ICU Nurse, Blogger
August 3, 2015 7:38 PM   Subscribe

An ICU nurse with a way for words details her shift reports elise the great is a Something Awful poster (in the hidden Goon Doctor section) who has a long history of frank and well-written posts detailing her shifts at work in a busy ICU. After a long period of trying to convince her to write a book, and a subforum experiment involving diary-style entries, she has agreed to a blog.

Most beloved is this description of diabetes: A colleague of mine related the tale of a pt, a young man with Type 1 diabetes, who went into diabetic ketoacidosis (DKA) and didn't get appropriate treatment. After a walk-in clinic failed to diagnose his impending health crisis, he went home and chugged sugar syrup-- the drink mix that's poured into soda machines, where it's diluted with carbonated water for serving-- until he lost consciousness. The next day he was delivered by ambulance to the hospital, where he died horribly.

So what the hell, you're thinking. If you know you have diabetes, why would you pound syrup like cheap beer? No, he wasn't just some stupid fuck who wanted a Darwin award. There's a genuine reason for this... it’s pathophysiology time, motherfuckers. (That will be the title of my children’s network show someday.)

We kinda tend to think of insulin and sugar as polar opposites. Too much insulin and your sugar goes away and your brain tissues starve; too little insulin and your blood sugar goes up and, uh, this is bad. Somehow.

That’s really just part of the picture. Yes, the syrupy-thick blood is super bad. Sugar is corrosive to the blood vessels (just ask any nurse who’s pushed dextrose 50% into an IV and watched the vein blow) and over time even moderately high blood sugars rip and scar your arteries and veins. This is incredibly bad for things like your legs, which are the farthest from your heart and have a hard time getting blood back and forth to begin with. A few years of sticky scratchy sugar blood, and the nerves die from poor circulation, wounds stop healing because no blood is getting to them, and eventually your legs just rot off. The syrupy-sweet blood is just fudge sauce on the leg-flesh sundae that bacteria love to eat. This is why diabetics lose their legs. (The nerve damage is why diabetics go blind.)

Your kidneys, likewise, are almost entirely made of blood vessels. Too much sugar gouging out your kidneys = scarred up kidney circuits that are too damaged to let the water through. Bonus: when your blood sugar is insanely high, your kidneys can try to compensate by squeezing sugar directly out through your blood filters, which lets you piss away the dangerously gooey stuff… but rips holes in your filters, essentially. This is why diabetics have kidney failure and end up on dialysis.

On top of all that, your heart and brain blood vessels get shredded to boot, which is why diabetics have so many strokes and heart attacks. Diabetes is bad shit.

But there’s something even more dangerous than just having your blood turn into razor soup. Thick, dense blood is like a sponge, sucking water out of your tissues (read: organs and muscles). When your body enters a diabetic crisis, you become so thirsty you can’t fucking stand it. Undiagnosed diabetics are often spotted because they pack a couple gallon jugs of water to bed with them when they sleep at night. And as soon as their blood thins out a little, their kidneys dump all that new water in an attempt to flush out the sugar, further ripping themselves to shreds… which is why undiagnosed diabetics are also often spotted because they pee themselves in public or spend 2/3 of their day pissing away the gallons of water they’re chugging.

Soda-fountain guy was thirsty as fuck, and all his body’s instincts were telling him to slam a bunch of liquid. But why the fuck choose soda syrup? What the hell?

To answer that one, let’s get back to what insulin does. It doesn’t magically make sugar go away; your cells have their mouths locked shut to keep them from eating every damn thing that goes by, and insulin is the key that unlocks them. If your body doesn’t make insulin (because it destroyed all its own insulin cells), fuckin blows to be you, because your cells will starve surrounded by delicious food. If your body is fat as hell and all that fat is secreting endocrine shit to inform your body that you have enough fucking food to last you a month, your cells become insulin-resistant and it takes a lot more insulin to open those locks. (This part is the least-understood part of the whole fat ---> diabetes cascade, but while we don’t know exactly how it happens, we do know that excess fat leads almost inevitably to insulin resistance, and the ‘almost’ is generous.)

So now your cells can’t eat. Your blood is getting thicker because the onslaught of sugar isn’t slowing, but your cells are starving to death, being ripped apart by sludgy sugar sauce, and having all the water sucked out of them by your spongey thick blood. Insulin also allows your cells to eat the potassium they need to keep their internal pumps running, so now your potassium is backing up, causing your blood to become acidic, and making all your cell’s pumps run backward. In desperation, your cells start burning protein, which is a really poor energy source because it’s actually the cell’s furniture and tools. At this point, shit inside your cells is so bad that instead of putting food on the table, they’re chewing on the table legs in case the varnish is edible.

This is why that poor motherfucker was drinking sugar syrup. He was literally starving to death.

Many diabetics think they have low blood sugar right up until they realize their blood sugar is actually high—their cells just can’t eat any of it.

Broken-down proteins and fats produce ketones. Starving cells produce lactic acid. Between those two and all the extra potassium, your blood turns to acid in your veins. Over time, your kidneys might have been able to slowly compensate for that by secreting bicarbonate, but right now they’re busy squeezing sugar and potassium out through their battered assholes. The only other way your body can try to fix the whole ‘acid blood’ problem is by blowing off as much carbon dioxide as possible, since carbon dioxide is acidic when dissolved in blood. Soon you’re sobbing for air like you’ve been running a marathon (another situation in which stressed-out and starving cells dump tons of lactic acid), your body is so dehydrated you’re losing your mind and your organs are failing, your cells are so hungry they’re literally eating themselves, and so much potassium is backed up in your blood that your heart’s muscle-pumps get overwhelmed by the back-pressure and your heart just… stops.

If you're lucky. Massive organ failure due to combined starvation and shredding is your other, slower option.

DKA is a horrible way to die.
posted by the uncomplicated soups of my childhood (109 comments total) 173 users marked this as a favorite
Not so hidden. She's been amazing on the health care stories thread according, erm, goon...errrrr....friend.
posted by Samizdata at 7:45 PM on August 3, 2015 [4 favorites]

I need a drink after that. Great writing, but... damn. Here's to Elise for doing something that would destroy me.
posted by OnTheLastCastle at 7:46 PM on August 3, 2015 [6 favorites]

Yeah elise the great is great indeed. My wife's an ICU nurse and I'm exposed to critical care. I love reading how elise the great turns a patient assignment into a goddam text based adventure. Really the "health care stories: inanimate objects in people's asses" thread is great in general.
posted by Sternmeyer at 8:00 PM on August 3, 2015

Unless you don't like Figure 1 I guess.
posted by Sternmeyer at 8:01 PM on August 3, 2015 [1 favorite]

Mod note: One comment deleted. If you want to talk to the mods, use the contact form, don't drag policy questions or protests into threads on the blue.
posted by LobsterMitten (staff) at 8:02 PM on August 3, 2015

Ain't no need to be ashamed of being a Goon. The forums there have a culture surprisingly similar to the one here.
posted by echo target at 8:35 PM on August 3, 2015 [5 favorites]

I should probably stop reading after that succinct and horrifying description of DKA, but...

By the way, DNR tattoos don’t count.

