sex, drugs, and saving lives

They so often come in, naive, having never experienced intubation or resuscitation. They are afraid of death. They are afraid of their disease. They are strong and fat and not yet worn down. They have good hearts and good immune systems. They will endure hell if it means they can go back to being alive. It's wonderful when this happens. Except when it doesn't.

A catastrophic PE, a lobectomy for lung cancer that should have been routine. They are motivated. They are terrified. They want everything done.

So we do everything. Tubes in every orifice. Feeding, venous, arterial, endotracheal, urinary. We crank up the oxygen and administer abundant amounts of PEEP. We defibrillate, we fluid resuscitate, we dialyze, we pour in antibiotics and inotropes and the good ol' Vitamin V. Family comes daily. They hold hands and pray and wish and stroke hair and hope and speak to silence.

But what if hope is not enough? What then?

Then there's heart attacks that were unexpected; strokes, more PEs, opportunistic infections, chronic infections, tracheostomies and muscle atrophy. Weakness sets in. Anxiety and panic gives way to drug habituation as the medications that we use to keep them settled and sedated manifest their less-than-desirable side effects. Hope grows dimmer as the weeks and months stretch on. Family are coming less often. The patient stares vacantly off into space, when they're not awake. We may diagnose them with depression and add yet another drug to the list.

Eventually the acute phase of their illness passes, and we are on to the chronic phase, the rehabilitative phase. This phase takes 4-10 times longer than the acute phase, but only the acute phase is sexy. IV pumps and machines which beep and swish and whirr, these are sexy. People yelling things like "clear" and "stat", this is sexy. Medevacs and ambulances and salvage therapy are sexy. Nobody makes hour-long tune-in-next-week broadcasts that detail the weekly painstaking struggle of a six foot man to stand up out of bed unassisted. Each week, with shaking arms and legs, a belt wrapped about his waist, two slight girls help him stand unsupported for a brief period, before he collapses back into bed, sweating, red-faced, and out of breath.

There's no alive like there was before. ARDS has scarred your lungs and given you a permanent lung disease. A stroke has left you with hemiparesis that you must now struggle to overcome. Those two heart attacks you sustained while under deep sedation and riding the ventilator have weakened your heart, and so even the rehab is more difficult than it was before. Perhaps you can no longer swallow, and so you can no longer eat. Perhaps you'll be coughing through and eating through a tube for the rest of your life.

They're thin, sometimes gaunt, now. Weak as kittens, losing weight in both fat and muscle mass. All sexy with the unkempt hair, the ass-exposing gown and the TED stockings. What once was a terrified young man is now a jaded old one, one who has been through hell and back and discovered that it's worse than dying.

So we get him home. Or close enough. He's ecstatic, gleeful, delirious with joy at the thought of eating something that didn't come out of a hospital cafeteria, at the idea of a change in scenery, at the possibility of sleeping in his own bed. It wasn't meant to be.

As sometimes happens, he turns on his heel 180 degrees, and starts to crump. Feet start to move faster. The bags under the family's eyes become a little more tattooed on. All the toolboxes come out, phones come off of the hook, and then finally --

STOP.

Freeze.

What?

"I don't want this anymore," he says to his daughter, an RN. "I've had enough. It's enough."

The maw of hell is agape, waiting, and the man who was so terrified to die is no longer afraid of death.

"He was a changed man," his daughter will tell me later, over a cigarette and drinks. "The man who went into the hospital was afraid to die. The man who died was not afraid of death."

He struggled, and struggled, and struggled. He improved marginally, and got stronger. He was nothing like his old self. His expectations were shattered. We're left with what reality can give us, and the reality is that flesh is weak, and has a finite limit. Six more months of hell?

We can save his life, and take away his chance at communication. We can prolong his life, but he won't be awake to remember or enjoy it. We can let his family watch him suffer, and try as hard as we can, in the face of overwhelming odds. We do it. Frequently. It's what we're asked to do.

But when someone who's had the tube out says they don't want it back in, because it's a fate worse than death? We could choke off his voice and leave him until he becomes fully paralyzed, until his organs fail him and it's impossible to keep him alive. But he knows, oh, how he knows what's in store for him. Moreso than his family does, or any of us do. He's done it all before. He doesn't want to live like that.

There are many diagnoses that are death sentences, waiting until the body fails, hoping you're coincidentally ready to die when your body's ready to let you. We can take that time we spend waiting to die to love our loved ones, to be joyful and happy, to tell our family that we love them.

I'm always a little sad when someone dies without getting to say goodbye. And when people say "I never should have", we always blow them off, as a 'but you did, and we're here, let's move forward.' We get so focused on today, and on what we can do today, what we can fix today, that it's easy to forget about the several months ahead. He will eventually get weak enough as to be unable to move or speak. His enjoyment came from eating and talking with his family. He can no longer swallow -- will we take away the one thing he has left?

