Lost on the Floor

Many more to go.  I realized that as of May 12th it had been 2 years since I graduated from nursing school.  Hmmm…it feels like more, and less.

No pithy observations or soul-searching, ’cause it’s my birthday tomorrow and I’m not even thinking about anything work-related right now!  Frosty adult beverages ahoy!

Maybe…

Rivercity Bicycles here in Portland was sponsoring a contest to win a bike for correctly guessing when gas will hit $4/gallon.  More people on bikes soon?

You’re helping turn your patient in bed as a nurses runs past going, “Where’s Mitch, I can’t find him.  87’s in trouble.”  It settles in for a second…”Oh shit!  I’m covering for Mitch!”  You then run for 87.

The patient is face down on the ground, legs splayed under the bed, maintaining an airway, but only briefly.  So, now what?  With the RT maintaining C-spine, we turn her over and start help her with her airway. By this time, the room is beginning to fill up.  Someone asks, “Anyone have a history?”

“Ummm, she’s not mine, but I know her,” I say, “30 year old, history of part-partum cardiomypathy, s/p ICD and pacer implant.  Issues with hypokalemia and fluid retention.  We found her face down.”

“You guys have a pulse? We have a rhythm…” a resident asks.  I feel around the area where a femoral pulse should be…nada, nothing.  I’m digging into the layers of subcutaneous fat and feel nothing.  “No pulse!  Starting CPR.”

So what do we have?  PEA. Pulseless Electrical Activity.  A tele nurse’s worst nemesis.  The monitor looks good, but no perfusion.  The AICD isn’t firing beacause it sees a rhythm.  The pacer is just going along all happy, but the heart ain’t working.  So, we all remember the famous H’s and T’s from ACLS, right?

Warning: Educational Content

Hypovolemia
Hypoxia
Hydrogen Ion (acidosis)
Hyperkalmia
Hypothermia
Toxins
Tamponade (cardiac)
Tension (pneumo)
Thrombosis (coronary or pulmonary)

I couldn’t remember these for the life of me, so I found a couple others, just to keep the mind fresh.

ITCH PAD
Infarct, Tension/Tamponade, Hypovolemia/hypothermia/hypo-hyperkalemia/hypoxemia/hypomagnesia, PE, Acidosis, Drugs.

PATCH MED
PE, Acidosis, Tension pneumo, Cardiac Tamponade, Hypovolemia/hypothermia/hypo-hyperkalemia/hypoxemia/hypomagnesia, MI, Electrolyte imbalance, Drugs

So there we are, performing CPR on the floor.  She gets tubed.  Draw labs, slaine running wide open.  We get a pulse back.  Then we lose it, start CPR.  Give Epi, get it back.  Hang dopamine.  Monitor shows wide-complex beats with pacer spikes.  Get a backboard under her.  Lose the pulse again, re-start CPR.  GEt her to the Unit and they start working her.  Levophed, dopamine cranked up, vasopressin, D40 w/10units of regular insulin - just in case, bicarb, as I leave the docs are there starting an arterial line in her femoral.

So what happened?

Brief synopsis:

Dilated cardiomyopathy, renal insuffciency, fluid overload, chronic hypokalemia secondary to diuretics (today was 2.2, got 60mEq of KCL x2 and doses of Lasix and Zaroxlyn), urine output over day was low, found down after complaining to nurse about shortness of breath.  Has implanted AICD/Pacer.

I’ll post the end result in a day or two after I finish my stretch of days on.  Or if people are begging…

I’ve been on a little bit of a sour note of late, and thought I needed to share some fun.

Went and saw it on Saturday night and it was…awesome. Big, dumb, loud, brainless fun. But a great adaptation of the Ironman mythos.

And I’m very excited for these last 2:

There’s a new trailer out in the theaters that’s even better than this. I just hope the movie lives up to the hype and anticipation.

And some local flavor:

Why you should wear a helmet…

Every time I turn around it seems there’s another fee or another hurdle placed in the way of me living my life.  Here’s some examples…

Tried to pay my gas bill online.  Should be simple and easy right?  Isn’t that what they want?  Minimal customer interactions, everything done digitally.  Nope, instead of letting you do it for free or at least on the cheap, they want $9.95 to pay with a debit/credit card online.  Are you kidding me?!  I understand the whole credit card processing fees, the extra cost of having a secure website to process the transaction, but $9.95?  Isn’t that excessive?  And considering it costs $0.41 to send it in, if you plan ahead.  I think they cut you a deal if you do a direct transfer from your account to theirs, but I am not sending my bank info into the wild.  At least with a  credit card you can track it pretty easily and if someone gets a hold of it you won’t get cleaned out y’know?  So we’ll trek to the pay station tomorrow to pay the bill instead of having it done right now.