Well, that's good to know--

his scrotum had inflated to the size of a basketball

--and then there's why I will never, ever be a clinician.
posted by Halloween Jack at 8:37 PM on August 3, 2015

His girlfriend met me in the hallway a little later. I won’t tire you with the entire conversation—it was very long and wandering and difficult to listen to—but the gist of it seemed to be that she wanted to stay in the methadone program and get clean. If she stayed with him, she said, he would never let her get clean; but if she left him, who would take care of him?

“I think you’re right,” I said. “He’s gotta find his own rock bottom, and hope that it isn’t a grave. If you want to get better, you’re definitely going to have to get away from him, and you’re going to need some professional support while you’re remodeling your life.”

“But what if he dies?”

“Then he dies, chickadee. Maybe you won’t die too. When you’re drowning, you gotta kick off your shoes.”
I think I have a new heroine.
posted by Halloween Jack at 8:43 PM on August 3, 2015 [38 favorites]

Elise is a treasure.
posted by subbes at 8:47 PM on August 3, 2015 [2 favorites]

The entry following the excerpted diabetes horror is well worth a listen as well, to cement the moral of "don't fuck with diabetes" even further. This is wonderful(ly horrible).
posted by Drastic at 9:23 PM on August 3, 2015 [1 favorite]

This nurse is amazing
posted by feckless fecal fear mongering at 9:27 PM on August 3, 2015 [1 favorite]

I just can't even imagine doing her job. Or any clinicians job for that matter. Because after reading her, all I can think is that Humans...just ew filled goo bags of yuck. There go an entire breed of people who really are heroes all the damn time, nurses. Bless them for doing it, because I never could in a million years.
posted by dejah420 at 9:36 PM on August 3, 2015 [5 favorites]

(I could never watch Robin Williams comedy. He just looked so sad all the time. He looked like he was joking so he wouldn’t cry, or like he was trying to make someone laugh to keep them from swinging at him.)

posted by feckless fecal fear mongering at 9:38 PM on August 3, 2015 [11 favorites]

Hard to read. I've been lucky to work with amazing nursing teams, I forget sometimes how shitty nurses can be to one another. I can't imagine one of my coworkers behaving like the nurse Elise had to hand over to in this entry:

I also wouldn't have to deal with an femoral arterial sheath as a rule, that shit is so old school I can't believe they still routinely do that in cath labs in the states. Certainly wouldn't be in trouble if it didn't get pulled on time.

The bit where her sister is crying over a death and then someone comes and tells her to clean up pooh rings true. We always have to back-bench whatever is going on with our lives to take care of someone else. Only for 12 hours but it's hard sometimes.
posted by supercrayon at 9:42 PM on August 3, 2015

Goodness gracious this is top to bottom incredible. Thank you for the post, thank you for sharing what is an instant bookmark for me.

This is a tremendous example of Studs Terkel v2.0: let the richness, the humanity of anecdata have a voice amidst the flood of sanitized statistics or broad nebulous 'trends'.

Metafilter has no shortage of gender-related posts. I regard this manner of post as having a primary importance amongst those discussions: nursing, historically, is an occupation filled by women. Elise brings it with all manner of savvy: she takes care of those patients on a day-to-day basis, she interfaces/accommodates family members visiting a patient (or, pt), she understands the broad themes of medicals diagnoses and can boil them down to laymen's terms. (I learned more than a little modern medicine reading three of her blog posts)

I fully acknowledge that I'm going to build a strawman of a doctor, but: the (traditionally male) doctor has but 15 precious minutes to devote to a patient, offers an assessment-from-on-high with a slightly detached communication style, and quickly delegates his Very Serious recommendations. He's gone.

I feel the doctor/nurse split is in many ways archaic and needlessly gendered. Let's elevate nurses for focusing on the demanding people-first work while understanding the big picture of medical diagnoses and the like; let's reframe the value of a doctor from that of "I see your symptoms, I can write your diagnosis" to instead "I can assess you an as individual".

I'm sure there are progressive doctors who communicate very well with patients, who operate with a more collaborative approach to medicine. I would welcome profiles of them, or windows into their approach to their professional lives. But, towards the goal of elevating nurses, I'm happy to pass Elise the conch.
posted by Theophrastus Johnson at 10:00 PM on August 3, 2015 [13 favorites]

Hmm, I had an ultra stressful day and was being a bad Type II by having a minor chocolate binge.

I think I'll go throw the rest in the trash now.
posted by Tell Me No Lies at 10:12 PM on August 3, 2015 [8 favorites]

Joslin should hand this out instead of doing the spiel where you're encourage to switch to smaller french fry orders for your snacks.
posted by michaelh at 10:27 PM on August 3, 2015

Omg. This is absolutely fascinating. I'll be binge reading all of these now. Thanks!
posted by astapasta24 at 10:31 PM on August 3, 2015

"Anyway, by midmorning apparently he was having a stool every couple of hours. When I got him, he had really picked up the pace, and was stooling almost constantly, especially when he coughed. The liquid had passed, and the rest was loosening up-- so we started out with mucus-lubricated pebbles that clinked against each other as we wiped, then progressed to greasy, frothy landslides that filled up the bed. There were perfectly-piped shit rosettes that wouldn't have looked out of place on top of a chocolate cake, and curry-slurry cascades that snuck out of the disposable linings and poured out across the sheet. There was an interlude of corn, beautifully intact corn so well-preserved that you could tell it was chewed from the cob rather than sliced into niblets."

That is some amazing writing right there, and it only gets better as it continues.
posted by Mei's lost sandal at 11:06 PM on August 3, 2015 [5 favorites]

DNR tattoos don’t count

Unless you are admitted into the hospital with literally no next of kin or personal contacts. I have a former colleague who currently works as a medical ethicist in a public hospital and part of his job is taking part in decisions on what to do with the "unbefriended," those people for whom there is no one to call regarding end of life decisions. In those cases (which are sadly more common than you might think), a DNR tattoo could actually be a significant piece of evidence as to how the lone patient would want their care to proceed (or not).

I feel the doctor/nurse split is in many ways archaic and needlessly gendered

The joke I've heard is that doctors treat the problem while nurses treat the person.

Also, while physicians are still primarily men (about 2/3 according to this study), medicine is probably one of the key areas to look towards for increasing gender parity. Nursing is also field which is rapidly correcting it's gender disparity, though from a greater deficit, with less than 3% of RNs being men in 1970 and less than 10% in 2011. In the 1970s, women already constituted almost 10% of physicians.
posted by Panjandrum at 11:57 PM on August 3, 2015 [1 favorite]

I...I don't think I'm ever going to need to read a horror novel again.
posted by happyroach at 12:46 AM on August 4, 2015 [6 favorites]

Panjandrum: "Also, while physicians are still primarily men (about 2/3 according to this study), medicine is probably one of the key areas to look towards for increasing gender parity."
In Denmark, university uptake of medicine students is two thirds female and has been for quite some years now. It proves harder to get more men into nursing.
posted by brokkr at 1:45 AM on August 4, 2015

I've switched from inner-city large emergency department RNing to small country town emergency (the change is awesome and I'd recommend it to any medical person who feels burnt out) and one thing I've always noticed is that male nurses are over-represented in ED and ICU, and that female-male doctor ratios is usually 50-50 here.

It often leads to older patients of either gender getting confused that all the nurses are men and the doctors are women.