Or will we tie his hands down as he pulls the ventilator off, thinking him confused? Will we sedate him into forced ventilation, assuming we know what's best, assuming this is how he wants to live? Locked-in, alone, in the husk that is his body? When we've given him a diagnosis that he knows is him waiting to die?

I believe in personal autonomy. I believe that when a person who's spent a year and a half in ICU says they want it to end, this isn't simple suicidality and mental illness, this is them saying they have had. Enough.

So we pull over the warm blanket of Dilaudid, and let the family pull up a chair. His family has discussed amongst themselves, in coalition with the doctor and the manager of ICU and everyone with his best interests at heart. Everyone agrees. This is not how he wanted to live his life. He wanted to go out and play hockey, he wanted his grandkids to climb up on his knee. He wants to be able to laugh, not just lay paralyzed while tears roll down his face.

And eventually, the decision gets made. To stop. Enough.

It's sad. I'd be lying if I said I'd never mourned anyone I've had a hand in killing. I've mourned them with colleagues, in back rooms debriefing, with their family members, over drinks and laughs. The surreality of it all. Going back to work and never thinking of ICU 5 or ICU 3 or 229.1 exactly the same ever again. Ethics is something that's easy to read about and hard to practice. It's easy to debate and discuss and consider possibility, it's easy to say, "Well, in this controlled situation, wherein I make up all of the hypothetical details..." It's much harder when you're intertwined, when you have to see his daughter the RN in ER for the rest of your tenure at this place.

I need to feel like what I did was right for them, then, that it was what they wanted, that I wasn't causing unnecessary and undue pain, that I wasn't inflicting cruel and unusual punishment. The things I do are so terrifying and painful that they've made grown Mounties cry, a man who's unintimidated by a bloody scrappy fistfight with an ex-con, who used to have one at work about as frequently as I have coffee. I have no illusions about my therapy feeling therapeutic. I know what I'm doing, and it hurts.

I need to feel like the hurting is worth it for them. I need to feel like I know what they want and I'm following their wishes. I don't want to read later in the notes "Patient states she does not want to be intubated. Patient intubated at 0630" because there'll be a lot of anger and oh dear, my blood pressure.

Most of the time it is worth it. But when is it not? That's a grey area the size of the arctic circle, a balance that can only be found in the moment, that is highly individual and situational and depends on having a firm grasp on all of the details. I will only do what I can. I can't take away the ALS, I can't replace a missing lung, I can't eradicate cancer and I can't fix a screwed up heart. I can't make an immune system respond. I can't force an organ to work, and I can't be Sisyphus pushing a rock up a hill only to watch it roll back down again.

I will do as much as I can until there's been Enough. And that's all I can do.

I made a 500 pound man cry by telling him he deserved to be treated like a person, and not to have his doctor call him a "beached whale."

A thousand times I’ve seen you standing,
gravity like a lunar landing,
make me want to run till I find you

I shut the world away from here,
drift to you, you’re all I hear,
everything we know fades to black

Half the time the world is ending; truth is I am done pretending,

I
never thought that I
had any more to give
you're pushing me so far,
here I am without you!
Drink
to all that we have lost
mistakes we have made,
everything will change
but love remains the same.

Find the place where we escape,
take you with me for a space
The city buzz, sounds just like a fridge
I walk the streets through seven bars
I had to find just where you are,
the faces seems to blur,
they’re all the same

Half the time the world is ending, truth is I am done pretending ...

I
never thought that I
had any more to give,
pushing me so far;
here I am without you!
Drink
to all that we have lost,
mistakes we have made,
everything will change,
but love remains the same.

So much more to say
so much to be done
don’t you trick me out,
we shall overcome
So all have stayed in place,
we should have had the sun,
could have been inside,
instead we’re over here...

Half the time the world is ending;
truth is I am done pretending,
too much time, too long defending,
you and I are done pretending!

I
never thought that I
had any more to give,
pushing me so far,
here I am without you,
drink to all that we have lost,
mistakes we have made,
everything will change,
everything will change!

I, oh I, I
wish this could last forever
I, oh I, I
As if we could last forever...

Butter Chicken / Murg Makhani

This dish can be made as spicy or as mild as you like, by adjusting the amount of chili added during the first step. It makes a tender chicken dish with an orange-coloured tomato gravy and is best served with something to mop up the gravy. I've served it over coconut basmati rice in this recipe; however, naan, pita, roti/chapati, daal (lentils) or plain rice would be just as acceptable.

Butter chicken varies in flavour from region to region and restaurant to restaurant and family to family. No two butter chicken recipes would taste the same and it's even fun to vary the spices a bit to suit your tastes.

