Has Critical Thinking Given Way to Rigid Protocols in the Medical World?

N95 Mask

During a busy week at the hospital where I work, it is announced that we need to be fit-tested for N95 masks. It has been two years since the start of the Covid 19 pandemic and this particular yearly task dictated by the Occupational Safety and Health Act (OSHA) of 1996 for medical institutions, has been allowed to be extended to two years. We have been wearing regular surgical masks throughout this whole time continuously and also wearing N95s during high-risk aerosol generating procedures and other contacts in the operating room. Covid numbers have now dropped significantly, and Employee Health has the time to concentrate on making sure all employees have the proper fitting N95s to wear.

There are to be several days during work time when we can sign up to be fit-tested at the hospital building. There is only one day available that I actually work. I find this requirement somewhat useless but decide I might as well sign up and get it over with. I try to follow the rules most of the time. One of my co-workers gives me the phone number to make this appointment. I dial the number.

“Do you have a time available on Tuesday for me to be fit-tested for the N95?” I ask.

“Yes,” says the Employee Health nurse, “We have a 12:30 slot that day. But wait… There is a note here that you need to have a medical evaluation before fit-testing.”

“No,” I say, “I don’t. I was fit-tested when I started working here almost two years ago and nothing has changed. I have been wearing an N95 for this whole time.”

“Well, let me check on this and I will get back to you,” she responds.

I don’t understand this. It makes no sense to me, but I let it go for the time being and go on with my day. My cell phone rings late in the afternoon while I am waking my last patient of the day from their surgical procedure. I let it go to voicemail. Once I am done, I call the nurse back.

“Yes, you need to be medically evaluated before you can be fit-tested. I don’t feel comfortable having you wear a mask until you are medically cleared.”

“What…..??? I don’t understand. I answered that questionnaire 18 months ago and no one seemed concerned at the time. Now they want to hold me to some standard from something I answered months ago. “What seems to be the problem?” I am totally frustrated.

“You marked some things on your pre-evaluation sheet that red-flagged you. You marked that you have had broken ribs, an arrythmia, and a stroke. You also marked that you have anxiety when wearing a mask. You should never have been fit-tested a year and a half ago before being seen by a doctor. I don’t know how you got through.”

This is totally ridiculous and now I am angry. My broken ribs were 10 years ago. The arrythmia has existed since I was a teenager with no one being concerned about it. The stroke several years ago was a mild one from which I am totally recovered. I have gone through the Covid 19 pandemic wearing my N95 without a problem. I have done my job diligently. I have never called in sick or even remotely been ill in the last 2 years. I have not contacted covid either but now suddenly I am too ill to wear an N95 without a doctor’s permission. The sheet I filled out 1 ½ years ago should be being replaced by the current one that I have ready for the appointment that will now not occur. What is even more ludicrous is that the medical establishment has been telling the public that they should all wear N95 masks now to protect themselves, but I apparently need a doctor’s approval to do so.

“Apparently, I need to stop being so honest and just check the boxes as you want them checked,” I grumble. “How about you write down that I refuse to be medically evaluated,” I shoot back at her.

“Then you can’t wear an N95 mask,” she follows the script set for her, “you will have to wear a C-papper (a large over the head hood). And I will have to notify your supervisor.”

I don’t know if I should laugh or cry. If the anxiety of mine is one of employee health’s concerns, then how is the astronaut suit going to help? Does she realize how irrational she sounds? I am not opposed to being fit-tested or wearing the mask. I am opposed to sharing my medical history with a physician who has no reason to even question me based on responses from time long gone by. I have proved I can successfully wear an N95 mask and that I am not going to die from doing so. The rest of this process is so unnecessary. I should be able to sign off that I am medically capable of successfully wearing the mask at this point. It is not my fault that they didn’t follow through on their proper procedures in 2020.

So this is what the medical field has come to? It is guided by protocols and algorithms from which one is to follow without question. No one is allowed to think anymore. No one is to analyze a situation or to think critically. The public especially the sickest people are told by the CDC that they should be wearing N95s at all times for protection from this virus, but the medical profession is still following a standard set forth by OSHA 25 years ago. And no one dare change how those who are responding to the pandemic on the front lines are treated or advised. If wearing an N95 is so potentially dangerous to one’s health, why are we asking millions of people to wear them and why haven’t millions of people keeled over from doing so? Have we all lost our ability to be rational? But then maybe I should just go back into my “I don’t care hole” before I lose my frickin mind.

Double masking with eye shield early in pandemic

              My Journey Into Genetic Testing

DNA Helix made in school by Kaitlyn

“We invite you to participate in the Tapestry study, whose goal is to understand how patient care may be impacted when results from DNA sequencing are in the medical record,” states the message that appears with my downloading e-mail. “The Tapestry study is a screening test. It looks at 11 genes associated with BRCA-related hereditary breast and ovarian cancer, Lynch syndrome and familial hypercholesterolemia. It is not a diagnostic test, nor does it look at all of the genes associated with hereditary ovarian cancer,” continues the dialogue.

