(Un)expected Reasons For an ICD

A recent post from Dr. Wes, News You Can Use: Sex and Your Defibrillator, reminded me about a patient I had taken care of in the recent past.

He was relatively young but suffering from dilated cardiomyopathy.  He had been admitted after a successful VT ablation and ICD placement and was recuperating overnight on our floor to ensure that the interventions had been successful.  As I got report the nurse gossiped to me that she had been told that he had passed out during sex and ultimately ended up getting the ablation and ICD.  But the off-going nurse didn’t have all the details. I had to find out.  How do you get from passing out to ablation and ICD?  Besides the obvious?  (here’s the ACC/AHA Guidelines for reference)

So as I was doing my initial assessment I asked, “What caused you to get to this point?”  I figure, give the ability to obfuscate and deny, or come clean.

“Well, you probably heard rumors from the other nurses, so I should start from the top…” he said and told me the colorful story.

He had been dealing with effects of the cardiomyopathy for some time and it was cramping his, er, style.  So he decided one evening to buy some herbal marijuana analogue and take it with his wife and see what happened.  In the middle of he act, he passed out cold.  Unresponsive for a good 20 seconds.  Scared the Hell out of his wife, he said.  She freaked out, called EMS who took him to the ED for treatment.

That started the cascade of events which the end was him getting ablated and an ICD placed.  He looked up at me and said, “A guy’s gotta’ do what he needs?  Right?  The doc doesn’t know if it was the K2 or the underlying issue I already had with my heart.  So he decided to fix it.  Now I’m good to go!”

We both got a good chuckle out of it, but it turned serious when he asked about restrictions.  Gave him the usual spiel and pointedly asked him to talk to his EP doc about it.  Just to be safe.

“Now I just have to convince my wife that it’s OK to have sex again.  I scared her too bad and she’s a little hesitant now.” he said to end.

“Just be careful,” was all I could tell him.  And, “No, I won’t tell her!”

So often we get guys who are asking when they can resume relations after heart attacks, stents, pacemakers and even after open heart surgery.  I guess certain priorities take precedence in life!

Musical Monday

And now for a musical interlude…

Must be on the road to Brooklyn cause I ain’t getting no sleep.

This should have been Obama’s campaign video.  Too bad he’s gone from “Yes we can!” to “Well, maybe we can…”

And why I go to work everyday…to get paid in full!

Free Speech, Jobs and Nurses

The case is now being decided by a federal appeals court, but raises the question of whether nurses and health care workers should be held to a higher standard than other workers.

via The Policeman vs. the Nurse – NYTimes.com.

The simple break down is this:  nurse gets speeding ticket, is pissed off and this  “I hope you are not ever my patient,” she reportedly told him., ” happens.  Cop gets mad, complains to her work, nurses loses job and ends up suing everyone.  Yeah, so simple.

Is it?

First, why did the police officer go running to her employer like a tattle-tale?  Was he truly threatened by her actions?  Was he directly threatened by her actions?  He went running because he seemingly felt that his position of authority, his power, was occluded and obscured, that this nurse (female to boot) was daring to speak her mind.  That’s at least what one can infer from the information that is available.  The truth may be different.

Second, was the intent of the nurse to threaten?  Who knows?  It’s not reported how the cop treated her, how her day had treated her, if this was a pattern of harassment or just a sotto voce expression of displeasure on her part.  I truly doubt that if the policeman ended up on her unit she would do anything but give excellent care.   Call me naive but I don’t think that a speeding ticket is the ticket to substandard care.  I’d like to think that nurses are not that petty.

But this incident has opened a huge can of worms.  Are nurses and other health care workers held to a higher standard?  Does our right to free speech disappear because we’re in health care?  If that is the case, pack up the blogs, log off of Twitter, burn the notebooks and stop expressing yourself.  It’s a slippery slope.  I say things regularly that  can be construed in a different manner than I intended.  I could see myself in the same situation as this nurse, mostly because often the filter between my brain and mouth isn’t in perfect shape.  For better or worse I tend to speak my mind, much to the chagrin of my wife.  But I’m working on re-building the filter.

