Banana Bags? I Got Them.

Crass-Pollination: An ER blog: Enough with the Banana Bags already.

Uh, yeah.  I’ll second that.

Unfortunately, our docs believe they can save every drunk and therefore, admit them all.  Of course all of them need telemetry monitoring because they are “tachycardic” forgetting that in tachycardia, you treat the underlying issue.  Y’know, like dehydration?  But no, these wonderful specimens of human existence get dumped on our floor for days, if not weeks while we dry them out.

A couple of weeks ago we had a nurse nearly knocked out by one of these assholes.  He got 4-point leathers and a ton of drugs.  The nurse got a concussion and no recourse but lost time and an injury.

Then there was the drunk who the doc didn’t want to send to the ICU and ended up needing more than 30mg of IV Ativan in a 12-hour shift, just to keep things to a dull roar.  Doc refused to send him even as he became more and more agitated and aggressive despite the Ativan, until the morning docs came to see him, where he promptly was sent to ICU for an Ativan drip in restraints.

My favorite of all times happened when I was an nurse extern.  We spent nearly 2 weeks drying this guy out.  Loads of Ativan, days upon days of sitters, thousands upon thousands of dollars worth of care.  The day he was discharged I saw him walking out of the convenience store 2 blocks from the hospital with a case of beer under his arm.  That was so worth it.

Our ED docs seem to have a major aversion to letting these guys (yes, they are 99% male) sober up a tad in the ED then kick them loose in time to get to detox to be admitted there – where they need to be.  We’re not going to save them.  If you have had 10 admits and 18 ED visits for ETOH in the last year, one more probably isn’t going to make a difference.

I am just so tired of it.

a caveat (there always is…)

I understand and know that delirium tremens can kill, that withdrawal seizures are just as dangerous and understand the pathophysiology behind chronic alcohol withdrawal, even the esoteric things like Wernicke’s  Encephalopathy, Wernicke-Korsakoff Syndrome and alcoholic cardiomyopthy and realize that admissions are justified in many cases, just not of the majority that I have encountered.  To me, ETOH is as good of an admitting diagnosis as “Incontinence”(not a neuro thing mind you) – in other words, full of crap.

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.

Gettin’ Ran

It was night three, about 3am.  I had just gone down to the cafeteria to get something fried and salty to satisfy the ravenous beast in my gut.  I had about 5 of the fries while still warm as I walked into near pandemonium.  It was like someone turned the crazy on the minute I left the floor.

Compared to the previous two nights, this one hadn’t been too bad.  While earlier in the week it had been “grab your ankles and hold on!” tonight was a little better controlled chaos.  Instead of a rapid response we calmly sent the patient with a pH of 7.19 and a pCO2 of 95 to ICU for BiPAP.  Instead of getting hit with a CVA admit with no orders at shift change, the only patient we admitted came with orders and hours after shift change.  It was better.  Kind of.

While technically we weren’t short, we were.  We had two floats filling in for the one we were short and the one we floated away to step-down, but strong they were not.  They had the easiest patients on the floor, but were barely keeping head above water.   In essence we were short as they couldn’t help the rest of us.  And the scheduled aide?  Yeah, stuck in close observation with the paranoid, impulsive, delirious ICU transfer out.

I don’t remember a whole lot after 3am, it’s just a blur as we ran putting out one fire after another.  Your previously calm patient is now fucking nuts?  Hey isn’t that your patient trying to escape out the fire door?  Hey, my patient sounds like a stridorous 3 year old and has that “oh shit” look in her eyes as she uses every muscle in her body to breathe.  Bed alarms to my left, call lights to my right and I’m stuck in the middle with you all.

Our only saving grace was the 3 of us left from our core staff formed a tight team, picking up where each left off, answering call lights and bed alarms without the petty stuff that gets in the way.  What, you need meds on 97?  Got it.  Can you tuck 93 back into bed?  No problem.  Tight teamwork saved the night and got us through until 0705.

No falls, no restraints and chaos reigned in by the time day shift rolled in the door.  It’s how we do it.  It’s how we did it.

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.

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.

Friday 12-Lead

Patient was a 30-something year old white female admitted for pancreatitis.  History of alcohol and  illegal drug abuse and yes, pancreatitis.  Currently undergoing fluid resuscitation with normal saline infusing at 250ml/hr.

Medications of note include a dilaudid (hydromorphone) PCA device with dosing of 0.2mg/dose with time lock out of 10minutes and verapamil 80mg PO twice daily.

Telemetry tracing shows normal sinus rhythm in the 70’s with a prolonged QT around 620ms (calcuated QTc of 650ms).  QT had increased since start of shift from around 360ms to current.

The following 12-lead is captured:

QT/QTc is measured at 622/671ms by the machine.  Quick manual calculation confirms this.

Patient is still asymptomatic and vital signs are stable.  She is just pissed you woke her up.

What is the probable diagnosis?  What needs to be done?  Should we call cardiology?  Call and wake up the EP doc?  Pacer pads?  Let her sleep?  Do nothing and pray she doesn’t have a R-on-T PVC?

Answers and discussion to follow in a day or two…