Fuel for the Fire

The EHANCE trial was published this weekend.  Many of you are wondering, “WTF?  What is ENHANCE?  And why does it matter?”

First question: techinally it is, “Effect of Combination Ezetimibe and High-Dose Simvastatin vs. Simvastatin Alone on the Atherosclerotic Process in Patients with Heterozygous Familial Hypercholesterolemia.”  Right.  In plain English “Does the combination of simvastation (Zocor) and ezetimbe (Zetia) the combination better known as Vytorin, work better than simavstatin alone in patients with family related high cholesterol?” The short of is is a resounding, “NO!”

It matter for several reasons.  This trial was supposed to prove that Vytorin was a better drug than simvastatin for the treatment of high cholesterol. Vytorin was going to be a new cash cow for Merck, cashing in on the same fears of baby-boomers that Lipitor has plundered over the years.  I mean why not, Vytorin is only $289.96 at Drugstore.com for a 90 day supply. Compare that to lovastain (Mevacor) where a 90 day supply would be $12 at Walmart.  Now I know that comparing drugs are almost like apples and oranges, but c’mon, this is big money.  Lipitor is on going generic, simvastatin already is, the companies “need to have high prices to fund research.”  No, they need high prices to fund Dr. Jarvik’s wonderful commercials.

I’m all for new meds, but shouldn’t there be priorities? I mean really, do we need another drug for erectile dysfunction?  (The stories my friend who works at VA urology clinic spins…)  Reducing cholesterol is a good thing too, decreases heart attacks and all the assorted nastiness that goes along with heart failure.  But isn’t just giving a pill and easy out?  What about diet?  What about exercise?  What about personal responsibility for one’s own health?  Naw, we’d rather take a pill.

So what does this rant all boil down to?  In the real world, nothing much.  But for those folks who are taking these meds every day, and shelling out thousands of dollars every month, it makes a big deal.  Now they have leverage to talk to their doctor and say, “I heard about this ENHANCE trial thingy, and I’m tired of shelling out $200 a month for Vytorin.  any chance of finding something different?”

Sources:

Junkfood Science: ENHANCE trial published today

ACC Statement on ENHANCE Study

 Schering, Merck’s Vytorin Should Be Last Resort, Doctors Say

Vytorin, manufacturer’s site

Don’t forget in January there was a big hoopla about the withholding of ENHANCE trial data, some suspect to pad stock prices.  I did a Google search and found some interesting reading.  Enjoy and Good Night.

No Snappy Title

This is just wrong.  I know that stuff like this happens in other workplaces (hello…Post Office?), but c’mon, we’re supposed to be healers, right?  Now read this:

3 dead in hospital shooting – Crime & courts- msnbc.com

Like many health care workers, I too have been threatened, called every name under the sun and have been afraid for my life, but this is an unbelievable case.  I don’t understand what would drive this person to commit this, 4 years after the fact.  I know revenge is a dish best served cold, but this is nearly random.  All I can do is shake my head and send prayers for those who are now left behind.

It also brings up the very real specter of violence against health care workers.  Many states have statutes that call for the prosecution of folks who commit violence against health care workers.  When I was in Arizona, we had signs all over the ER where I did my senior preceptorship that said, “Assault of a health care worker is a felony.”  Someone had taped a small sign below that which said, “And we do prosecute!”  Unfortunately, here in Oregon, we have no such protection.  We had a nurse get into an heated discussion that quite nearly came to blows, with family members who had brought a dog onto our floor (don’t even get me started on that) who the nurse had asked them to remove the dog.  The family members became increasingly irate, escalating the situation to where security had to be called.  But instead of doing the right thing, i.e. 86’ing the offending family members, they apologized.  Yes, they bowed down and apologized to this family and verbally chastised the nurse.

A quick note about this though.  First, it was not a therapy dog, nor an assistance dog.  Second, they were hiding it inside of their clothes to sneak it onto the unit.  Third and finally, one of our colleagues, who was working that day, in that section, is deathly allergic to dogs.  We’re talking full on airway closing asthma attack when exposed to a dog.  The nurse who asked them, politely, to leave had taken care of our colleague when she had been admitted awhile back because of an asthma flare after being exposed to a dog.  So there was some personal feelings involved as well.  So to continue…

So what does this tell me?  It tells me that if I were to be assaulted at work, administration would not back me up.  Plain and simple.  Why people believe they can assault us is beyond me.  I understand the stress of having a sick loved one, but why take it out on those trying to help that person?  It is because we are easy targets.  I also believe that it is because  they know that nothing may happen to them.  That they can get away with it.  Now I’m not talking about the crazed demented old guy who doesn’t want to get back to bed.  I’m talking about the intentional attack.  Until people realize that this is not acceptable, and that there will be consequences things will not change.

