Allow me to indulge a small self-pity moment…

Went to the doc last week, looks like I have sleep apnea (my neighbors could tell you that), my asthma is worse that I thought, my vitamin D and testosterone are probably low, my cholesterol is (kind of) high, my CRP sucks and I need to stay on my BP meds.

OK, I can deal.  Sleep study, ok.  Steroid burst, whatever.  Better regulate my diet and (re)start to exercise, now that I’m breathing better, it’s not such a daunting task.  I can do this.

Then we find out on Saturday that some piece of shit, worthless, bottom-dwelling, scum-sucking, reject turd of a rotten crotch cleaned out our checking account with a stolen check(s).  That has caused our rent payment to disappear and now the landlord is threatening to give us the ol’ heave ho’ unless we can get the bank working at a faster than (non-global warming) glacial pace.

Compared to others though, my life is good, so now I’ll shut the hell up.

How Low Can You Go?

As nurses we see wacky, off and plain old disturbing lab values.  But I think I saw a new record the other day:

Hemoglobin 3.2 mg/dL, Hematocrit 13.2%

The freaky thing?  The patient was doing fine.  Alert, well, they only spoke Russian, but they were fighting us.  Vitals were great, pulse in the 80-90’s, BP 140/80.  Maybe a little pale, but otherwise OK.  And refusing blood transfusion.

Figure she had been brewing this for quite awhile and had been able to compensate quite well for it.  After being told in no uncertain terms that, “You will die without blood.” she consented and received 5 units.

Meeting the Quota on C.Diff

What is it with docs and ordering C.Diff?  Why is it that if a patient has diarrhea, the order a test for C.Diff?  Some days it feels like they went to an in-service recently and all remembered that C.Diff causes diarrhea and now anyone with loose stool should be checked -even if there are no other reasons besides loose stools.  Here are some great examples of stupid rule-outs for C.Diff.

Dude who has ruled out 5 times within the last 3 months, ruled out the previous week on Friday and now on Monday they decide think that he needs to be ruled out again.  Why?  His white count is up.  Did they forget that he has pretty much chronic aspiration pneumonia?  Guess what?  He ruled out a second time.

How about end-stage liver disease chick on lactulose?  We all know lactulose, right?  Binds to ammonia and flushes it out of the system – in the stool.  And it’s always diarrhea.  Never met a lactuloser with normal, non-runny poop.  “But by God, she might have C.Diff!  She has loose stools!” say the residents.  “What are you stupid?” say the nurses.  Guess who was right?

Or the LOL on tube feeds with no real gut flora anymore who has loose stools.  Or the liver resection dude that ruled out last week and evidently needs to be ruled out again.  Or the ICU transfer with colitis?  (OK, I’ll give ’em that one)  How about the LOL in with constipation who we give docusate, senna, biscoadyl, Miralax and MOM to so that they can poop, and when they do, thanks to all the loosening products that stool is nearly liquid?  They surely have the Diff, right?  Or my tried and true favorite, the patient who had 1 loose stool 5 days ago, and has yet to poop this admission.  They must have C.Diff.  But the patient so that is so bound up from narcs that they are pooping marbles, yes, the poop rattled in specimen cup just like a marble, pretty much takes the cake.

It almost like each resident group has a quota to fill for C.Diff rule-outs.  And even when presented with rational evidence like lactulose, multiple bowel care products, rules-outs less that 72 hours prior, they blunder on blustering about antibiotics and gut flora and elevated white counts and diarrhea.  Then they walk into the room without isolation gear on.  I don’t get it.

Medicine Like 1699

Was helping a colleague out with a chart check late one dark and stormy night and came across a progress note from the chaplain.  Intrigued by the content and noting he was responding to an order in the system, I went searching for the order itself.  A couple of pages down I found it and it read:

Spiritual Care Consult – Reason: possible demonic possession.

