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!)

Another for the Record Books

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7.5L of urine output in 24 hours.

Yes, a little over 300ml of urine every hour.  And this wasn’t a patient with some weird endocrine dysfunction or SIADH, but a patient in decompensated CHF.

He came in with sausages for legs and 3+ pitting edema to his armpits (quite nearly…).  The cardiologists throw some Lasix at him, but according to the Laws of the House of God (lasix dose = age + BUN) it wasn’t even close.  Sure he was peeing, but still edematous.  Start up the ACE inhibitor and a little bit of Coreg, but he’s still wiped out walking to the bathroom and looks like the Michelin Man’s long-lost homeless relative.  So what’s next?  Just a touch of dobutamine.  6 hours later it was like a faucet had been turned on.

By the time we were done with him he had legs again, could stalk the hallways looking for food without being short of breath and leave our fine institution.  I’m sure he’ll be back.

Could this be why?

Y’know something’s wrong with our system when 5, yes, count ’em, 5 Zofran ODT cost $102.  And the only way Medicare will pay is if the patient is on chemo.  That tells me something is really amiss.  It ain’t right.

Possibly the worst part was that my mother-in-law, the one who is nauseated, told the ER doc that phennergan doesn’t really work for her, instead of the other way around.  So he writes for 5 ODTs.  Thank you very much.

Guess I’ll still be asking for them to dilute my dilaudid with phennergan!

Your Money, Well Spent

Yes, it is cliché to blame high drug prices on all of the marketing materials that the pharmaceuticals hand out.  But it is so easy.  Observe my haul from the conference I went to over the weekend.

The watch is mine.

Just the pens:

Sell out?  Corporate whore?  Money-grubbing swag monger?  Naw, the wife bitched at me the last time I went to a conference about the relative dearth of pens I had snatched, so I tried to make up this time.

As for educational content the conference was great.  Somethings were way over my head, others I could actually follow and possibly even incorporate into my practice.  Plus I snagged some cool imaging stuff that I haven’t had a chance to dig into.  Hopefully soon.

For All the ER NUrses out there…

Oh yes…”Top Ten Reasons People Use to Get Pain Medicine Early

Is that all you have? I’m sure there are more/better than that…

This sparked a reminder of someone on the floor lately…how they are still breathing I have no idea: Dilaudid PCA @ 4mg/hr w/4mg on demand q15minutes (max of 24mg/hour), 2 fentanyl lollipops q6 (a better invention I have never seen…mmmm…narcotic) and up to 100mg Phenergan IV q4. I also think there were prn Dilaudid orders on top ofthe PCA, but I could be wrong. Now do remember…1mg of Dilaudid is equianalgesic to 7mg of morphine – in other words, max. dose of Dilaudid via the PCA is like 168mg of morphine and hour. And yes, they were still breathing. The PCA pump though was a bit worn out.