For All the ER NUrses out there…

Oh yes…”Top Ten Reasons People Use to Get Pain Medicine Early

Is that all you have? I’m sure there are more/better than that…

This sparked a reminder of someone on the floor lately…how they are still breathing I have no idea: Dilaudid PCA @ 4mg/hr w/4mg on demand q15minutes (max of 24mg/hour), 2 fentanyl lollipops q6 (a better invention I have never seen…mmmm…narcotic) and up to 100mg Phenergan IV q4. I also think there were prn Dilaudid orders on top ofthe PCA, but I could be wrong. Now do remember…1mg of Dilaudid is equianalgesic to 7mg of morphine – in other words, max. dose of Dilaudid via the PCA is like 168mg of morphine and hour. And yes, they were still breathing. The PCA pump though was a bit worn out.

Seeker vs. Wanderer: The Rematch

I knew this day would happen: he would come back to the floor. I recounted our last encounter here. And tonight he was on the census. A cold chill swept over me as I looked over that innocent piece of paper. I knew. He was part of MY assignment.

For those not into reading the back story it is thus: admitted for a CABG due to severe diffuse 3-vessel disease; history of multiple psychological issues not limited to polysubstance abuse and ETOH. Not exactly what I would call a good surgical candidate. Our first match ended in a split decision. He got some of what he wanted, I got a little of what I wanted.

Now after a lengthy stay in the Unit, punctuated by a bout of pneumonia, a PE, septic shock along with the expression of underlying psychosis and delirium as evidenced by agitation, belligerence and violence towards staff. He had spent a long time intubated, more to support him through the wonderful detox process than anything else. He had become very good friends with a variety of restraints. But no longer was he critical enough to keep in the Unit, intubated and sedated. So up to the floor he came.

I knew that right away I was going to have to set boundaries.  It was the first thing I needed to do.  So in I walked.  “Oh yeah, I remember you.” he said.  “Can I get some pain medication?”

“Not right not, I’m going to have to look and see when you’re due next.”  I responded.

“Yeah, but it’s time.  Right?” he countered with.

So I looked him in the eye and said, “Let me tell you what.  I will make sure you get what is prescribed, when it is due.  Not before.  I will do this.  Your part is this:  no comin’ out in the hall, harassing us, creating a scene any of that.  You up for this?”

“OK, but I know it’s time.” he said.

“Let me go look.”  Out in the hall I looked.  It was a long time until it was due.  And out into the hall he wandered.

“I wanted to tell you.  I was wrong.  It’s not due for another hour.  I was looking at the clock wrong” he admitted.

“Alright.  I’ll be back at  10…on the dot.”

So I kept going, working my tail off trying like mad to make sure that I was in that room when it was time. I knew that I was walking a fine line, putting my credibility on the line.  If I didn’t show, my credibility was shot, null and void.  If I came through, I could establish a level of trust that would keep him calm and make my experience a little easier.  I looked at the clock, I had fifteen minutes to give meds to another patient and be back in time to give away pain meds.  Yeah, right.

You see, if the IV was OK and not kinked, it would have worked out perfectly.  But like most things in nursing, perfect is pretty damn far away.  I spent a couple of minutes wrangling the IV, re-taping it, flushing it and ensuing it was still patent before giving out some steroids.  All of sudden my charge nurse pokes her head into the room.  “Do you have meds for Mr. S.?  He’s causing a scene in the hallway.”  Shit, I mutter to myself looking belatedly at the clock on the wall: 10:01.  He’s nothing if not punctual.

“Yep, got ’em right here,” I said hading them over to her.  I knew I was screwed, that I had lost the credibility and trust I worked to create.  A wave of anger swept over me.  Why was I so enthralled…no controlled by this?  Was it more than just self-preservation, or was it something deeper?  No matter what he thought, I was in control of the situation, I had to be.  I had set the boundaries and what I expected.  So I headed over to the room.  “Didja’ get your meds?”  I asked.

“Yeah, but they were late.” he said.

“But you got them.  I was involved, but you got taken care of.  Next dose it at 2.  I’ll be in then. Anything else you need?”  I came back with.  Nothing but sullen silence.  He refused the other evening meds, but did let me check a CBG.  Small battles add up to a larger war.

Fast forward to 2am.  In I go, give the meds and let him get back to bed.  “I’ll be back at 6.  I need to do vitals and draw labs, let me know if you need anything.”

At 6, I walk in.  Silence greets me.  “I bought your meds like I said.”   Nothing.  He just rolled over.  “You don’t want them right now?”

“No” he blubbered, “they don’t do anything anyways.  I just want to sleep.” he finished with a whimper.

