Ready for the Ride!

What a rush it must be to get to ride this into orbit.  Too bad it’s the last night launch, and closing in on the last launch of the shuttle.  Nearing the end of an era.

Keepin’ the Beat

It looks like I’ve broken my streak.  I actually had almost 3 months without a Rapid Response or Code Blue on my shift.  It’s no more.  At least we didn’t have to do CPR on this little 40kg bag of skin and bones, just some airway support and off to the ICU.

But it got me thinking.  Thinking led to rooting around in my “book o’ fame” (my morbid collection of EKG strips of “bad things”) which led to me finding a couple of strips related to CPR.  Strange how a mind works.

Evidently, per the post-it note, these had been grabbed during a code last year where I did a TON of CPR.  Remember kids, a bad thing about being a big strong dude is that you get to do a lot of chest compressions.  I’m not dissing the ladies, I’ve seen many a round done by y’all, and you’re fierce, but for some reason whenever there is a code on my floor, yours truly gets roped in to do compressions.  Needless to say I had no need to go to the gym after that code.

My tele tech knows my predilection for interesting tele strips so he printed a couple for me.

First, near the beginning of the code:

CPR is in progress with a rate around 100bpm, stop to check for a rhythm, find VT, resume CPR, then shock.  This is why you resume CPR right after the shock.  That heart ain’t doing nothing.

Second near the end:

We’re still going fairly strong, figure the rate is around 80bpm, then nothing.  We called it about a minute after this strip was run.

In all fairness, they were dead from the get go.  Never once did we get a rhythm stable enough for transport, never a pulse, pupils were fixed pretty much from the beginning.  Morbid?  Probably.

But on to the beat.  They say 100bpm is the speed we need to keep when doing CPR.  It allows for adequate refilling of the ventricles with blood before the next compression.  In the midst of the controlled chaos of a code, keeping that speed can be tough when adrenaline gets the better of us.  So what do you do?  Keep the beat with a song.

We’ve all heard of “Stayin’ Alive” by the Bee Gees as the “perfect” CPR song.  Heck, I have it on my header.  My BLS instructor the last time around had a thing for “She’ll Be Coming Around the Mountain”.  There is the slightly more darker “Another One Bites the Dust” by Queen that fills the 100bpm measure.  Thanks to the American Heart Association, there is a large list of songs that fit the bill of 100bpm.  Some notables include:  “Kickstart my Heart” by Motely Crue (they would know), “Paradise City” by Guns N’ Roses. “Heart Attack Man” by the Beastie Boys and of all things, “Back to Life” by Soul II Soul.  The entire list can be found at Be the Beat, which is a website dedicated to educating kids about CPR, but here’s the playlist.

Will this help me set a new streak?  I doubt it.  As the rule of three shows, I have 2 to go before a new streak can start…

That’s Just Wrong

Not too long ago we had a patient on our obs unit who was dealing with some issues of constipation.  Unfortunately, they had 2 things working against them.  First, was being born with a congenital defect requiring surgery and leading them to a life of issues with their bowels.  Second, was being admitted to obs by Dr. Jackass.

Dr. Jackass wrote that the patient would be able to discharge after having a bowel movement.    After a phone call by the nurse for some pain medication, he decides to send things into overdrive and orders the following:

“continuous soap suds enema with rectal tube until clear”

“Say what?!” asked the nurse.

“Say what?!” asked the charge nurse.

“Fuck that!” said the patient who was young, alert, oriented and appropriate.

“He ordered what?!” asked Dr. I-have-a-clue who was the overnight cross-cover, “Yeah, nix that.  Go ahead and try a soap suds enema x1 – if they’ll let you.”

No enema.  Patient pooped, slept and went home.  Nice simple resolution.

original image here.

Totally Inappropriate, But Still Funny

Shocking Internal Retirement Home Betting Pool Memo | Top Cultured.

First off, it’s a fake.  Second off, betting/wagering on the lives of those you take care of is wrong.  But here’s the thing:  I can understand it.

We’ve bet on ETOH levels, BNP levels, how low a hemoglobin and hematocrit is, how much dilaudid a patient will request in a shift, when patients will be discharged and yes, even when patients may die (in a very vague, hoping it’s not tonight way).

I almost started a pool this weekend to see when one of our long-term patients will be discharged – mind you their visits are measured in weeks, not days.  And I would have had takers too!

Does this make us bad people?  No.  Does it make us callous and uncaring?  No.  It is a very nurse way of dealing with bad situations.  Black humor gets many of us through the day-to-day struggle that being a nurse can be sometimes.  A joke, even in a dark moment can bring a needed burst of levity and relief to a stressful situation.