Or a friend of mine who's consistently ranting on facebook about how older patients will often ask her when the doctor's going to arrive, after she's finished doing their consult.
posted by Silentgoldfish at 1:49 AM on August 4, 2015 [1 favorite]

THANK YOU for sharing! I'm not really involved in the health field, but between my nurse mother and my own morbid curiosity, I adore hearing about the experiences of medical professionals.
posted by Baethan at 3:23 AM on August 4, 2015

Elise is a wonderful wordsmith, and that SA thread got me through nursing school and set me off running a few steps ahead of the game. I'm glad she's made the decision to get her writing out there, as people have been hounding her to write a book for over a year now. If you're interested in supporting that project her patreon is here.

The residents/med student threads are also incredibly enlightening, but in a completely different way.
posted by sibboleth at 3:31 AM on August 4, 2015 [1 favorite]

On the walker, he made it out into the hallway and down the hall before he turned white, slumped sideways, and said: “Leave me alone, I feel fine.” His eyes stayed open, but his head sagged and his knees wobbled. The charge nurse came running up, pushing a rolling recliner she’d snagged from a nearby room. “I ain’t sittin down,” said the gentleman as he slowly toppled, trailing his chest tube behind him.

“Sir, you’re passing out,” I said, trying to maneuver his swerving backside into the recliner while bending around the walker and juggling the chest tube atrium. “Please, sit down.”

“I feel fine,” he repeated. He was definitely staying awake, but his body was absolutely done with this standing-up bullshit.

“You look like a package of used hot dogs,” I said. “Sit the hell down.”

He started laughing, which I guess was too much for him, because he lost consciousness and slumped back (mostly) into the recliner like a sack of wet bricks. Thirty seconds later, as his body caught up with the change, he came back to… still laughing. “Hot dogs,” he said. “Hot dawgs. This girl’s a pistol, bang bang.”

I’ve had worse compliments. Once a pt told me: “I’d marry you, honey, but you’re a bitch from hell.” Still a little heartbroken over that one. But I have to agree with him.

His chest tube had kinked off when he flopped over on it, and the pressure differential had him feeling a little stuffy by the time we got him back in his room. I straightened the tube and hooked the atrium up to wall suction, and he gave a little start as a huge bubble slurped from the tube through the water seal. “Whatna hell was that,” he barked.

“Well, sir… your chest farted.”

More laughter. “Does your mama know bout your mouth?”

And then she talks about black holes and Cherenkov blue!
posted by maggieb at 3:55 AM on August 4, 2015 [8 favorites]

Hats off to nurses in general. My grandma was a nurse (my mothers mother, Mormor, in Swedish) and she taught me everything I know about being competent and cool headed in a crisis, she was also taught me everything I know about being a sarcastic, cynical jaded asshole, I can't quite perfectly reproduce the tone of voice that she used that could force anyone to do what she demanded, but I can sometimes summon a decent approximation.

Specifically on topic this woman is a really good writer: in the Hunter S. Thompson, George Orwell and MFK Fisher at their best school of narrative non-fiction. Thank you very much uncomplicated soups...
posted by Divine_Wino at 5:11 AM on August 4, 2015 [2 favorites]

To amend she's not as polished as HST, GO and MFK but the talent is clearly there. In my experience, nurses and US Marines who have seen combat are the most unrecognized class of great story tellers and users of language.
posted by Divine_Wino at 5:20 AM on August 4, 2015 [2 favorites]

I told her that one story about the guy and his mother and all the cats, and she called bullshit, which is an appropriate reaction to a story that grim (I will probably never have another story to rival it), but I texted my coworker from that night: “Hey, remember that one guy and his mom?”

Thirty minutes later she responded: “FUCK YOU WHYD YOU BRING THAT SHIT UP AGAIN”

“But you remember it, right?”

“Uh I’m carrying that smell to my grave. How’s your week going, stinky oatmeal?”
Do I want to ask where I can find that one story?
posted by Rock Steady at 5:32 AM on August 4, 2015 [2 favorites]

Rock Steady, the story is in a SomethingAwful thread, here. You have to be a registered user to see it. It's... really, really rough. I don't know if she plans to add it to the blog.
posted by neushoorn at 6:03 AM on August 4, 2015 [5 favorites]

I can't quite perfectly reproduce the tone of voice that she used that could force anyone to do what she demanded

I am firmly convinced there is an entire course at nursing schools that teach Voice a la Frank Herbert.
posted by feckless fecal fear mongering at 6:15 AM on August 4, 2015 [5 favorites]

It's not a course. It's something woven into the fabric of the scrubs and the tubing of the stethoscope. Seriously, when I'm in scrubs with my stethoscope around my neck I can tell people anydamnthing and they'll listen to me.
posted by shiny blue object at 6:19 AM on August 4, 2015 [5 favorites]

This is great. I have a quick question for those in the know: in a couple of posts, Elise writes about "firing" patients (and, in one case, a patient's family), but I'm not quite picking up on the meaning. Maybe I haven't gone back far enough in the archives, but can anyone clarify what she's talking about?
posted by Zeinab Badawi's Twenty Hotels at 6:30 AM on August 4, 2015

I can't see the posts in question from my work but when my friends in healthcare talk about "firing" a patient they mean a patient has been so uncooperative or noncompliant with treatment that they simply stop treating them (or more often just wish they could). The term is most often used jokingly, though sometimes providers do actually formally terminate care for a patient based on the patient acting this way. There are legal/ethical considerations though.
posted by Wretch729 at 6:38 AM on August 4, 2015 [1 favorite]

To Rock Steady and everyone curious about the 'one guy and his mom' story, I just read it and that story is super, super rough. I have a high bar for gory stories and a morbid sense of humor, so I thought this would be some sort of hilariously gross bowel impaction story, but mostly I felt depressed and sad after reading. I can easily believe (and hope) she never has another story to rival it. Just, wow.

Elise herself writes that she took a week off after that case.

Anyway, this is some really well-written stuff, and I'll definitely be checking out the rest of her blog and her SA posts.
posted by angst at 6:41 AM on August 4, 2015 [1 favorite]

Thanks, Wretch729: noncompliance/uncooperativeness would fit the bill in context. She also fires a patient's family for meddling with his IVs, etc., which I'm assuming means denying them access to the room/ward?
posted by Zeinab Badawi's Twenty Hotels at 6:44 AM on August 4, 2015

When she mentions "firing" a patient, she means that she asks the charge nurse to rearrange the assignments so that a different nurse is caring for them. In the case of the family that wouldn't stop messing with her patient's IVs, she requested that she not be assigned to that patient in future shifts. She has also mentioned that, at least for a period, hospital security only allowed one family member in that patient's room at a time (I think after a while the whole family was allowed in again).
posted by neushoorn at 6:56 AM on August 4, 2015 [3 favorites]

I'll take the con-side of the argument. There are flashes of brilliance, and I was impressed with her technical understanding(1). But overall-- nah. She's too tightly wrapped up in what I call Internet Tough Guy, which I think most people will recoginize as SA and Cracked's house style.

It's an easily learned and easily aped style, and it's a huge crutch to writers learning their craft.

This is a freshman/sophomore level piece(2). Elaine is on her way, and I am happy for her. But she needs to purge the ghosts of SA from her work and grasp on to what's real.

