Drowned Boy’s Family Upset With Officer’s Response – KWCH – Kansas News and Weather –

Drowned Boy’s Family Upset With Officer’s Response – KWCH – Kansas News and Weather –.

Sad, sad sad…

That’s why every police/fire/parks & rec/ranger/scout leader should be trained in basic CPR.  I’m not saying much more as it is too hard to say what truly happened, but that it sounds like this may have been averted.

Can’t Put it Into Words

We had a code the other night.  It was by far the “best” code I’ve ever been privy to.  No yelling orders, no standing around waiting, no egos, just a concerted effort to save a dying (well, dead) patient.  The resident running the code was calm, cool and collected.  As we did our interventions he worked through the H’s & T’s trying to figure out if we could fix anything.  Outside of my ACLS megacode, I’ve never seen that.  But moreso, he asked the staff if there was anything that we thought he had missed.  And before he called it, he aksed if anyone else had any objections.  Truly it was a team effort.

But for some reason I can’t seem to shake it off.  I had no real connection to the patient, other than being the charge nurse.  They weren’t one of our frequent flyers.  But something reached ahold of me and won’t seem to let go.

Maybe it was the fact we found her already down in her room.  Or the fact I felt the ribs snap under my palms.  Or it was that we did CPR on her for 30 minutes, rotating between 2, then three of us.  Or that we threw everything in the code cart at her, and some things that weren’t,  but nothing seemed to help.  Our CPR was some of the best I’ve ever seen/felt.  We shocked her a total of 9 times.  She got tubed incredibly quick.  But it didn’t seem to matter.

For the last couple of nights, I’ve laid awake and thought about it.  Re-running it over in my head, which then sparks memories of other codes and then to the memory of running in to see them performing CPR on my little girl.  For some reason, this one cracked my shell.  Like the title says, I can’t put words to the feeling.

Maybe though, it re-affirms that I am human and that I do care, something that I’ve been feeling a great distance from.  Maybe I’ve grown cold over it all- something my wife mentioned in passing not too long ago.  Maybe this nagging sense of malaise over this event is me re-examining myself over this coldness and cynicism and the realization that I’ve moved that direction has left me a little out of sorts.  More than anything though, it serves as a reality check, a visceral reminder of what we do as nurses when things do go south.

I know with time this angst and malaise over it will fade.  I’ll make peace with the way I feel about it, but like all the others, I’ll never forget.

A Never Event?

According to CMS, we experienced a “Never Event” last month.  But the even itself illustrates in my mind the flaws inherent in the whole concept of a “Never Event”.  Theoretically, the idea is agood thing.  There should be events that could occur while a patient is admitted to a hospital.  Some things should never happen:  like wrong blood, surgery on the wrong part of a patient or abduction of a patient of any age.  Some stretch the bounds of rational thought though.  The one that comes to mind is patient falls.

In the hive mind of CMS, patients should never fall.  Once again, theoretically, not to mention from a public relations standpoint, the argument is sound.  What they and the public tend to forget, that unlesss someone it at the bedside 24-7, falls will occur.  You can follow every published guideline out there.  Scheduled toileting, hourly rounds, bed alarms, reduction of the use of medications that can cause or enhance delirium are all really great ideas and have been proven to reduce falls.  But the bottom line is that when our elders, especially those that may have dementia tned to fall.  Add illness, strange environment, odd noises, unnatural schedules and new medications and you cook up a recipe that could conceivably lead to a fall, in spite of any and all safety measures we as caregivers may take.

But people fall.  Sometimes people fall and there is nothing we can do about it.

