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The Wonderful World of Versed

December 6, 2010 1 comment

Just after shift change…

“Can someone give me a hand in here?!” came the frantic cry.  I looked up to see Dr. Flighty in full isolation regalia trying to keep a very naked guy from running into the hall.  As I got closer I saw the wild look in hie eyes, the look of fear, of the flight-or-flight reflex on overdrive.

“Hey, Mr. Smith…calm down there.”  I said interposing myself between him and the hall as three other colleagues ran to our aid.

“”I.  Have to.  Get out of here…”  said Mr. Smith looking around bewildered at the ruckus and chaos around him.

He was wiry dude.  Not tall, but strong – not in a bulging physique way, but the wiry lean cable-like strength of a life-long manual worker.  And I was having a hard time controlling him.  It was a battle between him running and him falling.

“Let go of me!  Leave me be!”  he said.  I could see the animal fear in his eyes.  “I’m not staying in that bed.  I’m not staying in this room.  I’m going home!”

“Look Bob,” I said, my tone calm, even, looking him in square in the face.  “I know you’re freaked out.  You’re scared, I can tell.  You don’t know what the heck is going on.  Am I right?”

He nodded his head so I continued, “You’re here because of the nosebleed, remember?  They gave you some medicine to calm you down so they could fix the nosebleed and now it’s making you feel very strange.”

The fear subsided a bit, but it was still there, a lingering caged animal lurking just below the surface.  “Now we’re just trying to keep you safe.  I know you’re scared, that you don’t know where you are, or that no one knows you’re here.  That’s my job, to keep you safe, OK?  Your job right now is to stay in bed, OK?”

He was still straining in our grip, so I eased up.  “Can you do that for me Bob?”  I finished.

Bob started to shuffle back towards the bed.  “This stuff will wear off, I promise you.  But you’re too unsteady to be up moving around by yourself, that’s why I need you to stay in the bed.”

Slowly Bob got into his bed.  We fixed his gown, re-hooked the telemetry leads, all the time reassuring him that this is what he needed to do.  It wasn’t complete capitulation on his part though, it was grudging at best, his glowering eyes told me that.  But he stayed in bed and slowly drifted off to sleep.

“He’s going to be a little embarrassed in the morning,” I said to no one in particular.  “And we’re going to add Versed to his allergies!”

“What did he have done?” asked Dr. Flighty, clearly shaken from having been chased out of the room by a naked guy.  “Had a raging nosebleed that wouldn’t stop, even around the balloons, so he went to cath lab for a coil embolization, think he had a little bit of reaction to the Versed or Fentanyl.”  I replied with a smile.

Skip ahead to the next morning.

“Hey Wanderer, Mr. Smith wants to see you.”  said another of my colleagues.

I walked into the room.  He was sitting there in blue paper scrubs with a sheepish look on his face.  He reached for my hand and said, “I’m so sorry if I caused any trouble last night.” he said, visibly shaken.

“You’re welcome,” I said, shaking his outstretched hand.  “Not really trouble.  You just kept on us on our toes for awhile.”

“I don’t remember much, but I do remember your voice.  Thank you for helping me out.”  he said.

“It happens from time to time.  We’re kind of used to it.  I don’t hold it against you at all, just glad you’re feeling better.” I replied and walked out of the room with a grin on my face.

If he only knew the extent of his behavior he would have been mortified as he seemed like one of those straight-laced types.  But we’re professionals and left him to his own memories because I know deep inside he knows and it would only shame him if we brought it up.  Best to leave it alone I figured.  Best thing though?  In the midst of all the commotion, neither his arterial site or nose bled!

Time For a New Hobby?

October 2, 2010 3 comments

Middle-aged guy comes in complaining of chest pain.

He had been sitting down to a nice recuperative meal after running a leg in a relay race.  ED work-up reveals elevated troponin and some signs of mild dehydration and thus is admitted for monitoring overnight.

When he gets to the floor he tells us that he actually started to have chest pain while he was running, but at the end of his leg, it went away.  Usual suspects:  male, age in 50’s, ex-smoker, overweight – check to all of them.  Then he drops the bomb:  he’s had a stent before.  After he had “mild” heart attack 5 years ago across the country.  And what was he doing then?  Running a half-marathon!