This is not what her real shift reports read like, and this is not how she really interacts with patients, and the inauthenticity drips from every line.

(1). I was an M.D. student in a previous life.
(2). I taught creative writing to freshmen at the University of Arizona.
posted by mrdaneri at 7:00 AM on August 4, 2015 [9 favorites]

Well duh obviously this is not what her real shift reports look like.
posted by feckless fecal fear mongering at 7:02 AM on August 4, 2015 [8 favorites]

You're interested in fake shit? I could write pretend ICU shift reports all day long and I'm a database guy in San Francisco. What's the point? Contact reality or go home.
posted by mrdaneri at 7:05 AM on August 4, 2015 [1 favorite]

Perhaps it would be useful for you to elucidate exactly what is fake about her writing. Be specific; not handwavy "I was a medical student once."
posted by feckless fecal fear mongering at 7:06 AM on August 4, 2015 [7 favorites]

oh and her name is Elise, not Elaine
posted by feckless fecal fear mongering at 7:11 AM on August 4, 2015 [4 favorites]

Specifically the adoption of The Tough Guy Internet Voice Cliche instead of a real voice, and the repeated use of cliche'd overstated anger instead of real emotion for humorous effect and the complete repression of all other emotional states. For starters.

Like I said, when she breaks through-- and she does in a couple places-- and starts writing more in her real voice-- I think that she's got a lot of potential.

And she should probably listen to a couple in-services about changing patient behavior. Scaring them with horrific imagery and angry tirades typically doesn't motivate positive behavioral deltas.

My bad on the name.
posted by mrdaneri at 7:11 AM on August 4, 2015 [3 favorites]

That's light on specifics. How do you know it's not her 'real' voice? And you clearly haven't read far enough--she does talk about other emotional states, repeatedly.
posted by feckless fecal fear mongering at 7:13 AM on August 4, 2015 [2 favorites]

Fair enough, I'll read more.
posted by mrdaneri at 7:14 AM on August 4, 2015

Starting to go through it now, I really liked this turn of phrase: "your blood fats are so high that butter chunks the size of thimbles are bobbing in your aorta." It's... evocative.
posted by showbiz_liz at 7:20 AM on August 4, 2015

Also, I think 'internet tough guy house style' can be done well or poorly, and if you do it well, it's a perfectly legitimate way of expressing yourself.
posted by showbiz_liz at 7:20 AM on August 4, 2015 [7 favorites]

It is the haiku form of post-capitalism and likely to endure for just as long.
posted by mrdaneri at 7:28 AM on August 4, 2015 [1 favorite]

A good jumping-in point is the first post that mentions Tiberius (the unnamed pneumonectomy patient) and the subsequent updates. I understand the criticism but I think there's much more here than standard ITG posturing (which, sure, can be wearing.)
posted by Zeinab Badawi's Twenty Hotels at 7:32 AM on August 4, 2015 [2 favorites]

Rock Steady, the story is in a SomethingAwful thread, here. You have to be a registered user to see it. It's... really, really rough.

holy fuck you weren't kidding
posted by showbiz_liz at 7:42 AM on August 4, 2015

Yeah, I see what people mean by the ITG style, and it can wear me out or put me off of things sometimes. (Especially in the baffling, to me, tendency for people to go over-the-top with it in recipes, of all things. No, I do not need you to tell me in allcaps to DUMP A CHUNK OF MOTHERFUCKING BUTTER ALL UP IN THAT BITCH AND LET IT MELT, thank you so much.)

And I agree that I see some ITG in her writing. But luckily for me, it's interwoven or interspersed with more subtleties that even it out, so I haven't yet gotten tired of her blog. Like, there's a nuanced discussion of the distress after malpractice that I think is really insightful, and her ongoing psychological warfare with abusive patient "Crowbarrens" is fascinating--a series of tactics that she criticizes herself for, even while we discover she developed said successful tactics from her own abused past, and with him they work so she needs to keep using them.

Also, her sheer tenderness for the dying is really apparent, tough-guy or no. I really appreciate that.
posted by theatro at 7:45 AM on August 4, 2015 [7 favorites]

The recipes + ITG thing, btw, theatro as near as I have it figured out, is the horror of the feminine that permeates the internet culture at large.

Oh no I am in kitchen traditional sphere of female influence must invoke ITG voice to protect my male animus etc. via compensatory defense mechanisms etc etc etc
posted by mrdaneri at 7:50 AM on August 4, 2015 [2 favorites]

A phrase like this (from the aforementioned SA post)--
as we poured peppermint spirits into our masks and poured the stuff into the trash cans and smeared the stuff on every lintel and doorpost of the ICU like an echo of the first Passover, a guard against the stench of someone's dying firstborn
--has quite a bit more going for it than standard-issue ITG, or even non-standard-issue.
posted by Halloween Jack at 8:25 AM on August 4, 2015 [5 favorites]

Well, nursing is also a traditional sphere of female influence.

I would actually say that this is less internet tough guy, and more House Of God / Cardiac Arrest burn-out. You see a lot of this in A&E and anaesthetic/ITU doctors because those are fairly high-stress work environments - I haven't worked with enough ITU nurses to know if it is common in them, but certainly most A&E nurses are pretty hard-bitten/seen-it-all types.

It's one of the many reasons why I went into nephrology - it's much calmer and more focused on long-term relationships with the patients. If you expect to be looking after somebody for 20yrs you do have to take a more holistic and multi-disciplinary approach to their care, and that turns out to be much better for my mental health and job satisfaction too.
posted by tinkletown at 8:29 AM on August 4, 2015 [2 favorites]

Yeah, having read much more by now, I'm seeing this as less standard ITG and more Intense Gallows Humor, although of course the two styles can overlap. Like, when I read this sort of thing from police officers, they often overlap to the point where I get put off.

But having gotten a better baseline on her particular style in context, here it feels honest and earned. This entry, which includes the sad ending of the ongoing story of a drowned teenager, plus a meditation on what "success" and "failure" might mean from case to case, is thoughtful and heartbreaking and also a seamless part of her voice right next to the rough-and-ready parts.
posted by theatro at 8:38 AM on August 4, 2015

Yeah, the more I read, I can see the evolution. She is definitely getting better.

I do stand by my original stance of wishing that she'd just purge all of the ITG/SA and be done with it.

But, I know, in reality, that's not how it's done.
posted by mrdaneri at 8:44 AM on August 4, 2015 [1 favorite]

The recipes + ITG thing, btw, theatro as near as I have it figured out, is the horror of the feminine that permeates the internet culture at large.

Please consider that alternative explanations can exist.
(1) Female writer who is really, really fed up.
posted by gnomeloaf at 9:01 AM on August 4, 2015 [11 favorites]

I'm enjoying this, even though it's difficult to get through in spots. I like her writing style. Thanks very much for posting it, 'the uncomplicated soups of my childhood.'
posted by zarq at 9:19 AM on August 4, 2015

Spent the ten bucks to join the SA forums. Can't say I didn't get my money's worth.

