The Tale of the Good Samaritan

“He’s a 55 year old male found down by a bystander and brought in by EMS. He’s being admitted to you for altered mental status, ETOH withdrawal, hyponatremia and chest pain. Any questions?”

It’s a common story. Passerby sees guy slumped over on the sidewalk, sleeping soundly In a drunken stupor and calls EMS. EMS comes and determines the guy is drunk as a skunk but “altered” so per protocol they bring him to the local ED. A workup by Dr. Caresalot show the altered electrolytes and altered mental status of a chronic drunk, but instead of giving him a banana bag and letting him sleep off the drunk, they admit him.

On admit labs his alcohol level is 456 mg/dl or .456 on a breathalyzer, over 5 times the legal limit. A level this high shows dedication and a long history of this kind of abuse, which means he is more susceptible to withdrawal symptoms at a higher threshold than normal. Guys like this start to have withdrawal symptoms when they hit the 150 mg/dl level, so the shakes, the autonomic symptoms, the hallucinations and agitation are starting when he hits the floor.

Ativan is given in copious amounts over the next couple of hours to control the symptoms. Then while on the toilet he has a withdrawal seizure and bradys down earning a trip to the ICU for more intensive Ativan therapy. He can’t protect his airway and aspirates while on the vent and develops pneumonia. A delirium develops during his stay in the ICU and when stable enough for the floor he needs a sitter to deal with his agitation while the delirium clears.

Every chance he is asked about quitting alcohol he states adamantly “I’m never going to stop drinking.”. So he stays with us for two weeks, detoxing him, curing his pneumonia, clearing the delirium, repleting magnesium, getting him fed, all of the healing that being in the hospital provides. So after the two weeks, with help from social services he is discharged to housing, clean and sober, ready for a new life. He then walks into the convince store around the corner from the hospital and walks out with an 18 pack under his arm to start over. And the cycle continues over and over again.

I’ve lost track of how many times we’ve done this. More times than not, a good Samaritan calls it in. Instead of minding their own business, they take it upon themselves to “help” with no understanding of the events they place in motion. Instead of leaving the drunk sleep off the drunk, they call 911 to get help. EMS is obliged then to treat and transport starting the whole series over again. I’m not against helping, I just wish people would think before they acted and our ED docs would not admit everyone who shows up on the doorstep.

 

Are we Evil?

“Why would you choose to do this job?  I know you’re killing people and hiding the bodies.”  such was the thought process of the paranoid post-op patient.  No matter what we said, what we did, the delusion was so real to them that while they got along fine with day shift, there was a lingering mistrust of the night shift because we were killing people.

Sometimes I do question the things we do, the horribly invasive things we do, breaking chests open, sticking needles in veins, catheters in any numbers of openings, slice, sew, defibrillate.

And heal.  That answers the question doesn’t it?

bonus…

It’s just too awesome not to include…

Random Filler

Been working a lot with our EMR roll-out, trying valiantly to hold in “there!! right fucking there! that button right there!” from coming out of my mouth, but I did run across a couple of interesting things in the last couple of weeks.

Chief complaint: suicidal, constipation.  Which came first?  Maybe it was “I’m so constipated I want to kill myself.”  I don’t know.  Don’t want to know.  Don’t even want to go there.

Chief complaint: rectal pain.  On the same night as the World Naked Bike Ride.  Coincidence?  Maybe?

And bringing up the end, possibly the highest glucose reading I’ve seen: 1056mg/dl.  Patient noted he rarely checks his sugars as they’re always high.  Too bad the HgbA1c wasn’t back when I left.  That probably would have been a winner too!

Get the Defib?

Just a little VT.  It’s OK.

Scrubs are My Uniform

Scrubs are pajamas. Initially a simple garment to be worn and left in the operating arena, the scrubs are now available in many a color and pattern to be worn by nurses, billing agents, medical assistants, doctors and anyone else in any way associated with physicians.

The fact that most people have no idea the difference between the girl who takes their copays and the nurse that evaluates them, most people assume they are all “nurses.”…

via The Pajama Brigade makes an Impression | The Happy Medic.

I get it all the time, “Well, you get to go to work in your pajamas.  How cool is that?”  I’ve worn many different uniforms in my work career from slacks, shirt and tie, to industrial workwear and just plain old jeans and a t-shirt and now I get to wear “pajamas” to work.  Sorry, that’s bullshit.  I am required to wear a uniform that happened to have been co-opted as pajamas.  To me, a uniform signifies that it is time to go to work, I call it “getting on my game face”.  Those “pajamas” tell me it is time to work, leave the world behind and focus on my job – my patients.