So if we’re held to higher standard, what’s next?  Garbage men can mutter, “we’ll see if I pick up your trash next week” and get fired.  They’re public servants too.  Or docs saying, “You’re getting a prostate exam next time”.   It can get ridiculous quickly.  Why should then nurses and other health care workers be held to any higher status?  Because we’re visible?  Because we’re supposed to be above all that?  Or as per an editorial in the Colorado Springs Gazette, we’re  “a person of impeccable character whom the community could trust to help anyone in need of cardiac care.” Right, I forgot when I earned that RN after my name I gave up right to opinion and bad judgment, especially in  public, off work, on my own time.

The more pressing question is why did the policeman go to her work and complain depriving thus her of work?  I’m sure that’s the nicest insult he has heard.  No references to farm animals, musings on his mother’s questionable background or his sexual orientation.  Just a cursory hope from her.  To me it is a hope that she never has to see him again, deal with him again, not inflict harm and withhold care.  Overreact much?  C’mon, grow some thicker skin.

Was it unwise of the nurse to say something?  Yeah, probably not the best idea, but we’re human.  We make human mistakes, say human things and have bad days like anyone else.  If you haven’t ever said something you regretted for one reason or another you’re F.O.S.  We all do it.  Sure it is probably different situations, than with a cop at your window, but we all make those mistakes.  Unfortunately for this nurse the mistaken slip of the tongue cost her a job and will shadow her for a long time afterward.  Was she wrong?  In a way.  But the officer was more wrong in taking it out on her livelihood.  That’s the part that is truly wrong.

Raise Your Glasses

If you’ve read my links/blogroll, odds are pretty good you’ve stumbled across one of the best nurse bloggers out there, Jo over at Head Nurse.  And in the course of that reading you know that she’s dealing with some seriously heavy shit right now.  She’s gotten plenty of support, at least her posts have painted a tale of a great outpouring of community support for her.  She may feel alone – but she ain’t.

So raise a glass of your finest and drink to her health.

It’s a small thing that I can do to help out a fellow nurse and blogger.


More Thoughts on Patient Satisfaction

How can we keep our patients “happy and satisfied” when we’re trying to carry out the business of being a hospital?

Kool-Aid Man

Image via Wikipedia

You can’t.  You can do programs, have meetings and task forces, play up the fact that these are our customers not our patients and roll out a plethora of initiatives to help increase the scores.  It will work for awhile, then the staff tires of being treated like crap daily while being asked to “be nice and please the customer” and things revert back tot he way it was.  Or the more common scenario, nursing busts ass to makes things better, increasing call light response time, hourly rounding and trying really hard to make the experience of being in the hospital as satisfying for the patient as we can, and the someone (docs, I’m looking at you…) comes in and fucks it all up.

I try.  I drink the corporate Kool-Aid and and do my part.  I try to explain to my patients that yes, I will be waking you up every 4 hours to check your vital signs.  Yes, you have to wear this heart monitor all night long.  No, you won’t be able to eat or drink, not even a little after midnight before your procedure.  I level with the ones who are in pain that I will never be able to make them completely pain free.  I will try to make them as comfortable as possible, but I like to still have them breathing.  I teach my other nurses the same, to reset the patient expectations from the get-go to reduce issues later on.  Some days it works, others, not so much.

In the end though, there is no pleasing everyone.  There will always be at least one or two bad apples that no matter what you do, will be upset and “un-satisfied.”  And too often, it is those who think they are entitled to everything that create the most havoc.  And how do we respond as an organization?  We tell them they are right, we are wrong and are taking steps to rectify the situation.

Sorry, you’re a patient, not a customer.  Anyone who tells you different is either trying to sell you something, wants something from you or works in an office far and away from the actual daily work of nursing.

Perhaps this video sums it up the best.

Welcome Our New Robotic Overlords!

Robots?  Tele-presence?  Robotic consultations?

Robot at the Museum of Science and Technology

Image via Wikipedia

Yep, it’s coming.

