A True Professional

Nation & World | Driver registered blood-alcohol level of 0.708 | Seattle Times Newspaper.

RAPID CITY, S.D. — South Dakota authorities say a woman found passed out in a stolen delivery van last month registered a blood-alcohol content of 0.708 percent, nearly nine times the legal limit and a possible record for the state.

Some people are professional sportsmen, others professional poker players, some though are professional drinkers.  To end up with a BAC of .708 you kind of have to be a professional drunk.  While it may be outrageous, you kind of have to respect the dedication this would take.  Not to mention the cost involved.

Strong work!

Holiday Cheer

I’ll admit to being a little bit of a humbug.  It probably has something to do with being forced into Church stuff at an early age, then working in industries where Christmas is just another day.

But I’ve started to enjoy the Holidays again.  How you ask?  By indulging in the twisted representations brought forth by our media overlords.  Favorite holiday movie?  Not “It’s a Wonderful Life” or “The Santa Clause” or some similarly trite celluloid concoction.  And while I love “A Christmas Story” except when it is on for 24 hours straight, my all-time favorite Christmas movie is still “Die Hard”.  But I also found some great clips from our friends over at SNL.

So kick back, light the menorah, have some Schweddy balls and wrap your presents…enjoy!

Schweddy Balls won’t embed, here’s the link: Schweddy Balls

Happy Holidays to all!

Funny Lookin’

We had just isolated a patient as it seemed they had C.Diff.  How did we know before we even sent a sample?  We’re nurses and rely heavily on the “deck method.”  Y’know, if it looks like a duck, acts like a duck and quacks like a duck, it’s probably a duck.  Translating that into poop, if it looks like the Diff, smells like the Diff and the patient is developing SIRS with a white count of nearly 20, we’re gonna’ guess it’s the Diff.  Lab tests?  Who needs that?  Nurses’ noses show and unbelievable 95% sensitivity and 98% specificity with diagnosing C.Diff.  But I digress…

So in isolation we gown up in the ever-fashionable yellow splatter-proof gowns, gloves and sometimes masks with just a touch of wintergreen oil to care for the patients.  The patient who was isolation thought we were just the funniest thing since Jerry Lewis.  As we walked in she looked up and giggled, “You guys look silly!”

From the mouths our elders…

Quite Possibly a New Record

I’ve seen some stinky ABGs. Probably not as many as some seasoned RTs or ICU type folks, but have seen my share. But I think this tops my list of worst ABGs. And the ED was wondering why they were a wee bit altered…

pH: 7.20
pCO2: 164 (yes, 1-6-4)
pO2: 177 (10L face mask)
HCO3: 62
Base Excess: 29.3

Looks like they’ve been working on this for awhile though. I heard they were still talking…

Really Classy

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I went with the wife to the Urgent Care today.  Nothing like a bit of sinusitis to brighten your day (her, not me).  Originally she was going to go solo, but I’m glad I went, because what we saw was so typical of how entitled some people are.

Dude comes blustering in the door, snuffling and coughing up to the window, “I need to see a doctor, I’m sick.” as he proceeds to cough all over the receptionist.  She politely asks him   to cover his cough as she gets a mask for him, but polite isn’t going to cut it.  “Don’t you see I’m f*cking sick?!  And I’m in a crappy mood”  He bellows at her.

“You need to watch your language!”  she says.  He mumbles more profanity under his breath.  “Do you have insurance?”  she asks.

“I don’t have time for this, just bill my ass!”  he says as he throws his ID at her.  “I better get to see him f*cking quick, I’m sick.”

“You need to wear the mask if you’re coughing,”  she says as he had it covering his chin only and had been spraying the room as he coughed.  She finishes her paperwork and asks him to have a seat.

“F*cking bitches,”  he mumbles as he struts to where his significant other, who has been holding her head absolutely mortified over his behavior is sitting.  He then proceeds to throw his mask on the floor.  Continuing his rants over how this sucks, how he’s SO sick, how he needs to get in fast to see the doctor, how this is all bullshit and what the f*ck was taking so long. He did everything but jump up and down and stomp his feet.

I’m glad that by this time my wife was done and we could leave as I could hardly hold the laughter in.  I walk out the doors and start busting a gut.  Here he was totally hysterical that he was sick, acting like a 3-year old child having a tantrum.  Frankly I’m surprised they didn’t 86 him.  It was as hysterical as it was uncalled for and plain wrong.  It has been awhile since I have seen an adult throw a temper tantrum.

But here’s the thing that really pissed me off:  so many people act like this towards health care workers.  Entitled?  You bet.  As he said, “I”m sick” as if that was supposed to condone bad behavior.  It’s not like these people walk into Safeway and throw a fit that there is a line at the registers (OK, as my wife pointed out, they probably do…), but get them into a medical situation all decency, restraint and class disappears.

I’ve seen this in EDs and on the floors.  It’s sad that according to the ENA, “finds that more than half of emergency nurses report experiencing physical violence on the job…”  I can’t find statistics for floor nurses and while it is not as high, it happens enough.  I’ve read some commentators that say dealing with this is a part of the job, that we should have known about it before signing up, and while I do agree that we see people at their worst, I didn’t sign up to be verbally or physically assaulted on the job. But some people think that because we are in health care we should just take it and that’s bullshit.