Can't say anything right now. Too much gibbering in the fetal position.
posted by whuppy at 9:24 AM on August 4, 2015 [4 favorites]

mrdaneri you are doing a fine job of walking back your first comment and I'm not trying to give you the gears, but since it's out there I'd really like to underline that the difference between ITGs and people who put themselves physically, emotionally and/or morally on the line every day is fairly clear cut. That said I do see what you mean about that certain tone of writing. I guess I don't expose myself to it enough to have the same reaction, but I think I understand where you were coming from.
posted by Divine_Wino at 9:29 AM on August 4, 2015 [2 favorites]

Vascular complications from hyperglycemia are not caused by syrupy blood or sugar crystals scraping up veins and organs. That is utter nonsense. The pathophysiology is much more complicated than that, involving oxidative stress and vascular endothelial inflammation/dysfunction. It is nonetheless a terribly destructive disease over the long-term, and learning about the medical complications will legitimately put The Fear into you.
posted by dephlogisticated at 9:32 AM on August 4, 2015 [4 favorites]

Question for nurses: I feel like I often read stories from ICU nurses which involve "and then the bed filled up with shit." Why... why does this constantly happen? Have we not moved past 1915 bedpan technology? It seems like this would be a thing you could control for.
posted by showbiz_liz at 9:32 AM on August 4, 2015 [1 favorite]

> Rock Steady, the story is in a SomethingAwful thread, here. You have to be a registered user to see it. It's... really, really rough. I don't know if she plans to add it to the blog.

For better or worse I put the grim story in a Pastebin.
posted by Monochrome at 9:41 AM on August 4, 2015 [11 favorites]

Mod note: A few comments deleted. mrdaneri, you've made your point, now please let it rest. Thanks.
posted by LobsterMitten (staff) at 9:42 AM on August 4, 2015 [8 favorites]

oh my god that guy and his mother story

my stomach is made of ice right now and my palms are sweating
posted by burgerrr at 9:55 AM on August 4, 2015 [1 favorite]

Vascular complications from hyperglycemia are not caused by syrupy blood or sugar crystals scraping up veins and organs. That is utter nonsense.

Perhaps instead of nonsense, it is a metaphor?
posted by Spathe Cadet at 9:56 AM on August 4, 2015 [14 favorites]

(Horrible story abbreviation, for those who are curious but know better than I did: DO NOT READ FURTHER IF YOU DON'T WANT AWFUL. The cats started eventually eating the son, when he collapsed and couldn't get up, and then the mom collapsed, tripping over the son in a daze and eventually also started eating him.)

Horror writing is unnecessary.
posted by lauranesson at 10:13 AM on August 4, 2015 [1 favorite]

And sometimes we fight tooth and nail to save them, and care about them, and care so deeply about their survival that when they die anyway we are all devastated and we go out and drink and wish we could have done anything, one more thing, to save them. Which, I don’t know, might not be a victory; but it feels like something more important than a defeat. It feels like a connection. It feels like we have successfully recovered our humanity, which we often hang on the break room wall next to the memo notice sheets and the spare stethoscopes, so that we can dig in a pt’s guts without cringing and accept verbal abuse without snapping and look death straight in the face without blanching. It’s inconvenient, but it’s easily lost, and even though it’s selfish we value those moments of realization that we aren’t as dead inside as we pretend to be.

Oh boy.
posted by showbiz_liz at 10:24 AM on August 4, 2015 [6 favorites]

That story - god I registered to read it, kind of regret it and kind of don't because my mother just put my dad in a nursing home because his dementia got too bad for her to care for him, and -she- has her own self-care issues and something like that happening is my greatest fear and now I'm going to call my mom and remind her SHE DID THE RIGHT THING.
posted by FritoKAL at 10:37 AM on August 4, 2015 [6 favorites]

Jesus hell that story. She deserves every award and medal there is, as does the entire care team that helped those patients.
posted by feckless fecal fear mongering at 10:45 AM on August 4, 2015 [2 favorites]

I do not often use the phrase "writes like a house afire" but this writer brought that to mind. Like all new writers, she will probably need a good editor to get an actual book out, but holy cats, she is talented and has great material and needs to publish it yesterday. I suppose fears of patient confidentiality lawsuits might make it hard to do under her real name, but a pseudonym would certainly work here.
posted by emjaybee at 11:01 AM on August 4, 2015 [1 favorite]

showbiz_liz, I was just about to post the passage you quoted. That's when, for me, she made the leap from a writer who is very adept at conveying horrifying and/or technical information in clear, engaging prose to one who is able to articulate amazing insights about the emotional demands of her job. I can't imagine myself in her position, dealing with all the things we avoid in life - bodily fluids, untreatable pain, impending death, endless paperwork - while keeping her focus during insane work hours. Some people are just better human beings than others (and I count myself among the latter), and I am grateful when they have the time and ability to give me a glimpse of their experiences.
posted by bibliowench at 11:03 AM on August 4, 2015 [5 favorites]

Jesus. That story. Oh!
posted by ramix at 11:07 AM on August 4, 2015

Why... why does this constantly happen? Have we not moved past 1915 bedpan technology?

A bedpan only works if:
- the patient can tell someone s/he needs one in time
- the patient can roll over, or be rolled over, to place the bedpan
- the amount of material can be contained in the bedpan
and undoubtedly some other stuff that's not coming to mind right now. With critically ill patients, general "none of the above" tends to be true.

You can't leave a patient on a bedpan for long periods of time, because the pressure will cause skin breakdown.

There is a "fecal management system" (google Flexiseal for example), which is kind of the equivalent of a urinary catheter -- a tube goes inside, held in place by an inflated balloon, which drains the material into a bag. These don't work very well, especially with, shall we say, firmer material.

Sincerely, (One Of) Your Resident Poop Expert(s).
posted by shiny blue object at 12:11 PM on August 4, 2015 [13 favorites]

Can't just make beds with holes in em?
posted by showbiz_liz at 12:17 PM on August 4, 2015

Not proper fully-adjustable hospital beds with pressure-relieving mattresses, no.
posted by shiny blue object at 12:25 PM on August 4, 2015 [2 favorites]

They do make them. A pressure- relieving system with the mattress in several pieces. I've worked with one twice. They're useless. Patient has to be exactly in position and stay that way. They need to have firm stools that will drop past the hole to the collection unit. (RARE) This all seldom keeps the patient clean and never keeps the hole (which is mattress-thick) clean.

Elise is an ok writer. She's great at metaphors and is probably a good patient teacher for patients who respond to that kind of language. I'll look forward to reading more from her as she gains experience as a nurse. She reads like she only has a couple-few years under her belt . I think her writing style will change as her audience does. Writing for SA possibly has encouraged a certain type of hardass verbiage.
posted by ptochocrat at 12:32 PM on August 4, 2015 [3 favorites]

Can't just make beds with holes in em?

Not proper fully-adjustable hospital beds with pressure-relieving mattresses, no.

(Though that is a management strategy for cholera in the developing world. )
posted by midmarch snowman at 12:34 PM on August 4, 2015 [1 favorite]

I just finished nursing school. I graduate on Friday. I've been luxuriating in some long overdue time off.

I want to start my career in geriatrics. Some experiences with elderly family and end of life friends and relatives convinced me that you need professionals.

I get warned that it's depressing. That people you form attachments to will die. When I went to the employment agency to inquire about my NCLEX fees, the nice lady said, "Now are you willing to work in a nursing home?" I get lots of inquiries about my "stomach for long term care", as if I haven't, in clinic, held and emptied bedpans, irrigated and repacked horrific wounds, given a corpse his last bath. Hell, I paid for those privileges.

