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.

He was relatively young but suffering from dilated cardiomyopathy.  He had been admitted after a successful VT ablation and ICD placement and was recuperating overnight on our floor to ensure that the interventions had been successful.  As I got report the nurse gossiped to me that she had been told that he had passed out during sex and ultimately ended up getting the ablation and ICD.  But the off-going nurse didn’t have all the details. I had to find out.  How do you get from passing out to ablation and ICD?  Besides the obvious?  (here’s the ACC/AHA Guidelines for reference)

So as I was doing my initial assessment I asked, “What caused you to get to this point?”  I figure, give the ability to obfuscate and deny, or come clean.

“Well, you probably heard rumors from the other nurses, so I should start from the top…” he said and told me the colorful story.

He had been dealing with effects of the cardiomyopathy for some time and it was cramping his, er, style.  So he decided one evening to buy some herbal marijuana analogue and take it with his wife and see what happened.  In the middle of he act, he passed out cold.  Unresponsive for a good 20 seconds.  Scared the Hell out of his wife, he said.  She freaked out, called EMS who took him to the ED for treatment.

That started the cascade of events which the end was him getting ablated and an ICD placed.  He looked up at me and said, “A guy’s gotta’ do what he needs?  Right?  The doc doesn’t know if it was the K2 or the underlying issue I already had with my heart.  So he decided to fix it.  Now I’m good to go!”

We both got a good chuckle out of it, but it turned serious when he asked about restrictions.  Gave him the usual spiel and pointedly asked him to talk to his EP doc about it.  Just to be safe.

“Now I just have to convince my wife that it’s OK to have sex again.  I scared her too bad and she’s a little hesitant now.” he said to end.

“Just be careful,” was all I could tell him.  And, “No, I won’t tell her!”

So often we get guys who are asking when they can resume relations after heart attacks, stents, pacemakers and even after open heart surgery.  I guess certain priorities take precedence in life!

The case is now being decided by a federal appeals court, but raises the question of whether nurses and health care workers should be held to a higher standard than other workers.

via The Policeman vs. the Nurse – NYTimes.com.

The simple break down is this:  nurse gets speeding ticket, is pissed off and this  “I hope you are not ever my patient,” she reportedly told him., ” happens.  Cop gets mad, complains to her work, nurses loses job and ends up suing everyone.  Yeah, so simple.

Is it?

First, why did the police officer go running to her employer like a tattle-tale?  Was he truly threatened by her actions?  Was he directly threatened by her actions?  He went running because he seemingly felt that his position of authority, his power, was occluded and obscured, that this nurse (female to boot) was daring to speak her mind.  That’s at least what one can infer from the information that is available.  The truth may be different.

Second, was the intent of the nurse to threaten?  Who knows?  It’s not reported how the cop treated her, how her day had treated her, if this was a pattern of harassment or just a sotto voce expression of displeasure on her part.  I truly doubt that if the policeman ended up on her unit she would do anything but give excellent care.   Call me naive but I don’t think that a speeding ticket is the ticket to substandard care.  I’d like to think that nurses are not that petty.

But this incident has opened a huge can of worms.  Are nurses and other health care workers held to a higher standard?  Does our right to free speech disappear because we’re in health care?  If that is the case, pack up the blogs, log off of Twitter, burn the notebooks and stop expressing yourself.  It’s a slippery slope.  I say things regularly that  can be construed in a different manner than I intended.  I could see myself in the same situation as this nurse, mostly because often the filter between my brain and mouth isn’t in perfect shape.  For better or worse I tend to speak my mind, much to the chagrin of my wife.  But I’m working on re-building the filter.

So if we’re held to higher standard, what’s next?  Garbage men can mutter, “we’ll see if I pick up your trash next week” and get fired.  They’re public servants too.  Or docs saying, “You’re getting a prostate exam next time”.   It can get ridiculous quickly.  Why should then nurses and other health care workers be held to any higher status?  Because we’re visible?  Because we’re supposed to be above all that?  Or as per an editorial in the Colorado Springs Gazette, we’re  “a person of impeccable character whom the community could trust to help anyone in need of cardiac care.” Right, I forgot when I earned that RN after my name I gave up right to opinion and bad judgment, especially in  public, off work, on my own time.

The more pressing question is why did the policeman go to her work and complain depriving thus her of work?  I’m sure that’s the nicest insult he has heard.  No references to farm animals, musings on his mother’s questionable background or his sexual orientation.  Just a cursory hope from her.  To me it is a hope that she never has to see him again, deal with him again, not inflict harm and withhold care.  Overreact much?  C’mon, grow some thicker skin.

Was it unwise of the nurse to say something?  Yeah, probably not the best idea, but we’re human.  We make human mistakes, say human things and have bad days like anyone else.  If you haven’t ever said something you regretted for one reason or another you’re F.O.S.  We all do it.  Sure it is probably different situations, than with a cop at your window, but we all make those mistakes.  Unfortunately for this nurse the mistaken slip of the tongue cost her a job and will shadow her for a long time afterward.  Was she wrong?  In a way.  But the officer was more wrong in taking it out on her livelihood.  That’s the part that is truly wrong.