            Hmmmm…. My attention has been captured. Should I consider a genetic study or is this a really bad idea? I did have ovarian cancer when I was 38 years old. But that was 25 years ago, and nothing has happened since. I am pretty sure I don’t have any genetic mutations for cancer. I have no family history of breast or ovarian cancer. But still . . . I do have a daughter who has become concerned here lately as to her risk of ovarian cancer. If all this testing were to come back negative, it would provide her with peace of mind.

            Three days later on October 23, 2020, I respond to the e-mail and join Mayo Clinic’s Health Tapestry Genomic Sequencing in Clinical Practice study. I am sent a kit into which I am to collect a specific amount of sputum. I spit into the collection container and mail it off to the lab in the pre-addressed box. Then I wait. The information given me was that the test results would take up to twelve weeks to be reported. That was simple.

            Several months go by and I do receive the fun results for the ancestry and genetic traits part of the study. I am 95% of European ancestry with 5% of Middle Eastern and African heritage. Mixed in there is a 0.8% Ashkenazi Jewish. I find out later this is important as 2% of those of Ashkenazi Jewish descent have a BRCA mutation. The results say I am not lactose intolerant (knew that). I have not adapted to be able to avoid malaria (Oh really!). I do not have the adaptation to be able to thrive in lower-oxygen environments at high altitudes (guess I’ll stay on the plains). I do have a genotype associated with the ability to adapt in cold climates (Brr… doesn’t seem like it some days in this cold MN climate). Along with lots of other useless tidbits, I learn I have brown eyes, tend towards curly hair, am taller, and tend to tan rather than sunburn; all things I have somehow managed to figure out after being on earth for 63 years. But what I really want to know, do I have a gene coding for cancer, is suspended in the health results that only say, “pending.” I think this very strange.

            Towards the end of January 2021, my husband is also invited to join this same study. He signs up on February 2, 2021, and submits his saliva sample a few days later. Ten weeks later, on April 19, 2021, his results are flashed to us as “ready.” He is negative for all eleven of the genes they are testing for that code for cancer. Hurrah, at least our daughter has a fighting chance!

            Puzzled as to why he has received his results and I have not, I send an e-mail to Helix, the company being used by Mayo for this study, “I signed up for the Helix genetic study back in October 2020. The information originally stated that we would receive results by twelve weeks. It has now been 5 months and there are still no medical results. I did get the basic genetic characteristics results, but I am just curious why I still haven’t gotten my medical results…?” Helix does promptly respond, “Our systems indicate that your sequencing has been sent out for interpretation. At this time, I cannot give you a time frame … Your Health results are taking longer to sequence than previously stated. We are unfortunately back logged due to Covid 19.” I find this all very confusing. Yes, maybe Covid is slowing down their results but that doesn’t explain how someone who signed up after me has already received their results and I haven’t. I am convinced that they have lost my sample and/or my results and are finding it convenient to blame it on Covid. It doesn’t occur to me until later that they are simply not telling me the truth; that they do know the results and because they are positive, they are not ready to tell me. If I could read between the lines, it would say, “Your results were positive. Therefore, we sent them to be confirmed by a second company.”

Mother and Daughter

            Three more months go by. I send several more e-mails to this company and each time I am told that my results, “are delayed due to supply chain issues” or “covid testing taking priority.” Finally, on July 26, they report that “it looks like your results are in a recent batch that should be released by Helix any day now.” Coincidently, Mayo sends an email three days later that says “you will receive an email from Helix very soon, with instructions on how to access your results on the Helix website. As a participant in this study, a Mayo Clinic genetic counselor would like to review your results with you over the phone.”  This should have been my clue that Mayo has already known the results for some time, and they are not good. Afterall, they never requested to talk to my hubby by phone to discuss his results.

            It isn’t until July 31, 2021, 9 months after signing up for this study that I get the results. “You were found to have an actionable* variant in the BRCA2 gene that is associated with a genetic condition called Hereditary Breast and Ovarian Cancer (HBOC). Individuals with HBOC have an increased risk for certain types of cancer, including breast, ovarian, prostate, and others.”

A numbness spreads over me. Why did I think joining this study was a good idea? I would have been better off never knowing. What I had hoped would provide peace of mind to my daughter has opened a yawning pit of anguish and anxiety. I am now 63 years old and have lived 25 years without any cancer reoccurrence. I have no desire to make any “might be possible cancer” a focus of my life. I can’t live that way. But the question remains, should I ignore what was better unknown or try to pursue some interventions, some of which are of a huge magnitude in order attempt to prevent what might happen? The medical community seems to be in a huge rush now to push me down this path towards interventions. No one seemed to care much before, and my cancer diagnosis 25 years ago has pretty much been forgotten. When I think about it later, the whole process of the genetic testing makes me angry. Helix and Mayo have known for at least 6 months but kept trying to pretend they didn’t by blaming other issues and now, it is all a big rush for me to respond.

