Wednesday, October 31, 2007

The Truth about MRSA (Without the Media Panic)

Okay, my friends. For the last week or so, the media have gotten Americans all worked up into a froth about this "deadly new bacteria" called MRSA. My ER is now inundated with frantic phone calls from people who have no idea what they are looking at, or what the disease really is.

One charming woman (who clearly smoked wayyyyyyyy too much) called amid the throes of a panic attack because she found a pimple and was convinced beyond all attempts to reason with her that she was "gonna die of Melissa."

"Ah, you mean MRSA." I corrected the hyperventilating woman on the phone.

"What's that?" she asked with a voice that reminded me of Bosley from Charlie's Angels.

"Never mind," I sighed, rubbing my eyes.

Well, after a full rotation of charming phone conversations such as that one, and a waiting room filled with wild-eyed impressionable souls, I have had just about a dang nuff of this.

I get tired of the media feeding crap to the public about infectious diseases. This case is no different. (But that perky anchorwoman wouldn't BS you about something that involves your well-being, would she? After all, she furrowed her brow when she said it. Furrowed! Her! Brow! And with all that Botox on board, that takes some effort, Spanky!)

Oh, of course that cute little newsbabe wouldn't BS you. She cares about you. Kum-bah-frigging-yah. Please clean up before you leave.

Well, here is the real scoop, Alley Oop.

I am an Emergency Department nurse, and I have encountered patients with MRSA a gajillion times. (By "encountered" I mean, "assisted in cutting open and draining their wounds, packed their wounds, and changed their wound dressings." And by "gajillion," I mean "gajillion.") I have- gasp!- touched a person who has MRSA. And wouldn't you know- I never got it. And I don't pass it on to other patients, either.

(Gosh! How can this be? He touches the leper and he does not become unclean! What manner of man is this!?)

Look, folks. It is really very simple. I know how to protect myself from it, and I know how to protect my patients from it. And because I understand MRSA, I don't get freaked out when I see an ingrown hair on my arm. I will tell you why. And when you read this, you will become just as confident as I am, because you will know the truth.

Are you ready? Here we go.

1. Wash your hands with soap and WARM water.

Any soap will do. It doesn't have to be Hibiclens(TM), or any other ludicrously expensive antimicrobial soap for that matter. Just plain old soap and water. ANY old soap is "antibacterial" when used correctly; All you have to do is make LOTS of suds. Its the suds that make a soap antibacterial. "Really?" you ask. "How so?" you ask. Well, settle down and I will tell you: Suds form micelles around dirt and bacteria and lift them from the skin's surface to be rinsed away to the black hell from whence they came.

Don't use hot water, because hot water dissolves the natural oils on your hand that keep your skin from drying out and cracking. (Cracks are openings deep into the skin. Openings deep into the skin invite bacteria.) Don't use cold water, either, because cold water will not produce decent suds, and it will not rinse all the soap away from your skin, so your skin will dry and crack. (Again, cracked skin says, "Hey bacteria! Par-tay over here!") So remember: not too hot, not too cold, but just right.

Wash- and rinse- AND dry- under those pretty rings on your fingers. Rings hide light- that means darkness. Moisture hides under rings- that means bacteria. Darkness + bacteria= EEEWWW.

And come on, folks. REALLY wash your hands. For fifteen seconds. None of that "happy birthday" song crap (which I can sing in five seconds). Sing your ABCs; THAT's a fifteen-second song. Fifteen seconds should also cover roughly two limericks, if that's more your style. That includes slurring of speech secondary to alcohol consumption.

Dry your hands completely, including under those stylish rings. Water = bacteria. If you don't dry, you just defeated the purpose of step 1.

And don't you DARE just splash your hands in the water and then shake them off! If you do that, you are the one spreading this crap around. Stop it! Bacteria L-O-V-E-S moisture. And where you just had your hands- bacteria loves that place too. So when you exit the bathroom and go smoke that cigarette and eat your sushi, guess what else you're putting in your mouth- or into the mouth of that hottie of yours when you try to be cute and feed her an hoeurs-d'oeuvres?