Image via Wikipedia

Yep, it’s coming.

Wait,  strike that, it’s already here.  Our friends over the New York Times published this great article last week about the incursion of robots into our already crowded lives and workplaces.  Obviously I’ve been asleep at the keyboard and didn’t notice this until this weekend.  Some call it a Borg takeover, the evolution of SkyNet or invasion of the Roomba, but the reality is that we can use the technology rather than letting the technology use us.  Take for example the first couple paragraphs of the story:

SACRAMENTO — Dr. Alan Shatzel’s pager beeped at 9 on a Saturday morning. A man had suffered a stroke, and someone had to decide, quickly, whether to give him an anticlotting drug that could mean the difference between life and death.

Dr. Shatzel, a neurologist, hustled not to the emergency room where the patient lay — 260 miles away, in Bakersfield — but to a darkened room at a hospital here. He took a seat in front of the latest tools of his trade: computer monitors, a keyboard and a joystick that control his assistant on the scene — a robot on wheels.

He guided the roughly five-foot-tall machine, which has a large monitor as its “head,” into the patient’s room in Bakersfield. Dr. Shatzel’s face appeared on screen, and his voice issued from a speaker.

Dr. Shatzel acknowledged the nurse and introduced himself to the patient’s grandson, explaining that he would question the patient to determine whether he was a candidate for the drug. The robot’s stereophonic hearing conveyed the answers. Using the hypersensitive camera on the monitor, Dr. Shatzel zoomed in and out and swung the display left and right, much as if he were turning his head to look around the room.

Is it perfect?  Hell no.  Is it a step in the right direction?  Probably.

We already have a lack of doctors in general, and a true dearth of specialists in rural areas, so this is a solution of a sorts.  Does this replace the doc?  No, not at all.  It is another tool they can use to make informed decisions.  Having another head in the game means twice the chance of getting the right idea first.  Sure it will be weird to wheel a robot in to see a patient, but it’s really no different than an EKG or X-ray machine, except it has a doc “inside”.  Eventually it will become commonplace, just like the other tools of our trade.

I can only imagine the reactions that will happen when our “altered” population gets a robotic consultation…

Labor Day.  Back to school time once again.  Even though there are a metric shit-ton of articles for new student nurses, I figured why not add to the mix?  Here’s some help from someone who’s been there and survived.

1.  Remember, this too shall pass.

Nursing school doesn’t last forever, so unless you’re undeniably stupid or way out of your league, there is a finish line.  It may seem like it is far, far away, but when you do finally finish, it will amaze you how fast it truly went.

2.  Eat, sleep, dream nursing.

Sounds cheesy right?  Maybe too New-Agey?  What I’m saying is you have to dedicate yourself 110% to the journey.  Like Big Daddy Kane once said, “Ain’t no half-steppin’.”

3.  Don’t be that nursing student.

Y’know what I’m talking about.  The one that does the bare minimum.  When presented with the opportunity to see a “really cool thing”© at end of clinical day, defers and says “I can’t, I have to go to post-clinical session with my teacher.”  Or the one that coasts by on the merits of others, using their skills and talents to bolster themselves.  The one that figures nursing school is just about showing up and that interaction is not neccessary.

4.  Learn from everyone.

Yes, you’re going to school to be a RN, but a good CNA can still teach you more than you might know.  Learn to trust the good ones, learn from them, because you won’t always have the good ones at your side.  Same goes for the multitude of other “allied health professionals”.  Y’know, RT, PT, OT, Speech therapy, pharmacists and yes, even the docs.  It might surprise you the little nuggets you can glean from them.

5.  Find a group of like-minded folks.

Going at it alone is doable, but not pleasant.  Find yourself a circle of friends to help you through this.  People outside of nursing school can’t comprehend what you are going through, but if you have a good group of school friends they know what you are struggling through.

6.  Take care of yourself.

Sleep, yes, sleep.  Studying until you are bleary-eyed and then sleeping for only 3 hours does you no good if you fall asleep during the test.  Getting sick because you have abused yourself too long does your patients no good either.  Eat right, get some exercise and sleep. Take some time for yourself to decompress, to let it all out and step away from the grind.  Sure, it seems to contradict #2, but every now and then you need to step away to find the clarity of thought needed to continue.

7.  Then End is not the End.

The end of nursing school is not the End.  It is only the beginning.  Good luck.

But truly I’ve had some records shattered.  We see far out and funky lab values all the time, but these were some doozies this month.

And the Winners are:

HbgA1C:  14.6!  Also had a 13.9 as a runner-up.  Both patients with Type I diabetes, both young, one with OK support, one with none.  We worked the diabetic educator to the bone trying  to teach these young’uns to not end up destroying themselves.  For those playing along with the home game, <6 is good control for diabetics.  And when you translate that to eAG (estimated Average Glucose) you get 372mg/dl and 352mg/dl.  Bad mojo.