            I take a breath and step back. There is no emergency here. I don’t have cancer. The first intervention I request is to be retested by another reputable company to make sure this is an accurate result and can be used to drive any decisions made going forward and will be accepted by health insurance companies. After being led along for 9 months, I do not trust the results I am being given. And it is not the first time such a test result has been wrong. I decide to give a blood sample this time as it has a higher rate of reliability than saliva and proceed to do so in early August. But if I was hoping for a different result, I will be disappointed. This test confirms the original finding of a “pathogenic variant (mutation) in the BRCA2 gene associated with Hereditary Breast and Ovarian Cancer syndrome.”

            So what is the big deal with this genetic mutation and what are it’s implications? BRCA1 and BRCA2 genes code for proteins that work to suppress cancer cells, mostly in breast tissue, and help to repair any DNA damage that occurs in the course of normal life. If they are missing or damaged, the cells cannot repair themselves and they go on to grow unchecked and become cancerous. BRCA2 is found on chromosome 13 while BRCA1 is found on chromosome 17 so they have slightly different cancer type expressions when missing. BRCA2 is associated with a 45 -83% lifetime risk, according to Mayo genetics, of developing breast cancer by age 70 (the average risk for the general population is 12%), a 27% risk of developing ovarian cancer by age 80 (the general population has a 1-2% risk). I think I have that one covered already. BRCA2 mutations also are associated with a higher risk of pancreatic cancers and melanoma than the general population.

Well, if that isn’t all depressing. And how is one even supposed to begin to deal with statistics like that? My first reaction is to have a double mastectomy without reconstruction and get it over with. I don’t want to be thinking about breast cancer every moment for the rest of my life. But after doing significant research on double mastectomies, I realize that they are not benign surgeries either. Many women have chronic pain afterward. Others have numbness and upper body muscle weakness. I am a fairly healthy 64-year-old by now. I run a chainsaw. I lift weights. I’m active. I do not want a life where I am cancer free but simply existing because I am debilitated and in pain constantly. And finally, having my breasts removed will remove any chance of having a meaningful intimate relationship with my husband. I am distressed to say the least about the dismal statistics but can’t decide what I want to do.

ME and my brothers

In October, I meet with a doctor from the breast clinic at Mayo. We go through my options: 1. Do nothing (that is not encouraged at all) 2. Have a double mastectomy (see reservations above) 3. Start taking aromatase inhibitors to help prevent cancer and/or 4. Monitor with alternating mammograms and breast MRIs every 6 months. I groan at each of them. I hate visiting medical facilities and doctors and have no desire to visit there constantly. Taking aromatase inhibitors sounds interesting but it is mostly a “hit and miss, maybe” approach. No one knows if I will actually get the kind of cancer that is prevented by drugs that block estrogen production and uptake. So there is a chance that I’m taking a toxic drug that is providing no benefit to me personally. I lean heavily away from their use after I read the side effects: hot flashes, night sweats, join pain by 50% of those taking it, muscle pain, and bone loss. I am back to the same issues of decreased quality of life to treat what currently doesn’t exist. I don’t know what to do.

Before I leave my breast appointment, I am offered the opportunity to join another study, “GENetic Risk Estimation of Breast Cancer Prior to decisions on preventative therapy uptake, risk reduction surgery, or intensive imaging surveillance: A study to determine if a polygenic risk score influences the decision-making options among high-risk women.” The polygenic risk score will take into account genetic risk factors, known as single nucleotide polymorphisms (SNPs) for breast cancer. While individually, these SNP risk factors are of little clinical value, when combined as a polygenic risk score (PRS), they yield a strong risk factor for breast cancer and can be used to personalize breast cancer risk. In other words, the polygenic risk score is an analyzing of 30 or more genes that influence whether a person develops cancer and coming up with a projection for any one particular person as to what their personal chances are of developing breast cancer. At first, I reject the idea of joining another study. I am already overwhelmed by all the information and decisions being thrown at me but the more I think about it, I wonder if it could provide me with the information to make a definitive choice as to the direction I should go. And so I sign up for one more genetic study. While I wait for the results, I try to go about life as normally as possible.