Exhibit A:

click for larger size

click for larger size

Anyone who knows EKG tracings can immediately grasp the bad things going on here.  But for those who may be a bit rusty, let me break it down for you.  The patient is rolling along in normal sinus rhythm until they get hit with a R-on-T PVC (a premature ventricular beat the falls when the myocardium is not yet fully repolarized, see below) initiating a run of Torsades de Pointes.  Torsades, meaning “twisting of the points” is a life-threatening ventricular arrhythmia that can rapidly devolve into ventricular fibrillation and death.  It is a form of ventricular tachycardia (VT, V-Tach) characterized by the rotation of the complexes around the isoelectric line illustrated by the increasing/decreasing amplitude of the waves in a near sine-wave pattern.  Treatment in an emergent situation is the following of the V-Tach leg of the ACLS algorithms, although usually a bolus of magnesium sulfate can terminate this as well.  Usually though, when we see this though, the proverbial shit has hit the fan.

In this particular case the patient had been ambulating in the hallway and flipped into Torsades.  The red mark is about where we figure when he hit the floor.  Not for sure, but the timing seems about right.  Now what would CMS say about this?  The patient was awake, alert and oriented x 3, ambulating under his own power when he fell.  So it is still a “never event”.  And this is why a one-size fits all labeling makes no sense.

First, does this mean we shouldn’t let patients ambulate?  They might fall.  Second, should we not give medicatons that may cause arrhythmias like this (more below…)?  They might fall.  Third, should we not anti-coagulate patients who are under treament for atrial fibrillation and thus increase their risk of bleeding with a fall?  Painting in broad strokes doesn’t always work.

Unfortunately, the patient had previously been in atrial fibrillation and been anti-coagulated with warfarin for an INR of 3.2.  He had been cardioverted out of a-fib into sinus earlier in the day and was intiating Tikosyn therapy.  The truly unfortunate part is that when he went down, it was like a tree falling in the forest:  straight back off his heels with his head striking the floor.  CT showed a massive cerebral bleed as a result and family chose to withdraw support allowing him to pass.  So this is a huge “never event”, as per CMS, “Patient death associated with a fall while being cared for in a healthcare facility.”  If he had not been ambulating, odds are pretty good that he would have made it out of the code, as there was a spontaneous return to sinus rhythm right after the scanned strip ends, with spontaneous return of circulation as well.  But since he fell in the hallway and hit his head, the deck was stacked.

As for the medication, Tikosyn (dofetilide) is a Class III antiarrhythmic medication that works by prolonging the cardiac action potential duration.  One major hallmark is that it subsequently prolongs the QT segment.  A prolonged QT interval increases the risk of ventriclar arrhythmias as the repolarization of the myocardium happens at different rates allowing myocytes that have already passed their absolute refractory period to depolarize early and possibly causing a re-entrant phenomenon, kind of like a viscious circle.  The FDA actually mandates that anyone being started on Tikosyn gets themsselves a 3 day vacation on a telemetry floor for this very reason.  Usually we monitor the QT/QTc closely in these patients, obtaining a baseline, then 12-lead EKGs 2 hours post-dose to ensure that the QT/QTc is still within limits.

So was this a “never event”?  Probably.  Could it have been prevented?  Probably not.  There were too many variables in play to do so.  Sometimes shit just happens, no matter what we do.

Coincidence?

While I may be superstitious, my rational side is usually able to concoct an explanation for circumstances of what may seem to be divine intervention, or lack thereof.  But I can’t on this one.  The only plausible explanation, the only one that makes even a shred of sense is the totally irrational one.  How else could you explain 6 codes in 1 night?

Yes, we have sick people, sicker than normal in house right now.  But 6 codes?  That’s more than a typical week, even more than a typical month.  So yes, 6 codes, 4 in the Unit, one upstairs and one on my floor.  The code team was looking ragged, the doc looked like she was one of the walking dead herself after being abused all night long.  I think our Materials people were going to throw a fit if they had to throw together another fresh code cart.  It was one of those nights.

But the explanation you ask?  Friday the 13th.  It’s the only one that makes any sense at all.  Even though it was only the 13th for half of last night, it’s insidious reach kept things interesting.  The worst part of it all though is that now, tonight, Mr. Blackcloud (me…) is in charge.  I’m calling staffing right now to make sure the ICU is well staffed and checking with Materials to get an extra cart up to my floor, just in case.  Let’s hope the universe got it all out of its system last night and things will go smooth.