Worst Case of Thrush EVER:  Candidal Esophagitis, from the oropharynx to just above the lower esophageal sphincter.  And in a twist, the patient was not immuno-compromised.

Highest WBC in a non-cancer patient:  68.8.  Yes, 68,800!  And it had jumped from 48,000 less than 12 hours earlier.

Lactate:  10.8.  Of course what do I say?  “Last time I saw a lactate that high we were coding the patient.”  Sure enough the patient did expire (they had the nasty white count).  They were sick with a capital “F”.

Dumbest idea of the month:  dude comes in drunk and complaining of nausea and vomiting.  After being triaged he goes to the bathroom and pops a couple of poppers, promptly turns grayish-blue with  a pressure of 50 and a raging onset of methemoglobinemia.  At least he was in the ED when he did it.

Oh, and for two Fridays in a row, had rapid responses at shift change…a helluva’ way to start the shift!

I hope September is better…

***

Nothing puts experience in perspective like having a doc ask you for advice.  It’s humbling and kind of scary all at the same time.  Really?  You’re the doc.  Y’know, medical school?  At least 1 year as a full fledged doc, writing orders, telling us lowly peons what to do?  Any of this ring a bell?

The conversation went along these lines…

“So I have a patient I want on tele, but they’re bradycardic.  I mean, you do that right?”  Dr. Obvious.

“Um, yeah.  We have brady folks all the time.  Not really a big deal.”  says perplexed charge nurse (PCN).

“OK, can you guys do pacing on the floor or do I need to send them to ICU?”  Dr. Obvious.

“Uh, if you’re thinking they need to be paced odds are pretty good they need to be in the Unit.”  PCN.

“Right.”  Obvious is thinking here.  “They’ve been brady and slightly hypotensive.  You guys can handle that right?”

“Uh-huh.”  starting to look around for Peter Funt and a camera crew.  “I mean, brady is fine.  If he drops too low we’ll just drop into ACLS and do our thing.  How low is he anyway?”

“He’s been holding steady in the 40′s.  Last BP was 100s over 60s”

face palm… “Look as long as he’s not doing any kind of funny block, I’m cool with them in the 30s with a pressure that good.  He’ll be fine.  If you want, you can write orders for atropine prn and we’ll put pacer pads on…”

I’m trying not to laugh here.  Really 40-50s with  pressures in the 100s?  I thought it was a real issue, like they’re runnning 30-40′s in a Mobitz II block or something funky.  Really?  Sure, I appreciate being asked what our comfort level was, but you’re the doc.  You get the special white coat and all that to make these hard decisions.  You want tele, fine.  We’ll deal with the the issues, and if the fecal matter hits the air oscillator, we know what to do.

Had a patient the other week that ran consistently in the low 30′s post-Sotalol.  I’m OK with that.  BP of 86/40 in a CHFer who’s talking to me coherently and making urine?  I’m good.  Now the guy who we were getting pressures of 70/palp with a heart rate in the 120′s and was minimally responsive, that made my sphincter pucker a little.  But that’s why I love telemetry, we take relatively unstable patients (even those that probably need to be in ICU) monitor them and do interventions to fix them.  Part of me appreciates the call, but part of me views it as an insult, in the implication we can’t take care of the (not)unstable patient.  Make your decision, you’re the doctor, right?

I’m down with dropping cash for apps.  It encourages the authors to continue their pursuit and make more and better apps.  But what if you’re on a tight budget, don’t have a credit card or are just plain cheap?  Looking around the app store, you’re pretty much S.O.L. (shit out of luck).  Not any more.  Here’s a list, by no means is it comprehensive, but it is free!  But Wanderer, if you can afford an iPhone, surely you can afford to buy apps especially the $.99 ones, can’t you?  Truth is, I’m cheap.  Plain and simple.  I can deal with ads if that means I don’t have to pay for it.

1.  Medscape.  My go to app for drugs and diagnoses.  Simple, searchable and easy to use.  It is missing one thing though, a Pill ID category.  You know for the LOL who is sitting there going, “I take a pink one, a green one and a blue one at night.  No, I don’t know their names, but I have some in my purse!”  For this I use…

2.  Epocrates.  The elder statesman.  Sure you can buy a subscription and get detailed labs, diseases, toxicology and all of that jazz, but all I ever need it for anymore is for the Pill ID.  When the LOL whips out her pouch o’ pills I’m ID’ing them like a bad mutha…  I used Epocrates on my Palm thru nursing school and my first year as a nurse, but got tired of carrying around my Palm and didn’t until I got an iPhone.  I like Medscape better, but it’s a personal preference.

