Young MIs

How I survived a heart attack at age 43 – CNN.com

Seen it.  Took care of a patient who had their CABG at 49.  Scary.  Sounds like familial hypercholestemia to me.  This blew my mind:

The oddest thing about the angioplasty was that for six hours they told me not to move my foot, and I didn’t know why.

I know whenI’m taking care of post-angio patients, the whole, “you had a large hole in your femoral artery” is the first thing I bring up when doing post-angio instruction.

ER Follies

“PCU, this is Wanderer, how can I help you?”  I said as I picked up the phone.

“Uh, yeah, this is Nurse FERN-tastic down in the ER, I’d like to call report on Patient So-and-So, going to room such-and-such.”

“Right,” I replied looking at the clock…10 minutes since I gave the bed away, “Let me grab who’s getting them.”

“Hey Nurse Floor-tastic, report’s on #1”  I call across the station.

“Already?” she says, “I thought you just gave the room away?”  as she picks up the receiver.  “Hold on a sec,” she says into the phone, “I’m putting you on speaker so my orientee can hear this too.”

From the desk I hear the muted wah-wah-wah from the ER nurse, kind of like the teacher in Charlie Brown.  “They’re 60 sumthin’,  wahwah-wah-wahwahwah, cardiac history, wahwah-wah, discharged today at 1700,wahwahwahwah.”  I tune out the rest as I go back to charting on my patients.

“Hey Wanderer,” I hear a second later as a phone is hung up, “so, downstairs has no idea why they’re even being admitted at this point,” says Nurse Floor-tastic.  “He just read off the labs and said the ER doc is still in there trying to talk to them.”

“Right, so I just gave the bed away, and they’re not even sure if they’re being admitted?” I ask.  “And they’re calling report?”

“Yep,” she says, “Nurse FERN-tastic said he had a moment to get report out of the way, not that he actually told me anything worthwhile that I couldn’t have gleaned from the chart notes in the system.  He said the rezis haven’t even been notified yet.”

So we wait.  And wait.  And wait.  I keep looking at the screen on the system that shows the ER status.  Then next to the name of the patient where it had said, “Admit PCU” I see, “D/C”.  At that moment the phone rings.  “This is Wanderer.”

“Hey Wanderer, Nursing Supe.”

“Hey.”

“I’m sure you saw already,” she says, “but they’re sending Patient So-and-So home.”

“Right, saw that.  OK, well we still have that room open.  Is the person I assigned to the other bed still coming?” I ask.

“So far.  I haven’t heard otherwise.” the nursing supe says.  “But I’ll try to keep you posted.”

“Thanks.”

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“PCU, this is Wanderer.” as I pick up the phone again.

“Yeah, this in Nurse FERN-tastis Jr.  I’m calling to give report on Chest Pain going to room such-and-such.”

“OK, let me grab Nurse Part-time-tastic.”  I say.  “Nurse Part-time-tastic, report on Chest Pain on 1”

Time slips by.  The clock marches forward.  Midnight.  1am.  I finish my chart checks, finish the staffing report.  2am.

“Hey Nurse Part-time-tastic,” I say as I look over, “Chest Pain here yet?”

“Nope,” she says.  “Still waiting.”

More time.  I have a snack staring at the rack of new charts awaiting the arrival of the patients.  Then from around the corner I hear the dulcet tones of the ungreased wheels of an ER gurney.

“Chest Pain, right?”  I ask the tech as they roll past.

No answer, but since they’re headed into that room, I guessing it’s them.  Look back at the clock on the wall:  2:40.  3 hours since report was called.  Up date?  Nope.  I guess it really doesn’t matter all that much, they’re still breathing.

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“PCU, this is Wanderer.”

“Yeah, this is FERN-tastic, calling report on Chest Pain 2.”

“Right, they’re mine.  Lay it on me.” I say

“OK, Chest Pain 2, 60 sumthin’, chest pain post-gardening, lower-sternum radiating to neck, called EMS.  VSS since arrival.  Chest pain free.  Took ASA at home and have 1 inch of NTP on.  Just gave them Advil for a headache.  So the labs..”

“It’s OK,” I interrupt, “looked at them already.  Looks like they had something of an event with that troponin of .54.”

“They’ve got an ER special (IV in the antecubital space) for a line.  They’re AOAx3, a real walkie-talkie.  The ER doc wrote holding orders to send them up to ya’.  You ready?”

“Sure,” I say, “Bring it on.”

“See you in about 15.” they say.

Sure enough, as I’m putting the finishing touches on the room, up they roll.

