Sudden Cardiac Death and ESRD

This article caught my eye while browsing Digg: Sudden Cardiac Death No. 1 Risk for Patients on Dialysis.

It’s a pretty interesting look at the systemic issues that can create the environment for SCD.  One thing I noticed they didn’t seem to address is the all-too common elctrolyte imbalances that ESRD patients, especially those who are non-compliant are well-known for.  Remember, hyperkalemia can cause PEA too!  In the famous words of a nephrologist I worked with, “Oh, it’s OK, they just need dialysis.”

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Almost There

Like the rpoverbial light at the end of the tunnel, the election is almost here. And it can’t come soon enough.  I’m tired of all the incredible amount of bullshit that constitutes the democratic process in this country.  If I see another attack ad yo’re going to have to put in 4-point leathers.  That’s how fed up I am.  I’m done with it all.  Can’t we just get it done with and get on with our lives already?

I feel like the driver in this video.  Enjoy!

As for me, I’m going into a hermit cave to hide out and play Halo 3 until this is over and the dust has settled.  My ballot is in, nothing can change it except the total collapse of our financial system (worse than it is) and the declaration of martial law.

Me? Primary Charge Nurse?

I’m enjoying a night off, thanks to gods of staffing.  It’s probably punishment for signing on to work extra this weekend (yes, I’m an idiot for working Halloween…) however.  Even if I use “vacation” time to pay for the night off, I won’t get the extra shift differential on Friday, but I may get overtime.  It sucks, but after talking to the charge on duty tonight, I’m glad I ain’t there.

Last year after much negotiating, repeated asking and at the end, abject begging I agreed to become a relief charge nurse.  That means I work every other or third weekend and get to adulate in the praise of my peers.  More likely I am the big target for every issue, question or family disturbance that comes up.  I’ve enjoyed it.  There has been good nights, decent nights and really shitty nights, but overall, it’s been an adventure.  Thanks to this I’ve earned myself a nickname, and apparently the respect of my peers.

One night as I was getting report from the day charge nurse, she hands me a note, which says, “call me, signed, Your Manager.”  I’m a little dumbstruck, scared and nearly ambivalent.  I hope that if there was a real issue, I would know about it before I came to work.  I’m going about the early stages of the shift, luckily I have a preceptee with me, so that is rather limited, when I get a call.  It’s my manager.

She says, “So, have you ever given any though to being a primary charge nurse?”

“Uh…no.  Never really crossed my mind.  Why?”  fearing the worst.

“Well, Anne is leaving, she has an opportunity that is really too good for her to pass up.” she continued, “I want you to take her place.”

“Why me?  I know I’m one of the relief charges, but me?” I said.

“We were looking for someone who would be a good fit into her spot. Mellow, easy to get along with, y’know, all the things you are.  Besides, since I’ve been doing a lot of reviews lately, they all rave about you and wish you were a primary.” she finished.

“I’m going to have to think about it.  It’s a big deal.  I mean, it would mean I don’t get to work in step-down (we’re a split PCU/Step-down unit, I would be in charge of the PCU side) hardly ever.  That’s why I came here in the first place, the post-open hearts, the caths…”  I sputtered.

“That was a worry we knew about.  It’s my biggest concern to why you would say ‘No’.” she responded.

Trying for a little more time I said, “Besides, I want to run it past my better half, she’s the rational one.  Can I give you an answer by Monday?”

“Sure, give me a call.  I hope you say ‘Yes’.”

I hung up the phone and turned around.  Anne is sitting there with a shit-eating grin on her face.  “How long have you known you were going to do this to me?” I asked.

“Oh, about the time I gave DeeDee my notice.” she said.  “It’s really not that bad, you’ve been doing chanrge long enough to know.”

So I thought about it.  The word spread and people kept coming up to me that night and further reinforcing why I should do this.  To a single one, they all said very nice things about me.  I still wasn’ convinced they weren’t part of the conspiracy.  On my break I talked to the wife.  She brought up her concerns, which were few and easily laid to rest.  That’s when I realized that this could be a  good thing.  If I was able to sell it to the wife and how it wold play out into our 5 year plan, then it must be the right thing to do.  Right?

So by the end of the night I had it made up in my mind.  I would take it on.  I cut a deal with DeeDee, basically to the tune that I would get to work in step-down a couple of times each month to keep those partciular skills sharp.  The other charge agreed to this as well, so it looks promising.

There was a huge hassle geting the schedule fixed, as our scheduler instead of doing the easy thing and sliding me into Anne’s spots, he tweaks it to hell and back trying to figure out what to do.  But in the end it worked out where it’s actually pretty pleasant.  And considering I’ve been the weekend bitch for some time now, not having to work weekends is a really nice idea.  So we’ll see how it goes.

