Boneheaded Quote of the Night

“Yeah, he’s got a single lumen foley in his left upper arm.”

Who said this?
A: 1st year nursing student
B: RN with 20 years experience
C: 2nd year resident
D: RN working on medical/cardiac telemetry floor.



Final answer?


If you guessed “D”, you’re right.  Yep, I’m the bonehead.  Think about it though, a single lumen foley… awww hell, nevermind.  Off to ride the short bus home.  Where’s my helmet?

Blackcloud’s back. Maybe.

I knew the streak had to come to an end.  The lack of code/RRT streak that is.  It’s ben since the 13th of June since I was involved in such a situation.  That really is a whole bunch of charge shifts too, by the way.  And nothing, nada, zilch.  Until tonight.  Respiratory distress, leading to a bed in the Unit.  I’m hoping Blackcloud was just in for a visit, nothing permanent.

We’ll see.

Is this a good thing?

Billionaires Back Anti-smoking Effort

Hypothetically speaking, is this really that great of an idea?

Call me cold-hearted, less of a human or downright mean-spirited, but I’m not sure if this is really a good idea.  1 billion less people?  Not necessarily a bad thing.  I mean, we’re seriously overpopulated as it is, with our environment straining to handle the ever-increasing load of folks clamoring for the resources necessary to life.  Water, food, room to live, all are going to be in increasingly shorter supply in a very short amount of time as the world population spirals towards 6 Billion (yes, 6 Billion, with a capital B).  It may just be one of those regulating functions, like war, famine, drought, disease and general chaos that combine to reduce the population load of our planet.

I don’t really believe that and am just thinking hypothetically out loud, but one has to wonder…

Floor Poker

Now that my unit has splintered in two, one being a traditional Progressive Cardiac Care Unit, the other an Intermediate Care Unit (on a different floor to boot) we have almost begun to compete or at least trade for patients.  Sometimes it may be like this:

“OK, so I’ll take this ETOH with a GI Bleed and you get the Chest Pain with elevated troponins since you called it first, but the next batch, I get first pick!”

So a couple of weeks ago downstairs had a pair of our frequent flyers and I had 3 GI bleeders and 2 ETOH protocols (in other words, drunks sobering up) upstairs.  The downstair charge nurse and I were joking around as to who was having the worse night.  As we laid out our cards, er, patients, I remarked, “It pretty much isn’t even worth trying to bluff me out of it, ’cause a full house always beats a pair!”

EKG wrap-up

Last week I posted a red herring of an EKG in EKG of the Month.  It was a diversion, interesting in its own regard, but a diversion from the true situation all the same.

Here’s the EKG again:

What do we see?  Flipped T-waves in the anterior and lateral leads, poor, even odd R wave progression, short possibly even absent PR intervals and bradycardia.  It’s kind of ugly.  One would expect the patient to be experiencing some sort of symptom of cardiac compromise.  Nada, nothing.

Here’s the presentation: 28 year old, 6 months post-partum, comes in with progressive left-sided weakness. Had been seen at the PCP earlier in the weak and given scripts for muscle relaxants and steroids on the idea this was a muscloskeletal issue.  Patient decided to come to the ER after dropping her child due to the weakness (the kiddo was fine).  The above EKG was shot prior to her going to CT for a head CT, followed by another imaging modality: MRI.  Both show a bilateral ischemic event, right greater than left, mostly in the frontal and prefontal area with some scattered subcortical spots as well.  Big time, acute ischemic CVA.

So what’s up with this EKG?  Neurogenic T wave inversion.  I found several articles on Ovid about this phenomenon.  According to one article, 74% of patients with cerebrovascular incidents exhibit alterations in cardiac depolarisation and repolarisation.  Most commonly these cardiac alterations are in things like prolonged QT intervals, T wave inversion, ST segment changes and abnormal U waves.  This possibly is caused by unbalanced autonomic control due to the location of the ischemic events.  The most common culprit is the insular cortex located within the lateral sulcus, overlaid in some parts but the frontal lobe – where the were several ares of ischemia.  Now I can’t say for sure that this area was damaged, and judging by the literature, usually the alterations are more defined and substantial.

Now here is where it gets really interesting. Why would a 28 year old have an ischemic CVA.  No history of hypertension, no cardiac history to note, normal birth, but an aunt who had a similar event at the same age.  Carotid and cerebral angiography was performed giving the diagnosis of moyamoya disease.  Simply put, moyamoya is a progressive occlusive disease that causes stenosis of the carotids and the Circle of Willis.  Leading to occlusion of the vessels.  A large collateral network does form and sometimes retrograde filling of the cerebral arteries is seen as well.  True diagnosis is through angiography where there is a “puff of smoke” appearance to the cerebral vasculature.  Most folks don’t even know they have it until they have an event of some variety.  Much of the time it is a TIA type, but sometimes it comes as a large cerebrovascular event.  Moyamoya is also a leading case of stroke in children, even very young kiddos.  The consensus is that it is genetic and considering that the patient’s aunt suffered a similar event, coincidence aside, that looks pretty solid.