Altering the recipe: I've called for whole spices if possible, which is the ideal situation. Ideally one would roast the whole spices and then grind them together as indicated. If you only have the ground spices, roast the spices you have whole, or, if none of them are whole, add them in the same step as you would add the turmeric. Marinating times are recommended, but I've also prepared it from scratch with little to no marination with delicious results; marination will simply intensify the flavours.

Instructions:

Mix:
1 kg (2 pounds) of chicken (I prefer diced boneless skinless chicken breast)
Juice of 1 lime (or 2-3 tbsp of commercial lime juice)
Salt to taste (I add about a teaspoon)
1 red chili pepper or 1 teaspoon red chili powder (adjust for desired heat)
in a large non-metallic bowl. (The lime juice will make a metal bowl transfer the metal flavour to the chicken.) Marinate for approximately an hour.

In a flat, dry pan, on medium heat, roast:
4-8 cloves (1/4 tsp ground)
1 tsp peppercorns (1/2 tsp ground)
a 1" stick of cinnamon (1/2 tsp ground)
2 bay leaves
10-20 cashew nuts (may omit if nut allergies)
seeds from the inside of 4 green cardamom pods (1/4 tsp ground)
1 tsp cardamom seeds (1/2 tsp ground)
2 tsp cumin seeds (1 tsp ground)
until fragrant and nuts are slightly toasted. Grind into a coarse powder with a mortar and pestle or a clean coffee grinder.

Mix the coarse spice powder, 1/2 teaspoon of turmeric, and 1 cup of fresh plain yogurt and mix with the marinating chicken. Allow to marinate for another hour.

Heat 3 tablespoons of cooking oil or ghee (clarified butter) in a deep pan on medium heat. (I use a wok because it's hard to stir a sauce in a large skillet without spilling. A stock pot also works.) When hot, add 2 small or 1 large onion, coarsely chopped. Fry until golden. Add 3 cloves of chopped garlic and 1 tbsp of ginger paste (or 1-2 teaspoons ground ginger.) Fry for about a minute.

Add only the chicken from your marinating mix and fry until the chicken is opaque and white, but not necessarily fully cooked.

Add one can (796 mL/28 oz) of crushed tomatoes and the rest of the yogurt marinade. Simmer until the chicken is tender and the tomato sauce has reduced somewhat in volume.

Garnish with cilantro leaves.



Indian Coconut Rice

My favourite way to make this is to throw everything in a rice cooker and forget about it. If you have that luxury, I highly suggest it. It's another recipe that can be prepared 1000 ways with any variation in the combination of ingredients. This is how I made it:

Heat 2 tablespoons of oil or ghee in a pan. Fry 1 onion, finely chopped in a large pan, until soft. Add:
1/4 tsp ground cinnamon
1/4 tsp ground cardamom
1 tsp salt
and stir.

Add 2 cups of basmati rice to the pan and stir fry until rice is coated and beginning to toast, about 2 minutes. Add 2 cans of coconut milk and 1/4 cup of water. (Throw this all in the rice cooker!)

If you have no rice cooker:
Heat and stir until boiling. Reduce heat to medium-low and cover the pot with a tight-fitting lid. Simmer for about 20 minutes, without lifting the pot lid, until liquid is absorbed and the rice is tender. Once liquid is absorbed, remove the pot from the burner, again, keeping the lid on, and leave it rest for about ten minutes. Fluff with a fork.

He and I.

He is quiet, preferring to keep his anger close, his sadness closer. He is in control. He is boisterous only when he is happy, which is most of the time.

I am loud. I am bossy and opinionated. Passionate, some say, and I guess it's the truth. I care too much, but I don't mind it one bit. My anger is biting. My sadness is the only thing I bottle up and hide.

I uncork it sometimes, for him. He knows me like no other human being can. He knows things I've told nobody else. He knows things I'd barely ever admit to myself.

I'm honest with him about what's happened to me. It's then that I see him truly angry. He laughs at work and jokes and has fun with all that emotional heaviness. He's mildly irritated, but he's under control. It's when I tell him what they've done to me, that I see his anger. It's subtle, and if you didn't know him like I do, you'd miss it in action. The tightness in his jaw. The way he thins his lips. His hands clench and unclench, trying to work out some impossible kink. I hear it in the determination in his voice, in the way he says things as if they're inalienable truths: "That will never. Happen. Again."

It's the first time I've felt this connected to another human being. I'd never felt this before I loved him. I'd never felt as if my pain could physically pain someone else, as if my happiness alone would make him happy. I've never felt before as if simply being comfortable together is enough; that I don't need to constantly be of service, don't need to constantly perform, don't need to constantly meet-or-exceed-expectations. I want to give him everything that I can offer and all he really wants is myself.