3.  MedCalc.  Mentioned in the other article.  It’s great.  Truly it is.  I doubt I will ever use the “In-Flight PaO2 Estimation” calculator, but it’s good to know that I have it should I need it!  One really nice feature is a “Starred List” where you can dump all your most used formulas to find with ease.  Additionally, in the “Infusion Management” calculator you can add in your own hospital formulary concentrations essentially building your own “Infuse” app!  I had this too on my Palm and had all of the common drips on my floor programmed in.  Yeah, it took a little time, but hey, the app is free!

4.  MD EZ Labs.  It’s not the most in-depth of lab apps, but it has normals and possible differentials.  Plus, each lab has a link to the web for further digging.  Simple and straight forward.  Besides, what do you think the residents do when they don’t know a lab?  Google it.

5.  Qx Calculate.  Another calc program.  I haven’t truly dug that far into it.  But if you need to calculate Framingham or CHADs2 scores, this one’s for you.

6.  iRadiology.  I’m a nurse.  I don’t pretend to be anything else.  But I do want to know what I’m looking at when I see an x-ray.  Not to diagnose, but to see and teach myself.  It becomes more of a “Hmmm…this one looks worse that prior.” than anything else.

7.  MedPage.  Need CMEs?  If you’re a member through the website, you can earn CME credits while on the go.  Stuck in line at the DMV?  Grab a 0.25 of an hour’s worth and help grow your knowledge and practice.

8.  Eponyms.  Free for students.  Again, another I used in nursing school and had forgotten about until I read the article.  Great collection of medical terms/definitions.  Need to know what the heck “Chikungunya Fever” is?  This is where I would look.

9.  iQuarters.  You have to stay sane, right?

There you have it.  9 free great apps for nurses on the cheap.  Feel free to add your free favorites while you’re at it!  And if you’re an Android user, jump in, I know nothing about that!

You know it’s not going to be a good night when the first thing you do is forcibly re-direct a naked man out of the hallway and back to his bed.  Even though he was suffering from a nasty case of Versed-itis© (odd, sometimes insane behavior in normally sane and calm people as an adverse reaction to Versed), he was jumping out of bed post-angio and running into the halls naked, as we were trying to keep him safe.  It’s always fun when the doc is yelling for some help as she is being chased by the naked dude in his nude adventures.

It gets better when the IV nurses comes out of a room and says, “Yeah, thanks.  I just saw your patient’s penis.  Oh, and he tried to come on to me.”  That’s a surefire way to ensure no one bothers you the rest of the night.

Perhaps the best is when the naked chick is running around the unit doing laps, with a nurse or two chasing her with a gown and sheets.  It’s pretty damn hilarious.

What is it about the hospital that promotes nakedness?  Could it be the drugs?  Could it be the lowered inhibitions due to neurological decline?  Could it just be that they don’t care?

Lucky for me it’s been all three.  There was the psych patient in with syncope that the residents stopped all the anti-psychotics on thinking they were contributing to the syncope (turns out it was the the pauses he was having) but he ended up naked every night, roommate be damned.  There have been several cases of drug-induced nakedness, like angio boy.  And the neuro decline brings to mind the Huntington’s patient who slept naked and would jump out of bed to run to the bathroom, except sometimes he got lost heading there and ended up in the hallway.

99% of it has always been guys though.  It’s like we’re so enamored of our own bits that we need to show it off to the entire world, whether they want to see it or not.   If it’s in the rooms, I could care less.  Like the dementia patient who’s wife told us they had slept naked for years, it was comforting to him and once we got the clothes off, he slept like a baby.  It’s been pretty rare to have a female streaker.  I guess the societal mores are too deeply embedded in them (they just tell you about their need for a new vibrating friend…).  But when the lights go down at the hospital, too often the clothes come off.  And not in a Grey’s Anatomy-way.  Some will argue that this is just part of nursing.  It is.  A damn funny one!

I know however, that when I’m of the age and in the hospital, I’ll be the one running naked down the hall, freaking everyone out!

Anyone who has read “The House of God” knows Fat Man’s Second Law:  Gomers Go to Ground.  It’s harshly worded and blunt beyond our politically correct society can accept, but it is true.  People, especially the elderly, fall.

And why not?  The elder with dementia that doesn’t understand their own limitations, the folks we pump full of beta blockers, diuretics, narcotics and anti-psychotics, and the TBIs and CHIs that can’t grasp their clumsiness are all part of the hospital (and in greater society) milieu.  They fall.  For multiple reasons.  If you do a quick search of the literature, I’m beyond positive that you will find hundreds, if not thousands of pieces of information of falls, causes, risks, sequelae, outcomes and the like.  And the chorus is the same:  falls are bad.  Falls that result in injury are bad.  Elder folks falling is bad.  Our friends of the Borg, er, The Joint (smoking) Commission have decreed that, Falls Shall Never Happen! Oh, and by the way, if they do pipes up CMS, we ain’t going to pay for the care costs related to the fall.  Go to ground and break your hip?  Hospital eats it as no one (even private insurers are starting to follow this trend), is going to pay for your care.