Having flash-backs to Jim Fixx as we’re hanging Integrillin and heparin.  He goes to the cath lab and we go home.

I just wish I could have shared a word of advice:  maybe running isn’t your thing!

Rapid Response Teams: Excuse or Tool?

October 1, 2010 2 comments

I know this has been discussed ad nauseam already, but I had to weigh in.

Thanks to an article out on Medpage Today, Rapid Response Teams Sign of Poor Bed Management, the whole idea of Rapid Response Teams has been brought into the spotlight.  The article’s premise is that poor bed management is the cause for Rapid Responses to be called.  Bullshit. 

Code Blog sums it up nicely by saying,

I don’t believe RRTs are called because the patient was already in bad shape and assigned to a low level of care.  I think they are called because stable patients just stop being stable sometimes.

Are there times where over-crowding and poor bed management are the cause?  Yeah, if it is crazy busy, the nurse might miss subtle signs or the patient is sent to a floor of lesser acuity, but these are the exception rather than the rule.  I can count on my hand the number of times I’ve called an RRT, of course now I’ve now jinxed myself, but each time it was from a rapid change in patient condition.  There have been times where I could have called an RRT, but managed it with judicious use of critical thinking and calls to the doc.  I think that some nurses use them as a crutch instead of critically thinking a situation through, but not because a patient was wrongly placed.  Like I noted above, there are times when the patient is placed wrong.  When our observation unit opened we had several times where they went from Obs to the Unit in a very short amount of time.  But again, these we patients who rapidly de-compensated – and a couple that never should have gone there, but those are the exception.

Have the authors forgotten that a hospital is an acute setting?  It’s not like these folks are healthy!  And thanks to the rise of observation (outpatient in the hospital) those who are admitted in-patient are the sick of the sick.  Having a resource to get help quickly is a godsend.  Sometimes all you need is some stat meds, or imaging and labs , or just someone to look and say, “Yeah, they’re sick!”  And sometimes you just need to have the ability to transfer to a higher level of care without jumping through hoops.

Even if we have the best patient flow possible, appropriate bed placement each and every time and proper resource management, there still would be a need to the Team.  Patients crump.  The article never addresses that simple fact.  It’s far easier to point out structural issues than the reality – of course structural issues are somewhat easier to fix.  Schedule better to make better use of the nurses you’re already overworking.  Staffing plays an important role in this as well.  A nurse that is stretched too thin can’t take the needed time to adequately assess their patients.  When you 5, 6, 7 or more patients at a time, you’re running and even the most perceptive, mind-reading nurse can catch a patient decline if they’re stuck cleaning and doing a massive dressing change because the wound is saturated in stool of a 400lb quad with the 3 other nurses on the floor because it takes at least 4 to move the patient safely.  That’s when the easy things to fix fall through the cracks, hence why we need a team to “rescue” the nurses.

It’s a complex multi-layered issue to which there are no simple and easy answers.  It impacts staffing, scheduling, patient flow and the vagaries of the human condition.  But would I choose to work somewhere without the back up of a RRT?  Not easily.

Record Setting Month

September 3, 2010 Leave a comment

I’m glad August is OVER!  What is normally a shit month in my life was a shit month at work too.  Low census, poor staffing, sick-ass train-wrecks and all the goodies of a urban tele floor.

But truly I’ve had some records shattered.  We see far out and funky lab values all the time, but these were some doozies this month.

And the Winners are:

HbgA1C:  14.6!  Also had a 13.9 as a runner-up.  Both patients with Type I diabetes, both young, one with OK support, one with none.  We worked the diabetic educator to the bone trying  to teach these young’uns to not end up destroying themselves.  For those playing along with the home game, <6 is good control for diabetics.  And when you translate that to eAG (estimated Average Glucose) you get 372mg/dl and 352mg/dl.  Bad mojo.

Worst Case of Thrush EVER:  Candidal Esophagitis, from the oropharynx to just above the lower esophageal sphincter.  And in a twist, the patient was not immuno-compromised.

Highest WBC in a non-cancer patient:  68.8.  Yes, 68,800!  And it had jumped from 48,000 less than 12 hours earlier.