As I dig into the orders, I’m missing something.  In fact I’m missing a whole lot of something.  Labs?  Nope.  Serial enzymes?  Nope.  I have tele orders, nitro, morphine and EKG orders.  No diagnostics, no guidance that maybe, just maybe they’ll be going somewhere, like the cath lab or at least nuke med.  Nothing.  Page the resident.

“Are you following Chest Pain 2?” I ask.

“Who?”

“Chest Pain 2,” I repeat, “let me spell it for ya’.”

“I have no idea who that person is,” she says, “we’re not following.”

“That’s all well and fine, but I need to know who’s going to write orders.” I say, “I have bare bone orders and nothing else.  D’ya’ want to order enzymes?  Maybe an EKG?”

“Oh, wait” after much paper shuffling and a muted conversation in the background, “looks like Cards will follow.”

“Any idea who?  It’s not like I can just call around and ask about it.  Don’t feel right just letting them hang out with nothing.  Sure I can’t persuade you…”

“Sorry, I ain’t crossing them.  If you don’t hear soon, call me back, sorry.”

And the powers that be wonder why weekend survival rates are so dismal.  The right hand and left don’t even know they exist.  Never good.

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Edit: I re-read the post and realize I need to be less trigger happy on the “Publish” button.  I’m going to leave the final summary and wrap-up and assorted ramblings below, but realize that I’m probably just adding fuel to the fire that is ER/Floor relations. It was a bad, bad weekend and this crap burbled out.  I’m not so usually full of vitriol and am able to make sense of what I’m trying to say in a more constructive way. Still wearing flame-proof Attends though! So if you just want to stop reading here and avoid the crap-tastic content of the post, do so now…

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So what’s the point you ask?  First, jumping the gun to give report, just to “get it out of the way” defeats the whole purpose of giving report.  Especially when the patient doesn’t even show up.  You’ve wasted your time and ours.

Second, a hell of a lot can happen in 3 hours.  Shit, it only took 20 minutes for my patient to circle the drain on me the other night.  From the time they started circling to the time we hit the Unit, was less than an hour.  A hell of a lot can change in 3 hours.  How about an update?

Third, that’s the way it should be, except where the docs dropped the ball.  Give report, clear, concise, and then bring the patient in a reasonable amount of time.  None of this lolly-gagging around. Unfortunately though none of the docs are talking to one another so the patient languishes.  Granted, the elevation was not critical, but it is relevant.  A coughing fit ain’t going to cause that. Something’s going on, and when your patient tells you that pretty much everyone in their family has, or had, cardiac issues, alarm bells start going off.  Things need to be done.  And we can only the push the docs so far.

Fourth, FYI Nurse Fern-tastic, there are other sites for IV starts besides the AC.  Really, I swear.  And on a “healthy” person, it’s even easier.  You’re picking that just out of convience.   But c’mon, if you’re going to drop a line in the AC on a Chest Pain-er, shouldn’t at least be a 18 gauge?  Yeah, a 20 guage will work in most situations, but if you’re using the biggest vein in the arm (typically), why not drop a bigger guage IV?  I know you feel like you don’t have anyting to prove anymore, as you told me that yourself once, but if we can get a 20 guage on the demented confused LOL who does not want it, I think getting at least an 18 in a “normal” person shouldn’t be all that far out of your ability.

Now I know that the ED is a different world.  The culture is very different from the floor.  Yes, you have multiple patients.  We do too.  I know that multiple nurses take care of the patients as a way of unloading the nurse in emergent cases, but wouldn’t you at least want to look at the patient before you call report?

And people are always wondering why the floors make life hard on the ED.  Really, it’s because we’re too busy hiding beds, playing canasta, taking our breaks and eating lunch.  Far be it from us to actually work.  I can’t speak for others, but on my floor unless we’re in the middle of some shit, like someone’s crumping, or we’re up to our armpits in poop ensconced in an isolation room, we take report when it’s called.  And when we can’t take report we offer to call them back.  Do we get snarky?  Sure, when you sit on a patient for over 2 hours to flush them at 0645 right as you change shift and just before we do, we get a little snarky.  It’s not you, it’s us, we know that the expectation of the day shift is that all the admit stuff will be done and if it’s not we’ll just get a bunch of flak, makes the last little bit of the shift oh so wonderful.  If we were to work together, there might not be such animosity.

And don’t get me started on the residents that admit these folks.  They’re starting to piss me off.

Any thoughts?  Don’t worry, I’ve got my flame-proof Attends on.

The Strange Language of Nurses

We speak a funny pidgin language as nurses.  It’s a mix of English, Latin, slang and the occasional cusre thrown in for emphasis.  It was driven home to me by my preceptee the other night.

