Monday, March 22, 2010

The ugliest rhythm I have seen so far in a person who wasn't actively trying to die...

I had a patient yesterday who was 81 (but looked much much younger) who was A-Fib brady (in the 40s, 30s when sleeping) with a bundle branch block and a long QT interval.

Needless to say, pacer pads were nearby....

Thursday, March 18, 2010

It always happens at shift change, right?

So after a busy but not-too-hectic evening, I finally sat down around 2245 to finish up my charting.

I had a lot to catch up on, because of a new admission to 63. He showed up on the unit around 1800, but was immediately whisked off to dialysis before I had a chance to do any assessment beyond "He's alive, A&Ox3, and doesn't look like he should be in the hospital." He came back to the unit around 2130. I did my admission sheet, got him dinner, and brought him his (late b/c of dialysis) meds in record time, done around 2230. He was doing just fine all through it.

So at 2250 his wife comes up to the desk with a worried look and says, "My husband is not acting normal at all. I need you to come take a look right now." She said it with such calm and straightforwardness that I was immediately terrified. When people come at you with histrionics it's usually something stupid like needing a repositioning. When there's an eerie calm, you know there's trouble.

I popped my head into the room, and he's staring off to his left, with a right-sided facial droop that I didn't recall seeing 20 min earlier when I was last in the room. We asked him to say his name, and his speech was slurred and unintelligible. He was able to lift his left arm on command, and give my hand a good squeeze, but we couldn't get any response from the right hand side. Couldn't even get him to turn his head that direction.

"Well, shit" I thought.

So I called the on-call doc and asked her to get up to us to check him out. Resource came in to check his vitals, which were fine. We decided to call RRT to get a little extra help.

Doc showed up a little before 2300, we called a Stroke Alert about a minute later. This involved doing an assessment on pronator drift, and getting a bunch of blood samples.

The lab had been in not too long before and said he had "slippery" veins. They weren't lying. Luckily, he had an 18g in his forearm with brilliant blood return that we were able to get samples from. Thank god.

He was off the floor and down for a head CT by 2313, which isn't too bad, timing-wise. Things seemed to move much more quickly, and I was always surprised when I looked at my watch.

His poor wife was rather shocked, because this wasn't what she expected at all. Hell, they were going to send him home from ED earlier that day. Got him dressed, took out his IVs, everything. Then they changed their minds and sent him up to us.

So after the CT they sent him to ICU, and I had to wait awhile to give report to the nurse who would take him. Hooray for overtime!

I was told by Pappa that they did find a couple blockages on the CT and he was eligible for tPA.

I'm curious to see how it all ends up when I go back to work today.

Addendum: So apparently they didn't do the tPA after all, owing to the severity of the stroke and how many areas it involved, as well as the fact that the pt was a Jehovah's Witness. If there were bleeding side effects from the tPA, it would be very problematic if he didn't accept transfusions. He is stable now, transferred to our neuro unit, already able to swallow safely and working on his communication skills. Apparently they called an erroneous code blue on him yesterday when he had a seizure post-dialysis. Luckily he's still okay.

Well, okay as can be expected....

Tuesday, March 16, 2010

Forget designer knock-offs.... here's the product I really want to see...

So going back to Hypoglycemia Girl and "I Need My Pills" Lady from a couple posts ago...

At one point during the shift I was chatting with Hypoglycemia Girl and her boyfriend, and had apologized a couple times for not checking in on her more often. I explained (without compromising confidentiality) about the issue with INMP Lady and how I wished there was something I could give her.

HG said, "Can't you just give her something else, like Tylenol, and tell her it's the right stuff?"

I explained that most of our patients (especially the older folks) know their pills by look more than by name or what it does. I said, "I've had patients refuse certain medications because at home they take two little green pills not one pink pill, even though I explain to them it's just a different manufacturer"

Together we came up with a fabulous idea for a business, creating Placebo knockoffs that look just like the real thing. That way if your patient is demanding Ativan but isn't allowed it for whatever reason, you can give the appropriately sized and colored placebo. Of course, they should be kept separate from the full-fledged medication, and be available only in hospitals.

But wouldn't that be damn helpful for confused folks who can't understand that if we give them Ativan when they're already having trouble breathing, they might stop breathing altogether....

I know we shouldn't be out to deceive our patients, and that we should educate where people don't understand. But some people are apparently ineducable and just giving *something* would reduce stress on everyone's part :)

Thursday, March 11, 2010

Dear Hospital Management,

My birthday is coming up in May, and I thought I'd let you know ahead of time what I'd like so you can get working on it.

I would like my unit to be appropriately staffed all the time. I don't want it to be an unexpected surprise when we have two CNAs on the floor, or when I get my 15-minute breaks.

Last night we were dangerously understaffed considering the complexity of our patients. We had all twenty-six beds filled. Three of our patients are worth *at least* the work of two our three patients themselves. We've been good. We are doing our PCHs as diligently as we can.

For a full house, we are supposed to have a Charge, two Resources, and two CNAs on the floor. There was one Resource and one CNA.

This is just plain wrong.

One of my patients last night has CDiff, is incontinent, and has a Stage II pressure ulcer on his coccyx. I cleaned him 5 times in my 8 hour shift. Each time I had to spend *at least* 20 minutes just trying to find someone, anyone, to help me clean him up. That much feces near that severe of an open wound for that long is just *screaming* to brew a massive infection. On top of that, this pt's wife is *very* involved in her husband's hospital stay, and not in the good way. This guy is doing his best for a TTJ and we just keep putting in new corpaks (Don't even get me started on the corpak adventure. Let's just say that after as many X-rays he got, I wouldn't be surprised if he started glowing in the dark.) and turning him every 2 hours and doing dialysis and putting restraints on so he doesn't pull things off.