Lactate:  10.8.  Of course what do I say?  “Last time I saw a lactate that high we were coding the patient.”  Sure enough the patient did expire (they had the nasty white count).  They were sick with a capital “F”.

Dumbest idea of the month:  dude comes in drunk and complaining of nausea and vomiting.  After being triaged he goes to the bathroom and pops a couple of poppers, promptly turns grayish-blue with  a pressure of 50 and a raging onset of methemoglobinemia.  At least he was in the ED when he did it.

Oh, and for two Fridays in a row, had rapid responses at shift change…a helluva’ way to start the shift!

I hope September is better…

Um, You’re the Doctor, Right?

September 3, 2010 Leave a comment

Back from a ID theft imposed digital holiday and stuck with a raging case of insomnia.  I mean, what did I do to sleep for 4 hours voluntarily?  I wanted to sleep, just couldn’t, so here I am.

***

Nothing puts experience in perspective like having a doc ask you for advice.  It’s humbling and kind of scary all at the same time.  Really?  You’re the doc.  Y’know, medical school?  At least 1 year as a full fledged doc, writing orders, telling us lowly peons what to do?  Any of this ring a bell?

The conversation went along these lines…

“So I have a patient I want on tele, but they’re bradycardic.  I mean, you do that right?”  Dr. Obvious.

“Um, yeah.  We have brady folks all the time.  Not really a big deal.”  says perplexed charge nurse (PCN).

“OK, can you guys do pacing on the floor or do I need to send them to ICU?”  Dr. Obvious.

“Uh, if you’re thinking they need to be paced odds are pretty good they need to be in the Unit.”  PCN.

“Right.”  Obvious is thinking here.  “They’ve been brady and slightly hypotensive.  You guys can handle that right?”

“Uh-huh.”  starting to look around for Peter Funt and a camera crew.  “I mean, brady is fine.  If he drops too low we’ll just drop into ACLS and do our thing.  How low is he anyway?”

“He’s been holding steady in the 40’s.  Last BP was 100s over 60s”

face palm… “Look as long as he’s not doing any kind of funny block, I’m cool with them in the 30s with a pressure that good.  He’ll be fine.  If you want, you can write orders for atropine prn and we’ll put pacer pads on…”

I’m trying not to laugh here.  Really 40-50s with  pressures in the 100s?  I thought it was a real issue, like they’re runnning 30-40’s in a Mobitz II block or something funky.  Really?  Sure, I appreciate being asked what our comfort level was, but you’re the doc.  You get the special white coat and all that to make these hard decisions.  You want tele, fine.  We’ll deal with the the issues, and if the fecal matter hits the air oscillator, we know what to do.

Had a patient the other week that ran consistently in the low 30’s post-Sotalol.  I’m OK with that.  BP of 86/40 in a CHFer who’s talking to me coherently and making urine?  I’m good.  Now the guy who we were getting pressures of 70/palp with a heart rate in the 120’s and was minimally responsive, that made my sphincter pucker a little.  But that’s why I love telemetry, we take relatively unstable patients (even those that probably need to be in ICU) monitor them and do interventions to fix them.  Part of me appreciates the call, but part of me views it as an insult, in the implication we can’t take care of the (not)unstable patient.  Make your decision, you’re the doctor, right?

Happy Birthday

August 10, 2010 1 comment

Happy Birthday Mia Rose.

You would have been 4 years old today, August 10th, but you left so suddenly and so unexpectedly.

I know it’s been 4 years and maybe I should have moved on, moved past or otherwise just moved, but some days I find it hard to do, well, anything.  I still have the snippets of images in my mind when I reflect, quick flashes of memory that can take me from normal to an emotional wreck in .25seconds.  It’s changed me.  Your life changed me.

I think of all the milestones you would have had, walking, talking, temper tantrums, special simple moments, that didn’t happen.  I wish I had reported the nurse who we think killed you, but the shock and trauma of it all had rendered us numb.  It’s like I let you down and now can’t forgive myself for it.