No one second guesses people who want to work in OB. If it's a privilege to see somebody into the world, it's privilege to usher them out.

People are so bizarre about it. I brush them off and say, "Oh, I just like crazy old people," but the real reason is that without caregiving to the elderly and stable-but-infirm, this world of long lived humans would grind to a halt. Even if we had blanket right to die legislation, it would not change that fact. (Mitigate some suffering, sure. I'm in favor of bodily autonomy across the board, but when you aren't of your right mind, consent is tricky. There will, always and forever, be a place in life dedicated to caring for the dying.)

Like Elise, I have a history of abuse. I know for damn sure that there is no way I will be the caregiver for my evil parents, both of whom have treated their bodies like garbage dumps and will no doubt spend years dying by inches. I feel as though I'm righting a wrong and stopping a cycle and earning back some karmic deficit. I'll care for people who didn't put me through hell and hopefully, there will be kind hands to help me when it's my turn.

The stigma associated with nursing homes is terrible and so damaging. Dementia is a profoundly difficult disease to manage, and you need trained professionals and well designed facilities and lots and lots of equipment and supplies to manage it. It's not a DIY endeavor.

This is a lot to explain. If anyone presses me, now I'll have this story to send them. That will make it easier to say that I really am looking forward to a career in tragedy prevention.
posted by Athene at 12:36 PM on August 4, 2015 [52 favorites]

Thanks, guys! I'd actually wondered about that on and off for years.
posted by showbiz_liz at 12:41 PM on August 4, 2015 [1 favorite]

We watched my mother-in-law die slowly in hospital, basically smothering over the period of a week. Her blood oxygen kept dropping and the hospital kept gaving her medication to increase her blood oxygen. What the hell for? So she can suffer for an additional day while labouring to breath? The woman is dying of cancer, she has been dying for two years, just let her die.

I told my husband, fuck that. If I get cancer I am not going to die in a hospital bed.
posted by Gwynarra at 2:09 PM on August 4, 2015

lauranesson: "(Horrible story abbreviation, for those who are curious but know better than I did: DO NOT READ FURTHER IF YOU DON'T WANT AWFUL. The cats started eventually eating the son, when he collapsed and couldn't get up, and then the mom collapsed, tripping over the son in a daze and eventually also started eating him.) "

Wait, for those who have read the story (which I do not intend to), is this a typo, or did the mom eventually start eating the son? (Please answer in as little detail as possible)
posted by Bugbread at 4:36 PM on August 4, 2015

Not a typo.
posted by feckless fecal fear mongering at 4:37 PM on August 4, 2015

Okay, wait, one last question (I know, I know, "Bugbread, just go read the story!", but I am really bad at reading even entirely fictional depressing stories, let alone non-fictional ones. Super-short recaps I can kinda handle) - was he alive when the mom started eating him?
posted by Bugbread at 4:52 PM on August 4, 2015

That depends on your definition of 'alive.'
posted by feckless fecal fear mongering at 4:55 PM on August 4, 2015 [5 favorites]

The mother and son story is truly horrific but well told. Personally, those of us who are aging and live alone ponder about falls in the home.
posted by maggieb at 4:56 PM on August 4, 2015

feckless fecal fear mongering: "That depends on your definition of 'alive.'"

Okay. Thanks for keeping it at just the right level of non-specificity, too.
posted by Bugbread at 5:06 PM on August 4, 2015

Athene, you are a good egg. You got a beer or a coffee or a whatever on me if you ever make it to my location, which is currently Cape Cod and there are a bazillion old folks here so I'm actually putting that money aside because you might show up. Regardless, please know that I super appreciate what you have chosen to do and I hold it in the highest regard.

As a bonus you can tell everyone in the G ward that a weirdo from the internet thinks you are a cool person.
posted by Divine_Wino at 5:16 PM on August 4, 2015 [2 favorites]

Rock Steady, the story is in a SomethingAwful thread, here. You have to be a registered user to see it. It's... really, really rough. I don't know if she plans to add it to the blog.

"Oh hey, i still remember my SA password, haven't been on there in a couple years"

"Oh, it's one of these threads!"

"Oh jeeze this is...


This is one of the roughest stories i've read on the internet, and i've seen some shit.

Just don't read it, honestly, if you haven't. It's not funny or cool or edgy or anything it's just upsetting.
posted by emptythought at 5:20 PM on August 4, 2015 [1 favorite]

Thanks, this was a fun read!

ICU nurses are somewhat unique in the hospital in that, over the course of a 8-12 hour shift, they are assigned one patient. Sometimes two, but usually one.

No other person in the hospital has that intense of a relationship. Nurses on the floor will cover >6 patients. Doctors > 12. Running around different rooms, floors.

With exception of breaks, ICU nurses are at the bedside constantly within a 10m radius of their patient.

Needless to say, it can get pretty intense.
posted by cacofonie at 5:22 PM on August 4, 2015 [2 favorites]

The part in the blog about never really knowing what happens to patients when they leave reminded me that I should take some cookies and a card to the nurses at the ICU where Nanopanda was a frequent flyer this winter. They were really kind and upbeat, sympathetic when we kept coming back, and a few nurses we got to know always stopped in to check on us even when we weren't assigned to them. One sat with me and talked me off the ledge when we got some truly terrifying lab results; others soothed Nanopanda to sleep in the crib when I just couldn't hold her any more. They taught me a baby restraint technique that quite impressed the folks in the ER the next time we were there.

They went to bat for us with the doctors at the times we sensed she was taking a turn for the worse, and they were fantastic about sharing their clinical observations with me in great detail when a particular specialist was handling her poorly and I was trying to answer some clinical questions he seemed determined to ignore. (That eventually played a key role in getting the correct diagnosis and stopping the medication that, ironically, was probably why she kept going back to ICU.)

Nanopanda wasn't a difficult ICU patient in that she didn't require constant intervention, mostly just monitoring and respiratory support, but it was still dark, dark days for us and the nurses were a real lifeline. I was careful to name names in the hospital surveys and follow-up phone calls, but I doubt they'll ever really know what they meant to us. But I imagine they would be happy to see a photo of a robust, happy toddler and know how much better things are now.
posted by telepanda at 8:33 PM on August 4, 2015 [19 favorites]

My, ummm, goon friend welcomes you to SA, and suggests maybe a MeGoon coming out thread. I think he's nuts, but I promised to post for them.
posted by Samizdata at 10:56 PM on August 4, 2015 [3 favorites]

"CPR is violent. It's effective enough to give us a chance to perform life-saving interventions, but if the meds and shocks don't work... well. Eventually it just becomes mutilation of the dead, the hidden ritual of American healthcare, the sacrament of brutality by which we commit our beloved to their resented rest."
that was the bit that stood out to me.
posted by gaspode at 6:12 AM on August 5, 2015 [6 favorites]

I know someone upthread took issues with the diabetes post, but by god, I did not eat any fucking sugar yesterday. When you're trying to come up with a way to make yourself say "no" to something you don't need, thinking "I don't want my blood full of little sugary razors shredding my veins" works in a way that "it might be nice to drop a few sizes" doesn't. At least for me.
posted by emjaybee at 7:33 AM on August 5, 2015 [12 favorites]

I like her writing. a lot. And her compassion shines through in a way I find extremely heartening.