This fear of non-payment has created a flurry of activity.  Fall programs, rounding programs to ensure falls don’t happen by addressing all the things that cause folks to fall (pain, potty, position…), new special booties that both identify the wearer as a high fall risk and provide excellent grip and with all of this loads upon truck loads of new paperwork and charting.  So where does this leave us?  Stuck charting and paperworking instead of providing patient care.

OK, now what do we do about it?  Simple:  accept the fact that people fall.  Don’t point fingers in a blame game or penalize institutions when it happens, accept the simple fact that this will happen.  Then start operating under the assumption that everyone is a fall risk in the hospital.  Actually reduce the paperwork and charting so we can be present and available to prevent falls.  But always know that it will happen.

It’s not an easy fix as say preventing BSIs or CA-UTIs where checklists and proper technique will prevent many if not all infections.  Falls are too dynamic to be placed on a rigid checklist.  For example, a certain patient on my floor was incredibly unsteady, but was strong enough to be “mobile”.  Even though we rounded on them, they were close to the desk, minimized meds that could alter their mentation (worse than it was), they could have fallen in an instant.  Many times, even though they were mere feet away from my typical charting spot, they were up and in the bathroom before I could get to the room after the bed alarm sounded.  There was the patient that threw themselves over the bedrails opposite of their hemiparesis, of the one who suffered cardiac arrest while up walking.  These things happen.  We can never stop them all.

I know why we do all the excessive charting and paper trails besides the whole, “Look we’re doing something about it!”  It’s a way of (hopefully) reducing our liability in court.  So we can say, “Look at all the things we did.  We should be paid (or not have to pay)  Aren’t we good?  Forms in triplicate and fall assessments every 4 hours!  We did everything!”  If we had the assumption that people were going to fall and the rational expectations of this, none of that would be necessary.  But there is no such thing as rational expectations in health care anymore so we all suffer.

The best thing though is when asked where you were while the patient fell would be to reply, “I was charting their fall assessment!”

Well, we got ‘em.  Last week I posted an EKG quizzer.  Funny looking 12-lead right?  Prolonged QT?  Dilaudid, Verapamil?  Remember?  No?  Go check the link to refresh your memory:  Friday 12-Lead.

Go ahead, I’ll wait.

Back yet?

OK, so we have signifcant QT prolongation.  Or do we?

Is it me or does that T-Wave look kind of funny?  Kinda’ looks a little flat-ish.

How about these two?

Hmm…I see a little bit of notching in the T-waves here.  Almost like this isn’t just the T-wave we’re looking at.  Maybe this will help a little bit:  the patient’s potassium level when drawn was *drum roll please* 1.9mEq/L.  Yes, 1.9mEq/L.  She had gotten some replacement during the days, but obviously it was not enough.

What we have here is actually a QU segment as the U-wave from the hypokalemia has merged into the normal T-wave.  More examples of this can be seen thanks to Google’s Book Search from Understanding Electrocardiography.  It notes that you start to see dominant U-waves that merge with the T-wave when serum levels of potassium below 3.omEq/L, most notable in leads V2-V6 (as shown above), with the U-waves actually becoming larger than the T-waves when the levels drop to around 1.0mEq/L.  Adverse events related to hypokalemia include AV blocks, torsades, V-Fib and cardiac arrest, which is not a surprise knowing how potassium works in the cardiac cycle.   Typical causes of hypokalemia include diuretic use, alcohol abuse, loss through the GI tract from vomiting or suction (think NG tube) and some antibiotics just to give short list.

Electrolyte imbalances are also relatively common with pancreatitis, especially when you have vomiting.  Our patient was pretty much past the vomiting stage having been NPO for 3 days.  Combine that with having NS going at 250ml/hr for the last 2 days and we were flushing her K+ out of the system.  Fluids were changed to add K and the rate was reduced.  She got several K+ riders during day shift as well.  Thankfully the on-call doc didn’t freak out and have us turn the dilaudid PCA off as that would have caused just a bit of a problem based on her usage.  Even better was we never had to talk to the EP doc.  Small things.

By the time I came back that night, her potassium was edging up to around 3.5 and her QT had normalized out to around 420ms.  We get so tuned in to hyperkalemia that sometimes we forget that hypokalemia is just as significant.  We were able to keep the potassium within normal for the rest of the stay and to no surprise, her QT intervals stayed normal and there was no recurrence of giant U-waves.

That’s your answer.

My life has been one set of aggravations after another lately and I feel like the picture implies.  And it sounds trite and trivial to whine about them in a pubic forum, but sometimes we have to vent.  The problem is that I can’t spin them in ways to make it sound less trivial and less trite.  When I do write it out and go back over it the words sound like some teen who’s parents took the car away from. So it’s kind of like a block.  But I’m going to spit it out, get the vitriol, hate and anger out.  We’ll see what happens.