Be safe out there.

Dear Doctor.

Letters I wish I could write, but never will.

#1

Dear Doctor Dumbass,

I realize in your three years of residency that you have seen and taken care of many patients with syncopal episodes. I know it in fact. But why this time, in spite of report that the patient lost consciousness for a full minute as he DFO’d, and not because he hit his head, did you write his activity to be up “ad lib”? You’re lucky us nurses can think for ourselves and suggested to your patient to stay in bed until we got him a little more rehydrated and then get out of bed, but only with help.

We know and understand that this is a small concept, but we’re big fans of patient safety and having someone pass out on you tends to sour our night. We would rather not have to scrape your patient up off the floor they hit as they passed out and fell. And honestly, the incident report takes far too much time to correctly fill out. Time that is spent saving patients from themselves.

Thank you,

Your Floor Nurses.

#2

Dear Doctor Asshole,

We would like to apologize for dragging you out from your peaceful slumber in the resident’s quarters when we called an RRT on a patient that needed a little extra special attention. We could tell by your rumpled clothes, lack of spark in those half-shut eyes of yours and the sheet impressions on your face that we had roused you from a good night’s sleep; and we apologize.

That said, do not treat us like shit. We have the right, no the responsibility to call a RRT for whatever reason, especially if we feel our patient is having an acute decompensation.  We are doing our job.  Do not belittle us by yelling over the presentation to you saying, “Why did you call an RRT?” with a sneer on your face and dismissive tine in your voice.  While we wanted to say, “Just to wake your sorry ass up,” we didn’t and pointed out the patient’s labored and frothy breathing, the patient’s heart rate of 170 (one which your colleague Dr. Dumbass hadn’t placed on tele on admit) and SPO2 in the 80’s with a NRB mask on. We asked for your exalted guidance and inspiring leadership in a tense situation made only tenser by the fact you are a fuckwad, who speaks to family, the husband of the poor woman about to buy herself a tube, the man who has stood by her side and cared for her every moment of her end-stage Parkinson’s disease, who bought all the necessary equipment, including a Hoyer lift, to care for her at home, lambasting him about his decision to keep the love of his life a full code, in spite of her terminal condition. Refusing to believe him up to the minute where that man tells you to, “Intubate her.”  Love drives us to do what many see as irrational things, but it is not our place to judge, especially in front of the loved ones.

And by the way, with an EKG with a rate of 150, those little triangular deflections in the EKG are not P-waves, see how regular they are? See how they merge into the QRS complexes? Yes, Dr. Asshole, that is a textbook example of 2:1 atrial flutter, not sinus tachycardia. It’s sad that the lowly floor nurse can spot that and you can’t. It also really sucks when your attending tells us that you were wrong and we were right. We’re sorry that you are trying to make up for some obvious lack in your life (may I say manhood…?) by being a complete dick to everyone around you. It will not win you friends. We will chafe under you ham-handed management and surly attitude (I mean really, you aren’t a surgeon or cardiologist and don’t have the chops to back that attitude) until management gets the hint that you are more of a hindrance than help, if only from the sheer volume of write-ups with your name on them.  Until then go find something else, may we suggest a 2-seat convertible, to fulfill your manliness.

So pardon us for being frank, but we figured you needed to be taken down a notch or two.

Thank you,

Your Floor Nurses.

Passive-aggressive? Maybe a little. The sentiment is there though. Two stellar examples we shown to me this last weekend. While it may not seem like a lot, it is a trend of things with these two. You just scratch your head and do your best for the patient and family.  Keep them safe and as the wise man once said, “Air goes in and out, blood goes round and round; any deviation from this is bad,” we try to keep that premise, everyday.

Mr. Black Cloud

Yes, that’s me.  A little black cloud of despair that casts a pall of shadow across any bright and sunlit unit.  It follows me, but only when I am in charge.  I’m still not one hundred percent sure of it, there may be other variables to the equation, but the only constant is me.   Let me explain.

The very first night I was flying solo as charge started with a bang.  OK, well, kind of a whimper, but as I am the superstitious type it was a bad omen.  It was innocuous.  Simple problem.  The copier wouldn’t work.  I’m sitting in the copy room, the walls closing in on my as the seconds count down until my staff arrives and I don’t have their assignments ready. I’m sweating like a hooker in church and ready to blow chunks.  Anxiety attack?  Only a small one.  And over what? A copier that I can’t seem to get to work.  Yes, blown waaaaaay out of proportion, but I really wanted things to be smooth.  Yeah right.  The silver lining was that all the patients ended up with nurses.  No harm done really.  Until 2am.