This time, I do not have as long to wait. Within 8 weeks, the results are back. “I have good news,” are the first words from the doctor’s mouth when I sit down with her. “You are in the lowest 7th percentile on the polygenic risk scoring. Because you had a hysterectomy at age 38,” she says, “I assess that you have a 9% risk of developing breast cancer in 5 years, an 18% risk in 10 years, and a lifetime risk of 27%.” That figure is still high compared to the general population, but I now know which direction I am going. At least for the present time, I will alternate the mammogram and breast MRI every six months. If any abnormality ever shows up, I will opt immediately for a double mastectomy without reconstruction. Now that I have made this decision, we have to come up with a plan for safely performing the MRI as I am allergic to the gadolinium dye that they use. This will be my biggest roadblock to following through on this decision.

In November of 2021, after loading up on methylprednisolone and Zyrtec, an anti-histamine, I successfully traverse the breast MRI. All findings are negative. I can breathe a sigh of relief, at least for six months. I begin to move on with life and focus on the future. And then, “your Cologuard test is positive.” Is there no end to this craziness? Is this what old age is all about? Waiting for the cancer shoe to drop? I reject that premise. I choose to live my life in freedom from such fear, God willing – to treasure each day for what it is.

The Other Side Of Medical Care – An Unexpected Journey

Beep! Beep! Beep! I roll over and hit the alarm for the third time. It is Friday morning and my day off. I am looking forward to a day of home activities. In the darkness of early morning, I slide out of bed and throw the covers back over the bed. As I pull open the bedroom door, I am hit by a sudden overwhelming curtain of silence followed by wooziness. That was weird. As I take that first step down the hall, my right leg wobbles and I reach out for the wall. My right arm also seems somewhat uncoordinated and I need to think about where I place them as I traverse the morning route to the bathroom in the dark. I shake my head several times trying to clear the cobwebs from my brain. It is not unusual for me to experience vertigo at times, but it usually passes in thirty seconds or so. This does not want to go away. I peer at my face in the mirror. All facial movements seem symmetrical. I console myself that it is probably not a stroke. I conclude that this must be an escalation of my normal vestibular (ear) problem. Afterall, I have been sick for most of the last week with the common cold. Maybe it has moved to my ears.

            “Are you OK?” It is the voice of my husband.

            “No, I am not OK.” I stand there trying to clear my head. “I would go downstairs to the bathroom, but I don’t think I can make it that far.”

            He offers me the commode as a seat, and I plunk down on it. I sense the watering in my mouth that precedes an upchuck. Oh dear!

            “Do you need to throw up?” he asks.

            “It’s coming. I don’t know what is wrong, but I think we need to go somewhere. I don’t know where to go at the clinic so maybe we should just go to the ER. Can you help me get dressed and then you should go plow first?”

            Thursday had been a day of receiving three to four inches of snow followed by high winds and significantly subzero windchills. As I had driven home from work at the hospital at 7 p.m. the prior evening, I struggled to see the road in places. I would find myself on the wrong side of the road, disoriented, and with the need to get myself back where I belonged. As I finally drove up the drive, the wind-driven snow hit me smack in the front. The drifts were piling up in the yard and in the driveway. I didn’t know if we could get out without plowing.

            I sit and contemplate my situation as Hubby makes his way downstairs and out the door. Because of the weather and the prediction of below zero temperatures, as well as an injured right arm from a fall on the ice on Wednesday, he has already decided to take the day off from work. If one has to be sick, I guess the timing could not be better. Hubby is home and neither of us are trying to get to work.

            After attempting to throw up, the ever determined me decides to comb my hair. I have to look respectable. I plant my feet wide apart for stabilization at the sink and with a little thought into directing my arm, I am able to accomplish this task. Now to get downstairs. I grasp the rail as I put one foot ahead of the other. As long as I think about what my right foot is doing and grasp the rail to stabilize the spinning room, I do quite well. I collapse in the recliner in the living room. Uh Oh! Almost immediately, I can feel that premonition in my mouth. I am going to throw up again. There is no way I am going to make it to the bathroom. What am I going to do? I don’t really want to throw up on the carpet. I drop to the floor and crawl the six feet on my hands and knees to the laminated flooring just in time to heave over and over. Exhausted, I crawl back to the chair.

            Bang! Hubby appears at the kitchen door. “I can’t get the plow truck to start but I think we can get out without plowing.”

            “Let’s just go then.” I grab my basin.

            The trees glisten with frost covered needles and branches. The sun shines brightly. It is flanked by the colored pillars of sundogs. The car thermometer displays 12 degrees below zero. On any other morning, this would be a beautiful scene to absorb and photograph. It is still a beautiful scene but not really enjoyable with one’s head in a barf bucket.

            A lady with a wheelchair is waiting for us just outside the emergency room. I could not be more thankful as I don’t think I can walk anywhere at this point. We are whisked into a room and soon introduced to a medical student. I was expecting hours of waiting to be seen but when one is really in trouble, the most efficient means of obtaining medical care is the emergency room. I suppose it was that telling them that my right arm and leg didn’t work right. That triggers a different response than just throwing up or some such thing.