But I hate myself. And so it is difficult to give him this thing which he loves and adores and cherishes more than anything in his entire life. I don't understand how I can be enough. I don't grok how it is that simply being myself is the reason he loves me. I can't fathom how 'what do you see in me' can be answered with "I don't know, you're just You." How am I supposed to exceed that expectation? How am I supposed to put on that performance? When it isn't a performance he wants, or an expectation that he has? How do I be myself when I am so uncomfortable in my own skin that I'd rather sleep, disconnect, withdraw, anaesthetize, hide, shrink, disappear or die?

I can't fake that. I can't pretend. I can't put on a show or deflect the attention. Pressing him for details about what behaviour exactly it is that he approves of, so that I can further model this for him, is replied to with a shrug. It frustrates me endlessly, here I am, offering to dance for him, wanting to do everything to please him, to impress him, to prove myself, and he won't tell me to dance.

He wants me and that's the thing I am most loath to give him, out of everything else in the world, because it is the only gift that I truly feel is deeply and pathetically unworthy.

And to him it's the most valuable gem in the world.

How to reconcile this? Prescription antidepressants cannot make one like oneself, they only make it possible to live with yourself on a day to day basis. How to unravel the tapestry of my deep-seated sense of unworthiness? How to pull at that thread saying that I'm not and never will be good enough, until it falls in a tangled mess at my feet and I can finally kick it away from me and be free of its constriction forever?

To him, I am more than worthy. To him, I am more than enough. It makes it all the more painful, to see the gulf between what he sees and how I feel, and to know, deeply and truly, that the yawning chasm in between is filled with darkness and all that is truly wrong?

And for the first time, learning to quiet the words I learned as a child, to ignore that sense that I should simply "stop feeling sorry for [myself]" and stifle the crying, hold in the sobs, and let the tears flow down my cheeks as the only expression of my suffering that I cannot hold inside. I did it at my brother's funeral, for Christ's sake, and my grandfather's funeral before that. No! That has to stop! My pain is real and pretending it is as insignificant and worthless as I believe myself to be will only end in more pain! Better to finally hold my suffering in my hand, to tell myself that I care that I'm in pain, that it's okay to cry and be anguished, instead of deriding myself for ever being so pathetic as to have feelings in the first place.

It is only when I accept that I'm allowed to be human that I will be able to love the human that I am as my love loves me: as a whole thing, not some collection of accomplishments and achievements, not some kind of walking résumé with a checklist of confirmations-that-I-am-acceptable.

He wants only the very, very best for me. How do I learn to want this thing for myself? He believes in me in ways that all self-deprecation aside, I truly do not deserve. His love for me is a lightning-rod for how this is abnormal: this me-on-a-pedestal that he's loved ever since we were skinny teenagers is truly the me he loves. He has never loved this paper-doll of pretend and pedantry. He loves the me that I can't stand to be.

I have found a thousand ways in the past to stifle this. Too emo, too begging of other peoples' sympathy, too much feeling sorry for myself, too pathetic, too a thousand things. I've got to stop folding parts of myself up and tucking them away in envelopes, thinking I can keep them hidden forever. It all bubbles to the surface in the end, or my attempts to keep it from doing so end up being so unsustainably self-destructive that not only will they end in my destruction, but the destruction of this thing most precious to me: my relationship with this man who I will soon marry.

That... that is unacceptable to me. So honesty it is. I cannot lie to myself any longer and pretend that I'm such a significant drama queen that nobody will be able to ever stand hearing of the many ways in which I've been wronged by the universe. Fact is, writing is therapy: and if I can't express who I am in the very journal that contains so many other pieces of who I am, then why bother writing in it in the first place? To change what I'd say on the basis of some kind of expectation of performance on behalf of my readers would be the exact kind of interpersonal dishonesty that is cramping my relationship with the one I love. I'm not some trained monkey who dances for the approval of others. I'm a whole person, with wants and needs, pain and fears, as unique and valuable as anyone else.

I just don't know it yet.

Sometimes at work, I'm rather selfish. Or at least, this is how I rationalize it, since it's hard to explain it any other way.

I could describe this patient a hundred times, and it would be at once a different person, and the same person. It's a situation I'm describing moreso than a person, what I am discovering is an archetype in health care: That Patient That Wants Everything.

A lot of the time, there's a point to doing everything possible. A lot of the time we catch someone in the middle of a bodily crisis, and we do everything we can to reverse this crisis, we intervene very aggressively and, for lack of a less dramatic term, we save their life.

Other times, however, the crisis itself is long past. Sometimes, there's no reversing the crisis. Sometimes, the situation is futile, and no amount of medical intervention will change that. Sometimes the only thing we can really do, medically, is relieve pain, and postpone the inevitable.

Some people want the inevitable postponed indefinitely, and this is when I get selfish. My coworkers appeal to my sense of grey in that spectrum of black-and-white, saying, "It's emotional. Those decisions don't get made based on logic. They have no concept of the kind of pain involved."