Report had it that she was circling, but no one knew how fast she would go.  Fast.  Six hours after changing her code status to DNR she was gone.  So what do I get to do my first shift?  Yep, post-postmortem paperwork, which incidentally I did not even know the location of.  But with help it got done.  “OK,” I said, “I can handle this.”  Second night, not so bad.  Just juggling beds and nurses.  Not a big deal.  Not that big of a black cloud.  Maybe partly cloudy.  The other relief charge nurses told me that having a patient expire on your first charge shift is almost like a right of passage:  nearly all had it happen to them.  Small solace that.

But it was the last weekend that my true status was cemented.

The night started off well enough.  We were full.  Usually when I go to bed rounds to let the supervisor know my open beds, the number is large and no one else has beds.  I usually have to come back and tell the nurses that, “Guess what?  We have the only open beds.  We’re the admit bitch, anything that comes in is ours.”  Not tonight.  I had one bed.  Female.  And all the admits were male.  I like that, makes life easy.  Gives me time to help out my nurses.

Then I hear the call for help echoing out of one of the rooms.  Patient is unresponsive.  RRT is called.  Then something weird happened:  time slowed down.  Not because we were moving fast, but because nothing was being done.  The resident was ordering squat.  Nothing.  Nothing was really being done, we’re all waiting with baited breath for something, anything.  Labs?  Meds?  We have extra O2 on.  Anything?  Finally then, “OK, I don’t like what’s going on with her airway.  Let’s get her to the Unit.”  “Thank God!” I say, more for the relief of something actually being decided, but also for the floor nurses’ Code credo, “Get them off my floor!”

Off to the Unit we go.  Nothing like a brisk walk in the morning to get the blood flowing.  We’re almost to the pod the patient is destined for when what comes overhead but, “Rapid Response to Wanderer’s floor!”   Crap, another one?  Sure enough as I head into the room I hear, “Yeah, her CBG is 12.”

Not good.  D50 is pushed, nothing.  No change.  Then narcan is given.  And surprise, the patient wakes up.  Crisis averted.  We have the resident write orders for PRN Narcan, just in case.  You see, with altered liver and kidney function all those wonderful little opiate molecules were just recirculating round and round.  Thru the night more narcan was given as its effects did not outlast the drugs.  So every time they would drift off to unresponsive-land, they got more narcan.  And they woke up.  Go figure.

So yes, reputation beginning.   I knew from the start that the next night wasn’t going to be a fun ride either when my fortune cookie with dinner read:

“Do not unexpected situations ‘throw’ you.” (in bed)

And what do you know?  Another RRT.  Another trip to the Unit.  Same nurse as the first the night before.  Hmmm, so it’s either her or me, hard to tell.  All told, 3 RRTs in 2 nights.  More than the previous 2 months combined.  I think I have  black cloud indeed.  Did I mention the copier crapped out on me the night of the double RRT?

I think I do have a black cloud.

Coffee Snob

Yes, I am a coffee snob.  But not nearly as bad as some.  One thing though really bugs the crap out of me:

It’s espresso.  Not expresso.

It’s not express coffee.  It’s espresso.  There’s no “x” in it.  It’s like when people call it “Warshington”.  There is not an “r” in “wash” is there?  No, I didn’t think so.  Same thing.  No “x” in espresso.   A nurse I worked with the other night kept referring to it with the “x” and it was driving me to the near side of insanity.

The lesson folks: its espresso.

That is all.

I can’t agree more (NSFW)

Came upon this while perusing Digg. Then I realized: I say these words far too much. And I don’t care.

Is it me or do the English just have a way with words?

Yes, it’s official. I am a nerd.

Here is the proof:

What can I say except, when 800 years you reach, look so good you will not errhhmm?

Take the test here.

The funny thing though is it’s kind of right in a strange, weird way.  Now, back to regularly scheduled blogging…

Did you see me?

 As a bicycle commuter I have had more than my fair share of close calls.  Right hooks, left hooks, failure to yields and once getting clipped for my troubles (which I freely admit was partially my fault), but here in PDX we’ve had more than our fair share of deaths and injuries as a result of car/truck vs. bike collisions.  As a cyclist, you have an extra insight into the habits of drivers, I mean you can see right into the car, literally reach out and touch somebody.  And I tell you, it’s frightening.  I stopped counting how many people were on cell phones and instead started counting how many were not.  Then there are the make-up appliers, meal eaters, drinking drivers (alcoholic and non-alcoholic) and sleepers.  It’s rough out there.  Still I wouldn’t change.  Riding is my escape.  I can have an absolute shit night, but by the time I roll up to my home I feel fine.  Calm, relaxed, loose and exhilarated, and ready to sleep.  But I (and my wife) worry about the dangers.  So, did you see me?