            “Is this your partner?” asks the nurse who takes my vital signs.

            “No, it’s the guy I picked up in the ditch along the way,” I intone.

            “She hasn’t lost her humor.”

            Soon, I am performing all kinds of neurological tests. “Squeeze both hands. Follow my finger with your eyes. Pick up your left leg. Pick up your right leg. Push down on the gas pedal. Pull back towards your nose.” I perform most of these with ease. I only stumble on two of them. “Touch your nose, then my finger with your right hand as fast as you can.” My finger has a hard time hitting my nose and it takes complete concentration to hit the doc’s finger. “Slide your right heel up and down your left shin.” To this command, I find my heel weaving down the shin bone. I just can’t make it go straight.

            “We think you might have vestibular neuritis (a viral infection that affects the nerve of the ear) but because of difficulty with those two tests, we are going to send you for a CT scan.”

            I grab my trusty barf basin and off we go. By this point, I am throwing up every fifteen to thirty minutes. If I keep my eyes open, the world has some semblance of stability. If I shut my eyes, the world goes around and around. When I sit up to transfer to the CT table, I sway back and forth like a branch in the wind. “I think we should just slide you over,” is the conclusion of the CT techs. Good decision!

            I make it back to the ER just in time to throw up again. I have given up waiting for them to bring me the promised medicine for nausea. I hit the nurse call button. “Can I have some nausea medicine?”

            “I don’t think there is anything ordered,” states the nurse who responds. Really? There have been two different doctors who have promised this. I am ready to collapse into a sobbing heap as I just keep heaving and heaving. I have lost track of the number of times now. Soon she is back with the treasured medication.

            The med student squeezes her body though the slightly open door, “The CT shows a small cerebellar stroke, so we are going to put through a neurological consult.”

Shock would be my reaction. Why would I have a stroke? I don’t have high blood pressure. I don’t have diabetes. I am not particularly overweight. I have never had a blood clot. I do not have atrial fibrillation. I am only sixty-one years old, exercise regularly, and I take a full aspirin every day. All I can think of is my father who had a major stroke at eighty-two years of age from which he never recovered. He could not write or talk or communicate for the next seven years before he died. I would rather die than be like that.

Within a few minutes, the neurology resident appears, and we go through the same battery of neurology tests again. “I am going to send you for an MRI to evaluate the arteries in your head and then we are going to admit you to the hospital.”

By this time, I no longer care. I just want relief from the nausea. I want to sleep but every time I close my eyes, the world spins and renews my discomfort. By the time escort comes to take me to the MRI scan, I have received some Compazine for the nausea, but I still do not trust myself. The nauseous feeling lies just below the surface.

“What am I going to do if I have to throw up in the MRI scanner?” I clutch my emesis basin close to myself as if it were my security blanket as we set off again for another test. No one seems particularly concerned but me. I try to calm my rising panic as they strap me onto the MRI table and snap the head piece into place. I am somewhat claustrophobic anyway. So I talk to myself. Just take deep breaths and close your eyes. Then you can’t see how tight the tunnel is. I clutch my call ball and shut my eyes. At least the world has stopped spinning. The air blowing into the tunnel is cold and I shiver. By this point, all I want to do is sleep anyway so I doze off and on and soon the test is done. I am so glad the medicine is working.

I sway back and forth as I sit up after being transferred from the cart to my hospital bed. I close my eyes and go to sleep. This whole situation is beyond comprehension. My hubby settles down in the chair next to my bed. His face is lined with worry.

My assigned nurse comes by to introduce herself. She holds up the ridiculous yellow band that says, “Fall Risk.” They put them on everyone who admits to having a fall in the last year. Everyone in Minnesota in the winter is a fall risk and I have always told my colleagues if they ever put one of those things on me, I would cut it off. I stare at it and sigh. I guess I really am a fall risk. I soon discover when I try to sit up on the edge of the bed that a loud obnoxious noise also emits from the bed!

Sleep seems to be the only thing I am capable of doing without supervision. Before long, I am awakened again. A transport cart is parked by my bed. “You are going for a CT scan with contrast.” How many scans can I possibly go for? I just had a CT and an MRI and now we are going to do another CT – this time with contrast!  So off we go again. I try to keep my eyes open to prevent the dizzying spinning.