But it's exactly that pain that I'm fixated on. A man with a heart the size of a baseball glove, with lungs riddled with cancer tumors, receiving as much oxygen as I can give him non-invasively and still hypoxic, tells me he is short of breath. I know we can relieve this shortness of breath with opiates, using the euphoria of Mother Morphine to carry him away into his last goodbye. I've seen it done many, many times now. It's peaceful, looks comfortable from an objective standpoint, and to me, it feels humane.

But he doesn't want that. He wants everything. He's a "palliative" patient in that he wants relief of his suffering, in that he knows that there is no cure, but he's also a full code. "So he wants us to palliate him softly into the night, and then when his big floppy heart finally decides it's had enough, I'm supposed to stuff tubes in every orifice I can find, break his ribs, infuse him with enough adrenaline to wake the dead, and breathe for him with a ventilator? Until when, exactly? Until his heart finally dies?"

"Yes," she says, and proceeds to explain to me what this will mean for his family, for him emotionally, to know that we're not just simply going to let him die. She relates a story from when she worked for an oxygen vendor, where she regularly recommended the book Every Breath I Take to patients and their families. Then she would receive both ends of the extreme as to reactions: the end-stagers who get to the section on death and dying, and lament at their husbands, "Don't you let them do that to me!" And the other extreme, the family who would tear a big, meaty strip off of her: "Who do you think you are? How dare you?"

Why do I want these people to die? I don't so much want them to die. More, I hate watching them struggle to not die. I hate struggling to keep them alive, painfully, with much blood and vomit and broken bones, knowing full well that all the Levophed in the world won't make their cancer go away. I hate walking out of a room after a 'successful' resuscitation, covered in sweat and filled with frustration, knowing that it is now my responsibility to keep this person alive on the ventilator for another couple of weeks until some stroke of macabre luck ends his life just as swiftly as it began.

I won't change them, and my frustration and passion and wailing behind closed doors about "what do they expect?!" won't affect the outcome, for better or worse. Really, everyone else standing around me is thinking the same thing: we are all hoping in our heart of hearts that this time, just this once, the adrenaline and shocking and CPR doesn't work.

And that's why I say I'm selfish. Because I'm not thinking about the patient's fear of death, of their mental status worrying that they're being left to die, of the very pregnant silence that exists alone in a room where you've been put to die, knowing full well that you're simply waiting for it to happen, that you won't see the outside again until they wheel you from the morgue to the funeral home minivan.

Instead, I'm thinking of my sweat and sore muscles, my frustration at being backed between a rock and a hard place with regards to the ventilator, my exasperation at being forced to watch someone die slowly and painfully, rather than comfortably and peacefully. I could go on and on about how I'm thinking of what's best for the patient, how I'd rather they be comfortable and pain free, and it would be true. But if that isn't what the patient wants, then it's my own selfishness that makes me want it to be humane, that makes me hope I get backed into the impossible corner sooner rather than later, that makes me wish that at some point, their body would just give up already and take the ability to take action out of my hands.

Sometimes, I would rather be powerless. I would rather have no choices. I would rather we could be cold and distant, saying "there is nothing more we can do," for my own comfort. But it is wrong to take those choices away from people when it is their very own lives at stake. And so my comfort goes by the wayside, and I put on my serene face, and I hug, and I touch gently, when I'm not drawing blood or leaning on epiglottis or causing ventilator-induced lung injury.

I comfort them, but I wonder if it's really them I'm comforting, or myself.

Idiot Pundit: "[Americans] have the best health care system in the world. Most Americans live within an hour's drive of a world-class medical facility filled with expertly trained individuals and state-of-the-art technology delivering medical miracles every day."

Actual Doctor: "You hear that? You're within an hour of being able to look at a building where you could get health care if you're lucky enough to afford it."

A building in which, he also points out, you are not likely to get the best care, but rather the most expensive, not because it results in a better outcome (in fact it quite often doesn't) but because it means the person doing the procedure will be paid 10x more.

I personally would rather my life-altering medical interventions were tied to things like actual need and likelihood of a good outcome. Complain all you want about "rationing" in Canada: if they save me a surgery due to watchful waiting because it's cheaper on the system, that's still a surgery I didn't have to recover from. My body remains intact, my health preserved from surgical complications. I don't see a problem with that.

Moko: "I'm gonna call that one the Titanic, because it broke in half and sank to the bottom."

Me: Oop, I'm prairie dogging. When are you stopping next?
Moko: Depends. Are you prairie dogging or turtle heading?
Me: What's the difference?
Moko: Prairie dogging is fast; turtle heading is slow.
Me: Turtle heading. Who has these conversations?!
Moko: Married people.

Posted via LiveJournal.app.

