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.

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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.