Kicking and Screaming

into the social century…

I did it.  I jumped.  Took the plunge.  Whatever.

Yep, now on Twitter.  Check me at @Wanderer _RN

Now a nap before work.

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Another Reason Why We’re Fat?

A Princeton University research team has demonstrated that all sweeteners are not equal when it comes to weight gain: Rats with access to high-fructose corn syrup gained significantly more weight than those with access to table sugar, even when their overall caloric intake was the same.

via Princeton University – A sweet problem: Princeton researchers find that high-fructose corn syrup prompts considerably more weight gain.

It could be though that they put high fructose corn syrup in everything.  It’s sad, but true.  Why do we need high fructose corn syrup in bread?  Isn’t it just flour, water, some yeast, maybe some eggs, salt, baking powder?  Why do we need sweetener in it?

I’m just sayin’.

How to Scare a Tele Nurse

Or, “oh shit!  That VT isn’t stopping!”

I’m walking into the nurses station the other night when I hear the “oh shit!” alarm ringing in the tele cave.  Y’know the one, that incessant, high-pitched dinging that is saying “Pay attention!”  Reflexes trained by my years on a tele floor I look up expecting to see someone bradying down, or maybe some nasty artifact, but instead I see this starting – and it’s not stopping!

Do I…
A.) Start screaming like a little teeny-bopper freaking out and run in circles?
B.) Shit my pants?
C.) Drop what I’m doing and high-tail it to the room in question?

Believe it or not, C is the correct answer.  Sphincter slams shut as I haul ass down the hall.  I bust in the room expecting to find a dude laying there, unresponsive, not breathing or generally not doing well.  Instead I see dude and his nurse clamly chatting.  I breathlessly ask, “Were you shaking the leads?”

“No” she replies, “What’s up?

Dude looks up and says, “Is my heart racing again?”

“Uh, yeah, he’s in VT.”  I say, amazed that he’s sitting there calmly chatting.  “Do you feel funny or anything?”

“Yeah, my heart feels like it’s going pretty fast.  But I’m used to it, it’s happened many times before, no big thing.” he replies nonchalantly, basically amused with the gaping look on my face.

So we hook him up to the bedside monitor, and sure enough, there it is VT, rate in the 150’s, BP is 100/53, he’s pink (ok, kind of yellow), warm and dry.  No light-headedness, no dizziness, he does admit to a little bit of chest pain, but in reality he’s in better shape that half the floor, except that he’s in this particular rhythm.

Prehospital 12-Lead ECG has a great quote on their wide complex tachycardia page, “If it’s a wide complex rhythm (fast or slow) it’s ventricular until proven otherwise!”  And that’s how we were treating it.  So we grab some labs, call the ICU team to come assess him and a 12-lead EKG.  Should we have called a Rapid Response?  Maybe, but we felt we didn’t have to.  He was stable.  He has had this many times before.  And he was sitting there cracking jokes with us.

So here’s the 12-lead:

So what to do now?  The ACLS algorithm for tachycardia with pulses starts with determining if the patient is stable.  Check.  He’s cool.  Establish IV access.  PICC line left upper arm.  Check.  Wide or Narrow complex?  Duh.  Obtain 12-Lead EKG.  Check.  Expert consultation advised.  Check, ICU team is here now.  Amiodarone if ventricular tachycardia or unknown, adenosine if SVT with abberancy.  Oh, wait…he has a history of WPW and 3 failed ablations.  Now what?

This is where expert consultation is really a good idea.  In our case, he’s now cracking jokes with the ICU team as well.  He’s still rolling along between 145-160 BPM.  We grab some labs.  Turns out his potassium sucked, magnesium sucked and his calcium critically sucked.  The Team decides that amiodarone would be a good idea and getting his electrolytes sorted out might help as well.  So we’re hanging amio, mag and they’re calling cardiology.  Mind you this is 2130 on a Friday night.  Do you think a cardiologist is going to come in at that hour?  Nope.  She says, “Oh, just have one of the ED docs cardiovert him and call it good.”