Saved the recording industry in the early 80s. Helped pull the US out of a deep recession. Broke barriers and taboos, including using his might as a recording artist to force MTV to show black artists.

For more articles by Alan Cross (one of my own personal Canadian heroes) feel free to add his syndicated account to your LJ friends list.

I remember reading Reading Lolita in Tehran and marvelling at how a real revolution happened, and this was the first I'd really heard of it.

Now, all I can think about is the Conservatives earlier this year who called a potential coalition government a "coup d'état" and how wrong they were. What is happening in Iran right now is a coup. To call a legally-defined procedure within Canadian law the same thing is to minimize its impact.

This is the first time an American president did not interfere with Iran's situation -- and it's a good thing. In the past, U.S. support for the protestors led the Iranian government to punish the people more, accusing them of being spies for or taking money from the U.S.

But I think Obama must hear the message of the protests: Ahmadinejad's government is a lie.

Indeed, being unable to step in and police the middle east is an interesting turn of events. I'm not so naïve as to believe that this is not at least partly circumstantial, but it's a bit of an experiment, as well. The Iranian people have seized their power. To meddle with this very powerful thing could be catastrophic.

Facebook pictures shared of smashed windowfronts and damage to cars from police grenades. It gives me the chills to think this is happening right now and the best coverage I can get of what's going on is on Fark.

flour tortillas

corn and tomato salsa

spicy fried catfish


salsa:
1 can (~300mL) diced tomatoes
1 can (~200mL) no-salt added whole corn
1 whole avocado, diced
1/2 red and 1/2 green pepper, diced
1/4 - 1/2 red onion (to taste) finely chopped
1 T or 1 whole jalapeno pepper, with/without seeds to taste for heat
1 T lime juice
1 T sambal oelek or 1 t cayenne pepper (for extra heat, optional)
1/2 cup chopped cilantro leaves, loosely packed

Chop above ingredients, mix, let stand for 1 hour.

spicy fried catfish:
2 fillets white fish (tilapia, basa, catfish, etc)
ancho chili pepper
salt (to taste)

Pat dry fish. Salt and dust with ancho chili pepper. Pan-fry on both sides until it flakes easily with a fork and is opaque throughout.

Assemble with cheese in flour tortillas while fish is still hot.

( lj-cut for a gnarly arm fracture, no clicky if queasy )

Intubated 13 year old with a BAC of 536.

Yay for long weekends?

There's entirely too much panic going on around here. I'm going to set things a smidge straight.

Cred: 1) I work with people with breathing problems for a living. 2) I run a high likelihood of being exposed to this pathogen at work and this is the upper-echelons-of-everywhere's recommendations for how I can avoid getting sick from being exposed at work. 3) All this information is verifiable, though I won't be citing in-line. Some of it is from notes I took from news releases passed around at work and thusly may not be in the public domain in print verbatim, however, is all based in verifiable fact.

My plan: to spread my strategy for staying safe, so that you can too.

Step one: Arm yourself with knowledge. The best knowledge we have right now comes from the Center for Disease Control's website, at CDC.Gov. That link is their most currently-updated list of recommendations for everyone involved. All of the knowledge I'm posting is subject to change if the CDC happens to have, say, a scientific breakthrough or something. If you want facts without panic or hype, this is your website.

Step two: could arguably be step one, according to most infection control experts. There is NO SUBSTITUTE in infection control practice for CLEANING YOUR HANDS to avoid spreading diseases or becoming ill. Alcohol-based hand-sanitizer with at least 70% alcohol is as effective as hand-washing, if not more-effective due to the lack of opportunities to re-contaminate your hands that hand-washing presents (towel, towel dispenser, doorknob, etc.) With alcohol hand sanitizer, as soon as your hands are dry, they are clean. If you are preparing food, be sure to rinse off any residues the sanitizer leaves behind with potable water.

Step three: Be polite about your cough. Influenza is a respiratory illness, which, by the WHO's definition, means a cough. Don't cough into your hands! Your hands touch everything around you. Influenza viruses can contaminate surfaces through contaminated hands, presenting a handy batch of germs to pick up and infect yourself with later. Cough into your shoulder/armpit/upper arm/elbow region, a region that will still keep you from spreading your droplets all over hither and yon, but which will not touch so many surfaces as your dirty mitts.

Step four: Are you sick? Do you have flu-like symptoms? What are flu-like symptoms, you ask? The criteria the World Health Organization is recommending our triage desks use to rapidly identify people who are considered to have "influenza-like illness" are the following: 1) a fever 2) a cough 3) and one of the following: aches/pains, lethargy, or shortness of breath. If you have shortness of breath, you are considered significantly ill and should be evaluated by a health professional.