“So when they arrive on the floor,” I said, “we need to check their ‘lytes, hook ’em up to the monitor and start implementing the docs orders.” as I explained what we do for cardioversions on the floor.  I looked up and noticed a quizzical look on her face.  “Question?”

“Yeah, never mind,” she said sheepishly.  “I was thinking to myself for a second there, ‘why would we be checking the lights in the room…’ and then I realized what you had actually said – electrolytes!”

I used to notice it more when I was telling my wife about my night.  I had to stop nearly every other minute to explain what I really meant.  Now, as she has learned the strange language, she can understand what I’m saying.  But still it is odd.  A couple of examples:

It’s not the Intensive Care Unit/ICU, it’s, “the Unit.”

It’s not the ER (ED if you’re WhiteCoat), as in, “What’s in the ER?”  It’s “downstairs.”  As in, “You got anything for us downsatirs?” as I’m talking to the House Supervisor as charge.

And then when you throw in the myriad abbreviations and acronyms it gets even more confusing.  I had a patient awhile ago who’s history was thus: CAD, CHF, HTN, DM, pHTN, OSA, COPD and left hip FX.  Meaning?  Besides having a busted hip they had coronary artery disease, congestive heart failure, hypertension, diabetes mellitus, pulmonary hypertension, obstructive sleep apnea and chronic obstructive pulmonary disease.

It flows with a fluiditiy at times where small things speak volumes, if only you know the language.

The Power of Prayer?

From msnbc.com: 1 in 2 believe prayer trumps doctor’s prognosis

I found it interesting that over 20% of health care professionals beleive so as well.  Having been thru the hell of dealing with a medical tragedy I can say that I don’t.  When I lost my daughter we prayed harder that we ever prayed before, but she still died.  I don’t beleive in miracles anymore than I believe in the Easter bunny, which is to say, ain’t much.

This too ties into my whole theory of denying death that permeates our society.  Are there “miraculous” turn-arounds?  Could be.  It could also be that the treatments are actually working.  But I’m not one to judge.  We so don’t want to die that in-spite of overwhelming evidence that the end is nigh, we press on.  That’s why we have 90 year olds with ESRD, CHF, so demented they don’t know their own name and a host of other conditions that are full codes.  If medicine can’t fix them, maybe prayer can.  We put our loved one through the torture of a code and expect them to come out bright and shiny, happy that they are still alive.  When you hit a certain age, that just isn’t going to realistically happen.

It reminds me though of a story I heard from a colleague it goes like this: the patient had passed away in the due process of their disease.  It wasn’t a total surpirse, but it was quicker than expected.  The whole family, all members of the same church piled into the room and began to pray.  For 2 hours.  And what did they tell the nurse?   “We’re going to raise him from the dead by the power of prayer!”

It didn’t work.

Watch What You’re Saying

Go take a gander at this great article by Sandy over at Junkfood Science: Sanitized for your protection.  It’s a interesting discussion over public and media perception of medical blogging.  One big bone of contention is about the anonymity and the perceived lack of ethics and integrity.  It’s good stuff, but frightening at the same time.  What if it becomes where we’re not allowed to speak our minds, share our experiences and talk about our lives via the blogs we write?  It goes back to the repressive age where only those with money are able to express themselves in a public forum.

Do I write about patients?  Yes, but I try to sanitize as best I can.  Do I portray them in a negative light?  Probably.  Sometimes my negativity is a reflection of the patient, the situation or how I’m feeling.  It’s a given that negativity may pervade one’s feelings dealing with what we do on a daily basis..  A blog is a chance to vent, to unload those toxic emotions that develop from caring for sick people.  It’s not always easy being in the trenches and that frustration gets unloaded here.  I share my experiences in the hope that they may help a fellow nurse in a similar situation.  Or if nothing more, allow them a moment of levity to break the monotony of life.

In my defense though, I said befroe:  I was a cynic before I became a nurse.  Being a nurse just made it worse…

What Not to Wear

One reason I love my job is that I literally get to work in pajamas.  Scrubs are perhaps the most utilitarian of all work uniforms:  comfortable, relatively inexpensive and easy to wear.  I would know.  Having worked in a variety of industries, I’ve had the pleasure of wearing multiple uniforms.

The worst:  slacks, shirt & tie.  I wore this as a cargo loadmaster for an international airline.  For me, being hands-on is an important part of the job, so I ruined numerous dress shirts, countless pairs of pant and a couple of ties as I squeezed in between cargo pallets and into the nooks and crannies of a modern cargo plane.  I was finally able to convince the powers above that as I was working nights, there was no need to wear said uniform.  Khakis and polo shirts became the new dress code.

