The Strong Suffer

English: A right MCA artery stroke.

~this was originally written the week before my last day

We are in the midst of the transition that prompted me to volunteer to quit my job and it sucks. Each day makes me realize what a good decision I made, but makes me worried for those left behind.

One of the biggest issues is that we’re combining two different units, one a typical med-surg/renal unit, the other a progressive care unit. Two very different staffs with different skill sets. The tele nurses are all ACLS and stroke certified, the others not. The tele unit started and built an observation unit and got used to and accepted the turn and burn mentality where you admit and discharge like there’s no tomorrow. The folks coming in rarely admitted in the levels we did and came from a more laid-back mentality.  SO yes, it’s a huge transition, especially for the new folks on our staff, huge changes in both practice and mentality. Add to that increased patient ratios and people are already starting to question the status quo.

The worst though is for the nurses perceived as “strong”. You know the ones that can take anything you throw at them, rarely bitch and just take their lumps, the ones with the advanced skills. They get the more difficult patients, the sicker patients, and more of them.

The other night was a perfect example of that for me. I started with 4, a decent mix of patients. (yes, I know, our ratios are low compared to some, but we have minimal support staff, it’s all about perspective too). Charge nurse comes to me with a proposition: drop one of my patients to take stroke admit. She figured it was easier for me to do this instead of giving the only other stroke nurse a 5th when she had never taken 5 patients before. This is a full on stroke, large MCA nastiness and there are a lot of things to do since we’re in the acute window. What choice do I have? I’m not gong to be a dick and say “no, let ’em suffer” am I? Not really. So I admit the stroke and considering now the CT looks, I lucked out. Then she comes back asking me to take a chest pain admit since the only other nurse just “can’t”. Whatever. They ask because they know I will only say no if I truly can’t. They ask because “you’re strong and can handle it, the others can’t.”

The last night I worked it happened again, I get the admit while the others don’t because “they haven’t done it.” And it’s not like I don’t want to work, I take my lumps but I believe it should be fair, at leadst to an extent. Give an equitable load, don’t dump on the strong nurses because you can. What comes out of that? Burnout. Demotivation. Animosity.

A good friend of mine who is staying mentioned all of this to me the week before we changed over.  He’s a guy who never complains, I mean NEVER.  And he was upset, worried and generally disaffected.  Did I mention he is a guy who always has a smile on his face, even when glove deep in poop?  To see him so upset truly shows me the folly of the madness being inflicted on us.  Here’s a nurse who smiles through everything, who gets every single LOL to love him, who’s clinical skills have grown immensely since hire to be a very competent, caring and effective nurse who will be put through the wringer because he’s “strong” and they run the risk of losing such an employee. But in the end “they” don’t care, it all comes down to money.

That is why I feel bad for my former colleagues.  It’s going to get worse before it gets any better, if it ever does.  The unit we spent years building was destroyed in one fell swoop and is reverting back to a mire of poor management, burned out nurses, massive regular turnover of nurse, disaffected staff and a manager who is crushed by those farther up the food chain.  Sadly it all lands on the patients and while there will be nurses who strive to keep the level of care the same, you can only fight the tide for so long.  Hopefully the worst of my prognostications doesn’t cone true.  One can only hope.

~disclaimer: I know there are places with far worse ratios and worse conditions, we’ve been incredibly lucky for a long time.  Leave it at that.
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EKG wrap-up

Last week I posted a red herring of an EKG in EKG of the Month.  It was a diversion, interesting in its own regard, but a diversion from the true situation all the same.

Here’s the EKG again:

What do we see?  Flipped T-waves in the anterior and lateral leads, poor, even odd R wave progression, short possibly even absent PR intervals and bradycardia.  It’s kind of ugly.  One would expect the patient to be experiencing some sort of symptom of cardiac compromise.  Nada, nothing.

Here’s the presentation: 28 year old, 6 months post-partum, comes in with progressive left-sided weakness. Had been seen at the PCP earlier in the weak and given scripts for muscle relaxants and steroids on the idea this was a muscloskeletal issue.  Patient decided to come to the ER after dropping her child due to the weakness (the kiddo was fine).  The above EKG was shot prior to her going to CT for a head CT, followed by another imaging modality: MRI.  Both show a bilateral ischemic event, right greater than left, mostly in the frontal and prefontal area with some scattered subcortical spots as well.  Big time, acute ischemic CVA.

So what’s up with this EKG?  Neurogenic T wave inversion.  I found several articles on Ovid about this phenomenon.  According to one article, 74% of patients with cerebrovascular incidents exhibit alterations in cardiac depolarisation and repolarisation.  Most commonly these cardiac alterations are in things like prolonged QT intervals, T wave inversion, ST segment changes and abnormal U waves.  This possibly is caused by unbalanced autonomic control due to the location of the ischemic events.  The most common culprit is the insular cortex located within the lateral sulcus, overlaid in some parts but the frontal lobe – where the were several ares of ischemia.  Now I can’t say for sure that this area was damaged, and judging by the literature, usually the alterations are more defined and substantial.

Now here is where it gets really interesting. Why would a 28 year old have an ischemic CVA.  No history of hypertension, no cardiac history to note, normal birth, but an aunt who had a similar event at the same age.  Carotid and cerebral angiography was performed giving the diagnosis of moyamoya disease.  Simply put, moyamoya is a progressive occlusive disease that causes stenosis of the carotids and the Circle of Willis.  Leading to occlusion of the vessels.  A large collateral network does form and sometimes retrograde filling of the cerebral arteries is seen as well.  True diagnosis is through angiography where there is a “puff of smoke” appearance to the cerebral vasculature.  Most folks don’t even know they have it until they have an event of some variety.  Much of the time it is a TIA type, but sometimes it comes as a large cerebrovascular event.  Moyamoya is also a leading case of stroke in children, even very young kiddos.  The consensus is that it is genetic and considering that the patient’s aunt suffered a similar event, coincidence aside, that looks pretty solid.

So what happened?  Since we are a nationally recognized stroke center, the patient admitted under our stroke protocol.  Through the first night and later on they would have alterations in their rhythms, running junctional rhythms, SVT and sinus tach along with normal sinus rhythm.  The biggest deficits was to the left arm with some mild to moderate in the left leg.  She didn’t experience any expansion of the ischemic areas during her time on our floor and was relatively stable.  Prior to heading to a rehab floor, referrals were given for surgical consultation through Stanford for a surgical solution to her disease.

I think this was a case of the long-tail of medicineHappy had a post about this and it sparked this post as well.  We get so used to seeing this kind of EKG in a totally different light that a new perspective sometimes throws us way out of whack.  I showed the EKG to a fellow EKG nerd and the first thing he asked was, “Did you call the doc over this?’  I explained the situation and the lights went on.  I had no clue about moyamoya prior to this, so it was a huge learning experience for me.  Fascinating and a little bit sad as well.

There you have it.  Hope you enjoyed this round of EKG of the month.  Hopefully next month there will be a crazy cardiac one…well maybe not, that would mean bad things might be happening.