If you are experiencing the symptoms above, the CDC is asking people to self-isolate by staying home, not going to work and not exposing yourself to other people, except for medical care. You will likely be contagious for a day before and up to seven days after you became sick. People are being asked to isolate themselves in this way for seven days, or 24 hours after their symptoms have disappeared, whichever is longer. Take your doctor's advice about your child, as they may potentially be contagious for longer.

If you must go out into the community while ill, it is recommended that you wear a mask or cover your face with a tissue to catch any droplets you may accidentally mist into your environment. Droplets are not airborne, they are heavier and so only tend to travel ~1m (~3 feet) in room air before settling to the ground due to gravity. As such, the CDC is not recommending the use of high-efficiency filters except during special medical procedures that are likely to generate the very fine particles which float in the air for long periods of time. This is when that alcohol-based hand-sanitizer comes in handy, so you can clean your hands after you cough while you are out and touching everybody else's environment with your germy paws.

There's specific protocols for who gets antiviral medication, because of the likelihood of developing resistance as well as of depleting stockpiles before there's a major outbreak with some critically ill people who may die without it. As a result, if you go to the doctor and your doctor won't give you any Tamiflu, please do not threaten anything particularly stupid, as this will only get you quarantined in your local police station's cells for the night.

Step five: If you are seriously ill, especially if you are short of breath, go see your doctor. Take precautions like wearing a surgical mask to avoid contaminating the doctor's office or the doctor, but get seen anyway. If you need medication it can be prescribed at this time, with some stern advice on the appropriate use of antimicrobial therapy. (I'll shorten it for you: TAKE EXACTLY AS DIRECTED. FINISH THE WHOLE COURSE OF ANTIVIRALS.)

If you have to take care of an ill person and are healthy yourself, follow the CDC's instructions. Avoid large crowds of people clustered in spaces less than a meter apart, and respect school and daycare closures. Avoid touching your eyes, mouth and nose, since how did you think your fingers got covered in germs in the first place? And if you're extra paranoid and want to build a flu bunker as a fun zombie-hunting exercise, they've even prepped you a handy list of starter items.

You'll notice there's not been a mention of Mexico yet. That's because swine flu is indistinguishable from the regular flu, and so means that aside from the Mexico component, you still have a viral respiratory illness that is particularly contagious and not easily treated with anything besides rest and fluids. If we get people all focused on looking for the Mexico link, they stop thinking about the cough-germy-hands-microwave keypad-lunch table-telephone-keyboard-clean hands-mouth-lungs link. Fever? Yes? Cough? Yes? Otherwise not feeling so hot in the aforementioned (achy runny nose sore throat nausea vomiting diarrhea lack of appetite really tired can't breathe) sort of ways? Act like you have something you wouldn't want to give to anybody you care about.

You health care dudes have it backwards: you have to treat those people like they've got something you DO NOT WANT. Those of you in the medical profession should contact your local OH&S office for specific instructions on the policy in your area. Be the most informed. Ask the pertinent questions. And be draconian about making everyone with a cough+fever+not feeling so hot wear a surgical mask or somesuch until they can have a rapid sputum test for influenza A and are determined to be negative.

If you medical peeps out there are involved in any of the following activities, the rules change slightly: suctioning, intubation, resuscitation, bronchoscopy, or patients who are unable to wear a mask (like trach patients.) These are all associated with the generation of aerosolized particles which are small enough (~4μm) to float suspended in the air and which are not effectively filtered by gross barrier filters like surgical masks and handkerchiefs. These particles require the use of a high efficiency NIOSH rated N95 mask which has been FIT TESTED and which fits to your face. Follow their guidelines on when to have your mask re-fit-tested (gain/lose 15 pounds, greater than two years, pregnancy, etc) and use them religiously if you feel it's warranted. They can't be re-used, that's their only downside -- you use it once, you take it off, you throw it out. In putting that mask back on, if that mask is contaminated, you WILL contaminate your nose and mouth with pathogens.

Not only do you have to wear your N95 mask, you have to wear eye protection, gloves, and a gown to cover your clothes. Paramedical types? Feel free to do a mask, scoop'n dash, rather than being the Big Hero who got the tube in on the scene (and all his coworkers sick.)

Questions? Type away. As for me, I've got to go suction a trach.

Moko: I would penis her bum, if you know what I mean.