Wait,  strike that, it’s already here.  Our friends over the New York Times published this great article last week about the incursion of robots into our already crowded lives and workplaces.  Obviously I’ve been asleep at the keyboard and didn’t notice this until this weekend.  Some call it a Borg takeover, the evolution of SkyNet or invasion of the Roomba, but the reality is that we can use the technology rather than letting the technology use us.  Take for example the first couple paragraphs of the story:

SACRAMENTO — Dr. Alan Shatzel’s pager beeped at 9 on a Saturday morning. A man had suffered a stroke, and someone had to decide, quickly, whether to give him an anticlotting drug that could mean the difference between life and death.

Dr. Shatzel, a neurologist, hustled not to the emergency room where the patient lay — 260 miles away, in Bakersfield — but to a darkened room at a hospital here. He took a seat in front of the latest tools of his trade: computer monitors, a keyboard and a joystick that control his assistant on the scene — a robot on wheels.

He guided the roughly five-foot-tall machine, which has a large monitor as its “head,” into the patient’s room in Bakersfield. Dr. Shatzel’s face appeared on screen, and his voice issued from a speaker.

Dr. Shatzel acknowledged the nurse and introduced himself to the patient’s grandson, explaining that he would question the patient to determine whether he was a candidate for the drug. The robot’s stereophonic hearing conveyed the answers. Using the hypersensitive camera on the monitor, Dr. Shatzel zoomed in and out and swung the display left and right, much as if he were turning his head to look around the room.

Is it perfect?  Hell no.  Is it a step in the right direction?  Probably.

We already have a lack of doctors in general, and a true dearth of specialists in rural areas, so this is a solution of a sorts.  Does this replace the doc?  No, not at all.  It is another tool they can use to make informed decisions.  Having another head in the game means twice the chance of getting the right idea first.  Sure it will be weird to wheel a robot in to see a patient, but it’s really no different than an EKG or X-ray machine, except it has a doc “inside”.  Eventually it will become commonplace, just like the other tools of our trade.

I can only imagine the reactions that will happen when our “altered” population gets a robotic consultation…

Back in the Saddle

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Labor Day.  Back to school time once again.  Even though there are a metric shit-ton of articles for new student nurses, I figured why not add to the mix?  Here’s some help from someone who’s been there and survived.

1.  Remember, this too shall pass.

Nursing school doesn’t last forever, so unless you’re undeniably stupid or way out of your league, there is a finish line.  It may seem like it is far, far away, but when you do finally finish, it will amaze you how fast it truly went.

2.  Eat, sleep, dream nursing.

Sounds cheesy right?  Maybe too New-Agey?  What I’m saying is you have to dedicate yourself 110% to the journey.  Like Big Daddy Kane once said, “Ain’t no half-steppin’.”

3.  Don’t be that nursing student.

Y’know what I’m talking about.  The one that does the bare minimum.  When presented with the opportunity to see a “really cool thing”© at end of clinical day, defers and says “I can’t, I have to go to post-clinical session with my teacher.”  Or the one that coasts by on the merits of others, using their skills and talents to bolster themselves.  The one that figures nursing school is just about showing up and that interaction is not neccessary.

4.  Learn from everyone.

Yes, you’re going to school to be a RN, but a good CNA can still teach you more than you might know.  Learn to trust the good ones, learn from them, because you won’t always have the good ones at your side.  Same goes for the multitude of other “allied health professionals”.  Y’know, RT, PT, OT, Speech therapy, pharmacists and yes, even the docs.  It might surprise you the little nuggets you can glean from them.

5.  Find a group of like-minded folks.

Going at it alone is doable, but not pleasant.  Find yourself a circle of friends to help you through this.  People outside of nursing school can’t comprehend what you are going through, but if you have a good group of school friends they know what you are struggling through.

6.  Take care of yourself.

Sleep, yes, sleep.  Studying until you are bleary-eyed and then sleeping for only 3 hours does you no good if you fall asleep during the test.  Getting sick because you have abused yourself too long does your patients no good either.  Eat right, get some exercise and sleep. Take some time for yourself to decompress, to let it all out and step away from the grind.  Sure, it seems to contradict #2, but every now and then you need to step away to find the clarity of thought needed to continue.

7.  Then End is not the End.

The end of nursing school is not the End.  It is only the beginning.  Good luck.