Later that afternoon, the neurology resident comes by the room. “None of the scans show any evidence of vertebral artery tears, plague in the arteries, or a bleed. Since we do not find anything in your head, we need to look at your heart. I am scheduling a TEE (transesophageal echo) for tomorrow.” Gads! How many tests can they come up with? By this time, I am starting to feel significantly better and am returning to my normal personality. I ask to visit the bathroom and am trilled that I can ambulate fairly well. I still cannot pass a roadside DWI test but with the compensation of a wide-stance gait and a tightly clutched gait belt by the nurse, I can walk. Bored with being in bed, I sit up in the chair for a couple hours. I attempt to find and write down a few phone numbers for calling my supervisors, but my hand produces mostly an illegible scrawl. I can text if I take my time. After notifications to some family members of my state of affairs, I crawl into bed and sleep some more.

Steam rises from the chimneys of the city outside my window on Saturday morning. My immediate view is that of the hospital chapel, its door surrounded by frost. My life feels a little bit like it is surrounded by frost too. I was not planning to be here today. I have life to live.

Not being inclined to be an invalid, I situate myself in the chair. I just need to be careful about not doing any spins or dance moves. Reassured that I am fine and won’t do anything stupid, the nurses have turned off the bed alarm and I have reverted to being the patient+. This means I maneuver my own IV pole, my bedside table, and IV pump the best that I can. The lab gal comes to draw my blood and I ask her to use my left arm because the right antecubital area is all black and blue. “But someone has to come and turn off the IV,” she declares.

“No problem. I’ll take care of that.” And I do.

Soon there is a knock on the door and a lady from occupational therapy enters. “How are you doing? My job is to evaluate you from an occupational standpoint and determine if you need therapy. Can we go for a walk?”

I sign heavily. I am fine but I am happy to go for a walk in the hall. She slips on the dreaded gait belt and off we go. The IV pole provides all the stability that I need. I am convinced that if I stumbled or started falling, this lady would not be able to help me. She seems more unsteady and feebler than me. My being as good as I am, I reflect, has nothing to do with my own abilities but to the grace of God and his goodness in allowing me full return of my faculties. This facade of independence, competence, and strength that we all present to the world is just that, a façade that can be crashed at any moment.

I have not eaten any breakfast as I am not to eat in preparation for the planned TEE.

Imagine my surprise when the escort shows up with the transport cart around ten am. “I am here to take you to your MRI with contrast.”

“My MRI??” I question incredulously. “I thought I was going to have a TEE today?”

“The directions say we are going to an MRI,” repeats the escort gentleman.

I just love the communication around here. No one talks to me. They just change plans out of the blue. I guess we are going to an MRI. I think I will have met my medical deductible with two CTs and two MRIs. This time I am more prepared and feel physically better. I open my eyes in the MRI scanner and look around the best that I can while being in a head vise. Above me is a mirror that reflects the head frame back at me. It gives the illusion of more space than there really is. I can’t actually see the bore that surrounds me. That’s interesting. I wonder if they can see me from the control room.

Back in my room, I get up to the bathroom. My legs and my upper arms are covered with red spots intermingled with white splotches and they are starting to itch. Great! I must be allergic to the MRI contrast used. The MRI tech told me that no one is allergic to the MRI contrast. There is always a first. The only time I have ever seen this on me before was after several mosquito bites in the same area and that rash lasted for weeks. The only thing that was helpful was to grit my teeth and not scratch.

The resident comes by later in the afternoon to inform me that this MRI did not show anything abnormal either. “I thought I was to have a TEE today. How come we went for MRI instead?”

“We can’t do the TEE on the weekend unless it is an emergency, so we have to wait until Monday. We wanted to definitively confirm that nothing is going on in your head anyway, so we decided to do the MRI instead.” I am beginning to wonder if there is anything at all in my head. Maybe they are just trying to find a brain.

I sigh. I am already bored and feeling over tested. I have so many things I could do at home. “Can I go home today then?”

She gazes at me and smiles. “You do look quite well. I guess we could let you go home and come back for the other tests we want to do as an outpatient. I will order a 48-hour Holter monitor for you and once you have the device on, you can go home. We will order the TEE for Monday as an outpatient.”

“Versed and Fentanyl medications do not work for me so I would really like one of my colleagues to use propofol for me.”

“Just tell them when you get there,” she brushes my request off.

“That isn’t going to work,” I impress upon her, “If you do not order it as anesthesia, no one is going to honor my request. I know how this works around here.” I can tell by her face that she has no intention of following my request.

Taking a shower is the next item on the agenda if I am going to have stickies all over me for 48 hours. With meticulous care and deliberate moves, I gather all the supplies necessary and bask in the warm shower. I am still somewhat like a waving reed but if I take my time I can compensate for any remaining deficiencies. This could have been so much worse. How does one wake up one morning and five minutes later, the world has been turned upside down? It hits me that we are not prepared for something to happen to me. I have always planned that my hubby would go before me. After all, his parents died in their early seventies and mine were both 89 at their time of death. The urgency of remedying this situation floods over me.

