Now, this will only work if it just happened - it has to be new blood - if it's dried blood or an old stain, it won't help you. If you're looking to get rid of an old stain, Miss Martha is your guru. If you catch it quick, good old H-O-O-H is your friend.

And that's the Nerdy Nurse tip of the month!

xoxo

If it ain't broke, don't fix it...on the other hand...

If it is...ouch!!

There are several ways to break a bone. I'm only going to discuss four of my favorites instead of going through them all to avoid boring the snot out of you.

Let's start with my favorite. It's my favorite because the name for it illustrates exactly what it is: the greenstick fracture.

Have you ever been building a fire or just walking through the woods and you've tried to snap a branch in two that wasn't dead, but still green inside? It just twists, breaks a little on one side, but mostly just bends, right? Children's bones, because they are still soft and pliable (bones calcify and harden with age, hence, brittle bones in the elderly) do the same thing. It's an incomplete fracture where the bone is mostly just bent. Treat it with a hot pink cast that gets lots of autographs and you're good to go! Children are so resilient!

The next fracture that I love is also visual: the burst fracture. These occur from a high-energy axial load, usually caused by falls or car accidents and involved the vertebrae, causing it to literally burst. Surgery is usually required, involving fusion, especially if the spine is unstable, but these fractures can definitely cause paralysis if they are severe enough to involve the spinal cord. So don't jump from tall buildings - even if you land on your feet you can do some serious damage.

The third fracture that I think is fascinating is called the "Hangman's Fracture." This is the severance of pars interarticularis of the axis vertebra, more commonly known as C2, named so because this is the mechanism of injury (and the resulting death) in judicial hangings. It's caused by the sudden and forceful hyperextension of the head (chin to chest), and is not only caused by the sudden drop and jerk when one is being hung, but also in motor vehicle accidents when unrestrained drivers go into the steering wheel or through the windshield head-first. So wear your seatbelts!! Your C-spine is one of your most treasured possessions, so please, please treat it with loving care!

Last, but not least, I love a good open, compound fracture. Not cutely or sensationally named, but man is it gross! Quickly shortened by us in the ER to "open [insert name of body part]", (e.g. "open tib-fib," "open ankle"), these come in as level 2 traumas on a regular basis. Very bloody, easily contaminated (with dirt, etc.), and wicked awesome, these fractures are, surprisingly, usually not particularly painful. If there is considerable nerve, tendon, ligament, muscle damage, first we'll reduce it (put it back to where it's supposed to be) under conscious sedation and then splint it, but eventually surgery is going to be the answer. Pins, rods, plates, and all kinds of bike-shop metal is gonna be placed in there to make sure you're back in one piece. I had a patient the other day with a GREAT open ankle fracture and even took a picture of it with his permission. But the damn picture wouldn't load so now we're stuck with a look-alike from Google. Just imagine way more blood! :)

Awesome! So, the moral of the story is: get your daily dose of calcium because you definitely don't want to end up in the ER with one of these because your bones are too brittle and can't handle normal wear and tear! (Also, don't try to hang yourself because a) we love you and want you to live and b) suicide attempts by hanging usually succeed because of slow, terrifying asphyxiation, not a quick C2 fracture.)

xoxo

Oh Conscious Sedation...you get me every time

"William James describes a man who got the experience from laughing-gas; whenever he was under its influence, he knew the secret of the universe, but when he came to, he had forgotten it. At last, with immense effort, he wrote down the secret before the vision had faded. When completely recovered, he rushed to see what he had written. It was "A smell of petroleum prevails throughout." - Bertran Russell, A History of Western Philosophy.

When someone is going through a painful procedure, whether it be putting a dislocated hip back into place, setting a broken bone, or pulling out wisdom teeth, patients are often put under what's called "conscious sedation." Usually using a combination of Fenanyl (for analgesia) and Versed (for sedation and memory loss), or Katamine and Propofol, patients will not be aware of what's going on, but can also maintain their own airways during the procedure, thus nullifying the need for intubation (which is a very risky procedure). Patients will also not remember the procedure or what they say or do while the medication is wearing off. These people may be breathing and blinking, but trust me - they are high as kites on a blustery day. And it's fun.

