Every Now and Then, You Win

“Hey Wanderer, there’s a guy in 32 that wants to talk to you.”

Great, I think to myself. It’s a complaint, or a problem, or something unpleasant. Prejudicial? Probably, but the way things have been lately it’s the reality. Head up, smile plastered on I head over to 32.

As I walk in I see a familiar face. He had been with us for about 2 weeks, dealing with the effects of alcoholic cardiomyopathy and most of us only gave him even odds to stay sober and in good shape. I had spent a lot of time educating, reinforcing and generally trying to help him beat the odds so it was good to see him because he looked like it all had worked.

“Hey,” he said, ” I’ve been sober now for 73 days thanks to you guys.”

We talked for awhile as he related everything that had gone on since discharge and how he had really turned his life around. It was nice to hear for a change.

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Ah, You’re So Sweet

Insulin and syringe

Image by momboleum via Flickr

Anyone who reads the news, watches the news, or is involved in healthcare knows that diabetes is a huge and growing epidemic. Sometimes you just know they’ve been brewing things for sometime, in this case it was probably true.

Admitted with polydipsia, blurred vision and dehydration and a glucose >600mg/dl. Did I mention that multiple family members on both sides of her family tree had diabetes too? Any guesses to the hemoglobin A1C?

>15!

So far off that our machines couldn’t process how high it really was. With a little math that works out to an average blood glucose of 456mg/dl. That’s about the highest I think I’ve seen, if not ever, at least in a very long time.

Whatever, Just Put Them on the Monitor

 

I wonder why new residents love to torment tele nurses?

 

Are we that easy of a target?

Or is it that they’re too intimidated by our drive? (True story, it was relayed to my manager that many of the 1st years were afraid of one particular charge nurse, mostly due to her breadth and depth of knowledge, but also that she was doing cardiac nursing before they were conceived.)

Whatever it is,they seem to think that the only true indication for telemetry monitoring is having a heart. Yes, true. But really does every single patient you admit truly need it?

I’ve heard some truly egregious statements with regard to this. One example is the 20-something year old with pneumonia who was tachycardic. Not SVT, not atrial tach or WPW, just straight up sinus tach with a rate in the 110’s. Gee, you think maybe that they were, A.) dry or B.) febrile? Or maybe a combination of both. A couple of days later, one of the attendings realized this and took off the tele, but the poor patient got charged the higher rate for the 3 days they were monitored when they really didn’t need to be.

Or the time there was a stroke patient on our neuro floor, probably the best place in the hospital for them, remote monitored on tele as well. “But the heartbeat was irregular.” complained the nurse to the doctor, “Shouldn’t they be on the tele floor?” Of course the young impressionable intern agreed, forgetting the patient suffered from chronic atrial fib…and had a pacemaker. The patient had been on all their normal home meds until admit and heart rate was well controlled, blood pressure was acceptable and all they were dealing with was the stroke sequelea. But out of the nice private room on neuro into a shared room on tele. Family was pissed. That was a fun one trying to smooth over.

Of course there is always the bleeders, usually GI in origin that HAVE to be on tele. I’m not talking the folks having gushing blood from mouth or rectum, but the LOL admitted with tarry stools and a slightly low H&H, or the post-surgical bleeder. The relatively stable ones. And on multiple times I hear the same refrain: we want them on tele so you can see if something happens. OK, maybe you forgot basic A&P, but really by the time we see something on the monitor, the damage has been done and they’re slip-sliding back to the ICU. Like the one last month who the nurse was helping get up to use the commode who syncopeed out and shit black stool all over the bed (luckily missing her)…guess what? Nothing on the monitor, beautiful sinus rhythm with nary a bump in rate from before. Off to the Unit they went.

It seems like everyone gets tele ordered. We’ve had a couple of new hires lately, all experienced nurses, one asked me, “So, patients get taken off tele and moved to med-surg, right?” I tried not to laugh too hard. “Nope, they stay here until they leave…”. It becomes a rote thing, just a part of the routine, not actually deciding if it benefits the patient.

On the other side are the times when you go, “What, they’re not on tele? Are you kidding me?”. Unfortunately due to the over-reliance on tele, I can’t remember a recent example of this! But it’s what comes with the territory. We take the ones that need to be on tele and theses that really don’t all the same. Because I really want the DNR comfort care patient on tele, (true story). I just wish I knew why.

What Protocol?

5am. My patient on a Lasix drip has a potassium of 3.0 from the labs I drew an hour before. Shit, what to do?

Wake the doc up and get my ass chewed?

Or…

Consult the protocol and start giving potassium replacement per protocol?