Now there are those that spoil this for those of us who take it seriously.  Since everyone and their uncle who works in health care  gets to wear scrubs, there are bound to be the one’s who abuse it.  I cringe when I’m out shopping and see people in scrubs, it sets the wrong idea, especially when those wearing them are misbehaving.  It is still bad behavior to break HIPAA whether you are wearing scrubs or not, it just makes it more conspicuous when you are in scrubs.

There are two issues here that get intertwined and blurred.  First there is professional behavior.  It doesn’t matter what you do for a living, you need to maintain a professional mien when representing that job/career/profession.  And yes, health care workers are held to a higher standard, get used to it.  It’s even more important when you are clearly identified by the public (by your wearing scrubs to the bar/lounge/grocery store/porno shop) to be a professional, because they associate scrubs with nurses/doctors.

Acting like an idiot in scrubs makes a bigger impression than it does in street clothes – people notice.  Second is the proliferation of scrubs into so many different fields.  Are they the doc/RT/PT/housekeeping/CNA/RN?  You can’t always tell.  Not to mention those outside of the hospital like vets, dental folks, office staff and the like where this has spread into.  Too many people wearing scrubs makes life confusing.  And due to this proliferation, clamping down and restricting use will be near impossible.  All that is left is some sort of uniform – like our friends in EMS/Fire/Police, or hospital color coding by job function.

As long as the color is not white, I can get behind this.  More so, I think that institutions need to require changing at work.  You get to work, change out of street clothes into hospital uniforms, then do the reverse when you leave.  If we are so worried about the spread of superbugs, why isn’t this a common sense idea?  I leave my work shoes at work and change clothes (partly because I usually commute by bike) on arriving and leaving.  It goes to the idea of getting my game face on.

The lesson here?  Scrubs are every bit a uniform, just like other professions.  Unfortunately there are those that wear my uniform that are unprofessional and act like idiots when in public.  Painting all of us with the same brush is just as bad.

Nursing Shortage? Not in Some Eyes.

I know this rant has been making the rounds on Twitter.  It is full of rage, a touch of woe is me and the grim reality of the situation we place so many new grads in.  A quote (shield your eyes if easily offended…)

Image via Wikipedia: They got jobs.

Well, after a year of getting rejected I have finally decided to give nursing the bird. FUCK YOU NURSING FIELD! Too bad the schools and media are still insisting that people go to RN school. Believe me THERE IS NO FUCKING SHORTAGE! New grads are considered garbage. On top of that, the degree serves no purpose in any other setting. BSN is a complete waste of time and money.   …And it is not just the economy. Hospitals turning huge profits stopped new grad programs and hire foreigners.

Wow.  The rest continues on in a rant that she (assuming a she) will never get a job, never put her degree to use and that she wasted 6 years of her life.

First gut reaction:  she’s right.  It sucks to be told there is a ready market of jobs just waiting for new grads.  Read too many job requirements of  “at least 2 years experience” and raged at the screen saying, “How am I supposed to get experience if I can’t get a job?  WTF?!”  I know many, many grads who have cycled through our unit for practicum who have yet to find jobs.  We have nurses on our unit who jumped at the first offer (methadone clinic anyone?) but persevered and got the jobs they wanted.  In fact that was me.  I got lucky.  I can empathize.  The betrayal of it all is painful, kind of like when you realized Santa was not real, or your girlfriend was banging your best friend.

Second reaction:  buh-bye.  Maybe we’re (as a profession) better off not having this person in our ranks.  Nursing is not easy…what happens the first time they get a difficult assignment?  Or have “one of those days”?  Run out?  Quit?  Nothing in this profession is given to you, one has to work for it.  Take for example NurseXY, who landed his dream job in a world-class CVICU.  Seriously, go read his stuff, he worked his ass off for it.  Nothing was easy.  No one ever promised (at least anymore) that a job would be waiting right when you passed NCLEX – and if they did you should make sure they aren’t selling a pile of hooey.  Just because there is a nursing shortage does nothing to guarantee you a job just because you passed the boards.  Anyone who degrades their education to this degree and doesn’t realize that sometimes sacrifice is a needed part of our job has no place being a nurse.