Nothing says "I love you" like a mouthful of Enterococcus faecalis or Candida albicans.

2. Use enough alcohol-based hand sanitizer to cover ALL of your hands, including under the nails and rings. With Brylcreem, a little dab'll do ya. With hand sanitizer, you need enough to wash EVERY FILTHY BIT of your hands for the same length of time as demonstrated in part 1, above.

3. Take a shower. I mean on a daily basis. Good personal hygiene is your friend. Remember those micelles? They do the same thing wherever you create them.

4. Cover your boo-boo. Even if you don't have MRSA, if you rub that boo-boo over someone who has it or something upon which MRSA rests, guess what? You get MRSA! See how this works?

5. Don't touch someone else's boo-boo. Wherever it is. Draw your own picture. Leave me out of it.

6. Don't touch any bandages that cover someone else's boo-boo. That's self-explanatory.

7. Don't share your towels, razors, or anything that touches your or someone else's boo-boo. Yes, that means you married/joint domicile people, too. Think about where that towel/razor/dressing has been. Can somebody give me a BLEEEEEEYAAHHHHHH!?

If you want a version of the game that tells you the same thing but spares you the rapier-like wit, go to The Official Center For Disease Control MRSA Website and fall asleep in the middle of it.

And one last thing: MRSA has been around for years. And that cute little news-floozy is just playing you for ratings.

UPDATE: It has been pointed out to me, and correctly so, that MRSA can stay viable on a hard surface for a long time (some studies state for three months). There is a way to defeat this threat: Simply wash all contact surfaces (countertops, toilets, sinks, doorknobs, etc.) with a bleachy solution. Those Clorox (TM) handy-wipes that you can pull out one at a time will do just fine. Just wear gloves while you use them, as bleach can irritate the skin.

Monday, October 29, 2007

The Living Dead

I saw a woman at the store near my house last Wednesday morning after I got off work. The moment I saw the woman, I knew she was on Meth. Her face was covered with black sores; she was pale, scrawny, dirty, and absolutely wild-eyed. She was practically dancing in place. Her speech was a jumble of pressured and confused babble; her movements were grandiose and repetitive. She constantly rearranged the items she placed on the checkout counter. At one point she looked right at me. Her expression was chilling.

She managed to pay for her groceries, but then loitered outside the entrance, pacing back and forth and mumbling to herself. She approached one or two people outside. I told the clerk to call the police. They would probably haul her to a local ER and dump her there, and the ER wouldn't really be able to do anything for her but watch her, but at least she wouldn't run into traffic or assault someone.

When people are 'cranked,' they seem to suffer a total disruption of reality. The laws of physics and of cause-and-effect seem to be suspended for them. They're stolen away to a kind of 'parallel universe.' On their side of reality, they race unfettered at light speed and are bombarded from every direction with pure stimuli; yet on this side of reality, their bodies literally fall apart from neglect and abuse. They are animated rotting corpses. They are real-life zombies. They are the living dead.

Yet because they still exist (the word 'live' no longer applies for their hell on earth) in our reality, they carry along with them the attachments of the people who love them. They are still somebody to somebody else: somebody's daughter, son, brother, sister, mother, father, husband, or wife. And we can only watch in powerless horror as our loved one is stolen away from us and, day by day, cut by cut, over months and years, butchered and left to decompose before our eyes.

This is Meth. This is what it does to us. Why have we as a society allowed our leaders and law enforcement agencies to pussy-foot around with this?

Sunday, October 07, 2007

Why Pregnant Women Frighten Me

I had spent the first half of my shift in the "Fast Track" section of the Emergency Department. Cases that are a level 4 and 5 on the 5-point triage scale are sent to Fast Track in order to make room for the more acute cases in the main ER. Cases that rate a 4 or 5 are cuts, sprains, bumps, bruises, series antibiotics, migraines, the mother who brings her six kids in because the ER is her family clinic, and such.