For the sake of my bony ass, the second option really seems the best, but, alas there is no protocol ordered, nothing in the regs saying I can implement it on my own, I am stuck calling the doc to get an order for potassium replacement. It went better than expected thankfully.

But I never should have been in the position if the docs had been anticipating that this might be an issue and planned accordingly. I mean, let’s thing this through…CHF patient, being aggressively diuresed with a Lasix drip running at 20mg/hour with a pretty awesome urine output, odds are pretty good that all of that peeing is going to impact the level of potassium… So to stave off the inevitable call, when there is a protocol on the books, wouldn’t it be a smart idea to write, “Potassium replacement per protocol.”. Unfortunately though, it appears that our residents missed that day in class. So they get the call.

While I rarely agree with the dog/tractor/child-posting Asberger-esque Happy Hospitalist, in his post about Call Parameters…blah, blah, blah he lays out a plethora of standing orders that would basically end calls to him. Call it extreme protocoling. But it has the under-pinnings of a decent idea. Give the nurses the tools they need so they can treat the patient instead of spending time on getting orders. There are issues with that though.

First, there is the issue of control. Some physicians tend to be a little on the control-freakish side, liking to micromanage care, which I get. Letting protocols run free deprives them of the minute control some need. I turn to say that it frees them to be more efficient with their time and reduces the amount of time spent on hold waiting to talk to the nurse who paged them. Win-win, right?

Which brings up the second issue: lack of nurse follow-thru. This can be an issue if you have lazy nurses. Lack of this follow-thru is what dooms it on my floor. Many of our nurses don’t even draw off scheduled labs, like cardiac enzymes q6, when the patient has a central line. How are these nurses gong to have the follow-thru to manage an electrolyte replacement protocol? They’re not. Probably what would happen is the patient would get the first dose and redraw, but odds are good that anything further won’t happen. I know this as I’ve seen it happen, so it’s not pure cynicism on my part to doubt it would be done right. There are some nurses that are very cognizant and would do well with such a protocol, but they are way out-numbered by those that aren’t. So we end up with the myriad and endless game of phone tag.

There are places where this works, critical care comes to mind, but it could work on the floor. All that is needed is staff buy-in, but in my milieu, that’s dreaming. So, I’ll just be calling the docs and making all of our lives inconvenient. There’s a protocol for that too…

What’s Wrong with Health Care?

A Burger King hamburger sesame seed bun, as se...

Image via Wikipedia

Customer service.

We’ve turned taking care of the sick and injured into fucking Burger King. Everyone wants it “their” way. Sorry folks, life isn’t like that especially in my house. When we turn patients into consumers, they begin to expect to treated like customers and hence have no skin in the game. This leads to unrealistic expectations and our administrative “leaders” play up that we are in the business of providing customer service instead of healing. That then becomes our problems on the floors and our “customers” think that “their” way is the only way.

Yes, I will be disturbing you at midnight to check your vitals and then doing it again at 4am.

Yes, you will have blood drawn, probably several times through the day and night.

No, you can’t have your hydrmorphodemerolepam every hour, even if that’s how you take it at home – which is probably what got you here in the first place.

No, burger and fries are not part of your heart healthy diet to help treat your congestive heart failure.

Yes, lasix makes you pee. And, yes, I will be giving you a dose tonight, as the doctor ordered, every 8 hours so that you can breath and not have a hugely swollen scrotum.

Yes, it would be nice for your family to come in to learn wound care techniques so they can care for you at home.

No, not all of them can stay the night with you in a double room.

No, you can’t go out to smoke, even just for a minute. And I’m definitely not giving you an oxygen tank and wheelchair to do it.

Yes, you are more than welcome to leave AMA because we’re all racist assholes who won’t give you IV narcotics every hour, please just sign this form.

No, you don’t get a cab voucher, discharge prescriptions or fresh clothes if you do leave AMA. Sorry.

Yes, Dr. First-Year Intern, they just left AMA after threatening the entire staff, but you might catch them by the ED if you hurry. I’d bring Security with you though.

I will be polite and respectful, but I will not fawn over ingrates, feed into those with unreasonable expectations or take the crap from the dis-respectful. I refuse to be turned into a cashier clerk at the local fast food joint or a Pez dispenser of Oxycontin. There is difference between customer service and letting the public run wild in our house.

It’s time to take it back.

To set expectations.

To educate our patients.

To let the world know that we are not there to be exploited, abused and disrespected.

It’s a long journey, but it starts with a single step, for nurses and other health-care providers to stand up and say, “NO MORE!” and start to expect our patients to be active and involved, to care about their health, to put some skin in the game and start behaving like responsible adults.

But that will never happen. Sad.