Test your awareness.

Best. Order. Ever.

“D/C Meth”

Ok, so it was in the progress notes. Still fitting.

…ok, back-story: male patient admitted with chest pain, previously treated with a bare metal stent 3 months ago. Can you say reocclusion? I thought so. Right, he never stopped doing methamphetamine even after a cardiac event and getting stented. In addition, the fork I ate breakfast with this morning has more teeth than he did.

Fun with EKGs

Yes, I admit: I am an EKG nerd. There’s nothing more “fun” to me than poring over a weird strip trying to figure out what exactly is going on with the particular patient. Maybe it’s just and exercise in academia, but i have found it to be useful. I just stick that little nugget of electrical conductance deep into my brain and ever so often it will pop out with an, “A-ha!” moment. What I love more though is putting the pieces together into the whole clinical picture.

So tonight I figured I would let y’all into my archive of nerdiness. Or at least show off the most recent additions.

1. Ride the Lighting.

No, not the Metallica song, (although I’m listening to it just to set the mood…), but an elective cardioversion. Just suppose a patient presents to the ED feeling, “weak.” According to the Cardiology resident, they’re in sinus tachycardia. But if you look closely, you can see the wonderful F-waves that are the hallmark of atrial flutter. The attending Cardiologist realizes this is new-onset, so a cardioversion can be done. Anticoagulation is prescribed as are beta-blockers. In the morning they do a TEE and see nothing to worry about. Then comes the fun. Nothing sounds as much fun as DC electricity coursing across your chest. So, here’s the first shock.

Starting out in atrial flutter (see those nice F-waves…) a shock of 150 joules is applied, reseting them to atrial fibrillation. That’s still no good, we’re looking for a fix. Hit ’em again!

200 joules later and a beautiful sinus rhythm is restored. Ain’t modern medicine (and a little electricity) great?

2. Why Door-to-Balloon time is actually important.

Suppose you were out ambling along in your back 40 when you start to feel this vague feeling of pressure come creeping over your chest. It soon transforms into badass substernal chest pain. Full-blown, elephant on the chest, clutching your left pec chest pain. Now think and remember that your father, bless his soul, died of a massive heart attack when he was 50. You’re over 50. Don’t panic, head for home. Get home, tell the wife and head down the road to the fire department. They see it and go, “OK, let’s head to town.” Along the way they tell you they are going to take you to Hospital V. Before they get there they hook you up to a 12-lead EKG. After reading it, the paramedic tells his partner, “Head to whatever’s closest and don’t spare the lights and sirens.” You arrive at the ED, they fuss all over you, drawing blood, hooking you up to a cardiac monitor, starting IVs, the full-monty. They shoot another 12-lead and get this:

You also over hear them talking about how your troponin is only 0.05, but nonetheless you’re whisked off into the cath lab to inflate a balloon in our heart, therefore reperfusing your heart and saving your life.

Now of course, this is hypothetical. It would also be hypothetical to say that post-intervention, your troponin level was 180.6. Yes, 180.6. That is high. In fact, I’ve never seen it that high. Looking at the EKG, besides the computer diagnostic screaming ‘ACUTE MI’ at you, what do you see?

I’ll wait.

OK. See those T waves in V1-V4, they look kind of funny right? Really wide and peaked. Not narrow and peaked like hyperkalemia, but wide and peaked. Look closer, see the J-point? Right, it’s kind of off the baseline isn’t it? Hmmm…what do we have?

Any guesses?

Right then.  You’re looking at an antero-septal MI in the hyperacute phase.  By looking at the J-point, you can see that ST segment elevations are beginning to start, but no other signs.  Rarely do we get to see this, so seeing one is a great learning opportunity.  I admit, I had to look it up to see exactly what was going on.  The hypothetical patient had a 90-95% occlusion of his proximal LAD and got stented for it.  The really cool thing was the timing.  Joint Commission goals are a door-to-balloon time of under 90 minutes.  This particular hypothetical patient had a pain onset-to-balloon time of just under 2 hours.  45 minutes to the ED and about 65 minutes to the cath lab.  But check out those troponin levels, pretty spectacular.  Sometimes knowing when to come in and not wait makes all the difference in the world.  Oh, the hypothetical patient?  Hypothetically, they had no loss of LVEF or other signs of myocardial damage.

Hope this was as fun for you as it is for me…