My doctor’s office.
They don’t seem to realize that I need answers sooner rather than later.  You see I had a result on a test which my doc wanted me to get further worked-up for.  They assured me that the office staff would get on it.  That was a week ago.  And today they don’t even return my phone call.  WTF?!  The results are life-altering and frankly I’m scared as hell about it.  I want, no I crave answers to what is going on.  That’s the fucked up thing as a nurse, you know enough to be totally freaked out, but not enough to be rational.  Reading Up to Date at work does not help the situation.

My Floor
I love my staff.  My co-workers are some of the most awesome nurses I have ever worked with and we’re one hell of a good team.  When shit goes south, I know they have my back and likewise for them.  But the patients, oh, our wonderful patients.  I’m slowly losing interest in little old demented ladies, the non-compliant trainwrecks that circle through every month or so, the stupid admissions and the psych cases that need “medical clearance” before going to in-patient psych.  It’s no longer a challenge.  Which is dangerous for me.  I get complacent.  I get bored.  I need to leave and find new adventures but the economy is still to fragile and based on item #1, I don’t want to be changing anything yet.  So I’m stuck.

The Floats
I’m tired of floaters to our floor.  I appreciate having them fill our holes and some days a body is better than nothing, but only barely.  What’s worse is when they get floated because our staff gets canceled (thanks to our convoluted staffing office’s system that no one understands and is about as transparent as mud), or they get floated to a sister unit as that unit can’t staff themselves.  Ever.  So I give up one of our floor nurses, trained in ACLS, stokes, rhythms etc., who can handle anything that gets admitted for someone who I have to carefully tailor the assignment for and hope they are there for the entire shift (one floor in the whole f-ing hospital has a special dispensation to have different hours 6-6 vs 7-7 and their nurses, even when floated keep that time, so we lose a nurse at 0630).  And if anything gets funky I pretty much end up taking over the patient(true story).

Our Aides
Who do as little as possible so it is like having no aide at all.  ‘Nuff said.

My Sister Unit
Them whose shit don’t stink, those that are better than us as they get “critical care differential”, those who take care of open heart patients and stent patients, those who can only take ACLS certified floats.  Yes, those bastards.  They tend to forget that I used to work with all of them before our units split apart.  So you have a post-open heart patient.  Big deal.  Been there, done that.  With four other patients.  Oooh, you had to pull a sheath.  And?  It wouldn’t be so bad if they weren’t so fucking condescending about it.  Yes, we’re the other tele unit, the dump unit, the one you turf the trainwrecks and pain in the ass patients too.  Even though you are an Intermediate Care Unit, the only true step-down type patients you take of are cardiac stuff, we get a ton of the nasty medical stuff that should probably go to you.  You stonewall any attempt to take any sort of non-cardiac patient all the time.  And I’m sorry that you had to take an admit the other night, we had 3 nurses and didn’t have the ability to take an admit at the time.  Yet in your busyness, you Ms. Charge Nurse-lifer still found the time to come up and chat with us for 45minutes.  You were really busy.  The classic line though was when one of you looked at our patients and said, “They have a chest tube!  Shouldn’t they be in the IMCU?  Can you handle it?”  No, we can’t.  I was wondering what that funny thing sticking out of their chest was, maybe I need to get them transferred!  No, the reason they are up here, I wanted to tell her, was because the surgeon wasn’t as picky as your typical guy is, because God forbid, his holiness, the cardio-thoracic surgeon would have to go a floor above yours and the ICU!  We can take care of a patient with chest tubes, it ain’t rocket science like you make it out to be.

Last, but not least, our Day Shift
I’m not starting a Days vs Nights war, this is not a general meditation of day shift, but my feelings towards our lovely day shift.  It can be summed up simply:  can you just get your shit done?  Ever?  Nursing is a 24-hour job, but that doesn’t mean you can dump everything on the night shift.  I am sick and tired of spending the first 3, 4, 5 or more hours of my shift cleaning up your messes.  I know I can’t say anything because all we do at night is sit around talking (yes, more than one has said this).  I mean we have to have something to do, right?  Nearly every night for the last 3 months has been  like walking into a war zone when I get to work.  Some days are better than others, but they are the exception.  It’s not a good sign when the nurse you get report from answers every question of “Did this get done yet?” with, “Oh, I didn’t see that.”  Not a good sign when the patient has been on the floor since 1600 and nothing is done and they’re lying in their own waste.  Having been around during the day for other things at work, I see the manic take hold until all of them are wandering around in circles looking like they are doing a lot but really doing nothing at all.  And if you really want to see frantic useless action, call a Code.  It’s like the proverbial chicken with their head off.  While it is nice to be welcomed by your patients, it’s never a good sign when they say, “I’m so glad you’re here!”  So yes, day shift, I’m not a fan.  Don’t you dare give my nurses shit when everything isn’t complete on a patient who arrived at 0630, because it never is when y’all do it.

At least I feel a little better now.