Alphabet Soup and Leadership

Alphabet soup. Y’know, all the wonderful letters after ones name that proves to anyone who can read that you’ve persevered though multiple rounds of education that are supposed to make you a better nurse. Does all that make you a leader though? Mother Jones asks a similar question in Are you smarter than a nursing leader?.

I’m with her. I’m not sold on the idea that more advanced education makes one a better nurse or leader. Sure you may have more classroom time learning all of the concepts and theories, but from what I’ve learned in life (not just nursing), theories and concepts tend to go out the window when the shit hits the fan. There is a developing caste structure in nursing based on degrees, that somehow nurses with “better” degrees are better nurses. BSN vs. ADN, MSN vs. BSN, where does it end? In all reality, one doesn’t need a MSN to be a bedside nurse and all this caste structure does is to further reinforce the idea of otherness and exploit the differences between nurses, rather than the commonalities and allow institutions to let education trump experience.

Advanced education has it’s place and in all likelihood I’ll be headed back to the classroom soon, but not because of a need to prove myself, but to improve my ability to move behind the bedside. But an advanced degree does not make one a leader. Sure you learn all the wonderful catch phrases, managerial double-speak and organizational ideals, but when it comes to it, leadership is inborn talent. Some have it, others don’t and no amount of education will fix that.

A Pacer Puzzler

Sometimes we see things on the monitor that while they look like things aren’t working correctly they actually are doing what they should.  Case in point from awhile ago.

The tech calls me and says, “Your patient in 75, they keep alarming for missing beats and pacer not pacing.  You going to call the doc?” as he hands me the following strips:

#1#2

I looked down, double checked and said, “Nope.  It’s working perfectly.”

In both strips you can see spots where it appears that the pacemaker is failing to pace, after 1st and 7th QRS complexes in strip #1 and after the 4th QRS in strip #2.  In each case you have a spike then a p-wave and nothing until a odd appearing PVC-like beat.  The tech pointed these out and I further reiterated that, “Yes, it’s working just fine.

But I had a cheat, I had read the interrogation report from when the patient had been admitted and knew what mode the device was set for, the tech hadn’t.  This is a pretty good example of a mode known as MVP, or managed ventricular pacing.  Basically this is a mode designed to reduce ventricular dysynchrony by allowing the heart’s natural conduction system to function while providing back-up in case of failure.  Excessive right ventricular pacing has been shown in studies to lead to congestive heart failure, increased incidence of atrial fibrillation, increased left atrial diameter and changes to hemodynamics and ventricular remodeling all of which can have detrimental effect on the patient and their quality of life.

In MVP pacing the pacemaker operates in AAI/R mode, as shown in both strips, with a set duration of time to allow for a ventricular beat.  If no beat arrives in the programmed time span the device will initiate a ventricular beat then return to the AAI/R.  If a beats are frequently dropped, usually 2 out of 4 complexes, the device shifts to DDD/R mode.  It will continue this way for a minute then attempt to return to AAI/R to detect AV conduction.  If beats are still dropped it will remain in DDD/R mode for increasing amounts of time, periodically checking for the return of AV conduction, at which point it will switch back to AAI/R mode.

Let’s break each strip down.

Strip #1:  starts with normal AV conduction in AAI/R mode and almost immediately, a beat is dropped and the device iniates the rescue beat.  It continues for 5 more QRS complexes until there is another dropped beat.  There is normal AV conduction for one more QRS then another dropped beat after which the device switches to DDD/R mode (it was too long to scan).

Strip #2: a little simpler.  4 normal QRS complexes then a dropped beat followed by a PVC, then another dropped beat.  Here you can see the device then switch into DDD/R mode due to dropping 2 out of 4 beats.

So, yes, the pacer was working exactly as it was supposed to.  I explained this to the tech and went on my merry way.  The next time he sees this he’ll stop to ask if they are set to MVP from now on.  Good learning moments come when you least expect them!

Sources:

Sweeney, M., Ellenbogen, K., Casavant, D., Betzold, R., Sheldon, T., Tang, F., & … Lingle, J. (2005). Multicenter, prospective, randomized safety and efficacy study of a new atrial-based managed ventricular pacing mode (MVP) in dual chamber ICDs. Journal of Cardiovascular Electrophysiology, 16(8), 811-817. Retrieved from EBSCOhost.

 Gillis, A., Purerfellner, H., Israel, C., Sunthorn, H., Kacet, S., Anelli-Monti, M., & … Boriani, G. (2006). Reducing unnecessary right ventricular pacing with the managed ventricular pacing mode in patients with sinus node disease and AV block. Pacing & Clinical Electrophysiology, 29(7), 697-705. Retrieved from EBSCOhost.