Once my shower is done, the Holter Monitor tech comes to hook me up. The last order of business is to read the discharge instructions. I notice that they changed my cholesterol medication without telling me and that the resident has marked sedation instead of anesthesia on the TEE order. She comes back to see me one more time at my request and I point out to her that there is a box to check anesthesia. “Alright, I will see what I can do,” she finally concedes.

How am I going to know when the TEE is planned for on Monday is my question? The resident has given me the phone number for the floor at the clinic where they do these, but I do not have a time. I am told that they will probably call me to let me know but no one really knows.

Monday morning, I anxiously wait by the phone. I check the on-line portal for patients. It tells me that there is a TEE scheduled for “undetermined time.” That is helpful! Finally, after hearing nothing by 8:30 a.m., I make a phone call to the clinic. “You are scheduled at 2:30pm in the cath lab at the hospital,” she tells me, “We don’t usually do them there for outpatients.”

She transfers my call to the cath lab. They clarify that I am on their list, but the nurse then hesitates, “Are you on an anticoagulant now?”

“Nooo… not more than aspirin and Plavix. And I got three heparin shots in the hospital.”

“That’s all gone by now. So that’s not enough. You have to be fully anti-coagulated before we can do this. I need to make a phone call to the doctor and then I will call you back.”

I do not know what to say. I am confused. This seems rather excessive. But then, I don’t do TEEs every day, so I have to assume he knows what he is talking about. I wish they had thought of this on Saturday. Maybe I should just have stayed in the hospital.

Finally, around 10 a.m., he calls me back. “My mistake,” he says, “We should be good. I thought you were having a cardioversion. We don’t need full anti-coagulation for just the transesophageal echo.”

The light bulb goes on in my head. Now I know what has happened. I have totally messed up the system and confused everyone. In order to meet my request for anesthesia-controlled sedation instead of nurse sedation, they needed to schedule my procedure in a place where anesthesia is available. And in doing so, the nurse there assumed that I was having the procedure commonly done there. It always amazes me how confused the system can get by changing just one aspect of the standard practice.

But I am delighted to find that one of my colleagues, a Certified Registered Nurse Anesthetist, is there to administer that special drug, propofol, that I handle so adeptly every day. I drift off into a blissful sleep to wake up feeling comfortable and secure at the completion of the procedure. Finally, I am able to reap a benefit of my career.

In spite of all these tests, no clots, or artery tears, or cholesterol plagues are ever found to explain why this happened to me. It leaves me wondering. Is there another time bomb waiting to go off some day? Only time will tell. And I think I like being on the provider side much better than on the patient side.

Too Young to Retire, Too Old to Change – A Day In Anesthesia

 

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From my trip to Guatemala in Feb 2013

“Relieve OR 108,” says the note written on the assignment board as I return from lunch on this scheduled day of surgery. Today is like any other day in my work life as a nurse anesthetist. I make a bathroom stop and then stride into OR 108 to relieve the anesthetist that was previously assigned there. The patient is already asleep and positioned, so all the physical work is pretty much done. The surgical staff is casually chatting as they wait for the surgeon to show up. I take report from my colleague and get settled in for what seems like it should be a rather routine anesthetic.

I now have two places to sign into when entering an operating room- into the charting system and into the drug dispensing system. In just the last couple of weeks, what is called Pyxis A has been installed in some of the rooms. Pyxis A is a drug dispensing system that is stocked with pharmaceuticals that we might need in caring for our patient during the course of an anesthetic. Most of these drugs used to be freely accessible without charging the patient or were gotten from a central drug dispensing system in the hallway or supply room. Now the patient will be charged for each drug used. Definitely, more cost effective for the institution, I would assume.

Change seems to be the order of every day in my workplace. In just one more month, we will be getting a whole new billion-dollar charting system throughout the hospitals. Change always has been a part of the Mayo system for whom I work but changes seem to be coming faster and faster in the last few years. Maybe it is just that I am getting older and no longer have the resilience and energy to quickly make the transitions. My brain is stressed by the continual changing of the rules and policies and systems. There are days when my head literally spins.

As preparation for any emergency that might occur, I make a quick survey of the setup of this room in order to establish in my brain where each supply or drug is located. This is necessary as all the general supplies for patient care have also been relocated to different cupboards and drawers in an effort to make way for the new drug machine and to “standardize.”

Soon the surgeon arrives, and we stop for our “pause” – it always reminds me of the practice of bowing our heads before digging into the food to thank our Heavenly Father. The “start” button is clicked, and we are off… I plunk into my chair to take the load off my feet. Ugh! I realize this is one of the chairs that I find causes my back to ache after about 30 minutes of sitting. I make a call to the anesthesia lead, “Can you bring me one of the chairs from the work room?” I am sure they are rolling their eyes at my request. I have come to realize that if I don’t want to be in agony for 10 hours and want to be able to work a few more years, I have to make some really strange adaptations to preserve my back. Five minutes go by and then a chair is pushed in the door at me with the comment, “Your funny!” Yes, I am.

