But I’m Not Dead Yet!

Truly, I’m not dead, just taking a little break from the interwebs. It’s been quite refreshing. Gonna’ get rid of some cable channels, trim my social media life (what’s left of it!), start trying to live life and continue my search for the next adventure.

So go check out the archives, hit some links and I’ll be back sooner than you know!

Happy Birthday

Happy Birthday Mia Rose.

You would have been 4 years old today, August 10th, but you left so suddenly and so unexpectedly.

I know it’s been 4 years and maybe I should have moved on, moved past or otherwise just moved, but some days I find it hard to do, well, anything.  I still have the snippets of images in my mind when I reflect, quick flashes of memory that can take me from normal to an emotional wreck in .25seconds.  It’s changed me.  Your life changed me.

I think of all the milestones you would have had, walking, talking, temper tantrums, special simple moments, that didn’t happen.  I wish I had reported the nurse who we think killed you, but the shock and trauma of it all had rendered us numb.  It’s like I let you down and now can’t forgive myself for it.

At least we’ll always have those small quiet moments where your Mom and I would just hold vigil in your little room.  The nurse would leave us alone in there with you, giving us some space to be a family.  It was dark in there, lit only by the blue bili lights and we would talk and dream about our future, your future.  We knew you heard us as you would calm down and seem to rest easy hearing those voices you knew so well if  only for a short time, the voices of you parents.  I treasure those moments.  When things were calm.  When things were hopeful.

All too often though I forget those special moments and remember the sheer terror of running into the NICU seeing them doing half-hearted CPR.  It was so bright in that room, thing were washed out by all the light streaming in but all I could see was your lifeless body and them looking at me.  I remember the pity on their faces, the pain they mirrored when they asked if I wanted them to continue.  I had to tell them to stop.  I let them stop.  I didn’t want to, but I knew it was far too late.  When you died, so did a little bit of me.  And I’ve had an empty hole ever since.

There’s still something missing in our lives.  Our life would have been nearly perfect with you in it, complete.  There are days where the rage is palpable, the sadness suffocating, the hopelessness immobilizing and I get into a funk so deep that all I want to do is hide in our house and bury myself into TV, praying to numb myself.  Perhaps this year is harder as I stopped the antidepressants, so I’m finally feeling the emotions again.  And while it feels good to feel again, it’s not easy.

But I’m trying to focus on the good.  You were with us for 8 days.  And what an impression you made.  Even though you were so young and so fragile, we could see your personality beginning to develop, our tiny little individual.  I’m lucky to have known you, one might say blessed (although I hate saying that I’m “blessed”…).  So I’m going to minimize the bad while remembering the good.

Happy Birthday baby girl!  We’ll never forget!

You can read Mia’s story here, here and here.

The Cheap Nurse’s iPhone app Guide

I saw this article the other day via Twitter, 10 more great iPhone apps for nurses and thought, “Hey!  This could be cool!”  Sure, it is cool.  It’s a great list.  The apps are polished and nicely made.  Only 3 of them are free.  This is not a slam on the author of that piece.  I just look at things differently.

I’m down with dropping cash for apps.  It encourages the authors to continue their pursuit and make more and better apps.  But what if you’re on a tight budget, don’t have a credit card or are just plain cheap?  Looking around the app store, you’re pretty much S.O.L. (shit out of luck).  Not any more.  Here’s a list, by no means is it comprehensive, but it is free!  But Wanderer, if you can afford an iPhone, surely you can afford to buy apps especially the $.99 ones, can’t you?  Truth is, I’m cheap.  Plain and simple.  I can deal with ads if that means I don’t have to pay for it.

1.  Medscape.  My go to app for drugs and diagnoses.  Simple, searchable and easy to use.  It is missing one thing though, a Pill ID category.  You know for the LOL who is sitting there going, “I take a pink one, a green one and a blue one at night.  No, I don’t know their names, but I have some in my purse!”  For this I use…

2.  Epocrates.  The elder statesman.  Sure you can buy a subscription and get detailed labs, diseases, toxicology and all of that jazz, but all I ever need it for anymore is for the Pill ID.  When the LOL whips out her pouch o’ pills I’m ID’ing them like a bad mutha…  I used Epocrates on my Palm thru nursing school and my first year as a nurse, but got tired of carrying around my Palm and didn’t until I got an iPhone.  I like Medscape better, but it’s a personal preference.

3.  MedCalc.  Mentioned in the other article.  It’s great.  Truly it is.  I doubt I will ever use the “In-Flight PaO2 Estimation” calculator, but it’s good to know that I have it should I need it!  One really nice feature is a “Starred List” where you can dump all your most used formulas to find with ease.  Additionally, in the “Infusion Management” calculator you can add in your own hospital formulary concentrations essentially building your own “Infuse” app!  I had this too on my Palm and had all of the common drips on my floor programmed in.  Yeah, it took a little time, but hey, the app is free!