She sounds like a person who thrives on intensity, who might've been miserable in a non-intense job, and I hope she is able to keep her balance between thriving on it and getting crispy.
posted by theora55 at 9:43 AM on August 5, 2015

Yeah, while the diabetes description may not be accurate from a pathophysiology perspective, it's an effective image to describe why so much sugar is a problem. I think she can have a pass when trying to relate to folks who don't have the A&P background.
posted by Pantengliopoli at 9:44 AM on August 5, 2015

I get the need to vent. I get the deep issues with our healthcare system. I value the difficult work that nurses do.

But. I don't understand why people think this is a great blog. It strikes me as cheaply exploitative with a really nasty undertone.

Yes, patients and their families are difficult, and yes, it is amazing more nurses don't quit due to burnout. But there is some value to keeping some reactions to specific patients "in the family" as it were. Not every feeling needs public statement, no matter how honest and genuine the speaker.

The posts I read displayed contempt for both the patients and their families. I don't see how this could make our healthcare system better. It seems the author is going for cheap sensationalism and shock value and having this published will likely make the public more cynical about our healthcare system.
posted by girl flaneur at 10:52 AM on August 5, 2015 [1 favorite]

The posts I read displayed contempt for both the patients and their families.

Did we read different blogs or something?
posted by showbiz_liz at 11:08 AM on August 5, 2015 [10 favorites]

After a friend who does hospice case management told me what cpr really does I was like fuck that.

My dad is an ICU nurse and the stories I've heard! I'm sure many of you know this but just because you can't feel breath or heartbeat does not mean those actions aren't being performed. They were doing CPR on a lady who's blood pressure was dropping just enough for her to pass out and then they'd do CPR for 20 or 30 seconds and she'd wake up in the middle of it really pissed, until they stopped doing CPR and she passed out again, and then they had to start CPR back up again...
posted by LizBoBiz at 11:48 AM on August 5, 2015

girl flaneur: "I don't understand why people think this is a great blog...The posts I read displayed contempt for both the patients and their families."

The posts I read did not. Maybe that's why people think this is a great blog. Either we're reading different posts than you are, or you're seeing the bad in them, and we're seeing the good. And given that so many people are enjoying these posts, it seems more likely that the good outweighs the bad and less likely that we're all coincidentally deluding ourselves in the same way.

Personally, I think it's great because just in passing it has explained all these medical things which I've never understood but never even thought to ask. Stuff about insulin, about the heart, about alcoholism, etc., etc., etc. Sure, this information is all available elsewhere, but I've never seen it presented in an interesting format that makes me want to read it. Plus stuff like "how you can be constipated for months and yet not pop", which would never even have occurred to me to look up or ask someone.
posted by Bugbread at 2:40 PM on August 5, 2015 [2 favorites]

So... I'm not sure if people are still reading this thread, but something has been nagging at me for a couple of days and I just want to put it out there.

I don't think the cat story is true.

I know this could come off as obnoxious and nitpicky, and I don't mean it that way - it's genuinely bothering me, and I'd like to hear other people's opinions. I'm totally open to the possibility that I'm wrong; that I'm just, like, unwilling to believe in something so terrible. I tore through Elise's blog last night, and I loved it. But then I read the cat story, and as soon as I finished it, my bullshit detectors were just blaring. I've spent the past 24 hours trying to think through what set them off, and here is what I've got.

[trigger warning: gore and awfulness]

1. It reads exactly like creepypasta. I read a lot of horror stories and NoSleep stuff, and this is just exactly in that format: creepy setup, fakeout kinda bad reveal, BIG HORRIFIC DOUBLETWIST NIGHTMARE REVEAL. Which, okay, terrible things do happen. And sometimes, the order in which you learn about them mimics the order of a horror story. But the familiarity of the structure and tone, while it doesn't *prove* anything, is what originally made me start to doubt.

2. A whole lot of things had to go right to make sure things went this wrong. Individually, nothing in the story is impossible, but taken together, it's a pretty carefully balanced construction. I started writing out a whole thing about the timing of the phone calls and the progression of rhabdomyolysis, (rhabdomyolosis is blood poisoning; it's still not entirely clear to me what caused the limbs to rot. Google hasn't really helped; regardless, let's just say it's a rare collection of symptoms) but it's taking more time than I have.

Instead, I'll just say, first, that I have a lot of experience with Alzheimer's (which is maybe why I'm taking this so personally) and it is a monstrous beast. But if you're so far gone from Alzheimer's that you not only can't make a phone call or open your front door to look for help (or even just to go outside - Alzheimer's patients tend to wander), and that you don't even recognize 'what a pillow does' or that your son 'is a person,' then I'm skeptical that you could keep yourself alive for several days without collapsing somewhere else in the house from dehydration or exhaustion, and I really, really don't believe you can make toast. The horribly realistic possibility here is that your son dies and then, a few days later, so do you.

But say you do. You live long enough that you decide to try and drag your son away from the refrigerator, and then you fall on him and break your leg. If you are too far gone to recognize that the smelly object on the floor is your dying son, then you are not going to recognize a pile of necrotic flesh as a food source. Like, to put it as crudely as possible: eating the ice cold flesh of your rotting but still living, flinching, and grimacing son to keep from starving to death - is a rational decision, something you might force yourself to do to survive. Alzheimer's patients often don't even recognize that they're hungry; it seems infinitely more likely to me that an Alzheimer's patient would collapse in front of an open refrigerator full of food and starve to death than that somehow she would overcome the instinctive human aversion to stench and decay and eat a hunk of her son's arm, even if she saw her cats do so first. That's actually a really difficult connection to make - a rotted chunk of ice cold arm is only recognizable as food to someone who knows what it is; I feel like a person with Alzheimer's would be as likely to try and eat the carpet or a hairbrush, or, y'know, something in the open refrigerator full of food that's right behind her. Again, not impossible, but it's just....this bizarre mix of confusion and rationality that doesn't make sense to me.

And okay, say she did. This elderly, ill, dehydrated, near-starving woman with multiple broken bones who is now chatting away asking for snacks (dramatic irony!) ate rotting flesh and you left it off the chart because you didn't want to burden her family? Um, don't you think her doctors should know about it? Because that seems like something that could kill her real, real fast. The kind of food poisoning you'd come down with from the rotting flesh of a corpse you'd been sharing with your cats for nearly a week seems epic. But somehow she's not even sick enough to end up in the ICU.

So yeah. I have doubts. And maybe I'm wrong, in which case I'm sorry for picking apart this tragedy in what might seem like a thoughtless way, and casting aspersions on the truthfulness of someone who is doing God's work. Because I genuinely, genuinely admire nurses more than just about anyone else on the planet (my mom is one.) But I also have seen Alzheimer's up close and personal, and the idea of someone making up a story like this, or even adding a couple layers of exaggeration onto what might be a real tragedy, bothers me a lot, and if she made up something like this I wonder how much else on the blog is exaggerated or untrue.

I'm not, like, out for her head or anything, or anything remotely like that. I really loved the blog. But the critique that dephlogisticated gave above about her hand-wavy explanation for diabetes is exactly the kind of thing that, in isolation, might seem like nothing, but points towards someone who is willing to bend the truth pretty hard in order to tell a good story. I think my reaction to this story is another. But if there are medical professionals or people with other experience who had similar alarm bells go off while reading this story, or others, I think it's worth saying so.