Record Setting Month

I’m glad August is OVER!  What is normally a shit month in my life was a shit month at work too.  Low census, poor staffing, sick-ass train-wrecks and all the goodies of a urban tele floor.

But truly I’ve had some records shattered.  We see far out and funky lab values all the time, but these were some doozies this month.

And the Winners are:

HbgA1C:  14.6!  Also had a 13.9 as a runner-up.  Both patients with Type I diabetes, both young, one with OK support, one with none.  We worked the diabetic educator to the bone trying  to teach these young’uns to not end up destroying themselves.  For those playing along with the home game, <6 is good control for diabetics.  And when you translate that to eAG (estimated Average Glucose) you get 372mg/dl and 352mg/dl.  Bad mojo.

Worst Case of Thrush EVER:  Candidal Esophagitis, from the oropharynx to just above the lower esophageal sphincter.  And in a twist, the patient was not immuno-compromised.

Highest WBC in a non-cancer patient:  68.8.  Yes, 68,800!  And it had jumped from 48,000 less than 12 hours earlier.

Lactate:  10.8.  Of course what do I say?  “Last time I saw a lactate that high we were coding the patient.”  Sure enough the patient did expire (they had the nasty white count).  They were sick with a capital “F”.

Dumbest idea of the month:  dude comes in drunk and complaining of nausea and vomiting.  After being triaged he goes to the bathroom and pops a couple of poppers, promptly turns grayish-blue with  a pressure of 50 and a raging onset of methemoglobinemia.  At least he was in the ED when he did it.

Oh, and for two Fridays in a row, had rapid responses at shift change…a helluva’ way to start the shift!

I hope September is better…

Um, You’re the Doctor, Right?

Back from a ID theft imposed digital holiday and stuck with a raging case of insomnia.  I mean, what did I do to sleep for 4 hours voluntarily?  I wanted to sleep, just couldn’t, so here I am.


Nothing puts experience in perspective like having a doc ask you for advice.  It’s humbling and kind of scary all at the same time.  Really?  You’re the doc.  Y’know, medical school?  At least 1 year as a full fledged doc, writing orders, telling us lowly peons what to do?  Any of this ring a bell?

The conversation went along these lines…

“So I have a patient I want on tele, but they’re bradycardic.  I mean, you do that right?”  Dr. Obvious.

“Um, yeah.  We have brady folks all the time.  Not really a big deal.”  says perplexed charge nurse (PCN).

“OK, can you guys do pacing on the floor or do I need to send them to ICU?”  Dr. Obvious.

“Uh, if you’re thinking they need to be paced odds are pretty good they need to be in the Unit.”  PCN.

“Right.”  Obvious is thinking here.  “They’ve been brady and slightly hypotensive.  You guys can handle that right?”

“Uh-huh.”  starting to look around for Peter Funt and a camera crew.  “I mean, brady is fine.  If he drops too low we’ll just drop into ACLS and do our thing.  How low is he anyway?”

“He’s been holding steady in the 40’s.  Last BP was 100s over 60s”

face palm… “Look as long as he’s not doing any kind of funny block, I’m cool with them in the 30s with a pressure that good.  He’ll be fine.  If you want, you can write orders for atropine prn and we’ll put pacer pads on…”

I’m trying not to laugh here.  Really 40-50s with  pressures in the 100s?  I thought it was a real issue, like they’re runnning 30-40’s in a Mobitz II block or something funky.  Really?  Sure, I appreciate being asked what our comfort level was, but you’re the doc.  You get the special white coat and all that to make these hard decisions.  You want tele, fine.  We’ll deal with the the issues, and if the fecal matter hits the air oscillator, we know what to do.

Had a patient the other week that ran consistently in the low 30’s post-Sotalol.  I’m OK with that.  BP of 86/40 in a CHFer who’s talking to me coherently and making urine?  I’m good.  Now the guy who we were getting pressures of 70/palp with a heart rate in the 120’s and was minimally responsive, that made my sphincter pucker a little.  But that’s why I love telemetry, we take relatively unstable patients (even those that probably need to be in ICU) monitor them and do interventions to fix them.  Part of me appreciates the call, but part of me views it as an insult, in the implication we can’t take care of the (not)unstable patient.  Make your decision, you’re the doctor, right?