Second worst: white shirt, bow tie and black slacks.  Worn as a server.  What really topped it off was the full body apron, very classy, especially when you spill food stuffs on it.

The normal:  working as janitor I wore whatever I had been wearing that day.  No changing to go to work, just show up.  Shorts and t-shirt?  Just fine.  Sandals?  Sure.

When I loaded planes, it was jeans and shirts.  Then when winter arrived it was full-on rain gear and insulated coveralls.  But none of these can hold a candle to scrubs.  They are, in my mind, the perfect uniform.  But they are a double edged sword.  Just as you can look good in them, you can also look like a slob.  Dirty, wrinkled, strange color combos and prints, it can all add up to something less than professional.  And many folks don’t care about how they look, they just show up saying, “I’m here.” looking like they rolled out of bed.  Any wonder why image is a big problem for nursing.

A problem I have is finding scrubs I like.  Not a huge fan of the pastel colored prints, for obvious reasons.  And there is not a plethora of “manly” scrubs out there.  While I do agree that this is a female-centric industry, there are more men arriving every day.  For some of the chaps, the unisex scrubs fit great, others not so well.  While there are plenty of scrubs just for the gals, there ain’t much for us boys.  Now I’m not saying we need crazy prints, but prints could be a nice addition.  For now we have to sort through the rests to find those we like.  I’m not completely happy with what I’ve found, an am always on the lookout for different styles, but they do the job well.  I’m still looking for the penultimate scrub set that makes me totally happy.  The search will continue

One thing that scares me though is the public perception.  Recently in a survey at our hospital, a large (>50%) portion of patients identified not knowing who the RN was as a problem.  We all look the same:  RNs, CNAs, Techs, Phlebotomists, etc., all rock scrubs.  Granted, we do look the same, or at least similar.  In the solution portion, in a throwback to an earlier time, 28% responded that whites would be the best way to identify nurses.  Whites?!  Are you kidding?  I have a hard enough time keeping my colors clean and whites would be a nightmare.  I wore white as a student, it was only a top and only for a year, but it was not pleasant.  Not to mention that whites further the image of the nurse handmaiden.  We’re professionals, no longer the pillow-fluffers of yore.  Not that I’m saying those that came before were not professionals, far from it, but that image, the nurse in white is seen as that stereotype.  When you look up naughty nurses (not that I’ve done this…) I’m told they wear whites, not scrubs.  Perception.  Requiring nurses to wear whites, brings this back.  What’s next? Hats?  Candy stripers?  A more palatable version might be profession specific colors, but that could get old in a big hurry.  There may not be a solution to this that works for everyone, but I know that the solution is not whites.

Rise of the Superbugs

Dramatic huh?  Found a fascinating article over at the New Yorker titled: Superbugs:  The new generation of resistant infections is almost impossible to treat.  And quite frankly it scared me, like all article about multi-drug resistant strains of bacteria do.  It’s a worrisome topic.

The article focuses in on gram-negative bacteria, most notably Klebsiella pneumoniae, but also touches on the other usual suspects, Acinetobacter, Enterobacter, and Pseudomonas.  It goes into treatments, causes and what other countries are doing.  I found this particular quote really enlightening:

In Sweden, the government closely monitors all infections, and has the power to intervene as needed. “Our infection-control people have a lot of authority,” Giske said. “This is power from the legislation.” Once a resistant microbe is identified, stringent protocols are put in place, with dramatic results. Fewer than two per cent of the staphylococci in Sweden are MRSA, compared with sixty per cent in the United States. “Of course, it’s only around ten million people, so it’s possible to intervene because everything is smaller,” Giske said, adding, “Maybe Swedes are more used to this type of intervention and regulation.”

I think about how may folks we come into contact with that are infected with MRSA, and how we as health-care workers are more than likely at least colonized with it, and probably other nasties.  The funy thing ithough, is how resistant bacteria really showcase Darwinian theory.  These bugs are evolving to survive in their unique environment, adapting survival techniques thru the accquisition of resitance to live longer and multiply.  And based onwhat I’ve read lately, we’re not making it any harder for them!

via Allnurses.com and the New Yorker online

Happy Birthday Mia!

Yesterday was Mia Rose, our daughter’s 2nd birthday.

It’s hard to believe that it has been 2 years.  But I can.  Things are so different now, but still the pain comes back.  The pain has evolved into an ache, not the searing pain of a open wound.  Do I miss her?  Every day.  I had flashbacks to that night 2 years ago when I was at work, and while I didn’t break out into tears or cold sweats, being in a hospital on the anniversary of my daughter’s birth was tough.  We were thinking last evening how different the day would have been if she was still with us.  Instead of a dinner alone, we would have had the whole family around.  It would have been very different.