Addendum…
My GI doc appointment is actually scheduled now, my PCPs office called at 1900 last night to let me know.  Guess they heard my ranting.  Dude looks like a child though.  Could be interesting.

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…

Trusts are introducing new wraparound garments which tie at the side rather than the back – ensuring their wearer’s rear is not exposed on the wards.

Patients have long complained about the old-style gowns, which are designed to allow surgeons and doctors easy access to their body, but do nothing for patients’ dignity when they are walking around a hospital.

Not only are they embarrassing, they can also be uncomfortable – the lack of a back means they can be very draughty to wear.

via ‘Bottom-flashing’ hospital gowns replaced by new, ‘modesty’ version | Mail Online.

I guess I’m just used to little old dudes up for their 6am constitutional with the back flapping in the breeze on their way through the ward.  I will say the gowns are pretty much horrible – even to those working with them.  We snap our gowns at the shoulders so when you’re getting a new one it’s like Build-A-Gown, which sucks when you’re trying to be quick.  But the one saving grace of the old-skool gowns is the ease in which we can change someone who is in bed.  Besides the chronically bed-bound, there are times when the patient can’t get out of bed, like after an angio and the gown needs to be changed.  Easy and simple with the open back, but I’m sure the new desgnn takes this into account…

According to the already gushing reviews, the iPad is a “game changer” and “the device health care has waited for.”

Not really.

I do believe that there will be areas in health care where it could be very useful and could make a difference.  One example that comes to mind is the typical office visit.  My primary care doc uses the computer in the exam room while in the midst of our visit.  He can look up past visits, lab values, meds and all the ephemera of a medical visit.  Instead of staring at a computer through the visit, he can look at me and be more engaged with the patient, instead of being engaged with the computer.  Another w0uld be for rounding on the wards.  How useful could it be to have everything at your fingertips when you’re at the bedside conducting rounds?

But for the average nurse at the bedside it is a horrible idea.  First, it does not appear to be very durable, able to deal with the crap a bedside nurse could unleash upon it.  Us nurses are hard on equipment, especially things we use near continuously in our work.  It is more a repetitive stress type brutality than “give a shit” mentality.  I don’t think Jobs’ fancy, purty piece of engineering could stand up to a typical 12-hour floor shift.  Then there is the issue of exposure to bodily fluids, urine, blood, mucus, poop.  Bedside nurses deal with all of that on a daily basis and while we wold probably be careful with it, shit happens.  No one starts a shift wanting to get pooped on, but it happens y’know?  Then there is the infection control issue.  We have enough issues with nosocomical infections like MRSA and VRE in health care and a portable tablet could be a very effective fomite.  Not only would we then be reminded to wash our hands, but to sterilize our iPads.

Second, it’s lacking in important features.  Bar code scanner?  Nope.  With our new EMR, all meds will be bar-coded, lab slips will be the same, even the patients will be bar-coded, so not having that is fairly significant.  If you’re going to have a device to help with the  tasks and functions of a bedside nurse, we better not have to carry multiple devices, like the pad and a bar code scanner. Swappable batteries?  Uh-uh.  We work 12-hour shifts and according to the press, battery life is around 10-hours.  I don’t have the time on shift to stop, plug in my device for an hour to get more juice so I can finish my work.  Device integration to monitoring equipment?  Not yet and probably not without a very expensive software patch.  In our new EMR, our monitors and vital signs machines are supposedly going to be integrated so that instead of entering values, we click and the values populate.  Now I’ll believe it when I see it, but having used that before, it is cool beyond a doubt.  But is Apple going to open things up to support multiple standards?  Not without a hefty price tag, if at all.  And these were only the first three I came up with.

Third, and probably most important is price.  Even if we get the barebones version, with academic pricing, it’s still going to be expensive.  And if each nurse, on each shift needs one…that could get costly.  If my floor is full, we have 7 nurses, 2 aides, a unit secretary and a tele tech on days, at night, it’s 7 nurses, 1 aide and a tele tech.  To cover the needs we would need to have 14 tablets – at least, probably with one or two for back-up.  That’s one unit.  My manager handles 3 units of varying size, so you do the math.  And that’s just one group of units.  So what?  Do you issue them to nurses on hire?  Are we now responsible for the upkeep and cost should it be damaged?  Hard questions.  What about the “walking away” of the devices?   Some people will steal anything that isn’t bolted to the floor (and some will try to steal that as well) so a tablet you can slip into your coat could disappear quickly.

Would I love to see imaging results live at the bedside?  Sure.  Would it be great to have the last set of vitals, labs and meds at my fingertips when assessing the patient?  Yes, but we already have that thanks to in-room computers.  Would it be awesome to have a cool Apple toy to play with every day I work?  Yeah, it would be cool.  But cool doesn’t always make sense.