And Comcast…charging $3.95 to speak to a live person?  Get real.  Same way with your card fees.  It’s in the mail.

And the water company who told me that they would process my request to turn on my water and I should expect to have it on the first part of the week after we moved in.  Not like I needed to have water for the first weekend I was in the new place.  Technically, I wasn’t a renter until the day I set it up, so I couldn’t get services yet.  Messed up.

Don’t even get me started on my garbage folks. Take away my cans because I didn’t pay no big deal…it is my fault.  Take them away because you lost the record of my payment and make us come into the office with the receipts to prove we had paid, then not give us the cans back until after the weekly collection so we have an extra weeks worth of garbage festering in the garage just pisses me off.

And a date is like a Mastercard commercial:

Dinner for 2: $47

Movie with candy for 2 $35.50 (yeah, really, almost as much as dinner!)

Date night with the wife:  Priceless (but broke…)

It all makes me want to pack up and move into a single-wide in the deep backwoods, off the grid, off the map.  Or not, I saw Deliverance.

Like this is news to anyone who has been to the doctor or picked up a script lately.

Even the Insured Feel Strain of Health Costs via The New York Times

While I’m not juggling the decision to buy food or buy medicine, I can sympathize with those that have to. And other than hot air and grand ideas, there seems to be no real solution in sight.

At least we have health insurance.

No.  Not that kind.  But a happy ending to a code.  It’s rare.  I’ve seen it now only twice (and a third may be underway, but that’s for another post).  Most of the Codes we have on the floor do not end well.  It either ends in the patient being pronounced on the floor, or later on that night, or sometimes week in the Unit.  Our Rapid Responses seem to have better outcomes, but then again, folks usually aren’t dead when we call a RRT.

The other night was going along as planned.  Assessments and vitals, med and insulin being handed out like candy when I walk out into the station from the med room.  You could tell something was afoot, there was just a buzz, almost an anticipatory buzz that something might happen.  Hoping not, but sometimes you just know something bad was coming.  We knew one of our co-workers had a patient who was starting to decompensate, badly, but was still stable.  I had run into her in the med room about an hour back and learned what was up, but she was holding her own.  John, as I’ll call him, had been admitted for pulmonary edema, spent a night in the Unit and come up to us in the afternoon.  He was going for an angio the next day, but was becoming increasingly short of breath, and his BP was way up, like 190’s over 100’s.  So I decide to go check on her.  Sometimes just having someone pop their head in to check on you when you’re in a situation can be stressful (see the landing scene in Airplane), but in others, it’s comforting to know you’re not alone.

I get in the room and look over at John.  He does not look good.  He’s sitting up at the side of the bed, in a semi-tripod sort of position, non-rebreather mask on, and working pretty hard.  I glance down at the portable pulse oximeter on the bed beside him; it reads 78%.  On 15L NRB.  Not good.  Angie, the nurse looks at me, “Let’s get him back into bed, see if we can get him breathing better.”

We move him back, but as we’re getting him settled, he lolls his head back.  “Shit!”  I think.  “I’m going for the cart, you might want to call an RRT”  I say as I dash out the room.  Luckily, John’s doc is still at the station, as I blow past him, “You really need to go see John, he’s crashing quick!”

Down the hall as I hear the clarion call of the overhead calling out for an RRT.  I look at the other nurse’s station and make eye contact with my charge nurse and say, “You might want to join us, we’re having a little fun down here!”  Totally calm, totally collected.  Her jaw drops, but I’m already down the hallway with the cart.  Twenty feet down I hear a Code being called overhead and see the unit secretary gesturing violently to “get my ass down here, now!”

The other staff are pulling furniture and family out of the room as I run the cart inside.  The doc is at the bedside as we hook John up to the monitor.  We’ve got a pulse, but his beating is getting worse, more wet, more ragged and he’s working very, very hard.  By now the room is filling up with people; RT, ICU nurses, our charge, dietary, other nurses, housekeeping and a couple of residents.  Break the cart open to grab airway supplies.  The doc calls for a Mac 3, which I hand over to him.  Funny thing, I only worked in the ER as a student for 3 weeks, but knew exactly what to hand him and even checked to see if the light was working, almost by reflex, weird.