Answers to the Game

I’ve been at work all last week, so I haven’t had much of a chance to post.

Here’s the denouement to “Let’s Play A Game…

According to the labs drawn at the beginning of the code, her potassium was 7.7mEq/L.  Yes, a lady with hypokalemia, had a K of 7.7.    I came to understand her renal function was (is) incredibly screwed up and since they had been fighting hypokalemia, she got a large dose of KCl before bed.  Hence the PEA episode and subsequent transfer to the Unit.

Here’s the cool part:  by the end of my shift she was awake and following commands.  Two days after the code (my back still hurting) she came back to the floor with zero(!!!) neuro deficits.  She complained her head, neck, chest and back hurt, but other than that, fine. She walked out (well, was wheeled out) 2 days later.

Now she’s coming back twice a week to get puffed (pure ultrafiltration dialysis) for both fluid and from what I heard, for even worsening renal function.  And she’s doing well.

Let’s play a game…my turn

You’re helping turn your patient in bed as a nurses runs past going, “Where’s Mitch, I can’t find him.  87’s in trouble.”  It settles in for a second…”Oh shit!  I’m covering for Mitch!”  You then run for 87.

The patient is face down on the ground, legs splayed under the bed, maintaining an airway, but only briefly.  So, now what?  With the RT maintaining C-spine, we turn her over and start help her with her airway. By this time, the room is beginning to fill up.  Someone asks, “Anyone have a history?”

“Ummm, she’s not mine, but I know her,” I say, “30 year old, history of part-partum cardiomypathy, s/p ICD and pacer implant.  Issues with hypokalemia and fluid retention.  We found her face down.”

“You guys have a pulse? We have a rhythm…” a resident asks.  I feel around the area where a femoral pulse should be…nada, nothing.  I’m digging into the layers of subcutaneous fat and feel nothing.  “No pulse!  Starting CPR.”

So what do we have?  PEA. Pulseless Electrical Activity.  A tele nurse’s worst nemesis.  The monitor looks good, but no perfusion.  The AICD isn’t firing beacause it sees a rhythm.  The pacer is just going along all happy, but the heart ain’t working.  So, we all remember the famous H’s and T’s from ACLS, right?

Warning: Educational Content

Hypovolemia
H
ypoxia
H
ydrogen Ion (acidosis)
H
yperkalmia
H
ypothermia
T
oxins
T
amponade (cardiac)
T
ension (pneumo)
T
hrombosis (coronary or pulmonary)

I couldn’t remember these for the life of me, so I found a couple others, just to keep the mind fresh.

ITCH PAD
Infarct, Tension/Tamponade, Hypovolemia/hypothermia/hypo-hyperkalemia/hypoxemia/hypomagnesia, PE, Acidosis, Drugs.

PATCH MED
PE, Acidosis, Tension pneumo, Cardiac Tamponade, Hypovolemia/hypothermia/hypo-hyperkalemia/hypoxemia/hypomagnesia, MI, Electrolyte imbalance, Drugs

So there we are, performing CPR on the floor.  She gets tubed.  Draw labs, slaine running wide open.  We get a pulse back.  Then we lose it, start CPR.  Give Epi, get it back.  Hang dopamine.  Monitor shows wide-complex beats with pacer spikes.  Get a backboard under her.  Lose the pulse again, re-start CPR.  Get her to the Unit and they start working her.  Levophed, dopamine cranked up, vasopressin, D50 w/10units of regular insulin – just in case, bicarb, as I leave the docs are there starting an arterial line in her femoral.

So what happened?

Brief synopsis:

Dilated cardiomyopathy, renal insuffciency, fluid overload, chronic hypokalemia secondary to diuretics (today was 2.2, got 60mEq of KCL x2 and doses of Lasix and Zaroxlyn), urine output over day was low, found down after complaining to nurse about shortness of breath.  Has implanted AICD/Pacer.

I’ll post the end result in a day or two after I finish my stretch of days on.  Or if people are begging…