The Birthday Girl

Happy Birthday baby!

you can read her story in three parts:  Part One, Part Two, Part Three

The AMA Queen

We don’t seem to get many folks wanting to leave against medical advice.  Many times the floor nurse can somehow pacify them enough to allow us to care for them.  It’s something  I don’t understand.  You get yourself admitted to the hospital, but absolutely refuse to participate in your care.  What?  It’s not like we came down to your house, picked you up for no reason and then proceeded to admit you and perform ungodly amounts of tests and whatnot in order to just torture you.  And this is in folks who are lucid, non-demented and fully cognizant of their situation.  With some you can talk until you’re blue in the face, laying out the horrible things that could happen to them if they left.  It doesn’t faze them.  They want out.  Now.

Then there are those that use the threat of leaving AMA as a lever to get their way.  Like petulant little children who didn’t get a lollipop, they throw a tantrum in the guise of leaving AMA, somehow hoping to get what they wanted: smoking privileges, more narcotics or a private room.  Many times it works.  I’ve lost count of how many the residents have talked out of leaving.  And then they give them what they wanted.  Most of the time I’m of the nature to say, “OK, don’t let the door hit your ass on the way out.  Oh, can you sign this (AMA) form right here?”  But sometimes, when the reason for admission is very grave, I don’t want them walking out the door; mostly for the fear they’ll just bounce back in worse shape, but more because I like my license.

This weekend one nurse had 2 patients demand to leave.  Evidently, this had happened earlier in the month as well.  So she got a new nickname: the AMA Queen.  This weekend she had one of each:  one we wanted to stay, they other was welcome to leave.

The first woke up screaming after her stent placement.  Screaming in pain, cursing the nurses, the doctor, threatening to sue anyone who crossed her path.  After some Fentanyl and Ativan, she calmed down (…was gorked out of her mind!).  She woke up again, and the cycle was repeated.  Then night shift arrived.  By now she wasn’t feeling so happy anymore as the effects of the meds had pretty much worn off.  For awhile she was compliant.  Yes, inspecting your insertion site into the femoral artery in the groin is not a pleasant thing, especially when it happens every hour because you’re on Integrillin and had gotten 600mg of Plavix.  But we need to check for bleeding, hematomas and a variety of other unpleasnt things that could go wrong from the opening of a large hole in you artery.  Finally she had enough.  “I’m leaving.”  she proclaimed, “Get this IV out of me and take your stupid box!” as she tore off her telemetry box.

This was one where I was leery about letting her go.  Besides the evident cardiac instability, there was the fact she had a large bore hole in her femoral artery, albeit closed and was on a large does of anti-platelet medications.  The Queen put in a call to the cardiologist, the residents and after some time, with her patient see-sawing back and forth of her promising to stay, then threatenting to leave, a solution was reached:  more drugs, more frequently, no more groin checks with vitals and assessments Q8 instead of Q4.  The Queen was beside herself, as I would have been, as she had a patient on Integrillin and she nothing to go on but faith that the site was free from bleeding, hematoma formation and that the patient still had distal blood flow.  Not good.  Faith is good, but fixing a pseudo-aneurysm from a hematoma or vascular surgery to save a leg isn’t pretty.  The patient however was near ecstatic as she had won.  And me? As charge I was furious, at the residents, at the cardiologist and at the patient.  She had played us and the docs gave in.  We had lost any chance to deal rationally with her now or in the future as she had learned that if you scream loud enough and long enough, you get what you want.  Just like a child in the supermarket.

The second one was just the opposite.  About an hour into the shift he announced to the Queen, “I’m ready to go now.”  Baffled at the apparent rewind of events she did what we do and called the on-call resident.  Only this time, the resident had been the patient’s primary doc for the last 3 days.  Up to the floor she came, explained the risks of leaving, did the whole informed consent thing and let him go.  We knew that this wold have been better than fighting with him all night.  Before the consensus fo rhim to leave was reached, he put on his light.  As I answered it he said, “Oh, I don’t want trouble. I just want to leave.”

“OK,” I said, “we’re talking with your doc right now.  Give us 5 minutes, OK?”

“Sure” he mumbled.  And good to my word, his doc with there in about 5 and he was out the door 30 minutes later.

Now that’s the way it should go.

***disclaimer:  if a patient is truly unstable, you better believe that I’m doing anything and everything  I can to get them to stay, but many times it’s more of a relief that they leave!