It’s not that we don’t care, but perhaps we care too much…

Then again, I’ve never put odds down on folks, that’s just inviting disaster, like saying the “q” word while still on shift.

A Nurse’s View on the iPad in Healthcare

According to the already gushing reviews, the iPad is a “game changer” and “the device health care has waited for.”

Not really.

I do believe that there will be areas in health care where it could be very useful and could make a difference.  One example that comes to mind is the typical office visit.  My primary care doc uses the computer in the exam room while in the midst of our visit.  He can look up past visits, lab values, meds and all the ephemera of a medical visit.  Instead of staring at a computer through the visit, he can look at me and be more engaged with the patient, instead of being engaged with the computer.  Another w0uld be for rounding on the wards.  How useful could it be to have everything at your fingertips when you’re at the bedside conducting rounds?

But for the average nurse at the bedside it is a horrible idea.  First, it does not appear to be very durable, able to deal with the crap a bedside nurse could unleash upon it.  Us nurses are hard on equipment, especially things we use near continuously in our work.  It is more a repetitive stress type brutality than “give a shit” mentality.  I don’t think Jobs’ fancy, purty piece of engineering could stand up to a typical 12-hour floor shift.  Then there is the issue of exposure to bodily fluids, urine, blood, mucus, poop.  Bedside nurses deal with all of that on a daily basis and while we wold probably be careful with it, shit happens.  No one starts a shift wanting to get pooped on, but it happens y’know?  Then there is the infection control issue.  We have enough issues with nosocomical infections like MRSA and VRE in health care and a portable tablet could be a very effective fomite.  Not only would we then be reminded to wash our hands, but to sterilize our iPads.

Second, it’s lacking in important features.  Bar code scanner?  Nope.  With our new EMR, all meds will be bar-coded, lab slips will be the same, even the patients will be bar-coded, so not having that is fairly significant.  If you’re going to have a device to help with the  tasks and functions of a bedside nurse, we better not have to carry multiple devices, like the pad and a bar code scanner. Swappable batteries?  Uh-uh.  We work 12-hour shifts and according to the press, battery life is around 10-hours.  I don’t have the time on shift to stop, plug in my device for an hour to get more juice so I can finish my work.  Device integration to monitoring equipment?  Not yet and probably not without a very expensive software patch.  In our new EMR, our monitors and vital signs machines are supposedly going to be integrated so that instead of entering values, we click and the values populate.  Now I’ll believe it when I see it, but having used that before, it is cool beyond a doubt.  But is Apple going to open things up to support multiple standards?  Not without a hefty price tag, if at all.  And these were only the first three I came up with.

Third, and probably most important is price.  Even if we get the barebones version, with academic pricing, it’s still going to be expensive.  And if each nurse, on each shift needs one…that could get costly.  If my floor is full, we have 7 nurses, 2 aides, a unit secretary and a tele tech on days, at night, it’s 7 nurses, 1 aide and a tele tech.  To cover the needs we would need to have 14 tablets – at least, probably with one or two for back-up.  That’s one unit.  My manager handles 3 units of varying size, so you do the math.  And that’s just one group of units.  So what?  Do you issue them to nurses on hire?  Are we now responsible for the upkeep and cost should it be damaged?  Hard questions.  What about the “walking away” of the devices?   Some people will steal anything that isn’t bolted to the floor (and some will try to steal that as well) so a tablet you can slip into your coat could disappear quickly.

Would I love to see imaging results live at the bedside?  Sure.  Would it be great to have the last set of vitals, labs and meds at my fingertips when assessing the patient?  Yes, but we already have that thanks to in-room computers.  Would it be awesome to have a cool Apple toy to play with every day I work?  Yeah, it would be cool.  But cool doesn’t always make sense.

So what would I find useful as a bedside nurse when it comes to a tablet-type device?  Here’s a short list:

• Small form factor – bigger than the iPhone, not quite so big as the iPad.  Big enough to view screens without scrolling too much, but possibly be able to slip into my scrub pocket.
• Durability/ease of cleaning.  It’s going to get dropped, exposed to fluids and bugs.  It needs to be able to stand up to that.
• Bar-code scanner.  It’s the wave of the future in EMRs, so any device coming into the arena will need that.
• Good battery life.  At least 12-hours worth, or with hot-swap capability.
• Easy transfer of notes.  I can think of how this would revolutionize the report-process.  You gather the info needed and send it to the next caregiver’s pad, report becomes easier.
• Solitaire.  We need a moment of brainless fun every now and then!
• Device integration.  I want to see the current telemetry on my patient and be able to review past alarms.  When I take vitals, I want it to populate the fields with one click.  I want to see what pumps I have going, volume left in an infusion and even order new meds if necessary from another patient’s room if I need to.
• Multi-tasking.  We’re doing it all the time, why can’t the device?  I want to be able to look up a drug in the database while calculating the dose, as one example.