Again, apologies if I'm wrong. I'd be interested to hear what you guys think.
posted by pretentious illiterate at 10:08 PM on August 7, 2015 [5 favorites]

I literally just woke up thinking about this.

I kept thinking that the actual diagnosis part was kind of hand-wavy - the way she drops in rhabdomyolysis as though that explains why the guy was rotting alive, which as far as I can tell, it does not. It's not that it's not likely to follow a stroke, it's just that it's no explanation for why chunks of flesh would be sloughing off this guy's body after a week.

But okay. The guy has had a stroke. He can't move at all, which is why his arms and legs are literally necrotic and gray and rotting. His mother eats him alive, leaving him covered in 'half-moon bites,' while he lies there, completely paralyzed, unable to do anything about it. Because he's paralyzed.

When the medical team gets him to the hospital, they test to see if he's responsive by giving him "a hard fingernail-pinch," on his arm...and in response, he twitches his fingers.

I'm not a doctor, so maybe there's a gap between 'so paralyzed your flesh starts rotting off your bones' and 'not so paralyzed you can't move your fingers.' But if someone doesn't come in here and tell me I'm totally off-base, I think I'm going to post this to Metatalk.
posted by pretentious illiterate at 12:26 AM on August 8, 2015 [1 favorite]

The rotting was because one arm was still in the fridge.
posted by showbiz_liz at 3:41 AM on August 8, 2015

The limb people think of in its entirety as "arm" is very technically arm (brachium, i.e. upper arm) plus forearm (antebrachium). So you can pinch proximal brachium (upper arm near the shoulder), get a response, and still have seriously fucked up antebrachium and even distal brachium (upper arm near the elbow). Moreover, proximal brachium motor and sensory is conveyed by different nerves than distal brachium and antebrachium.

This is how some people with spinal injuries that impair all four limbs can still have some use and sensation in their arms, or even some hand motion. It's also possible to have fibers from one nerve remain relatively intact and so "withdrawal" reflexes* may be weak but present, as the flexors of the fingers have sensory and motor overlap between nerves, and the nerve governing extension branches into all of its tiny offshoots at the forearm near the elbow. If some of the muscle fibers supplied by those nerves and nerve branches are still active, then the fingers can move. In addition, most of the muscle mass of the muscles controlling finger motion is located at the distal brachium and proximal forearm and not in the fingers or hand. So if there are intact tendons, the fingers can move when the muscles twitch. To be fair about the perception part, basic withdrawal reflexes don't require intact pathways to the brain, nor consciousness. The amount and way you move can give information about whether or not that info is registering in the brain and in what way. The grimace response to noxious stimulus at the sternum is more telling of some level of intact perception at the level of the brain, though hardly full consciousness. Grimace response and finger-twitching when you consider what is happening to the pt is pretty low-scoring. Which is good.

Basically, the body is complicated and doesn't die or shut down neatly. Nor is innervation as obvious as you'd think. (This is one way neurologists test for somatization symptoms, because many times you get "glove" or "sleeve" paresis when your mind involuntarily shuts function down under stress as opposed to the less intuitive effects of other disorders.) Anyway, this is extreme and weird, but given someof the things I have seen where "that doesn't seem possible, but it's actually happening and I am watching, so holy shit my intuition is wrong," I believe it.

*withdrawal reflex: very simply, you burn your hand, your hand and arm move away before the information is registered in the brain. This means sensory and motor info is going to and from the spinal cord intact. If you also go "OW" or hold your hand or just give some acknowledgment that "that hurt," as well as some other signs of higher level involvement then this shows the information is getting to and from the brain as well (e.g., looking for signs that your brain is still constantly shutting down the extreme reactions at the level of the spinal cord. If it's not, you would be more likely to kick out at your doctor involuntarily when you get your patellar tendon tapped).
posted by Naamah at 7:03 AM on August 8, 2015 [3 favorites]

Also, as much as you shouldn't eat rotting meat, sometimes you walk away from it and all your doc can say is "don't do that again."
posted by Naamah at 7:10 AM on August 8, 2015

I could write pretend ICU shift reports all day long

Tell you what: you do that, and link them on Projects, and drop me a memail, and if they're anywhere near as compelling as Elise's, I'll FPP them.

But I don't expect I'll be needing to.
posted by flabdablet at 9:19 AM on August 8, 2015 [7 favorites]

I'm kind of surprised people are buying this whole cloth. I mean, there's surely an element of truth in these stories - most of them anyway. But they are clearly very embellished. Which is fine but they're not real presented with the "stories based on true events" labeling.
posted by bgal81 at 8:55 PM on August 8, 2015

The cat story is so out there that I find I don't actually have an opinion as to whether it's real or not (having an opinion about that feels somehow like missing the point), but I'm also a little concerned that maybe the blog is more fictionalized than it admits to.

I mean, I read the whole thing, beginning to end, and I enjoyed it, and all that, but toward the end there was something a little off about it. I can't put my finger on anything specific; I just had this weird sense that things were working out a little too neatly a little too often, or something. Whatever I was picking up on, it was noticeable enough to affect my enjoyment of the last few posts.
posted by Spathe Cadet at 11:22 PM on August 8, 2015

(1) Regarding authenticity: There are enough details that remind me of ICU nurses I know that I can actually picture who Elise might be friends with at work. I suppose that's victory enough for a writer. The cat story is similar to a lot hospital legends that get passed around. Legends tend to accumulate a lot of drama. One thing I can say, people who are not forensic investigators tend to make terrible forensic investigators and really smart people can misinterpret what they see. Tooth marks are pretty characteristic but there are a lot of variables at play and Elise interprets everything to give an amazing story. You know, great claims require great evidence, so legends like this are useful as legends, I don't know what else you'd do with a story like that.

Everything else is, of course, likely re-arranged. She makes it clear a lot needs to be done to protect identities. Speaking of that...

(2) Elise is flying pretty close to the sun with regards to keeping her job. I've seen a nurse fired for vaguely referring to a family on facebook. Elise has a picture on herself on a patreon site removing plausible deniability. Nothing in her posts is blatently unethical or illegal assuming she was thorough in mixing personal features to obscure idenities. But privacy laws forbid sharing health information with a broad definition of "identifiable details." There's a picture on the site that isn't identifiable, so I'm not sure about legality, but sharing pictures without expressed consent is expressly forbidden by most employee contracts. She mentions her hospital has a union so maybe things are different...

(3) Whether you find her stories respectful or tasteless is probably a personal reaction, and I'm way too biassed to weigh in, but I will say she strives to establish her patients as real people, has ample sympathy in her tone, but also honestly express her personal reactions to the blatant absurdity of the situations in an ICU. Many health care professionals would be jealous of her ability to balance. Also Elise approaches difficult patients with an interest in problem solving, which I always admire.

(4) Peoples' description of pathophysiology are usually filled with copious analogies and simplification to create a narrative where science only provides disparate nuggets of evidence. Elise's pathophysiology stories are super interesting because they stress the concepts important to her job.
posted by midmarch snowman at 3:49 AM on August 9, 2015 [10 favorites]

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