Now granted, the patient was all sorts of crazy, alternating between catatonic states with rabid manic outbursts.  They looked much like the freaky chick from “The Ring”.  Acting like stark raving mad lunatic may seem to generate a need for an exorcism, but we’re not that society any more.  While I think that putting people in the stocks for petty crimes might be a good thing and that we’re using leeches for medical therapy,  maybe we’ve moved past the time where issues of the psyche were cured by the exorcisms of the “unclean” spirit.

Or have we?

No More Streakers?

Traditional hospital gowns which expose patients’ backsides could soon be a thing of the past as part of a dignity push across the NHS.

Trusts are introducing new wraparound garments which tie at the side rather than the back – ensuring their wearer’s rear is not exposed on the wards.

Patients have long complained about the old-style gowns, which are designed to allow surgeons and doctors easy access to their body, but do nothing for patients’ dignity when they are walking around a hospital.

Not only are they embarrassing, they can also be uncomfortable – the lack of a back means they can be very draughty to wear.

via ‘Bottom-flashing’ hospital gowns replaced by new, ‘modesty’ version | Mail Online.

I guess I’m just used to little old dudes up for their 6am constitutional with the back flapping in the breeze on their way through the ward.  I will say the gowns are pretty much horrible – even to those working with them.  We snap our gowns at the shoulders so when you’re getting a new one it’s like Build-A-Gown, which sucks when you’re trying to be quick.  But the one saving grace of the old-skool gowns is the ease in which we can change someone who is in bed.  Besides the chronically bed-bound, there are times when the patient can’t get out of bed, like after an angio and the gown needs to be changed.  Easy and simple with the open back, but I’m sure the new desgnn takes this into account…

Tour of Pain

It is projected that by 2020 the U.S. will spend $685 billion a year in direct medical costs for persons with chronic diseases, and by 2050–$906 billion.

Hoffman, Catherine and Dorothy P. Rice. Chronic Care in America: A 21st century challenge. San Francisco, CA: The Institute for Health and Aging, University of California. 1996. [ Permalink ]

It’s a sobering thought – $685 billion a year in direct costs, which doesn’t even begin to address indirect costs.  As a friend would say, “That’s shit-ton of money!”  We all know that early intervention in chronic diseases, like COPD, heart failure and diabetes can curb and reduce the effect of these diseases over the long term.  Sometimes though, getting the message through in words alone just doesn’t work.

Even though programs like “Scared Straight” where convicts are unleashed upon juvenile offenders in an effort to make them come correct have been shown not to work (and in some cases do more harm than good), the idea is sound.  Imagine if you can show a patient with the beginnings of these chronic diseases the ravages they face.  Maybe putting a visual, a face on the horrors could make them start making better choices.

We had the perfect storm scenario for this a couple of weeks ago.  Our census was more than representative of what diseases like diabetes, COPD and heart failure can do.  These patients, while nice, every last one of them, they are were what many call gomers – the chronically ill.  We all know them, they get admitted and never leave.  Ravaged by their diseases their life is pretty much a never-ending cycle of meds, dialysis, fingersticks, lab work, scans, pneumonia, renal failure, decubitus ulcers and other skin issues, trips to the hospital and back to the skilled nursing facility.  You know them by name, family, diagnosis, code status and how many times they’ve gone to the Unit.  So imagine if we were to expose folks in the beginning of the journey to them.  Sure it’s a HIPAA nightmare, but maybe some good could come of it.

So back to the other night.  The patient I have in mind is a young man, has Type 1 diabetes and has been admitted with a blood glucose of 600mg/dl.  After a bout with osteomyelitis, he’s already lost a finger, thanks in part to being unable to heal well with elevated blood glucose.  His A1C, when last checked was over 11% (normal for good control is around 7%), so obviously he’s not doing well in managing his disease.  So I wanted to take him on a tour of pain, what could happen if he continues this path.

“So how old do you think this patient is?”  I ask as we walk into the room.