4.  MD EZ Labs.  It’s not the most in-depth of lab apps, but it has normals and possible differentials.  Plus, each lab has a link to the web for further digging.  Simple and straight forward.  Besides, what do you think the residents do when they don’t know a lab?  Google it.

5.  Qx Calculate.  Another calc program.  I haven’t truly dug that far into it.  But if you need to calculate Framingham or CHADs2 scores, this one’s for you.

6.  iRadiology.  I’m a nurse.  I don’t pretend to be anything else.  But I do want to know what I’m looking at when I see an x-ray.  Not to diagnose, but to see and teach myself.  It becomes more of a “Hmmm…this one looks worse that prior.” than anything else.

7.  MedPage.  Need CMEs?  If you’re a member through the website, you can earn CME credits while on the go.  Stuck in line at the DMV?  Grab a 0.25 of an hour’s worth and help grow your knowledge and practice.

8.  Eponyms.  Free for students.  Again, another I used in nursing school and had forgotten about until I read the article.  Great collection of medical terms/definitions.  Need to know what the heck “Chikungunya Fever” is?  This is where I would look.

9.  iQuarters.  You have to stay sane, right?

There you have it.  9 free great apps for nurses on the cheap.  Feel free to add your free favorites while you’re at it!  And if you’re an Android user, jump in, I know nothing about that!

Naked Time!

Nothing dirty here, just a rumination of nakedness in the hospital.

You know it’s not going to be a good night when the first thing you do is forcibly re-direct a naked man out of the hallway and back to his bed.  Even though he was suffering from a nasty case of Versed-itis© (odd, sometimes insane behavior in normally sane and calm people as an adverse reaction to Versed), he was jumping out of bed post-angio and running into the halls naked, as we were trying to keep him safe.  It’s always fun when the doc is yelling for some help as she is being chased by the naked dude in his nude adventures.

It gets better when the IV nurses comes out of a room and says, “Yeah, thanks.  I just saw your patient’s penis.  Oh, and he tried to come on to me.”  That’s a surefire way to ensure no one bothers you the rest of the night.

Perhaps the best is when the naked chick is running around the unit doing laps, with a nurse or two chasing her with a gown and sheets.  It’s pretty damn hilarious.

What is it about the hospital that promotes nakedness?  Could it be the drugs?  Could it be the lowered inhibitions due to neurological decline?  Could it just be that they don’t care?

Lucky for me it’s been all three.  There was the psych patient in with syncope that the residents stopped all the anti-psychotics on thinking they were contributing to the syncope (turns out it was the the pauses he was having) but he ended up naked every night, roommate be damned.  There have been several cases of drug-induced nakedness, like angio boy.  And the neuro decline brings to mind the Huntington’s patient who slept naked and would jump out of bed to run to the bathroom, except sometimes he got lost heading there and ended up in the hallway.

99% of it has always been guys though.  It’s like we’re so enamored of our own bits that we need to show it off to the entire world, whether they want to see it or not.   If it’s in the rooms, I could care less.  Like the dementia patient who’s wife told us they had slept naked for years, it was comforting to him and once we got the clothes off, he slept like a baby.  It’s been pretty rare to have a female streaker.  I guess the societal mores are too deeply embedded in them (they just tell you about their need for a new vibrating friend…).  But when the lights go down at the hospital, too often the clothes come off.  And not in a Grey’s Anatomy-way.  Some will argue that this is just part of nursing.  It is.  A damn funny one!

I know however, that when I’m of the age and in the hospital, I’ll be the one running naked down the hall, freaking everyone out!

Five for Friday

This Friday it’s five songs that have been in heavy rotation on my iPod.  Enjoy!

Dada – Dizz Knee Land.  Too funny, 8 years after the sing originally came out we were still singing “I just flipped off President George!”

Cake – Sheep go to Heaven, Goats go to Hell.  Guess I’m a goat…

Less Than Jake – Johnny Quest (Thinks We’re Sellouts!)  I think I have 3 versions of this song on my iPod right now for some reason and each one is different.

Cherry Poppin Daddies – Irish Whiskey

But instead I’ll
Hang in there and suffer with the rest
I’m a drunk and a sentimental man, so –
Dust us off a bottle of your best
Irish whiskey and drink with me
To departed friends…
To departed friends…

Bad Religion – Let Them Eat War

Great song, great band.  I always get extra pumped when this song comes on while riding.

At least this will take my mind off of things when I visit the GI doc…

Falling Down

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Anyone who has read “The House of God” knows Fat Man’s Second Law:  Gomers Go to Ground.  It’s harshly worded and blunt beyond our politically correct society can accept, but it is true.  People, especially the elderly, fall.