When I told other folks on the floor that night that I had pretty much decided, I looked over at them and with a maniacal grin, clenching my fist, “Hahahahaha…now I will have ultimate power!!!!!  And you are all unable to oppose me! HAHAHAHAAHAHA!!!!”

I’ve got a feeling that I’ll have so much more fodder to write about now, but time will tell.

It Was Only A Dream

It’s early. That witching hour when everything seems quiet, calm, nearly serene.  I’m sitting at the nursing station being lulled to sleep by the gentle hum of the tele monitors, the whir of the HVAC system, and the whoosh, clunk of the pneumatic tube system depositing goodies for our floor.

I hear movement over to my right.  Rustling of covers, the fumbling of old person hands attempting to figure out how to unhook their tele, IV and any other innumerable inconvienences of spending time in a hospital.  Languidly I lean back in my chair, just enough to see the scene as it starts to play out. There’s Mrs. Olsen, trying once again to crawl out of bed.  And if almost on cue I hear her fire up once again in a high-pitched keening wail, “Kaaaaathyy.   Kaaaaaaaathy!   Kaaaaaaathy!”

I look above the tele monitor and see the red countdown clock ticking away, “5,4,3,2,1…” and then a gentle hissing sound.  Over Mrs. Olsens bed a nozzle pops out of the ceiling and dusts a fine mist over her.  Just a little Vitamin A (or Vitamin L depending how you call it), slowly drifts down onto her soft white hair.  I call out across the hall, “Mrs. Olsen, where are you going?”

Momentarily distracted by my unexpected arrival she looks up, surprised, shocked in the fact someone is in her house.  Then just as soon as the shock registers, she seems to sigh, then settles back into bed.  I roll back to the station to check the status monitor.  The Sector 51 Aerial Sedation System™ status lights show all in the green.  Ativan levels show well-stocked.  I double check the timing system, sure enough, q2 hours, set to fine mist.  I ratchet open the cabinet, double check the syringes, run the diagnostics, close the door and settle back into my chair.  All is well.  All is calm.

Time goes by like a French surrealist film, dragging into the wee hours of the morning.  Then I hear a commotion from down the hall.  “Hey, I need some help down here!” comes the anxious cry of a co-worker.  I jump up and sprint down the hall.  Skidding around the corner like Tom Cruise in Risky Business I’m confronted by a 6’11” tall, naked beast of a man.  He’s hold our defibrillator above his head slowly rotating around his head like a planet orbiting our Sun.  He has that vacant look of menacing paranoia and ill will, ready to snap at the wrong move.

“Hey Wanderer,” whispers the nurse standing next to me, “think you can get some Haldol?”

“I’m on my way!” I say as I run back down the hall.  Into the Pyxis room and punch in the access code.  The drawer opens and I pull out a tube filled with jelly bean-like lozenges.  Another door opens and a simple blow-gun apparatus is revealed.  I grab both and head down the hallway.  I load as I run racking in a full clip.

He’s still there.  Just as pissed.  Just as on edge.  He’s distracted by the 5 burly gents from security surrounding him with 4 point restraints hanging from their belts.  I stop and take my time.  Line up my shot, just like they taught us duing the in-service.  Then “whap” a slight breath of air and the lozenge flies out towards our irate gentleman.  It flies straight and true, splatting on his chest like a bug on a windshield.

“One-one thousand, two-one thousand, three…” and like a tall tree falling in the forsest he starts to teeter.  Then over the edge.  Security grabs him easing him to the floor.  I dash in and grab the defibrillator.  The crisis has passed.  He’s snoring on the floor, drooling onthe freshly cleaned linoleum.

“Wanderer….hey Wanderer…hey Dumbass, wake up!”  I slowly open my eyes straring out my friend George.  “Your lady is climbing out of bed again…”

Yep, just a dream.

Staph and the NFL

A little Monday morning football related shenanigans for y’all:  A Slew of Staph Infections Tackles the NFL.

As health-care providers we all see this.  We know staph.  We’re almost all colonized by some variety, many of us probably with MRSA thanks to our unique patient populations.  It never ceases to amaze me though how this little bugger pops up in all sorts of odd places.

There were several telling quotes though from the article that I found both hilarious and frightening.  Now remember folks, the is Time (not Ma’ n’ Paws’ Newsie Magazine).  When talking about the the frequency of staph they drop this gem on us, “were either treated for staph or symptoms caused by the virus.”

Wait a sec’.  Did they say virus?  Uh…, yep.  Gee, I guess that’s why all the anitbiotics we’re throwing at it aren’t working: it’s a virus.  Wrong.  Big time wrong.  We all know staph is a bacteria, a gram-positiive cocci usually found in clusters.  It seems Time never got the message.

I also liked little gem:

In 2003, a team of researchers tracked the St. Louis Rams and found five players who caught eight MRSA infections. “We observed a lack of regular access to hand hygiene (i.e., soap and water or alcohol-based hand gels) for trainers who provided wound care,” they wrote in The New England Journal of Medicine. Other offenses included “skipping of showers by players before the use of communal whirlpools; and sharing or towels — all factors that might facilitate the transmission of infection in this setting.”