As I monitor my patient, most of the time I don’t pay much attention to the chatter that goes on on the other side of the drapes, but today I begin to pick up snippets of conversation that grab at my attention.

“I just can’t get this in,” says the surgeon. And to the nurse, “Can you call interventional radiology and see if they can take this patient directly from here?”  OK, I need to be part of this conversation. THIS affects me. “Are you thinking of taking this patient to IR?” I question.

“Yes, and it would be in the best interest of the patient to go directly from here rather than waking him up and sedating him again later.”

I would agree with that, but this is not something I was planning on. I have not been to IR more than once in the last 2 years since it was moved downstairs to the main level of the hospital. I don’t usually work there, and I don’t even think I can find it. My anxiety level has shot up a few notches and heat begins to creep out of every pore. Off comes my scrub jacket. This is not how I foresaw my afternoon beginning. I make a phone call to the anesthesia lead and soon the transfer is coordinated and finalized. Now to have someone fetch a monitored transfer cart and get the patient ready.

I turn to find Sam, another nurse anesthetist, standing behind me. “I am supposed to help you take this patient to IR,” he informs me. That sounds like music to my ears. We move our patient to the cart, get him hooked up, tucked in, and I am ready to go once I switch over to the Ambu bag for ventilation on the trip. As we start down the hall, I am struggling to ventilate the patient with my right hand and to steer what seems like a semi with my left hand.

“Sam, can you help me guide the cart before I crash into the wall. I have this habit of paying attention to my patient and not paying much attention to where I am going.”

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Kinda like this, not quite this bad

“Why don’t you let me push and steer,” he responds, “And you run ahead and make sure the doors and elevators are open and ready?’

I hesitate for just a second and then I willingly turn it over to this strong young man. It is time to stop trying to be the macho woman I have always been and let the younger generation help me. Soon we arrive at our destination. Many hands are waiting to help flip our patient prone onto the Interventional Radiology table and he is soon comfortably repositioned. Sam helps me with all the tasks of getting the patient in the computer and settled. Before he leaves to go home, he takes the extra time to point out where all the items I might need are stored. My stress level has settled back to a comfortable hum. I can do this. As I think about this whole situation, I realize how just one person has made what seemed like an overwhelming situation into a manageable and even fun one. My co-workers are the best. I think I will nominate Sam for a “Best at Helping Old Ladies” award.

Progress at the Destination Medical Center

Wednesday morning – I haven’t been to work since the weekend. How much could possibly change in two days?NightCrossesJohnsonWedding 138

I stride down the hall from the parking ramp, lost in thought in another world. Suddenly, the hall turns right and trails down a corridor that I have never traveled before. Where am I? Oh yes, I remember seeing a sign last week posted to the main hallway sidewall that stated, “Hallway to be closed on May 24.” Precipitously a new hall has appeared. The only choice is to keep moving forward and see where this passageway comes out. I feel like I am completely in another world physically as well as mentally. I turn this way and that, not recognizing anything. My brain is confused. Did I park my car in the wrong ramp this morning for I am hiking down hallways that sport appointment desks, waiting rooms, bathrooms, and decorated sidewalls? Where did all this come from? Eventually, after an endless walk, I come back out to an intersection where my brain is able to finally say, “Ah, yes, I can go back to my non-alert state.” Apparently, behind all that plastic lining the other old hallway for the last year or so has been growing another clinic building.

I change into scrubs and head down to the operating rooms to begin breaks for my fellow nurse anesthetists as I always do. Somewhere during those first couple of hours, I arrive at the realization that what used to be the recovery room has also closed during my two days away and a new recovery room has opened. This new facility has small individual rooms for each patient while the old one was a large open room with clusters of bays for patient care. It is a modern work of art. I even have to scan out with my name badge to get back to the operating room suite. Strange. Are they afraid the patients are going to make an escape back to the OR?157

Here again, my brain struggles to figure out the new rules. Does everyone go to this new recovery room? Or do some patients go to what we call “the far east” which currently serves as the pre-operative area? And who decides? Within the first 30 minutes, my pager goes off telling me that “Patient John Doe is to go to the east pacu postoperatively.” That is an odd page. And why am I getting it, I wonder? I am not this patient’s anesthetist. And where does this page originate from? No one seems to have an answer to my questions.NightCrossesJohnsonWedding 162

As a final addition to all this change, a change has also been made as to how some of our drugs are packaged. They look different and they are harder to distinguish one from the other. I have worked here for 29 years but today, I think I unknowingly got off the wrong bus at the wrong hospital. I just don’t remember doing so. Maybe that is how Alzheimer’s works.