It’s Never This Clean

CPR
Image via Wikipedia

A code last week reminded me that the biggest problem with classroom ACLS is that it is too clean, too managed, too un-chaotic.  Here’s a couple of recommendations to the AHA for inclusion in the next set of guidelines for ACLS curricula.

1.  More people, smaller rooms.  Codes almost never happen in big rooms, so you end up with 20-30 people cramming into a 10×10 (or smaller).  I swear besides the code team, everyone else tends to show up.  Housekeeping, dietary, looky-loo nursing staff with nothing better to do, extra docs not involved in the case, maybe a couple of pharmacists and an administrator.  To best simulate that feeling of claustrophobia and having to work under such conditions, the schools hosting the classes should hire extras to crowd around you so there is barely enough room to work.

2.  Auditory competition.  It’s usually a cacophony of noise as people are barking orders, shouting back values, yelling at each other and general noise in a code.  ACLS mock codes are just too quiet, like a quaint afternoon tea in the country.  They’re full of thoughtful contemplation, “Hmmm…we gave Epi, CPR is in progress, let’s see what the next step should be.”  Where usually it is, “What!!!  Did you give EPi yet?!!!” and “GET ON THE CHEST!!!!”  To solve this, using the extras mentioned above, have them loudly carry-on conversations to provide a sort of white noise effect and teach students to think with 10 different voices giving you information all at once.

3. Smell-o-vision.  Think it through.

CPR training

Image via Wikipedia

4.  Realistic dummies that either poop, pee or vomit during the code.  Ever done CPR while trying to keep your scrubs out of vomit?  Yeah, it’s difficult, the hands slip off of their position as the gloves slide over the vomit on the chest so it’s kind of like hitting a moving target.  Also, the training should incorporate  identification of emesis into the H’s & T’s differential diagnosis.  Maybe call it T-H-Es?  We’re trying to look for a causative reason, ID’ing dinner might be a good start, it’s usually easily viewed.  One of the extras could smear chocolate pudding on the dummy with each rhythm check to add that extra layer of realism.  To make it better, the manufactures of the dummies could add an optional module that uses the force of the compressions and triggered by breaths to spew liquid material out of the dummy’s mouth.

5.  Re-organize the algorithms by using a drunken dart toss for each step, say every 2 minutes.  Many times the actions are just so random it is like that.  This way by using the toss method, random changes to the procedure would be accounted for and awaited thus allowing practioners to think ahead.  Besides, wouldn’t playing darts in ACLS be awesome?

Finally,

6.  Teach clean-up as part of post-recusitation care.  We’ve all seen rooms after a code.  Wrappers everywhere, boxes from meds strewn about, random pieces of detrisius tossed to the side of the bed, pieces for the intubation tray lodged in the computer keyboard, sharps hiding under piles of plastic and the puddles of body fluid.  What should be taught is that everyone goes on break, leaving one person to clean up the mess.  That job should be assigned with as much if not more importance than the compressors to ensure the rest of the team gets to take a break post-code.

If the AHA would consider incorporating these elements into ACLS training, it would make the providers so much more capable in handling the realities of the true in-hospital codes.  Just sayin’.

 

editors note:  your results may vary, data is compiled from triple-blinded, beer-goggled, non-placebo, peer un-reviewed observation of events on medical/telemetry/geri-psych nursing floors over a 5 year period of time.

10 Long Seconds

You’re talking to the patient, carrying on a normal conversation whilst finishing some mundane task.  Abruptly in the middle of a sentence they stop talking to you.  You turn in time to see their eyes roll back in their head and them slump lifeless back into the bed.  What goes through your mind?

First, denial:  “Maybe they’re just messing with me.”

Sternal rub and nothing.

Second, more denial:   “Oh Hell no, they better not be playing with me now.  Wake the Hell up!”

Third, even more denial:  “That was a  twitch…ahhhh shiiiiit.”

Slam the head of the bed down, take one more attempt at noxious stimuli.  Nothing, nada, zip.

Finally, acceptance:  “Someone call a Code!!!!!”

All in less than 10 seconds, probably only 5.  The longest 10 seconds of the night.

Rapid Response Teams: Excuse or Tool?

I know this has been discussed ad nauseam already, but I had to weigh in.

Thanks to an article out on Medpage Today, Rapid Response Teams Sign of Poor Bed Management, the whole idea of Rapid Response Teams has been brought into the spotlight.  The article’s premise is that poor bed management is the cause for Rapid Responses to be called.  Bullshit. 

Code Blog sums it up nicely by saying,

I don’t believe RRTs are called because the patient was already in bad shape and assigned to a low level of care.  I think they are called because stable patients just stop being stable sometimes.

Are there times where over-crowding and poor bed management are the cause?  Yeah, if it is crazy busy, the nurse might miss subtle signs or the patient is sent to a floor of lesser acuity, but these are the exception rather than the rule.  I can count on my hand the number of times I’ve called an RRT, of course now I’ve now jinxed myself, but each time it was from a rapid change in patient condition.  There have been times where I could have called an RRT, but managed it with judicious use of critical thinking and calls to the doc.  I think that some nurses use them as a crutch instead of critically thinking a situation through, but not because a patient was wrongly placed.  Like I noted above, there are times when the patient is placed wrong.  When our observation unit opened we had several times where they went from Obs to the Unit in a very short amount of time.  But again, these we patients who rapidly de-compensated – and a couple that never should have gone there, but those are the exception.