He tries to intubate, but no joy, tube’s in the stomach.  He calls out, “Can I get some roc (rocuronium, a paralytic)?”   Someone else pipes up, “Don’t you want some sedation first?”  John is bucking now, he was fighting the tube on the first pass and now his pressure is through the roof, 220’s over 120’s, but with a strong pulse and good rhythm, his body is just in survival mode.   Dude was a rock.  The rest of the room was pretty much chaos.  Pharmacy didn’t have Versed with them, so it had to be raided out of Pyxis.  The portable suction machine was about to die.  RT is trying to maintain a patent airway and bag John.  Calamity.  Then anesthesia steps up ad takes over.  Like a captain of a foundering ship, he takes control.  It was intense to see.  Totally cool, calm and collected, he starts giving orders.

He asks for vitals.  The ICU nurses can’t seem to figure out how to cycle the automatic BP cuff and are getting increasingly flustered.  I can’t do it, I’m guarding the only site of access available at the moment.  I look over and my buddy Ken is next to me, contorted taking a manual blood pressure.  He’s tucked under my arm, craning his neck to see the dial on the wall behind anesthesia, and in spite of everything, gets it.  We push nitro and labetalol to bring down his pressures, then Versed to knock him out and now, some rocuronium to paralyze him.  I’m juggling syringes and flushes, wishing I had an extra hand, but somehow keeping them straight.

Now sedated and paralyzed, he gets intubated. But when the stylus is pulled out, a stream of pink frothy liquid comes shooting out of the ET tube.  Massive flash pulmonary edema.  The look on anesthesia’s face is priceless: a mix of awe, wonder and sheer terror, as he had been in the line of fire seconds before.  More meds, start running a nitro drip and we get John packaged for transport.  RT is bagging John sporting the oh-so fashionable face mask provided to them to protect from flying froth.  And off to the ICU we go.

We get John settled into his new bed in the ICU and one of the ICU nurses, who had previously been, well, freaking out, looked over and said, “You guys did a great job up there.”

“Thanks,” I said as I grabbed the bed and our transport monitor along with the other little bits we needed to return and headed back upstairs. Waiting for the elevator I feel the adrenaline slowly staring to fade and the post-rush shakes starting.  When I get back upstairs, anesthesia is still there writing his note, looks up and says, “You guys did a great job in there.”  Wow, twice in five minutes, I guess our floor does have it together.  Talking about it later with Ken, he says, “Y’know, we (our floor’s nurses) were the only cool heads in that room.  You totally calm, it was awesome.”

Fast forward a week.

I figured John had been in pretty bad shape.  I wasn’t expecting to see him sitting in bed as I walked into one of my rooms to introduce myself as his nurse for the night thought.  I said, “You look a heck of a lot better than the last time I saw you!”

“I’m sure” he replied, “But I really don’t remember all that much about it.  Just glad I came out of it OK.”

Well they had done the angio and found he had severe triple vessel disease only correctable through bypass and was schedule for surgery in the morning.  I made sure I spent a little extra time with him that night, just making sure he was comfortable and ready to roll.  He was up bright and early to get prepped for surgery, and for once I didn’t forget to do anything off the checklists. I wished him luck as he slid over to the gurney on his way to the OR and said, “I’ll see you when you get back up here.”

And you know what?  He sailed through surgery and recovery like a champ.  Last I saw him, the day before discharge, he was up, walking around, weak, but doing well.  He ended up going home the very next day.  Like I said, a happy ending.

I am so damn tired about everyone and their uncle telling me I should go out and spend my rebate.  “It will stimulate the economy!” is the refrain the journalists, and our commander-in-chief is telling us.  Personally, I would have liked it better if they had never taken the money in the first place, but that is a whole other ballgame.

I believe the American way to spend it would be on porn, guns and alcohol.  But I don’t have the time to defile myself in that manner.  That and it isn’t for me.  The alcohol? Yes.  But I can live without the others.  So I did some looking around, pulled out the calculator and opened a cold, frosty beverage and came up with some ways to spend your rebate.

So the rebate is based on a married family of 2 with no children, which is $1200.  Since I live in Portland, OR, average prices are either local or via Internet.  Some are anecdotal.  Remember, this is for fun…

To set one up, here’s a patient:  56y/o male, CHF, Diabetes, HTN, s/p placement of stents X2 to the RCA.  Med prices are based on 3 month supply ordered without insurance from drugstore.com.

Cost: $1468.99, or 122% of the rebate.

Breakdown:
Lisinopril 10 mg QD: 31.99
Lasix 40mg QD: 46.63
Lipitor 40mg QD: 335.97
Norvasc 5mg QD: 105.97
Metoprolol 50mg BID: 26.95
Plavix 75mg QD: 389.96
Novolog 1 bottle: 261.54
Lantus 1 bottle: 256.18
ASA 325mg QD: 12.99

Doesn’t even get 3 months worth of meds.  Yes, I know, grandly exagerrated.

