Flight Crews Down

6 Dead in Medical Helicopter Crash

This hits far too close to home as I called Flagstaff home for 3 years and did my training at Flagstaff Medical Center. Hell, the wife was airlifted out of Flagstaff by Guardian Air (one of the parties involved in the crash).  I used to go by the area where they went down, daily ( it’s hard not to in a small town!)  It’s far too close, even though I don’t know the victims.

My thoughts and prayers go out to the families they left behind.

Dear Doctor – Again

Dear Doctor Single-minded,

I know that my patient’s chief complaint is C. Difficile colitis, but are you perhaps forgetting his rather substantial cardiac history? The fact he has coronary artery disease, congestive heart failure, has had both an MI and open heart surgery? I realize that his renal function stunk when he was admitted, but do you think it was all that wise to run IV fluids on him continuously for 5+ days? So now, instead of just slight bibasilar crackles like the first night I had him, he now has crackles all the way to under his shoulder blades. That he’s puffy like the Michelin man and we have to prop his scrotum up with towels because it is so edematous. Yes, as a matter of fact his saturations are within normal levels, but he doesn’t seem so peachy. He’s working a little harder to breathe and for the first time in 3 nights, when he got up to the bathroom to have a movement, he had an episode of chest pain, the first in his whole hospitalization. You say “call me if his respiratory status changes” but how about being pro-active and treating the issue before he decompensates and has to stay longer? Yes, I am a nurse, but you see your patients for 5 minutes a day, I’m with them 12 hours at a shot and get to know them, so when I ask if you’ve considered giving a little Lasix, I do have a clue and a reason for asking: I’m seeing a progression here that you and the Team are obviously missing. But I know, it’s nearly the end of June and you’re about to move up a year and have interns of your own, and not have to do the night shift as much anymore, but for now, can you just please treat my patient?

Oh, and while I’m at it, I know you guys have a quota for testing for C.Diff, but think about it before you do. When the you ask about the patients bowel habits and the nurse tells you that, “Well she had a couple loose stools, but days had given her Miralax, colace, senna and milk of mag,” the resulting loose stools is probably not C.Diff, just a side effect of over-medicating with stool softeners. If it was C.Diff, we’d tell you: if it looks like CDiff, acts like C.Diff (24 trips to the toilet in a shift) and mostly, smells like C.Diff, it probably is. If it doesn’t fit, why would you order the tests and the isolation it requires? And to add to that, when you’re sending a patient to my floor, you better tell us in advance that they are being ruled out for C.Diff because we have to give them a private room due to the contact isolation they must be in until they rule out for C.Diff.

Thanks and Best Regards,

The nurses who are trying to heal your patients.

Rollin’ Old School

I admit it: I’m lazy. I will use whatever I can to make my life easier. Microwave food? Sure. Canned soup instead of from scratch? Any day of the week. Automatic BP machine? A necessity.

Usually the start of the shift involves the staff running out of the report room, like the famed running of the bulls in a frantic search for a Dynamap to call our own. I’m serious; it’s nearly like a food riot some nights, complete with taunting and trash talking. Hell, some folks, will stash machines in empty rooms before going into report just to ensure they have one when they come out. When you look at it though, it’s quite amusing and rather pointless. It’s all about the ease of it. You just wrap the cuff, slap on the sat monitor and hit the “go” button and chat it up with your patient. Easy.

So I wasn’t on my game the other night and didn’t snag one. Standing in the middle of hallway, desperately searching for that blue-colored savior and none were to be seen. All that was left was a lonely old manual cuff on wheels, sitting long-forgotten at the end of the hall. Sighing resignedly, I grabbed it. Went and checked out a portable sat machine and thermometer and went to start rounds.

The first patient looked at the old cart and said, “I haven’t seen one of those forever, y’all seem to only use the automatics all the time.” To which I replied, “Yep, I’m just old-school tonight.” But as the night went on, I came to an epiphany: it worked better. It was quieter, no noisy alarms, no loud start-up sounds, just the old wheels skidding across the linoleum. I even tried an automatic on one patient and it couldn’t find her pulse to take a pressure and ended up flashing “Error” at me. Hooked her up and took it manually and had not an issue.

Now it’s not like I never take manual blood pressures when I have a machine, but admittedly, it is rare. Sure, if I get a reading that is way out of whack, or just doesn’t seem right by machine, I’ll check it by hand. In the last Code I was, in the machine couldn’t get a pressure and I could only get one by palpation. They have their use, but I’m a reconvert to manuals. So call me old-skool, but I’m OK with that.


Someone asked for an update on the six codes from the night into Friday the 13th. I don’t know a whole lot as most of them were not even on my floor, but here is what I do know.

They lost one, after and hour and a half of work. The others I do believe are still in the Unit. The guy we sent had been extubated by the time I came back the next time, but was still still on multiple pressors. I will say though that we have been incredibly busy, full many nights. The other night, excluding L&D, the only open bed in the house was the code bed.

At least we haven’t had a night like that since, and hopefully won’t for awhile.

Anyways, my Internet connection has been and is kind of spotty so if it seems like I disappear for days at a time, I’m OK. Plus, I have 6 days off, and the weather is going to be AWESOME! Who can argue with blue skies, a slight breeze and temps. in the 70-80’s?


While I may be superstitious, my rational side is usually able to concoct an explanation for circumstances of what may seem to be divine intervention, or lack thereof.  But I can’t on this one.  The only plausible explanation, the only one that makes even a shred of sense is the totally irrational one.  How else could you explain 6 codes in 1 night?