For example, I had one of my patients go on and on and on about "chaos and waterfalls" while coming off a Ketamine and Propofol conscious sedation. I had his girlfriend write down the things he said so she could tell him after he came to. We all had quite a few laughs. I had another patient say he was in "Zu-Zu Land" after we pushed his hernia back into place.

While some people like to smirk and giggle and observe people for their own private amusement (me), some people like to film their loved ones under the influence of conscious sedation.
Watch these two videos and try not to bust out laughing. Sorry guys - I'm having technical difficulties and YouTube is not letting me embed these links, so please feel free to click the two links, and enjoy.

David after Dentist: http://www.youtube.com/watch?v=txqiwrbYGrs

Unicorn after Wisdom Teeth: http://www.youtube.com/watch?v=LQD2y-ZL8s0

xoxo

Welcome to the Emergency Room

It's scary how accurate this is

Ways to lose face (two lessons from the ER)

Make that, two ways to lose your face.

1. Do not taunt, prevoke, anger, or piss off a pit bull. I happen to be a huge fan of pit bulls. I love their sweet flat cow faces and the way that they seem to smile. But they can look like this (my favorite - the white ones that look a little pink):

or like this:

And can leave you looking like this if you rub them the wrong way:

Note: this is not a picture taken from Vanderbilt Emergency Room, but it's scary how uncanny the resemblance is to the patient I may or may not have seen the other day, who saw fit to get into it with a pittie. Just add an endotracheal tube and subtract a lot more nose.

Pittie: 1, Patient: 0.

2. Sledding is great fun. I have very fond memories of going to Great Grandma James' house and sledding down the great long hill onto the frozen lake every year on Christmas Day. Sledding should be done on hills that end in grass, a fence, or, like in Dousman, WI, a frozen lake. Sledding should look like this:

Your sledding route should not, however, end in the interstate. The most busy interstate of Nashville. I repeat: do not go sledding on the interstate. That is a terrific way to lose your face.

Take it from me - if you're stupid, you're bound to lose face in more ways than one.

First Aid 101 - You Got Burned

I've done it. You've done it. You've splashed boiling water, you've touched the brownie pan straight out of the oven, you fallen asleep in the lounge chair by the pool. We've all gotten burned. However, what now? Aloe isn't a fix-all, so what do you do? Since I don't want to go down the path of heat stroke and sun poisoning, I'm going to mostly leave sunburns out of this. We'll talk about that another time.
There are a lot of myths out there about burns (e.g. Don't you slather a burn with butter?) so here's the rundown.

Immediately....Stop the burning. Are you outside in the sun? Get in the shade or inside. Are you touching something hot? Stop touching it. Is there something hot on you (e.g. wax, spaghetti sauce, tar, etc.)? Cool it. Run a burn under cool water for 10 minutes minimum. When wax cools, it hardens and will easily come off. After it's cool and you can pick off the wax and then run the affected skin under cool water. (note: This does not mean ice water. cool water.) If you have tar on yourself, a) what are you doing with tar on yourself? and b) mayonnaise. Just like peanut butter is the key to getting gum out of your hair, mayo is the answer for taking tar off skin. It's true. Apparently we (we being Vanderbilt, not my family) used to keep a big tub of mayo in the trauma bays for precisely that reason. Fun fact.

While you're running your burn under cool water for 10 minutes minimum, assess the burn. There are four degrees of burns. A first degree burn involves only the epidermis - the top layers of skin. A first degree burn appears reddened and is tender. A mild to moderate sunburn is usually a first degree burn. Aloe should suffice.

A second degree burn involves the middle layer of skin called the dermis. Second degree burns usually manifest themselves as painful, superficial blisters. Ouch. Aloe should also do the trick here, although there are some really sweet "after burn" topical treatments with lidocaine in them that will cause some superficial numbing. You may want to try that as well.

Third degree burns involve the subcutaneous tissue. Nerves and muscle are damaged by the burn and usually appears charred (i.e. brown or black) in appearance. Yiggity. Go to the ER. The good news? Due to the damaged nerves, third degree burns can be predominantly painless. The bad news? Hair follicles are destroyed and wherever you got burned will now forever be bald. Mrr. Fourth degree burns are really bad news. Shocker, I know. Fourth degree burns, or full-thickness burns, are the deepest burns and involve not only skin and muscle tissue, but tendons and ligaments as well. Fourth degree burns are generally white and waxy in appearance. See the picture below - the middle of that burn is a fourth degree. The outer, brown edges are third degree. And the I'm not sure what the pink dotties are on the other leg - my best guess is that they're skin graft sites.