These are just few things I came up with off the top of my head.  Sure some of this may sound like it based off of laziness (see infusion pumps and ordering), but I believe in working smarter, rather than harder, so if I can see what’s going on in another room without having to go there,I’m all for it.  I do think that at some point we’ll have tablet-type stuff at the bedside.  But right now, I think devices like the iPad are more suited to physicians and non-bedside nursing than to the bedside nurse.  Time will tell.

Hypotension Causing Nursing Hypertension

Hypotension Causes: Three Cases Of Severe Hypotension and Their Dramatic Response To Treatment.

I’m almost going to print this up and drop it in a couple of hospitalist’s mail boxes as they completely buggered their management of the hypotensive patient.
So here’s the story…
50-odd year old dude comes in with bilateral foot wounds, both medicine and podiatry are seeing him.  They start antibiotics and aggressive debridement of the said foot wounds.  To complicate matters, dude is “fluffy”.  Y’know, 400+ and we can’t tell if he is edematous or not.  It’s all fluff.  Instead of thinking sepsis, they’re thinking he needs to be diuresed.  Considering a history of CHF, not a bad idea.  But as he’s getting massive doses of IV Lasix, we’re talking drip rates in the 40mg/hour range here, his urine output starts to drop.  It dwindles, then nearly completely stops.  Bad sign, right?

As this is happening, his pressures are following the exact same path, dwindling down to nothing over nothing.  We’re talking 60/doppler and his pulse is dandy.   But here’s the thing:  he is completely alert and oriented, talking a mile a minute watching the Food Network.

This goes on for 4 days and 5 nights.  Yes, 5 fucking nights.  The nursing staff would call the the on-call staff, explain the situation and be rewarded with, “Oh, uh, turn off the Lasix.”  or “Uh, um…give him a 500ml bolus of NS.” The staff leave detailed notes in the progress notes about the situation so that they can be reviewed by the next day’s docs, but still nothing is done.  Maybe some more piddly-ass boluses that do a whole lot of nothing, but produce no net effect.

Finally on Day 5 (yes, Day 5) as his kidney function is truly in the shitter (creatinine is like 4.0), his ‘lytes are all wacky, his H/H is crap, he barely has any albumin, he hasn’t made urine in 4 days and has been getting goofy at night needing higher amounts of O2, someone decides to actually DO something.  2 units of packed cells, albumin q8, a couple of decent fluid boluses and dopamine.  Finally.

And as if by magic, he gets a blood pressure.  A real blood pressure, like 120’s/80’s.  He slowly starts to make urine.  His O2 need starts to go back to baseline and he’s no longer goofy.  Podiatry decides that now that he is stable it is time to do surgery to lop off the now gangrenous foot and get on with definitive care.

Here’s the thing:  we could have fixed him on night 1 had the on-call doc been willing to look and realize something was not right.  Could we have called a Rapid Response?  Yes, but he wasn’t truly in need of it.  He was relatively stable, with the exception of no blood pressure and no urine.  Besides, we figured that we could manage him on the floor without the ICU.

No one seemed to be cognizant of the fact he was in septic shock from those nasty feet of his.  That is until a prog note was written post-surgery that basically said, “acute on chronic renal failure and septic shock.”  Finally someone got it.

Callous Comment of the Night

“Oh look, Mr. Sleep Apnea is in the ER, ‘hearing voices’.” says one RN.

“Someone just needs to tell him that it’s only his trach whistling again.”  replies jaded charge nurse, barely looking up from their charting.

Somedays it’s hard to be warm and sincere.  It’s easier to be cold and callous.  Thankfully those are far and few between.

Add Another to the List

From the folks that brought you…

fibromyalgieurs

chest painieurs

methadonians

chronic drug seekieurs/chronic painieurs

comes a whole new group of fun-time pains in the asses:

*drum roll please…*

gastroparesis-ieurs

Yes, you too can have nebulous complaints that never seem to be fixed without the aid of “dilauntin”.

Why pay rent when you can convince the docs that your symptoms are still sooooo bad that you can’t go home?  And in spite of having a jejunostomy tube, you too can be a bulimic by sucking out the stuff you just swallowed through said tube.