“Uh, dunno, 70 something…” he replies.

“Yeah, try 55.  See where her legs should be?  Not there right?  See that tubing under the skin of her stump?  That’s a dialysis graft where she’s hooked up to a machine 3 times a week that cleans her blood because her kidneys can’t.”

Diabetes continues to be the leading cause of kidney failure, nontraumatic lower-extremity amputations, and blindness among adults, aged 20-74.  CDC – Chronic Diseases and Health Promotion.

And we’re walking…

“And over here is a gentleman with a tracheostomy, otherwise known as a hole in his windpipe so he can breathe because he had pneumonia so bad he was on a machine to help him breathe for 2 months.  The other day he blew eggs right out of it as he aspirated them and instead of going into his lungs they flew out the hole.  He pretty much just lies there.  He’s had at least 3 heart attacks, that we know of, he craps the bed as he has no control – which you did this morning as well I heard, and spends more time in the hospital than home.  Oh yeah, he also has an implanted penis pump to get that to work because his vascular disease is so bad.”

“Diabetes can cause nerve and artery damage that can make achieving an erection difficult. Between 35% and 50% of men with diabetes experience ED, according the National Institutes of Health. Some estimates are higher, stating that up to 75% of men with diabetes will experience at least some degree of ED during their lifetime and the risk increases with age.” WebMD

Continuing on…

“See those funny looking scars on this guy’s face?  That’s where he melted his oxygen cannula to his face when he caught it on fire while smoking with oxygen on.  He smoked 3 packs a day for 3 years and now can’t go anywhere without his oxygen, or as he says, ‘It’s my lifeline man!’ as he clutches the tank like Gollum and Precious.”

We all know the issues with smoking, there’s even a warning on the bloody pack.  “Nuff said.

And last but not least…

“This guy looks pretty young right?”

“Yeah, I guess, I mean I can’t tell.”

“Yup, he’s barely 40.  See how he can’t move his left side and that arm is all twisted?  He had a stroke 5 years ago.  Y’know why?  He’s a Type 1 diabetic, just like you.  He didn’t take care of himself, figured he’d be fine.  Now he too gets dialysis 3 days a week, has had a stroke and is barely into his 40’s.  You could be him in 15 years – or less.”

“…results indicate that incident dialysis patients are at five to ten times the risk of hospitalized stroke when compared to patients without renal failure. Although this high rate of stroke may not be unexpected given the accelerated risk of atherosclerosis among ESRD patients, previous public health initiatives have focused primarily on controlling cardiac disease among dialysis patients34; our results suggest that similar initiatives are needed to control the high risk of stroke in this population.”   Elevated risk of stroke among patients with end-stage renal disease.  Stephen L Seliger, Daniel L Gillen, W T Longstreth Jr, Bryan Kestenbaum and Catherine O Stehman-Breen.  Kidney International (2003) 64, 603–609; doi:10.1046/j.1523-1755.2003.00101.  http://www.nature.com/ki/journal/v64/n2/full/4493920a.html

Of course in an ideal world he would swear on a stack of Bibles that he would change, but it ain’t a perfect world.  I expect to see him soon.

Keepin’ the Beat

It looks like I’ve broken my streak.  I actually had almost 3 months without a Rapid Response or Code Blue on my shift.  It’s no more.  At least we didn’t have to do CPR on this little 40kg bag of skin and bones, just some airway support and off to the ICU.

But it got me thinking.  Thinking led to rooting around in my “book o’ fame” (my morbid collection of EKG strips of “bad things”) which led to me finding a couple of strips related to CPR.  Strange how a mind works.

Evidently, per the post-it note, these had been grabbed during a code last year where I did a TON of CPR.  Remember kids, a bad thing about being a big strong dude is that you get to do a lot of chest compressions.  I’m not dissing the ladies, I’ve seen many a round done by y’all, and you’re fierce, but for some reason whenever there is a code on my floor, yours truly gets roped in to do compressions.  Needless to say I had no need to go to the gym after that code.