Final reaction:  no seriously, buh-bye.  If you want to work as a nurse enough to devote 6 years and thousand of dollars to do so, giving up isn’t an option.  She never says that she looked out of state for jobs, into different avenues than the traditional hospital based nurse or for other ways to be a nurse.  Our system interviewed over 500 grads for spots in our residency program and they came from all over the Northwest.  They tried to make it work.  There is nothing to say she did this, just a whiny, “why isn’t it given to me!” rant.  We have too many toxic personalities in nursing and truly don’t need anymore.

I know this is harsh.  Maybe this person is a amazing nurse, top notch clinical skills with empathy to boot, is driven far beyond belief and tried EVERY avenue to make things work, but based on what I’m reading, what they posted onto the internet for everyone to read, I doubt it.  And with this rant, I doubt any but the most desperate, worst, idiot recruiter would ever even consider asking for a resume.  I know it sucks, but maybe it’s for the better.

It’s Never This Clean

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.

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.

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.

Stupid Questions

“Uh, hey Wanderer?  You said the super-pube would just easily come out after we deflated the balloon, right?” the nurse asked me from across the hall.

“Yeah, might have to tug a little, but should just be able to remove it and swap in the new one.”  I said.

“It seems like it’s stuck…can you come take a look?”  he said.

Gown up, glove up (isolation rooms are the best!) and head in.  The catheter is in the stoma the nurse looking at me with question marks above his head.  “You have all the saline out of the balloon?”

“Yeah, can’t pull any more back.”  he confirms.

I reach down and grab it, give it a good tug.  Nothing.  Twist it a little around.  Still no dice.  Twist and tug.  It’s not going anywhere.  Short of putting my foot on the patient’s chest and pulling, which probably is a bad idea, we’re not getting it out without expert (read: someone with an MD to take responsibilty) help.  I say as such tot he nurse and suggest he call the intern on duty.

The intern calls back and the nurse explains the situation.  She proceeds to ask, “Well, did you deflate the balloon?”

It’s a good thing it was him and not me.  He was cordial and didn’t roll his eyes too much.  Me, at that point it would have been, “Really?  Do you think I’m that stupid to not deflate the balloon?  Really?  I’m not some novice who’s never done this.  For f*cks sake, give me at least a little credit here!”  That’s why he called, not me.

Be careful of who you ask stupid questions of…

You want what?

“Hi, Dr. Heart, I’m calling you about Mr. I’ve-gone-crazy who your partner did a pacer generator change on today.  He’s become very agitated and combative since the start of our shift.  I need something now to calm him down as nothing else has worked.  Would something like Depakote sprinkles or Zyprexa, maybe even Haldol be OK with you?  said the nurse into the phone.

Seriously, the guy was freaking out.  Every non-pharmacological method we have in the arsenal had been thrown at him.  He was confused and rightfully so.  It’s not nice to put folks with dementia through surgery, it leads to some very funky things.  He went from perseverating over his pants to perseverating over his wheel chair, then he wanted to be in bed, now in the chair and wherever you put him he wanted out of it.  Did I mention he could not stand and bear his own weight?

The other nurses looked at me imploringly to help his nurse out.  “You’ve got to do something!” they said to me.

“She’s his nurse, and yes, we’re doing all of her work for her, but I cannot call the doc for her.  I don’t know the details, I don’t know enough about his history to state my case for what I think is needed.  But I will talk with her.” I said.

The nurse came up to me minutes later and asked what to do.  I reeled off the things that might help, meds that we have used time and time again in these situations.  She agreed and went to call the doc.  Above is how I pictured the conversation (she likes to hide in the med room or pharmacy office to call).

I can surmise how the rest of the above conversation went.  “You want what?  I have no idea about any of those meds.  He’s agitated?  Um, not really used to dealing with this, is he covered by Medicine?  No?  Really?  I don’t even know what the doses would be for those meds in this situation.  Uhhh…how about some Ativan?”

To which the nurse readily agreed.  Really we would have taken anything at that point.  This is not to say that our cardiologists don’t know what they are doing, they’re just not as adept at helping us handle the agitated and combative elder as say our medicine interns or geriatrics service.  It’s a level of comfort.  Our geri docs would readily agree to something like Depakote far faster than Ativan, but it’s their milieu.  Would not want one of them dropping a stent in my patient.  It’s what you know.

And the Ativan?  It worked for a while but he ended up with a sitter by daybreak, still confused and combative, but staying safely in bed.  Lesson?  Avoid general anesthesia and things like Versed and Fentanyl on demented elders:  it makes them worse.

(Am not saying to not do procedures on folks of advanced age, make sure you give us the tools to manage them and ensure their safety post-operatively when you do!)