Ran out of IV fluids and phenergan at home?  Come on down, we’ll hook you up!  Mix some dilaudid in the IV piggyback bag they now make us use for phenergan and throw it all down at once…it’ll be great!  Just don’t complain that, “I get bigger doses of phenergan at home!” because we just might tell you to go back there!

But in all seriousness…

I know that gastroparesis ican be a debilitating medical problem, whether from diabetes, destruction of the vagus nerve, what have you, it can make one’s life miserable.  I feel bad for those that truly have it.  These aren’t the ones I speak of.

Lately we have had a string of patients with “gastroparesis”, where the etiology is more psych related that physical.  And these are the patients that wear you out physically and emotionally.  Manipulative?  Yep.  Borderline personalities?  Probably.  Entitled?  You better believe it.  It’s almost like they have a local club where they get together, talk “shop” and trade secrets and regale each other with new stories of how they pulled it over on Doc So-and-So.  Several of them have implanted ports and administer IV fluids, pain medications and anti-emetics at home, but “decompensate” and get admitted to our observation unit for treatment of “nausea and vomiting.”

They seem to be the ones where nothing you throw at them works.  Zofran, compazine, phenergan never seem to take their nausea away.  (Maybe next time I should suggest droperidol or thorazine…)  Their favorite for pain relief? The Big D, baby.  Dilaudid, or as one so eloquently put it, “diluantin”.  And not small, infrequent doses either.  1-2mg q2 hours.  Srsly.  One even sets their cell phone alarm to when they can have it next.  And boy do some of them have tolerance.  One had an endo and received 10mg of Versed IV and   300mcg of Fentanyl IV.  If you have given me that last week I would still be gorked today.  But it did “nothing.”

Luckily though, the docs are wising up.  The one I had the other night had written in the orders section, “NO NARCS!” in bug, bold strokes.  Two of them have been black-listed from our observation unit as they tend to stay for days-weeks at a time instead of the obs stay of 24-48 hours.  I’m sure that as of now, they are passing the info and will soon to migrating to another local hospital for the cycle to begin anew.  I hope.

One last thing that bugs the shit out of me:  when you ask for nausea medication, don’t ask for 2 yogurts, some graham crackers and a turkey sandwich to wash it down with.  The nausea you’re feeling is probably just hunger pangs…

A Look Back

I got thinking today how my life has changed in the last decade.  Decade?  That’s kind of a weird concept, I mean usually it is looking at a year gone by, not ten.  Suffice to say the last ten years have been the hardest years of my life, well OK, last 13 or so to be honest, but looking where I’ve been makes me think of where I’m going.

I started the decade off dancing with my girlfriend (later to be my wife) to Lonestar in the bar of the Grand Canyon Railway Hotel, then waking to several inches of snow the next morning.  I ended it with some work colleagues in an empty room watching the ball drop in Times Square – Dick Clark looks just like he did 10 years ago.

Then I got thinking, how does it really break down?

7 moves, including to and from Arizona.

6 jobs, including what I have now.

6 cars.

2 “real” vacations.  Going to visit family does not count.  Usually, it is not fun, nor is it relaxing.  Cross-country moves don’t count either.

Hundreds of songs, books, tapes, movies, games consumed.

Digging ourselves deep into the debt, then (still) trying to climb back out.

2 pregnancies that ended in heartbreak, with 2 angels, one who we got to know, the other not.

2 times I thought my wife was going to die.

1 career that found me, which I love.

1 marriage to the woman I love, that in spite of everything we’ve been through is still strong.

1 decade of trials, good times and bad times, a decade I am more than ready to leave behind.  I hope the next decade is a little better.

Another for the Record Books

7.5L of urine output in 24 hours.

Yes, a little over 300ml of urine every hour.  And this wasn’t a patient with some weird endocrine dysfunction or SIADH, but a patient in decompensated CHF.

He came in with sausages for legs and 3+ pitting edema to his armpits (quite nearly…).  The cardiologists throw some Lasix at him, but according to the Laws of the House of God (lasix dose = age + BUN) it wasn’t even close.  Sure he was peeing, but still edematous.  Start up the ACE inhibitor and a little bit of Coreg, but he’s still wiped out walking to the bathroom and looks like the Michelin Man’s long-lost homeless relative.  So what’s next?  Just a touch of dobutamine.  6 hours later it was like a faucet had been turned on.

By the time we were done with him he had legs again, could stalk the hallways looking for food without being short of breath and leave our fine institution.  I’m sure he’ll be back.