Have the authors forgotten that a hospital is an acute setting?  It’s not like these folks are healthy!  And thanks to the rise of observation (outpatient in the hospital) those who are admitted in-patient are the sick of the sick.  Having a resource to get help quickly is a godsend.  Sometimes all you need is some stat meds, or imaging and labs , or just someone to look and say, “Yeah, they’re sick!”  And sometimes you just need to have the ability to transfer to a higher level of care without jumping through hoops.

Even if we have the best patient flow possible, appropriate bed placement each and every time and proper resource management, there still would be a need to the Team.  Patients crump.  The article never addresses that simple fact.  It’s far easier to point out structural issues than the reality – of course structural issues are somewhat easier to fix.  Schedule better to make better use of the nurses you’re already overworking.  Staffing plays an important role in this as well.  A nurse that is stretched too thin can’t take the needed time to adequately assess their patients.  When you 5, 6, 7 or more patients at a time, you’re running and even the most perceptive, mind-reading nurse can catch a patient decline if they’re stuck cleaning and doing a massive dressing change because the wound is saturated in stool of a 400lb quad with the 3 other nurses on the floor because it takes at least 4 to move the patient safely.  That’s when the easy things to fix fall through the cracks, hence why we need a team to “rescue” the nurses.

It’s a complex multi-layered issue to which there are no simple and easy answers.  It impacts staffing, scheduling, patient flow and the vagaries of the human condition.  But would I choose to work somewhere without the back up of a RRT?  Not easily.

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…

The Shakes

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By the time I got home the adrenaline was finally starting to wear off, the shakes trailing off.  I don’t really remember the drive, it was an automatic drive home.  I was aware, but detached as the images of what happened to my patient just minutes earlier kept running through my head.  Those images were accompanied by the snippets of conversation, the shock and fear, the cool, clammy sweat sticky back of my t-shirt as it clung to my back.  Numb, but not comfortably.

How quickly things can change with our patients.  One moment you’re waking up not feeling well, but OK, waiting for surgery, the next you’re vomiting up copious amount of blood and huge chunks of clots.  How strange it must be to not understand what happened because you went totally unresponsive right before you vomited.  Did you hear your nurse yell out in fear “Can I get some help in here?!  Someone call a Code!!!”

How odd it must be to open your eyes and see 15 people swarming your bed, frantic in their energy asking questions, asking you how you’re doing, sucking something out of your mouth.  Do you feel it when you vagal out, go asystolic, vomit more blood and have someone start pumping on your chest?  And when you ask, “Did I throw up?”  the the nurses tells you that you did, but all you can worry about is that you might have lost control of your bowels.  What goes through your mind when the nurse who has taken care of you for the last 2 nights is asking you to “Stay with me!”  Do you know when your blood pressure is 60 palp?  That you’re pale, diaphoretic and ashen?

Does riding in a bed moving like the furies are after it down the hall cause motion sickness?  I’m guessing that the worried looks, the terse simple descriptive language the nurses and docs are using, the speech of people under pressure must worry you.  Does your mind rebel at the unfairness of it all?  Did realizing you had stomach cancer make you mad?  You were a healthy guy.  Sure you drank, but you sobered up years ago.  Yeah, you smoked, but otherwise, healthy.  No chronic medical conditions, just some elevated lipids.  In fact your doc at your last yearly check-up said you were about the healthiest 80 year old he had seen in a long time.  Or is the only thing you’re thinking about is your wife of 50 some odd years and whether you’re going to see her again?

I know that when you got to the ICU you vomited more blood and clot chunks.  You looked incredibly pale, blood pressure barely registering.  There was blood all over the floor, all over you, all over the bed.  I wish you could see the cluster of docs outside your road, the 7 nurses around your bed, the cluster of medical knowledge all focused on saving you.  I wish I could tell you that it was going to be OK, that we’re going to take care of this, but deep down I know I can’t.  You’ve lost a lot of blood, it’s got to be close to 3 liters, blood and huge gelatinous chunks of clot, like something tore loose inside of you.  But you were in the best place and I was in the way.

It was the fastest 30 minutes I can remember in a long time.  The adrenaline was still surging as we brought the bed back upstairs but as I began talking to my colleagues the shakes started.  I knew they would, was waiting for them.  The shakes, the weakness in the knees, the self-doubt came crashing down, barely held back by an iron will.  It’s odd how I can remember bits and pieces, little flurries, but not a seamless narrative of the whole thing.  Maybe it’s a protective thing.  I remember the looks on my co-workers faces, the awe, the respect, the one who said, “I want you in my code, you were so in control.”  If they only knew.

If they knew that I spent the drive home going over every little bit of the previous 12 hours.  Could I have done anything differently?  Should I have checked your vitals at 4am instead of letting you sleep?  You had been rock-solid stable all day, all night, no sign that anything was amiss.  I know rationally that this was a quick thing, bright red blood spewing out is a rapid thing.  The clots?  Well the EGD pics were beyond nasty, huge masses of clot on the wall of the stomach.  It is like something broke open.  Still I wonder if there had been a sign early, if there was something I missed, or if it just came down to when you went unresponsive and started to vomit up blood.  You should know though, that I went home, and even though I’m not a religious guy, said a prayer for you, knowing you needed all the help you could get.

I just looked down at my hands, the shakes are gone.  Finally.