I spent at least four hours of my eight-hour shift just on him, nevermind my other three patients (two of whom were mentioned in my adventurous last post) who thank god didn't do anything exciting.

So much time could've been saved if there'd been more help around. I had to rush to check on bed alarms because there was no one else. And bed alarms are only effective if there's someone to hear and react, much like the tree falling in the wood.

I know we're going through a lot right now, what with our realignment nonsense. I know you don't want to hire any new outside people until you figure out where all of us inside are going. But just because you're planning for the future doesn't mean you can ignore the present. When you are in the hospital, the present is all you have. If you don't take care of it, you don't have a future to worry about.

So, Management, if you have any shred of love for your faithful employees, you'll give me this one little thing I'm asking for. You still have two months to get it together.

Thanks for your time,


Wednesday, March 10, 2010

Adventures of the day.... I hate adventures.

My day had started off with an adventure in hypoglycemia. Young patient, early 30s, had a gastric bypass a few years back. For the last 2 years, she'd been having issues with hypoglycemia because her pancreas decided to go apeshit at her. She eventually came in because of a loss of consciousness r/t hypoglycemia. The doctors discovered she had reactive hypoglycemia. (Long story short for the non-technical types: person eats a meal, blood sugar increases. Pancreas goes "HOLY SHIT THERE'S SUGAR! ATTAAAAAAACK!" and sends a flood of insulin, dropping the blood sugars like a ton of bricks.) I told her to give me a call the moment she started feeling funny.

So around 1640 I get a call "...ssuugar low. trieddd.. drink juice" and that was it. I experienced an impressive bout of tachycardia and ran to go check on her. She was barely responsive with eyes closed. Checked her sugar on our machine, 56. Apparently she went down to 24 yesterday. I tried to contain my panic as she started twitching uncontrollably and looked for a mobile computer so I could look up the Doctor's number and be able to scan in the Glucagon. Gave the IM Glucagon and waited a little while; she didn't come out of it and continued twitching/jerking. Decided it was time to call RRT to come keep an eye on her for me. When RRT came I took the opportunity to grab another Glucagon (our last one!) from the Pyxis and dose her. Her sugar went up to 118 but she still didn't wake up.

Finally after about 45 minutes she came to, thank god, with a FS of 134. I spent the rest of the shift terrified she'd do it again. Luckily, her sugars stabilized, at least till I went home. Curious to see how she is today.

Then I had a shift-change adventure with a confused patient. She was A&Ox3 at the start of shift, because that's how these things work. The trouble started around 1930 when she started asking for a sleeping pill. I called the doc, and he didn't order any because of her recent stint with intubation in the ICU (good call!) and wanted to make sure her respiratory status was good before worrying about sedatives. But the patient didn't let it go. Every time I went in the room she demanded her pills. I explained what was going on and why she couldn't have her normal sleeper, but she didn't understand. She kept asking me to go to the middle bedroom and get the little pill bottle out of the bedside table. Her daughter even tried to reorient her, and we took a short walk out of the room to show her the hospital hallway. No luck.

Eventually we agreed that we'd just turn out her lights, give her earplugs, and hope that she settled down enough (after not sleeping for 2 nights) to pass out. Her son was staying the night, and with any luck he'd keep her calm.

So come shift change, I get rung at by the tele monitor saying that her HR was steadily climbing. 120s, "okay, she's AFib, it happens." 130s, "hm this is weird". 160s "holy shit let's see what's going on."

So I run down the hallway and go in the room to find her legs out of the bed, and her lying at an awkward diagonal. I ask her where she's going and she said "I fell." For a moment I freaked out because patient falls are a huge issue. Then I thought to myself, if she ended up on the floor, there's *no way* she's strong enough to get back in the bed like this. She's a moderate assist just to stand from sitting. So I assist her to sit at the edge of the bed, and the bed alarm went off. Okay, so the bed alarm was armed (I'm pretty obsessive about the bed alarm now) and functional, so if she had fallen out of bed, it would've rung before.

I look at her, and notice she's very upset and teary eyed. I asked if maybe she had a bad dream in which she fell. Lord knows we've all had that awful "tripping off the edge of the sidewalk" dream and then jerking awake slightly freaked out. She said that she had, and that she needed to use the commode. The oncoming nurse and I helped her to the commode and I stood by while she attempted to go (with no success). We helped her back into bed, and she continued on about getting her pills.

Meanwhile her son in the pull-out bed lifted his head a few times, but at no point did he attempt to help us reorient his mother. What's the point of spending the night if you're not going to be useful?! It's not like it's fun or comfortable staying in the hospital. Help out or go home...

Anyway, we get her settled and comfortable, turn the bed alarm back on, and I went home. I look forward to reading the night's notes...

I can't wait to get off the Tele floor. It's a spirit-crushing, down-heartening hell-hole lots of nights. Makes you sad for the elderly and pissed off at the family who thinks that death can be prevented indefinitely. We all have to die someday, and we all have to die of something. Why torture people in the interim?

Monday, March 8, 2010

Step one in solving our healthcare crisis...

Let's reduce the price of diagnostic supplies. Imagine a slip of paper the size of your fingernail that can tell you if you have HIV, Hep C, or TB. Medical technology is frickin' awesome!

Thursday, March 4, 2010

A quick laugh

Everyone gets a kick out of less-than-savory medical abbreviations (like GOMER: get outta my ER) but somehow I'd never heard this one.

WNL = We Never Looked

Short, sweet, and totally true half the time lol

PS: here are a couple more lists of funny abbreviations. I am particularly a fan of CTD (Circling The Drain), LOL (Little Old Lady), and TTJ (Transfer To Jesus - which I wish more of my patients would do).