2:30 AM: call. From the pediatrician. "Hi, I need your assistance. And a vent." Okay. I'm on my way. 8 months old, crappy gases. Apparently has other chronic problems of a congenital nature. Was intubated a month ago for the same thing. This seems routine.
3:00 AM: ask Mum to let go of her pink and warm 8 month old so we can put the tube thing in and get ready for the peds team to come take her south. Kid has obviously gross sounding chest and snotty nose but wiggles and looks around.
3:30 AM: drugs in, tube in, CO2 detector doesn't change colour, chest doesn't rise, but the tube is audibly for sure without-a-doubt in. Sats are 2. Heart rate is 65. We extubate and bag by mask.
3:45 AM: The best sat we get is in the 60s. We need to get a tube in and vent the kid with higher pressures: as it stands his nasogastric tube is draining all over the bed because of the bag-mask ventilation. I have a hand cramp from bagging at a rate of 70 with high pressures through a mask.
4:00 AM: We call a code. A smaller tube is in: we couldn't get the same size in, I'm going to blame it on laryngeal edema. Pediatrician is literally throwing his hands up in the air. We are shooting in Ventolin every route we can possibly think of. We take another chest x-ray. The lungs are an opaque mass of gelatinous pulmonary edema and pneumonia. This is a complete 180 from an hour ago, the last chest x-ray standing in stark contrast. There was air in there once. Not anymore.
4:30 AM: We let mom back in to hug her pale, waxy, ashen baby girl. I feel like a dick because I have to move her aside to get my Winnebago of a ventilator out of the room so she can be left alone. Pediatrician assures me the kid was a ticking time bomb: according to the Peds ICU South where she was going, they've had this happen a few times in the last few months and they aren't surprised.

I have never seen things turn around that fast in an adult. Not without there being some big arm-waving obvious cause, like a tension pneumothorax. I'm glad I don't work in PICU.

A five-pound swing in the wrong direction (ah, Christmas and your chocolate deliciosity) and it's post-christmas eat-properly time. Note I am not calling it a diet: just two straight weeks of not eating a vegetable without it involving cream soup or cheese sauce has taken its toll. Not having time to grocery shop and being forced to eat whatever is edible out of the work cafeteria has its down side.

The plan:
play wii fit at least four times a week, ideally daily, for 30 points
take the stairs at work (I cover a lot of mileage across six floors, this should get interesting)
every meal must have at least two (you heard me!) servings of fruits/veggies
we will continue the breakfast-oatmeal-and-an-apple routine, and expand this to include "while I'm not at work"
make lunches the night before, thusly eliminating the need to go "OH SHIT I have to buy something from the cafeteria"
stay out of moko's coca-cola stash as nothing makes a fatass faster than 100 empty calories per cup; drink juice, preferably unsweetened, preferably watered down
when bringing salads for lunch, making sure to include enough protein that I am not starved a couple of hours afterwards, and bringing healthy snax (like carrots/sugar snap peas/bananas/apples) so that I am not tempted to eat the ubiquitous junkfood off of the breakroom table

tonight's supper
butter lettuce salad with green onions, cilantro, and sprouts (3 servings of veg)
1/2 serving of cheese sprinkled on top of salad for protein
2 tbsp tangerine lime vinaigrette

2 legs of leftover butter chicken made with organic low-fat yogurt instead of cream

for work tomorrow
ziploc of veggies for snax
imitation crab wrap
- 1/2 serving of cheese
- 1 serving of lettuce
- 1/2 serving salsa
- 1/2 serving sprouts
- 1 serving of crab
- 1/2 serving of low fat sour cream

Secondary goal: in keeping with my family's history of kidney failure and my own signs of kidney damage on laboratory exams, all efforts will be made to keep sodium intake to less than 1500mg a day.

2 avocados
2 tablespoons of medium salsa
1 teaspoon each garlic, minced jalapenos and sambal oelek*
1 tablespoon of lime juice

mash like you mean it
adjust to taste

* I buy these pre-done in jars. I prefer the chunky sambal oelek to the squirt-style.

wrin's regular guacamole
1 diced tomato, seeds removed
2 avocados
1 crushed garlic clove
2 teaspoons sambal oelek (or more if you like it spicy)
1 tablespoon lime juice
dash o' season salt
2 minced green onions
finely chopped fresh cilantro leaves (optional)

mash it like potatoes
adjust to taste

store in the fridge in an airtight container, preferably jar-ish; cover surface of guacamole with saran wrap and leave no air spaces, close lid tightly. this should hopefully keep it from browning too terribly much though its deliciosity will remain unaltered.

for extra delicious, sprinkle tex-mex cheese on top.

made it too spicy? stir in a tablespoon of sour cream.

eat it. all.

get made fun of for stinky breath.

I intubated a lady at a code today using an anaesthetist's dirty trick.

It was totally the opposite of how everyone is first taught to intubate. It's so not a beginner trick. And I had trouble with the styletted tube, and instead of stab-stab-stabbying the stiff end of the stiff tube against her larynx, I hauled out the stylet and went at it anaesthesia style, with no stylet, using the patient's upper airway anatomy to manipulate where the tube ended up getting pointed.

It wasn't as if this was the operating room and I have like 45 seconds to intubate somebody who's flaccid, with 4 assistants and uninterrupted silence. It was a code in a part of the hospital that has never had a code, and she was gagging on the tube while getting chest compressions.

I feel like doing an end-zone dance around the apartment.