At least we’ll always have those small quiet moments where your Mom and I would just hold vigil in your little room.  The nurse would leave us alone in there with you, giving us some space to be a family.  It was dark in there, lit only by the blue bili lights and we would talk and dream about our future, your future.  We knew you heard us as you would calm down and seem to rest easy hearing those voices you knew so well if  only for a short time, the voices of you parents.  I treasure those moments.  When things were calm.  When things were hopeful.

All too often though I forget those special moments and remember the sheer terror of running into the NICU seeing them doing half-hearted CPR.  It was so bright in that room, thing were washed out by all the light streaming in but all I could see was your lifeless body and them looking at me.  I remember the pity on their faces, the pain they mirrored when they asked if I wanted them to continue.  I had to tell them to stop.  I let them stop.  I didn’t want to, but I knew it was far too late.  When you died, so did a little bit of me.  And I’ve had an empty hole ever since.

There’s still something missing in our lives.  Our life would have been nearly perfect with you in it, complete.  There are days where the rage is palpable, the sadness suffocating, the hopelessness immobilizing and I get into a funk so deep that all I want to do is hide in our house and bury myself into TV, praying to numb myself.  Perhaps this year is harder as I stopped the antidepressants, so I’m finally feeling the emotions again.  And while it feels good to feel again, it’s not easy.

But I’m trying to focus on the good.  You were with us for 8 days.  And what an impression you made.  Even though you were so young and so fragile, we could see your personality beginning to develop, our tiny little individual.  I’m lucky to have known you, one might say blessed (although I hate saying that I’m “blessed”…).  So I’m going to minimize the bad while remembering the good.

Happy Birthday baby girl!  We’ll never forget!

You can read Mia’s story here, here and here.

Friday’s EKG Answer

August 1, 2010 3 comments

I want some answers!!!

Well, we got ‘em.  Last week I posted an EKG quizzer.  Funny looking 12-lead right?  Prolonged QT?  Dilaudid, Verapamil?  Remember?  No?  Go check the link to refresh your memory:  Friday 12-Lead.

Go ahead, I’ll wait.

Back yet?

OK, so we have signifcant QT prolongation.  Or do we?

Is it me or does that T-Wave look kind of funny?  Kinda’ looks a little flat-ish.

How about these two?

Hmm…I see a little bit of notching in the T-waves here.  Almost like this isn’t just the T-wave we’re looking at.  Maybe this will help a little bit:  the patient’s potassium level when drawn was *drum roll please* 1.9mEq/L.  Yes, 1.9mEq/L.  She had gotten some replacement during the days, but obviously it was not enough.

What we have here is actually a QU segment as the U-wave from the hypokalemia has merged into the normal T-wave.  More examples of this can be seen thanks to Google’s Book Search from Understanding Electrocardiography.  It notes that you start to see dominant U-waves that merge with the T-wave when serum levels of potassium below 3.omEq/L, most notable in leads V2-V6 (as shown above), with the U-waves actually becoming larger than the T-waves when the levels drop to around 1.0mEq/L.  Adverse events related to hypokalemia include AV blocks, torsades, V-Fib and cardiac arrest, which is not a surprise knowing how potassium works in the cardiac cycle.   Typical causes of hypokalemia include diuretic use, alcohol abuse, loss through the GI tract from vomiting or suction (think NG tube) and some antibiotics just to give short list.

Electrolyte imbalances are also relatively common with pancreatitis, especially when you have vomiting.  Our patient was pretty much past the vomiting stage having been NPO for 3 days.  Combine that with having NS going at 250ml/hr for the last 2 days and we were flushing her K+ out of the system.  Fluids were changed to add K and the rate was reduced.  She got several K+ riders during day shift as well.  Thankfully the on-call doc didn’t freak out and have us turn the dilaudid PCA off as that would have caused just a bit of a problem based on her usage.  Even better was we never had to talk to the EP doc.  Small things.

By the time I came back that night, her potassium was edging up to around 3.5 and her QT had normalized out to around 420ms.  We get so tuned in to hyperkalemia that sometimes we forget that hypokalemia is just as significant.  We were able to keep the potassium within normal for the rest of the stay and to no surprise, her QT intervals stayed normal and there was no recurrence of giant U-waves.

That’s your answer.

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