So here was jerkwad yelling at some poor woman just doing her job, trying to help him out.  She should have given him a warning and as he continued to berate her, 86’ed him and called the cops.  But thanks to EMTALA (at least what I could find relating to urgent care centers associated with a hospital) they could not.  As home-skillet was complaining about the time it was taking, literally mere minutes, I wanted to say, “Hey, go the ED – you might get seen by the doc in an hour, maybe, ’cause any triage nurse worth their salt can tell you’re just full of shit and while you may feel like shit, there is nothing life-threatening about you being “sick”.  Plus they won’t stand for your histrionics.  You’re not that sick:  you walked in the door, are still breathing and are well enough to bitch about this place.  So suck it up and deal with it, act like a grown-up.”  And I’m not even an ED nurse…

Got to love what our society has transformed some into – a need it now, instant gratification, mass of no respect or class.  I hope they made him wait and then double charged him.  Or called the cops.

We’re Just Not Compatible

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I’m down at the blood bank the other night to pick up some RBCs for my patient who was a quart low.  The tech is all atwitter about releasing the blood saying how she just doesn’t feel right about it.  Knowing that my patient is pale and the hemoglobin and hematocrit are not exactly near par, I know that I need the blood.

So through the rigamarole of signing out the blood.  Name, age, medical records number, mother’s maiden name, shoe size in metric, type and crossmatch, verify donor number, yadda, yadda, yadda.  Done it plenty.

But then she says, “And can you verify if he is compatible?”

Look at the label, brow furrows for a sec, “Uh, right, it notes incompatible.  Warm antibodies.”

“OK, I just wanted to make sure you realized that.”  she says.

Then it dawns on me:  this is why they’re all atwitter, the blood is technically incompatible.  I knew this already having seen the “High Risk Blood Transfusion” form in the chart and from my conversation with the blood bank a couple days prior where they were reccomending not to transfuse.  But since it was night #3 I was a little slow to put the pieces together.  I was prepared, I wasn’t prepared for their reaction.

The tech said, “Yeah, it goes against all of my training to give out incompatible blood.  It just doesn’t seem right.”

“I can understand,” I say, “But they’re just a little pale and the H/H keeps dropping, plus they started them on a wooly-mammoth sized dose of prednisone.”

Truly though, they were sick.  Originally in for “weakness”,  come to find out they were having a NSTEMI secondary to anemia.  H/H on admission was a whopping 5.9 and 18.0.  Not the worst I’ve seen (that would be like a 3 and change…), but not good.  About 6 units later, the labs looked good, they were pinking up and starting to feel human once again.  Then they started to go yellow.  Not end-stage liver yellow, but this wan faint tint of yellow.  H/H started to drop and their bili started to rise.  Something was hemolyzing the blood.

On top of the nasty rumor that their previously stable chronic lymphocytic  leukemia was undergoing a Richter’s transformation (turning into large B-cell lymphoma) they were developing autoimmune hemolytic anemia of the warm variety.

But what is warm autoimmune hemolytic anemia?  To quote:

Autoimmune hemolytic anemias (AIHA) are caused by autoantibodies directed against a patient’s own red blood cells that result in accelerated red cell destruction…AIHA are divided into warm and cold autoantibody types based on the temperatures at which the antibodies maximally react with red blood cells in vitro. Warm autoantibodies are more reactive at 37oC than at lower temperatures, whereas cold autoantibodies react optimally at 5oC and less strongly at higher temperatures.

Signs often include anemia (duh), elevated billrubin (check), elevated urine urobilinogen (check, urine looked like Coke), LDH elevated (yep) and haptoglobin decreased (uh-huh).  And then there is the presence of warm autoantibodies shown by a positive direct antibodies test.  Uh, yep.  That was what the call entailed the couple of nights before.

So here I am, incompatible blood in hand, which seems wrong to start with.  I know the patient needs it.  I know that they had received a unit already earlier during the day (why the second hadn’t been run in subsequently but left for night shift is a whole ‘nother bag o’ worms) with no issues, but still it left a lot of room for thought and worry.  To top it off as I’m leaving another tech comes up and says, “You don’t mind if I do a direct observation , do you?” in the tone that says, “I going to whether you object or not…”

“Sure, come on down!”  I reply, “The more the merrier!”

So off we go.  As all of us march into the patient’s room (me, the witness, the lab tech), they go, “What’s the big to-do?  I must be a bigger celebrity than I thought!  I guess the word has spread of my case and everyone wants to come see me!”  Which is true.  As they are under the residents, there has been a literal line of people in and out of the patient’s room for the last week.  It is not something we often see.  At least they’re a good sport about it!  They wink at me and say, “You’re giving me the high-octane blend, right?”

“Sure enough,” I joke back,  “High octane, nearly racing grade!”

Blood goes up and in.  I administer it like I have many times before, maybe running it a little slower than normal and things work out just fine.  The H/H, while still in the single digits is better and the patient seems to feel a little bit better, but it’s hard to say.

The worst thing though, is knowing that they have months left.  All we’re doing is symptom relief at this point, ’cause whatever is truly going on, is going to kill them in less than 6 months.  You hope that the treatment you’re doing won’t add to the burden of indignities already endured, but hopefully make them feel a little more human to go home.  Plus you get to re-learn about something you haven’t seen since nursing school!

Cold with a Captial “F”

We’ve been having a little bit of a cold snap. Daily highs are in the 20’s, maybe inching into the low 30’s. This is Portland, OR – not Portland, ME. There is something terribly wrong with this. I mean how can this be with all of the talk of “Global Warming”? According to the ‘Net it is 19 degrees at my house at only 10pm. I can’t begin to imagine how cold it is going to be on my way home in the morning. At least it’s not snowing…

UPDATE:  Here’s the screen shot when I got home.

Walked to and from the bus.  It didn’t seem that cold though…