He gets packaged and ready to roll to the ICU, ’cause by this time he was pretty much a 1:1 and the nurse had 3 other patients she was already neglecting.  Grab the defib off the code cart, because with our combined luck (this nurse and I have a history of codes/RRTs) dude will decide to stop having a pulse once we’re between floors in the elevator.

The rest is rather boring.  A little bolus of propofol (yeah, we MJ’d him good!) and the judicious application of 100 joules of DC electricity fixed him right good.  One shock and back into sinus.  But it was a good thing he was in the Unit as they spent all night getting his ‘lytes repleted.

What could have been a very bad thing ended up being a very, well, fun thing.  Too often on our floor a busy night consists of incontinence, wrangling demented patients back into bed 30 times an hour or chasing naked psych patients down the hall, so dealing with a true cardiac issue was a rather refreshing change of pace.

At Work Stand-Up Comedy

You know it’s going to be a good night when you ask your 80 year old female patient how they’re doing and she looks up at you and says, “I feel kind of raunchy.”

“What do you mean?”  I ask.

“Right here,” points at stomach, “The food here is terrible, I just feel a little raunchy.”

“Tums on the way!”

OR

Better when the 70+ demented guy calls for help as he has to “Go drop a deuce!”

OR

WHen you’re sitting for a moment and the whole station is a-twitter about the patient in the ED with a “FB Rectum”.  It’s gets worse when you find out said FB is a vibrator.  Worse still is when our half-crazy Fillipino nurse goes, “I listen to bowel sounds and all I hear are bees!”

OK, maybe you had to have been there.

Observation Lovin’

Our observation unit is lovingly called the Hooper Annex (Hooper is our local detox unit) as not a day goes by that we don’t have at least 1 in with ETOH-related issues.  But we get dumped on, a lot.  Usually it’s because the docs can’t or won’t make up their mind and end up passing the buck.

Can’t figure out what to do with grandma, but there’s really nothing medically wrong with her?  Admit to obs.

Oh, you’re drunk and it’s cold outside?  Admit to obs.

Gastropareisis needing dilaudid?  Obs.

I know that an observation unit is a place to send the patient if they just a little too unsafe to send home, but not sick enough to be admitted.  And it can be a great thing.  Take for example uncomplicated chest pain.  No family history, no pain at rest, pain resolved PTA, but you’re male, age >50 and smoke.  OK, perfect obs admit.  Grab some serial enzymes, an EKG in the morning, maybe a stress test and off you go.  Or when your troponin I jumps to 5.0, we can start beta blockers, integrillin and call the cath lab.  Either way, we’ve done the right thing.

On the other hand you get a patient that needs a little IV antibiotics for an upper arm abscess.  The labs from their PCP are borderline icky, not enough to say definitively one way or the other if in-patient admission is warranted.  What to do?  Based on old labs, because why would we pull new ones, just plan to admit them to obs.  Then maybe grab a few new labs to direct therapy.

But if things had gone the right way, y’know like accurately triaging the patient, doing a complete workup before sending the patient out of the ED, like with labs and stuff, we wouldn’t be looking at this trainwreck patient rolling by the desk looking at each other going, “Uh, oh.”

If you had drawn labs first you would have been floored by the lactate of 2.2, the WBC >18, a H/H in the shitter, mult. 4+ accumulations of gram-positive baccili and cocci and gran-negative baccilli growing from the wound culture you just did the in ED or the raging case of rhabdomyolysis with a CPK of 96,000!  Yes, 96,000.

Luckily for you,we queried this lack of workup where you found all of these values.   We had a funny feeling, y’know that gut-level, spidey-sense feeling that this patient is not going to turn out well without a higher level of care.  Thankfully you ended up placing the patient in the ICU so they could run pressors and hang lots of lots of fluid on his septic self, instead of on observation where we would have had to rapid response them to get them to the unit as they crashed before our eyes.  Yeah, good call.