“No problem.  I’m going to draw labs out of your PICC and leave you be to sleep.  Let me know if you need the pain meds.”  I said.

I realized what he was playing at.  Sympathy.  He wanted me to feel sorry and say, “Oh let me call the doc and see if I can get something that will work.” No, I was not going to play that game.  The docs knew and were aware of the situation.  They wouldn’t have given me anything even if I had called.  Back at the nursing station one of my colleagues said to me, “Did you hear what he said when he came out to get a drink?

“No, do tell.”

“Yeah, he pretty much said this:  I can’t wait to get out of this place. First thing I’m goin’ to do is get a 12-pack of beers, sit down and drink the whole thing.”  she said.

Great, I thought, we fix him and he goes back and does everything he could do to ruin all the hard work we did.  It made me mad.  I knew that it wasn’t an insurance company that was going to eat this.  No, it was working folks like you and me that were going to bear the burden.  Yes, your tax dollars hard at work.  Here we were, paying (indirectly if course) to save someone who really did even want to be saved and who vowed to undo all of it the moment he left the hospital.  Now I don’t have a problem taking care of folks who aren’t as lucky as I am.  In fact I would like to do more things to help out those who can’t help themselves.  But in this case it was all I could do not to tell him exactly how I felt, and it wouldn’t have been in the most socially-acceptable terms.  Many people see this as a chance to start fresh, like getting a new lease on life and try to do anything they can to make sure it sticks. They take the lessons to heart and become personally invested in the process.  Some don’t. They pass on the opportunity.  They’re the ones that will keep getting admitted.  The ones that we will again and again until they drop.  We’ll keep tuning them up and sending them back out, until they eventually stay for months at a time and maybe get a celestial discharge.  If we’re lucky.

But I digress.  He got discharged.  And hasn’t come back.  Yet.

Chalk this one up as a split decision too – ’cause I don’t think you can ever win in this situation.

Expanding Multidrug-Resistant MRSA

We were talking at work the other night about a news report about  a new fiercer clone of MRSA.  It seems to be adding to it repertoire of resistance.  This is of particular interest on my floor as we see a fair share of MRSA infections, they range anywhere from skin-popper with abscesses to post-CABG patients with sternal wound infections.  Like Sun Tzu noted, knowledge about your enemy is vital.  Here’s some stuff I found.

Panton-Valentine leukocidin

This is what makes the USA300 strain of CA-MRSA so nasty.  From the CDC:

Most CA-MRSA strains carry the intracellular toxin Panton-Valentine leukocidin (PVL), which is known for pore formation on polymorphonuclear cells of the host (10,11). In addition, the USA300 clone contains the arginine catabolic mobile element (ACME), which inhibits polymorphonuclear cell production (10)

So in essence it goes after the very cells intended to take it out.  The USA300 variant has been most common in skin and soft tissue infections, but now has spread into pneumonia and necrotizing fasciitis.  In some places, the USA300 variant is the most predominant form of MRSA, with extremely high mortality rates in pneumonias, especially in the immuno-compromised.  In a case study presented at a conference I went to in November, they illustrated a case of PVL positive USA300 MRSA pneumonia.  From time of presentation to death in this particular case study was approximately 72 hours.  Granted, this was a immuno-compromised individual who had delayed treatment, but the rapid onset, even with supportive therapies was astounding.  At the same conference they showed pathology specimens of rat lungs infected with non-USA300 and USA300 MRSA.  The non-USA300 lungs looked worse for wear, but the USA300 lungs looked nearly liquid due to the effects of the PVL.

Multi-Drug Resistance

The frightening development in the USA300 variant is the expansion of drug resistance.  From a SF article:

Further along the gene map are sections that produce resistance to the antibiotics tetracycline, erythromycin, clindamycin, Cipro and mupirocin, a topical ointment often used to kill MRSA colonies living in people’s noses.

And from a article:

Thanks to its acquisition of multiple resistance genes, the multi-drug-resistant USA300 strain is also able to battle fluoroquinolones, tetracycline, macrolide, clindamycin, and mupirocin.

This extra level of drug resistance will only increase the use of vancmycin to treat MRSA infections.  For many of our MRSA patients, this is all they are on.  Increasingly though, we’ve been seeing Levaquin, Cubicin and Zyvox being used to combat the infection, especially in re-offenders (we had one guy come back 3 times with recurrent MRSA sternal infections, even with Wound V.A.C. and I&D therapy the 2nd and 3rd times, he still kept coming back).  It’s only a matter of time before we start seeing increased resistance to those drugs.  All that we really need s someone with VRE to have a MRSA infection.  While there are a few (inter)national cases of vancomycin intermediate resistance Staph and only 1 documented case of resistant Staph, odds are it will only be a matter of time.  So instead of MRSA, we’ll be talking bout VRSA.  Unfortunately, the hospital becomes a hotbed of evolution due to the co-mingling of conditions and infection.  While infection-control tries, they aren’t always able to keep up.