And why not?  The elder with dementia that doesn’t understand their own limitations, the folks we pump full of beta blockers, diuretics, narcotics and anti-psychotics, and the TBIs and CHIs that can’t grasp their clumsiness are all part of the hospital (and in greater society) milieu.  They fall.  For multiple reasons.  If you do a quick search of the literature, I’m beyond positive that you will find hundreds, if not thousands of pieces of information of falls, causes, risks, sequelae, outcomes and the like.  And the chorus is the same:  falls are bad.  Falls that result in injury are bad.  Elder folks falling is bad.  Our friends of the Borg, er, The Joint (smoking) Commission have decreed that, Falls Shall Never Happen! Oh, and by the way, if they do pipes up CMS, we ain’t going to pay for the care costs related to the fall.  Go to ground and break your hip?  Hospital eats it as no one (even private insurers are starting to follow this trend), is going to pay for your care.

This fear of non-payment has created a flurry of activity.  Fall programs, rounding programs to ensure falls don’t happen by addressing all the things that cause folks to fall (pain, potty, position…), new special booties that both identify the wearer as a high fall risk and provide excellent grip and with all of this loads upon truck loads of new paperwork and charting.  So where does this leave us?  Stuck charting and paperworking instead of providing patient care.

OK, now what do we do about it?  Simple:  accept the fact that people fall.  Don’t point fingers in a blame game or penalize institutions when it happens, accept the simple fact that this will happen.  Then start operating under the assumption that everyone is a fall risk in the hospital.  Actually reduce the paperwork and charting so we can be present and available to prevent falls.  But always know that it will happen.

It’s not an easy fix as say preventing BSIs or CA-UTIs where checklists and proper technique will prevent many if not all infections.  Falls are too dynamic to be placed on a rigid checklist.  For example, a certain patient on my floor was incredibly unsteady, but was strong enough to be “mobile”.  Even though we rounded on them, they were close to the desk, minimized meds that could alter their mentation (worse than it was), they could have fallen in an instant.  Many times, even though they were mere feet away from my typical charting spot, they were up and in the bathroom before I could get to the room after the bed alarm sounded.  There was the patient that threw themselves over the bedrails opposite of their hemiparesis, of the one who suffered cardiac arrest while up walking.  These things happen.  We can never stop them all.

I know why we do all the excessive charting and paper trails besides the whole, “Look we’re doing something about it!”  It’s a way of (hopefully) reducing our liability in court.  So we can say, “Look at all the things we did.  We should be paid (or not have to pay)  Aren’t we good?  Forms in triplicate and fall assessments every 4 hours!  We did everything!”  If we had the assumption that people were going to fall and the rational expectations of this, none of that would be necessary.  But there is no such thing as rational expectations in health care anymore so we all suffer.

The best thing though is when asked where you were while the patient fell would be to reply, “I was charting their fall assessment!”

Friday’s EKG Answer

I want some answers!!!

Well, we got ’em.  Last week I posted an EKG quizzer.  Funny looking 12-lead right?  Prolonged QT?  Dilaudid, Verapamil?  Remember?  No?  Go check the link to refresh your memory:  Friday 12-Lead.

Go ahead, I’ll wait.

Back yet?

OK, so we have signifcant QT prolongation.  Or do we?

Is it me or does that T-Wave look kind of funny?  Kinda’ looks a little flat-ish.

How about these two?

Hmm…I see a little bit of notching in the T-waves here.  Almost like this isn’t just the T-wave we’re looking at.  Maybe this will help a little bit:  the patient’s potassium level when drawn was *drum roll please* 1.9mEq/L.  Yes, 1.9mEq/L.  She had gotten some replacement during the days, but obviously it was not enough.

What we have here is actually a QU segment as the U-wave from the hypokalemia has merged into the normal T-wave.  More examples of this can be seen thanks to Google’s Book Search from Understanding Electrocardiography.  It notes that you start to see dominant U-waves that merge with the T-wave when serum levels of potassium below 3.omEq/L, most notable in leads V2-V6 (as shown above), with the U-waves actually becoming larger than the T-waves when the levels drop to around 1.0mEq/L.  Adverse events related to hypokalemia include AV blocks, torsades, V-Fib and cardiac arrest, which is not a surprise knowing how potassium works in the cardiac cycle.   Typical causes of hypokalemia include diuretic use, alcohol abuse, loss through the GI tract from vomiting or suction (think NG tube) and some antibiotics just to give short list.

Electrolyte imbalances are also relatively common with pancreatitis, especially when you have vomiting.  Our patient was pretty much past the vomiting stage having been NPO for 3 days.  Combine that with having NS going at 250ml/hr for the last 2 days and we were flushing her K+ out of the system.  Fluids were changed to add K and the rate was reduced.  She got several K+ riders during day shift as well.  Thankfully the on-call doc didn’t freak out and have us turn the dilaudid PCA off as that would have caused just a bit of a problem based on her usage.  Even better was we never had to talk to the EP doc.  Small things.

By the time I came back that night, her potassium was edging up to around 3.5 and her QT had normalized out to around 420ms.  We get so tuned in to hyperkalemia that sometimes we forget that hypokalemia is just as significant.  We were able to keep the potassium within normal for the rest of the stay and to no surprise, her QT intervals stayed normal and there was no recurrence of giant U-waves.

That’s your answer.