My tele tech knows my predilection for interesting tele strips so he printed a couple for me.

First, near the beginning of the code:

CPR is in progress with a rate around 100bpm, stop to check for a rhythm, find VT, resume CPR, then shock.  This is why you resume CPR right after the shock.  That heart ain’t doing nothing.

Second near the end:

We’re still going fairly strong, figure the rate is around 80bpm, then nothing.  We called it about a minute after this strip was run.

In all fairness, they were dead from the get go.  Never once did we get a rhythm stable enough for transport, never a pulse, pupils were fixed pretty much from the beginning.  Morbid?  Probably.

But on to the beat.  They say 100bpm is the speed we need to keep when doing CPR.  It allows for adequate refilling of the ventricles with blood before the next compression.  In the midst of the controlled chaos of a code, keeping that speed can be tough when adrenaline gets the better of us.  So what do you do?  Keep the beat with a song.

We’ve all heard of “Stayin’ Alive” by the Bee Gees as the “perfect” CPR song.  Heck, I have it on my header.  My BLS instructor the last time around had a thing for “She’ll Be Coming Around the Mountain”.  There is the slightly more darker “Another One Bites the Dust” by Queen that fills the 100bpm measure.  Thanks to the American Heart Association, there is a large list of songs that fit the bill of 100bpm.  Some notables include:  “Kickstart my Heart” by Motely Crue (they would know), “Paradise City” by Guns N’ Roses. “Heart Attack Man” by the Beastie Boys and of all things, “Back to Life” by Soul II Soul.  The entire list can be found at Be the Beat, which is a website dedicated to educating kids about CPR, but here’s the playlist.

Will this help me set a new streak?  I doubt it.  As the rule of three shows, I have 2 to go before a new streak can start…

That’s Just Wrong

Not too long ago we had a patient on our obs unit who was dealing with some issues of constipation.  Unfortunately, they had 2 things working against them.  First, was being born with a congenital defect requiring surgery and leading them to a life of issues with their bowels.  Second, was being admitted to obs by Dr. Jackass.

Dr. Jackass wrote that the patient would be able to discharge after having a bowel movement.    After a phone call by the nurse for some pain medication, he decides to send things into overdrive and orders the following:

“continuous soap suds enema with rectal tube until clear”

“Say what?!” asked the nurse.

“Say what?!” asked the charge nurse.

“Fuck that!” said the patient who was young, alert, oriented and appropriate.

“He ordered what?!” asked Dr. I-have-a-clue who was the overnight cross-cover, “Yeah, nix that.  Go ahead and try a soap suds enema x1 – if they’ll let you.”

No enema.  Patient pooped, slept and went home.  Nice simple resolution.

original image here.

Totally Inappropriate, But Still Funny

Shocking Internal Retirement Home Betting Pool Memo | Top Cultured.

First off, it’s a fake.  Second off, betting/wagering on the lives of those you take care of is wrong.  But here’s the thing:  I can understand it.

We’ve bet on ETOH levels, BNP levels, how low a hemoglobin and hematocrit is, how much dilaudid a patient will request in a shift, when patients will be discharged and yes, even when patients may die (in a very vague, hoping it’s not tonight way).

I almost started a pool this weekend to see when one of our long-term patients will be discharged – mind you their visits are measured in weeks, not days.  And I would have had takers too!

Does this make us bad people?  No.  Does it make us callous and uncaring?  No.  It is a very nurse way of dealing with bad situations.  Black humor gets many of us through the day-to-day struggle that being a nurse can be sometimes.  A joke, even in a dark moment can bring a needed burst of levity and relief to a stressful situation.

It’s not that we don’t care, but perhaps we care too much…

Then again, I’ve never put odds down on folks, that’s just inviting disaster, like saying the “q” word while still on shift.