But what could be better than buying stock in the pharmaceutical industry? You could make a portfolio that looks like this:

6 of Merck $41.44/share
5 of Sanofi Aventis $78.35/share (converted from euros)
5 of Bayer Schering Pharma AG: $84.76/share (converted from euros)
7 of Pfizer $20.20/share

You’d be so money!

Or you could get 1 MRI (of the lower back), price before insurance.

80 GP Doctor visits, or 40 Specialist visits on my health plan.

171 Generic Prescriptions

66 Venipunctures, not to mention the cost of doing the labs.

You could get one of these:

A 2007 GT GTR Series 2 Road Bike from Performance for $1099 and still have a buck or two for cool gear.

Or you could get 2 of these:

Mongoose Sabrosa Single Speed Commuters, so you and the wife can ride to work and avoid blowing your rebate on 330 gallons of gas which is 25 fills of my car.

If you were really wild and crazy you could get 36% of a Gary Fisher Superfly, like this one:

Still you could buy a Trimet Monthly Pass for 15 months.

How about 8 dinners at Ruth Chris’s Steak House?

Better yet, 1.6 Ambulance rides due to either a heart attack from all the meat or from a cycling accident.

How about adding $260 for a birthday weekend in Las Vegas, including flights and 3 nights at Treasure Island?  You’re already in the hole and haven’t begun to gamble!

Instead of paying someone to fly, buy 346 gallons of jet fuel, just over 2900 lbs., which is not even enough to get a 737 to taxi.  That idea’s bunk.

How about a nice donation to the Joe Snow Memorial Fund?

Or give Nurse K a week off from triage.

Or help Ian (and others) support nursing students in Nigeria with Project N.

Or get something (like a mini jump kit) for EE, who’s expecting.

Or a cup of coffee and wifi for Kim.

Or a donation to Nurse Sean to help replace a sacrificial stethoscope.

Heck, I’d even take $15 to turn this into lostonthefloor.com…

Or we could spend it on something like 150 (not like I did the math or anything) six-packs of beer…

Most of all, have fun with it.  And don’t buy anything from WalMart.

A robot. The story is here.

The best line is, “He said: “i-Ward would mean hospital staff being able to spend more time with their patients, relieving them from the drudgery of mundane tasks.”  In other words, more time to spend completing JHACO mandated forms (in triplicate…).  Isn’t that real nusing?  Why do patient care when  you can be filling out multiple forms about your patient?

At least we’ll have a robot to wipe butts for us.  The real winner would be a robot that would actually take care of JHACO-related bullshit and let us be nurses, not secretaries.

This week has been a wash.

First was our annual skills day where we get to show we are competent to work in our unit.  Rhythm interpretation and needed interventions, 12-lead interpretation, use of a temporary external pacemaker and removal of arterial sheaths.  Plus the ever famous in-services where we get told that we’re “doin’ OK, but need to get better at documenting things.”  Also included was a blurb about National Patient Safety Goals that has the dreaded “anyone can call an RRT” verbiage in it.  A consensus was reached that we will put it in the patient guidebooks, but in point size 3 font and in UV ink so it can only be seen under a black light.  I can only imagine the chaos and carnage our frequent flyers will bring when they realize that they can do this.  I mean calling an RRT because the nurse is 5 minutes late with your pain meds is acceptable, right?  My comment of “so are there going to be consequences for repeat inappropriate offenders?” was met with laughs and the ugly realization that there wasn’t going to be.  Thank you so much JHACO Joint Commission, for another safety goal that sounds absolutely horrifying on paper and probably worse in reality.  Also found out that according to our RRT documentation, none of our RRTs in well, forever, have ever ended.  Funny thing that documentation.

Then mother-in-law houseguest left for a month to Norway; wife and I have not had the house to ourselves in 5 months..I don’t think we’ll know what to do.  Yeah right.  I remember.  I don’t think there will be much blogging…

Next was new grad interviews.  Nurse Manager asks staff nurses to be a part of the interview panel adn gives nearly unlimited power of decision over who gets an offer.  She trusts our judgment.  In her words, “You’re the ones that are going to have to work with them.”  It was very interesting.  The first time I helped out with this about 3 months ago, we had candidates show up in jeans.  Not fashion denim stuff, but work in the garage jeans, minus the grease stains.  They didn’t get an offer.  Like with any hiring situation, we had some good, some bad.  Some were possibly dangerous.  I said of one, “Day shift will eat them alive and frankly, I don’t want to have to carry them on nights.”  Cruel?  Maybe, but completely honest.

I end this week as charge.  I really, really hope my black cloud has dissipated. Judging from my deleterious effect on a quickly going south patient a week ago (to be blogged about soon, I swear!) it is still in effect.  Only time will tell…