The biggest and baddest sequlae of a fourth degree burn is when the burn is completely circumferential and goes all the way around, say, a leg or arm. The stricture and consequent loss of blood supply to the extremity is called compartment syndrome and threatens the life of the limb and possibly of the person. The treatment involves something called a fasciotomy and you don't want that. You also don't want to see a picture of it either, so I didn't include it. If you're curious, Google Images will more than quench your thirst.Let's talk for a brief second about chemical burns. If they are minor, the treatment is dilution of the area with massive amounts of water. Best bet is to hop in the shower for a good 30 minutes or more. Don't try to "neutralize" an acid with a base or vice versa because you'll probably end up causing a not-so-awesome chemistry 101 experiment and your skin is not the place for that. That being said, any chemical burn is a legit reason to seek the professionals so you can feel justified in coming to the ER (or at least going to the doctor) if you've had any kind of chemical burn.

Whatever you do, don't....use ice. Cool water is not the same as cold water, ice water, or straight up ice. If you place ice straight on burnt skin it will cause further tissue damage.

Butter your bread, not your burns. Butter and oils actually retain heat and can prolong the burning. If you want to stick with old school remedies, use milk. Soaking a (first degree) burn in milk will soothe it. Slathering yourself in butter will only result in you more burned...and covered in butter. Insult to injury.

Don't pop your blisters. Burns love to get infected so don't mess with your blisters. This goes for blisters of all origin. Let them heal on their own.

Seek the professionals if....You've received an electrical burn. Even the smallest electrical burn is considered a third degree burn. Both entry and exit wounds are possible and can have deadly consequences.

If you've received a chemical burn and you are having trouble seeing, breathing, if you're dizzy or having chest pain. Come see us.

If your burn covers a portion of your body larger than a quarter (for a child) or a silver dollar (for an adult). If you were sunbathing naked for a little too long and now every inch of you is red and angry, sorry, but you're just going to be miserable for a few days and probably want to make best friends with a big bottle of aloe. If you have big festering blisters all over your back or beyond, come see us.

There's a way to measure the total surface area (TSA) of body burned called the Rule of Nines. Here's a picture:

So, if you've burned your entire right leg (front and back) you've burned 18% of your body. If the TSA number scares you, seek medical attention.

You can never be too careful when it comes to dealing with your burns. As mentioned previously, most any burns are a totally legitimate reason to seek medical attention. Always err on the side of caution with these puppies. And please please please wear sunscreen. Anything SPF 15 or greater will do.

Next time: Epistaxis: The fancy word for "nosebleed."

xoxo

Nurse Nerdy - a fine example

There are so many delightful things about this. Everyone knows about the overly-marketed "word" decorations. Life. Love. Dream. Believe. Family. Happy. To be fair, it's Christmastime and I've always loved the word "joy" and have considered buying that as a word decoration. (on a side note, I never did purchase said word decoration because I received an amazing homemade Christmas hanging quilt with the word "joy" on it courtesy of my fantastic Grandma MJ - Thank you!!)

However, instead of conforming to the masses, try something a little subtler. Something that requires a little more sophisication and a little more imagination. Like this:

At first glance one might say, "Well this is ugly. It's cold and modernist and silver and not at all my style." However (and this is a big however), one's opinion might change when they learn this is the serotonin molecule. That's right. The neurotransmitter. Of the approximately 40 million brain cells, most are influenced either directly or indirectly by serotonin. This includes brain cells related to mood, sexual desire and function, appetite, sleep, memory and learning, temperature regulation, and some social behavior. It's widely believed (although officially not proven, because apparently such studies cannot be performed on live brains) that a lack of serotonin can cause dysfunction in these areas and can lead to depression. It is also belived that an increase of serotonin (caused by selective serotonin reuptake inhibitors (SSRI's) like Paxil, Prozac, Celexa, etc.) can lift many symptoms of anxiety and depression. It's like a Happy word decoration without being a Happy word decoration! I love it!

And that, my friends, is nurse nerdy.