Yes, we have sick people, sicker than normal in house right now.  But 6 codes?  That’s more than a typical week, even more than a typical month.  So yes, 6 codes, 4 in the Unit, one upstairs and one on my floor.  The code team was looking ragged, the doc looked like she was one of the walking dead herself after being abused all night long.  I think our Materials people were going to throw a fit if they had to throw together another fresh code cart.  It was one of those nights.

But the explanation you ask?  Friday the 13th.  It’s the only one that makes any sense at all.  Even though it was only the 13th for half of last night, it’s insidious reach kept things interesting.  The worst part of it all though is that now, tonight, Mr. Blackcloud (me…) is in charge.  I’m calling staffing right now to make sure the ICU is well staffed and checking with Materials to get an extra cart up to my floor, just in case.  Let’s hope the universe got it all out of its system last night and things will go smooth.


Yep, 10,000 visits according to WordPress.

The jump from 5,000 to 10,000 happened much quicker than the 0-5,000.

Yeah, I know some folks do this in a month, a week, a day or hour, but this is just me rattling on and on.  Nothing all that ordinary, right?  Just my thoughts, feelings and experiences as a nurse.

So to #10,000, who visited sometime on the 31st of May or 1st of June, I thank you.  And to all of you that have visited leading up to that 10,000th visit, in the humble words of Apu Nahasapeemapetilon, “Thank you, please come again!”


Fun With EKGs, Again

We’ll be having fun with junctional rhythms and AV pacemakers. This is only because I was able to snag a couple of strips that illustrate these particular rhythms very well. It is rare to get strips as clear as these, and in the case of junctional rhythms, rare (at least for me) to see them all that frequently.

***Caution! Educational Material Ahead!***

Click here to avoid said educational content.

OK, that out of the way, here goes…

Junctional Ryhthms

Usually an escape rhythm initiated by the junction (hence junctional…) at the AV node, a back-up if you will for when the normal conduction of the heart is altered. In the strip below, the patient had undergone an EPS and targeted ablation for recurrent atrial fibrillation. They had been throwing everything thing from junctional escape beats, straight junctional, accelerated junctional, junctional tachycardia, idioventricular beats and ventricular pacing. To define:

Junctional Escape Beat: 1-2 beats, originated in the AV node, rate is 40-60 bpm.
Junctional Escape: 3 or mores beats, in other words, continuous junctional beats, again rate of 40-60 bpm.
Accelerated Junctional: 60-100 bpm, where the AV junction has taken over as the primary pacemaker.
Junctional Tachycardia: >100bpm, again where the junction is the primary pacemaker.
Premature Junctional Beats: same as escape beats, but earlier than expected. QRS morphology is usually different as well, like a PVC.

How to spot:
Usually has “normal” QRS structure with either a PR interval <0.12s, a missing P wave (buried in the QRS) or a retrograde P wave appearing after the QRS.

What it means: something ain’t right, as in, “that boy ain’t right.”  Something is causing the conduction system to be slightly out of whack, or if you’re a carpenter, half a bubble off. In his case, they had probably caused some collateral damage in the process of targeting his aberrant foci during his ablation, in fact, when asked if he wanted to do anything, the doc pretty much said he was expecting some weirdness from this patient and just to watch him. This can also be caused by drug (dig anyone?) toxicity, ‘lyte imbalances, ischemia, even trauma – we see a lot of rhythm disturbances on our folks post-valve surgery.

So here it is:

We’re looking a accelerated junctional, maybe junctional tach. Notice the 5th and 12th beats look a little different, both I and the tech were calling these PJCs, although they may be PVCs. Also notice the retrograde P-waves popping up after the QRS. The other strip, which I left at work showed the true anarchy of the patent’s rhythm. This looks good comparatively. Hemodynamically, he was stable, just every 10 minutes or so, the tech would come up to the nurse with a new strip to show how his rhythm kept changing. She just kept looking at him like, “uhh, OK, I’m looking at what now?” Like I said, we don’t see this all that much. He was supposed to go back to the lab for a 3rd ablation, but the general consensus among us was that they needed to adjust his pacer and wipe out the node completely, but hey, we’re just nurses, right?

Pacemaker Goodness

While a full AV pacemaker is not as rare, this particular example was just too pretty to pass up.

Beautiful clear spikes with the correct waves following right behind. I love it when a plan comes together.

I’ll see if I can track down the strip that showed nearly every rhythm the patient was throwing that night. Until then, back to our regularly schedule non-educational programming.


Why would you come to the ER for a sunburn?  I guess I can stretch the imagination and come up with blistered, throbbing pustules, more in line with scaldings etc., but not really that far.  Really?  A sunburn?  You came in to the ER on a Saturday night at 1am for a sunburn?

I saw this on the ER screen in our system. I usually check it out a couple of times an hour when I’m charge to see if there is anything pending for admission, just so I can give a heads up.  But I couldn’t believe that “sunburn” was the chief complaint.  I mean, yes, it was a Saturday night, so it was mixed in with the psych holds/SI, ETOH, heroin OD, Alzheimers/AMS, Dr Referral and the typical “just not feeling well” but it blew me away.  I’ve had some horrible sunburns and will probably seeing a dermatologist frequently when I’m older anb never thought to go the ER for any of them.  Why can’t people just “cowboy up”?

I can’t wait to talk about the needle-phobic patient we had…but can’t right now.  I’m waiting for the wife so we can go celebrate our wedding anniversary.  I just had to get this off my brain; now I can relax.