So what happened?  Since we are a nationally recognized stroke center, the patient admitted under our stroke protocol.  Through the first night and later on they would have alterations in their rhythms, running junctional rhythms, SVT and sinus tach along with normal sinus rhythm.  The biggest deficits was to the left arm with some mild to moderate in the left leg.  She didn’t experience any expansion of the ischemic areas during her time on our floor and was relatively stable.  Prior to heading to a rehab floor, referrals were given for surgical consultation through Stanford for a surgical solution to her disease.

I think this was a case of the long-tail of medicineHappy had a post about this and it sparked this post as well.  We get so used to seeing this kind of EKG in a totally different light that a new perspective sometimes throws us way out of whack.  I showed the EKG to a fellow EKG nerd and the first thing he asked was, “Did you call the doc over this?’  I explained the situation and the lights went on.  I had no clue about moyamoya prior to this, so it was a huge learning experience for me.  Fascinating and a little bit sad as well.

There you have it.  Hope you enjoyed this round of EKG of the month.  Hopefully next month there will be a crazy cardiac one…well maybe not, that would mean bad things might be happening.

EKG of the Month

Things aren’t always what they seem at times as our patients like to throw the proverbial knickle ball.  It just kind of hangs there, then goes in a completly different direction, baffling both you and the batter.  While there are very few knucklers left in the Majors, it seems that they come in droves in medicine.  There almost always is a strange case that grabs your attention and makes you think.  All the signs point in one way, but the reality is far different.  Such is the case here.

First, a brief  synopsis.

Deborah Peel, a 28 year-old, 6-month post-partum patient arrives at the ED complaining of weakness.  This EKG is grabbed on admit.

To give much more information (including what kind of weakness it was) would give this away.  Suffice to say, labs were normal, including cardiac enzymes.  Vitals signs were stable, blood pressure was slightly elevated though.  Patient was complaining of no chest pain or other symptoms that would be expected with the tracing shown above.  No previous history, normal delivery without complications 6 months prior.  The other clue I will lay out is that the patient went for a CT, followed by another imaging modality before arriving on my floor.

Any guesses?  C’mon, fame and glory await!  Leave your guesses in the comments.

P.S.  I have to work the next couple of days,but I’ll be checking to see and will confirm or deny guesses,also in the comments.  I will also say that my firend who looked at this said, “Did you call the doc? How about an EKG when they got to the floor?”  Both of which were answered in the negative.  Is your brain in gear?

Mapping Prescription Narcotic (over)Consumption

Check out this interactive map: Prescription Narcotic Consumption.

It is more than fascinating, it is mind-blowing.  The sheer amount of presciption narcs out in circulation, based on this map (which I can’t vouch for the validity of, but…) is any wonder why we have drug seekers sowing up ERs daily, or why our post-op patients are requiring higher doses of more potent narcotics, and even why they are now running anti-prescription drugs ads aimed at scaring families with children (my favorite is the one with the sleazy guy who says, “I used to be your kids’ dealer, now they just steal it out of your medicine cabinet.).

According to the map, we’re (Oregon, that is) is #2 in Methadone consumption (better than, ahem…Lousiana), #16 in Oxycodone and #18 in Hydrocodone.  The statistics are just left as that, numbers with no explanation.  No in-depth reasoning or analysis, just straight up numbers.  I guess we either have many, many ex-heroin addicts, or an astounding number of fibromyalgieurs or other chronic pain condition sufferers being treated with methadone.  Personally based on what I’ve seen on the floors, it is the latter.

I think that if nothing more, it shows a marked shift in the prescribing habits of doctors with a more liberal attitude towards narcotics.  In relation to that, is the societal aceptance of said narcotic uses.  It appears more acceptable these days to be on prescription pain medication than it ever was before, showing a shift in cultural mores and attitudes.

Does this translate at all for nurses?  You better believe it.  First, there is more access, bringing on the occasional spate of OD’s and the frequent drug seekers to our doors.  And second, there is the tolerance factor for folks undergoing surgery, planned or unplanned, requiring higher doses of pain medication to remain comfortable. I’m sure there are more than that, but this is what came to mind.  We try to ease pain in our working lives and sometimes dealing with a set-up where nothing, except the total abscence of pain, will make a person happy, it gets frustrating. I guess what my point is here, is that we have been set-up in a way by the liberal prescribing of narcotics, illustrated (in my opinion) by the graphic above.  Since we nurses are the front-line, we take the abuse.  We can’t just tell our patients to “cowboy up” and not treat their pain.  But what does one do when treating the pain becomes physiologically dangerous?  And what happens when expectations are that there will be no pain at all?  We have all seen it where the patient is getting enormous amounts of narcotics and still complaining of pain, but to give more would be akin to completely knocking out their repsiratory drive.  It’s a conundrum with no easy solution.  Sometimes a little pain is the reminder that is needed that something has happened to our bodies.  I always try to let my patients know that odds are, I won’t be able to reduce their pain to nothing, but try my damndest to get them comfortable.  Maybe this is what the docs are doing:  just trying to get people comfortable.  Maybe we need to be a little uncomfortable at times.  Maybe a little pain is a good thing.