Cross-species evolution

One final reason that USA300 is so nasty is that it appears to have picked up genes from another Staph species.  In the SF article:

The gene map, published in the British medical journal the Lancet in February 2006, has yielded clues to why this strain spreads so quickly. The bug appears to have swapped genes from Staphylococcus epidermidis, a usually harmless staph species that is commonly found on human skin. Researchers theorize that, by stealing a trick from the milder staph bug, the malevolent USA300 may colonize on human skin more easily than other varieties of MRSA.

This evolution does make it more virulent and a bigger to threat to health-care workers.  Think about it.  We’re in contact with the patient, doing our nursing duties.  Yes, we’re applying the principles of universal precautions and good hand-washing, but still there is a decent chance of us acquiring it.  With resistance to mupirocin, knocking out the colonies that may develop on health-care workers becomes infinitely more difficult.

The fascinating element to all of this is the ability of this little bacteria to do this.  I didn’t do so great in microbiology and have a basic understanding of resistance, transference and mechanisms of evolution with bacteria and it piques my interest.

Hope you found the information useful .  Here’s links to the articles above, it’s good reading.

S.F Researcher follow strain of drug-resistant bacteria

Multi-Drug-Resistant MRSA Hitting Gay Men

Skin and Soft Tissue Infections Caused by MRSA USA300

Oh the Weather Outside…

Blue Sky Oregon

Yes, folks! Blue sky! This is Oregon, I swear.

I was going to go for a ride today. And why not? Bright blue skies, not a cloud in sight. I had a day off and actually slept like a normal person. For once is a great while, I felt rested. Yes, the back was kind of sore. But I was excited. I could go ride without riding to work! I had nowhere to go – which translates to I had nowhere to be. It was all very freeing.

Then I looked at the weather gauge on my desktop.


Yeah, it’s small but here’s the important information:

30 degrees. Feels like 20 degrees. Winds ENE @ 14mph.

But it’s sunny!

The bike is staying parked. I’m usually pretty hard-core, but not today. I’m going to go see what’s on cable…

RSS and Syndication Updates

I realized WordPress has their own RSS feed service, but having used Feedburner previously, I decided to add links to a Feedburner RSS feed for those that need the extra linkage.  Besides, I like to see how many folks are subscribed that way.

Life has been crazy.  Work has been crazy.  I don’t have much to give right now, so I won’t.  Enjoy the archives though.

How I Spent New Year’s

Being the lucky devil I am, I spent the start of 2008 at work.  But what a night it was.  So instead of a New Year’s look back or Top Ten list or any other nonsense fun stuff that bloggers usually trot out to end the ear with, I present my favorite things from working New Year’s Eve.

Best thing overheard: “Yes, that’s right, the Beverly Hillbillies are coming to pick me up to take me home!” said the slightly demented older lady.

Best thing said by a patient’s friend:  “So how is that crazy bitch?” said with a spot-on English accent.

Best patient-family interaction:  “Shut up momma’! Everyone here is telling the truth now go back to sleep!”  said the daughter of the slightly paranoid older woman claiming no one had been telling her the truth all night.

Best moment by our intrepid tele tech:  not notifying the nurse that her patient’s heart rate had shot up to 180.  And also missing another patient converting to sinus, then a-fib, then back to sinus and another dropping out of a-fib into a junctional rhythm. Yes, we are responsible for the monitor, but when you’re elbow deep in something lovely, you need someone to watch your back.  He got set straight and afterward each time a patient broke wind our pagers went off.

Best way to ring in the New Year: cleaning up a minor blowout of tube feeding fecal matter at 5 minutes past midnight on a total care patient.

Sure it wasn’t the best way to ring in the New Year, nor the worst, but based on that, there’s only one way to go:  up.

Oh yeah, someone got a new laptop for Christmas…now they can blog from the living room, or Starbucks, or the mall, or downtown or…

Race and Pain Meds

According to an article published in the Washington Post there appears to be large differences in prescription of pain medicine between blacks and whites.  They also go onto note that whites are more likely to abuse said prescription drugs.  In the immortal words of Rodney King,”Can’t we all just get along?”  Does it happen?  I’m sure it does.  I’ve found myself prejudging patients purely on the basis of their diagnosis and history, and feel like shit later about it.   It’s an interesting read and raises lots of issues and items for thought.

Read all about it here: Whites More Likely to Get ER Narcotics.