(I am a fervent proponent of "Fast Track." It keeps the patients suffering from non life-threatening ailments from having to wait too long to be seen, and it keeps the really sick people from having to wait for a bed.)

But this night was tough. Every patient I had was a pregnant woman. One had a headache (she was dehydrated, and needed to drink enough water for two instead of only one). Another woman had abdominal cramping but no spotting. (fetal heart tones were reassuring, she was not spotting, and she turned out to have gastroenteritis.) Others were there for coughs, colds, fevers,and so on. In all cases, FHTs were obtained and the 'passengers' were all just fine. But I was ready to be done with pregnant women.

Don't get me wrong. I think that pregnancy is, in itself, an amazing process. But at the same time, even a "normal" pregnancy is fraught with danger to both child and mother. Pregnant women are like the X-planes of the 1950s: awesome things happen inside them, but they can self-destruct in spectacular fashion without warning and without the slightest provocation. Pregnant women scare the crap out of me.

Fast Track closed at Midnight, and I was assigned the Float RN position until 0300.

At about 0100, the medic call came, signified over the intercom system by a soft,sweetly-intoned, bong-bong-bong that belied its urgency. The MD picked up the phone to receive the report. As he took notes, his brow furrowed and he rubbed his forehead with his free hand. He hung up the phone and handed me the Medic Call sheet.

A pregnant 25-tear-old woman had an on-scene BP of 226/116. Heart rate was 52. She complained of severe headache and numbness to her left arm. ETA was 10 minutes. I groaned.

We had taken care of pre-eclamptic patients before. Magnesium is the weapon of choice because it reduces the risk of seizures associated with eclampsia. Lopressor (a beta blocker) is also favored because it protects the heart and lowers blood pressure. But since this woman's heart rate was less than 60, we could not give Lopressor and thus intended to use magnesium as aggressively as possible. She was really rummy from the Mag; her speech was slurred, her limbs were floppy. But her vital signs were great. So we sent her to CT. Since I was the 'float' RN at the time, I went with the patient. She was on a portable monitor so I could continue to see what her body was doing.

She made it through CT like a champ. No evidence of a brain injury was found. As we were exiting the CT control room I said to the CT tech with a sigh, "Taking care of pregnant women scares the crap out of me. It's like being a demolitions expert." The CT tech said a heartfelt "Amen!" We carefully transferred the woman from the CT table to the stretcher for the trip back to her room. I looked up to reach for the oxygen tubing, and then looked down at her.

At that moment, she seized.

I rolled her onto her left side and barked to the CT tech, "Get the doctor NOW!" The other tech in the room frantically stuck a Yankauer wand onto the end of some suction tubing and handed the wand to me. I suctioned the secretions out of her mouth to keep her airway clear and waited the thousand years it seemed to take for the MD to get there. He finally arrived, breathless, and asked, "How long has she been seizing?"

"About a minute," I replied. The seizure was just beginning to abate.

"Let's get her back to the room now."

We pushed her back into the exam room (which was only thirty feet away from CT) while keeping her on her left side. The seizure had stopped by the time we got her back on the full monitor. She then entered the post-ictal phase and became combative. She swung, punched, kicked, and screamed gibberish.

"Give her 1mg of Ativan. Ramp up the Magnesium to 4 grams per hour. Keep her in soft restraints. I don't want to lose that IV, and I don't want to intubate her. Get her back on the fetal monitor," the MD said as he left the room.

We followed the orders. The patient was hemodynamically stable soon thereafter, and the Ativan helped settle her down. But the problem was not solved yet. Her passenger was in grave danger, and she was not out of the woods yet, either.

The on-call OB-GYN came in the room and said, "Get her ready to transfer to the University. I've already signed the orders." I set about getting the paperwork ready while the patient's primary nurse continued direct care. Within the hour, the patient was on her way to the other hospital.

We heard the next day that the patient underwent an emergency cesarean section. The baby was in very bad shape and not likely to make it. The mom had a massive stroke during the procedure and was also not likely to survive. It was her first pregnancy.