Like our infection control folks have been saying for a long time: wash your f*cking hands!  Yes, even big, bad, strong football players need to do simple things like hand-hygeine.  Simple ain’t it?

Plus with the recent news that Tom Brady has to go under the knife again, which sounds like a washout procedure of an infected knee, it shows that anyone can contract this, not just skin-popping junkies.

Nickled and Dimed, part 2

I went to an overnight conference for work this week.  You know how there are nice places and nice places?  This was a nice place that charged like a nice place.  From the outside it looked like a run-down old apartment complex.  Inside the rooms were nice, but not that great.  The catered food was adequate and the conference room well appointed.

But I am so tired of being charged for little things.  I had brought my lap top along to catch up on shows I had been missing and have something to play DVDs after hours when i was just hanging out with the wife.  I fire up the lap top and log on.  A page comes up and says this:  24-hour access, $4.95.  Charge to your room?

Really?!  I’m paying over $150 a night and on top I have to pay for internet access too?  The Econo Lodge down the highway gives it away for free.  One would think that in a nice place, it would be included, not a nickel and dime operation trying to additionaly separate me from my money.

Not to mention what they charged me for a whiskey with a beer back at the bar!

It was a nice escape from work though and a great opportunity to spend some quality time with the wife, in spite of the crap.  It’s late though and I have some stuff to write about, changes shall we say, but they’ll have to wait.

Ratings, the Whole Story?

Cued in by a story on CNN.com to HealthGrades.com I decided to venture in a look around.  I mean why not look up your institution to see how you rate?  I picked bypass surgery and angioplasty as these are things I’m familiar with.  It wasn’t pretty.

I don’t know their methodology, nor did I take the time to sort through it, but we didn’t stack up so well. Comapred to the rest of the hospitals in the area we really sucked.  Our scores for in-hospital mortality for CABG and angio was 1-star and 3-star respectively, poor and as expected.  For 180 days out we were as expected and poor respectively.  Not exactly stellar.  Not horrible, but it wasn’t what I thought.  I started to doubt myself, thinking that, “yeah, I guess we’re not as good as I thought.”  Then I realized:  it’s only numbers.

Here’s what I mean.  These are just scores based on statistics and numbers.  Surface level, no drill down or adjustments for severity, acuity or complexity.  Why?  I think that no one outside the medical establishment cares much for that.  The public wants to know the simple straight forward numbers.  1-5 star.  Easy, simple and uncomplicated.  I may be wrong and underestimating the American public, but I’m not too sure.

Why, I asked myself were our ratings so low?  Complexity.  We take complex folks, especially to surgery.  It may not be the wisest choice, but someone has to do that.  Our bypasses are not simple, far from it.  Last week I took care of a 4-vessel CABG with aortic root replacement and a 5-vessel CABG with intraoperative arrest and re-bleed requiring re-opening of the chest off-pump bypass followed by closure.  Our CABG patients are sicker than most.  Diabetes, COPD, sarcoidosis, thrombophilias, smokers, alcoholics, drug addicts, end-stage renal disease and the morbidly obese.  We take them when no one else seems to.  The worst I saw was a morbidly obese patient, end-stage renal disease, had a 4-vessel bypass, replaced the aortic and mitral valve and the ascending aorta.  I sat in on the surgery for over 10 hours and they were still going strong when I left.   It’s not that our surgeons are inept, nurses uncaring and unprofessional and our units unkempt and filthy, it’s that our people are sick, with a capital “F”.

I would venture to say though, that if you have a complex situation and needed bypass surgery or a valve, there’s not a better place to be.  If you want a minimally invasive mitral or aortic valve replacement, there’s not a better place to be.  It’s just that our reporting and the pure numbers suck.

A couple of days after I looked up the numbers and thought this all through two patients reinforced my belief in my institution.  The first was the family of a patient transferred from another hospital with a stroke.  They had previously had their CABG in our facility, but had been taken by EMS to the other facility with their stroke. Being a curious sort, I asked why they were here.  The daughter said this to me, “Well we had such a great experience with you guys when we were here for bypass so we thought it would be good to come back.  I asked my brother-in-law who works up at the large educational institution up the hill and he said that even with his loyalty to the educational institution he would take them to Good Shep.”

It blew me away.  Even someone else was saying we were good.

The other was a CABG patient I was taking care who told he this: “My boss looked up and down the West Coast and he told me that for the surgery I was having, it was between you guys and a place San Fran.  I just knew you guys were the best.  Y’all have been great.  No bullshit, just straight shooters everyone.  From the doc to the nurses.  It’s been real good.  Y’all have changed my life.”

To me that’s better than any rating, statistic or number in the world.