So what would I find useful as a bedside nurse when it comes to a tablet-type device?  Here’s a short list:

• Small form factor – bigger than the iPhone, not quite so big as the iPad.  Big enough to view screens without scrolling too much, but possibly be able to slip into my scrub pocket.
• Durability/ease of cleaning.  It’s going to get dropped, exposed to fluids and bugs.  It needs to be able to stand up to that.
• Bar-code scanner.  It’s the wave of the future in EMRs, so any device coming into the arena will need that.
• Good battery life.  At least 12-hours worth, or with hot-swap capability.
• Easy transfer of notes.  I can think of how this would revolutionize the report-process.  You gather the info needed and send it to the next caregiver’s pad, report becomes easier.
• Solitaire.  We need a moment of brainless fun every now and then!
• Device integration.  I want to see the current telemetry on my patient and be able to review past alarms.  When I take vitals, I want it to populate the fields with one click.  I want to see what pumps I have going, volume left in an infusion and even order new meds if necessary from another patient’s room if I need to.
• Multi-tasking.  We’re doing it all the time, why can’t the device?  I want to be able to look up a drug in the database while calculating the dose, as one example.

These are just few things I came up with off the top of my head.  Sure some of this may sound like it based off of laziness (see infusion pumps and ordering), but I believe in working smarter, rather than harder, so if I can see what’s going on in another room without having to go there,I’m all for it.  I do think that at some point we’ll have tablet-type stuff at the bedside.  But right now, I think devices like the iPad are more suited to physicians and non-bedside nursing than to the bedside nurse.  Time will tell.

Every now and then I run into a patient that reminds me why I do this job.  It’s not the ones that we save, the ones we see over and over again, the ones who are generally pleasant, polite and just nice, but one who manages to touch that part of you that lives behind the wall that so many of us put up to stay detached and uninvolved.  That remove becomes so ingrained that it is a reflex.  So often we shy away from letting our patients too close for fear that something untoward might happen.  Maintaining our professional distance is a survival tactic in our increasingly chaotic work world.  Many times the ones that say, “Thank you.” and truly mean it are those that break the wall.

In our age of patient satisfaction scores, core measures, Joint Commission surveys, evidence-based practice and the overall stress of caring for the sick and dying it gets a bit dark, like the light on an overcast day.  It’s still light out, but the clouds filter it down to a dull gray glow.  But that simple act of saying “Thanks,” can make the sun come out.

My patient the other night was one such person.  As I introduce myself, I hear the words so many of us dread, “I remember you!”  Immediately my mind starts turning, rooting around in the dark recesses trying valiantly to match the name, the face and the situation of where I know him.  But I can’t.  It’s blank.

“That’s great,” I reply, “No offense I can’t seem to remember you though. “  And it’s true, I’ve drawn a complete blank.  Usually I have a pretty great recall of the patients I have taken care of, but not tonight, not even now.  “I’m hoping I did OK.”  I finish.

“Oh yeah!”  he enthuses, “You were great.  You took care of me when I was here for 20-some odd days with my valve surgery.  It’s good to see you again!”  Slowly the details are starting to come back, but really nothing.  From there I go into the normal nursing things as we chat.

Through the night he tells everyone that will listen how awesome our floor is, how dedicated and talented our docs are and how great of a nurse I am.  I bring in a pair of my nurses to hear his mechanical valve and he says, “Y’know, Wanderer is really great!  A number 1 nurse!” as they listen to his clicking heart.  I wink at him and say, “OK, how much do I owe ya’ for that one?”

The next evening as I come on and get report, the off-going nurse says, “He is so glad you’re back.  I told him I wasn’t sure, but he said he sure hoped you were!”

Sure enough when I walk in, he’s got a huge grin that I’m back.

So through the night we continue to chat.  He tells me how he thinks that our team, the physicians and the nurses at our hospital are amazing, that he wouldn’t go anywhere else for his care.  Compared to so many of the folks we have taken care of lately, who pretty much hates us, it is a needed breath of fresh air.

Finally in the morning as I do my final rounds before heading out he says, “I just wanted to say it was a pleasure to have you as my nurse,  thank you for all you do.”

I grin, turn and say, “No, the pleasure was all mine.”  as  I walked off the unit with a bounce in my step, a small bit of faith in humanity restored.

Today while going over charge capture methodology for our Epic transition, one of the billing people said the following, “My clinical experienced is pretty limited, so let me see if I understand this correctly…”  So what’s wrong with that you ask?  She’s in charge of auditing charts for billing/regulatory compliance.  One would think that some degree of clinical expertise/understanding would be required to accurately understand the charts.

And the folks making the BIG rules, CMS, is suffering from such a case of rectal-crainio inversion it’s not even funny.  A perfect example we went over today was blood transfusion.  Simple right?  Drop a charge every time you enter a unit of blood into the computer.  But no, that would be too easy.  For CMS (and thusly everyone else) beleives that you should only get paid per instance.  In other words, per MD order, not number of units.  So if the order is for 1 or 6 units, we get the same thing, even though we do the exact same amount of nursing care for each unit.  Every time we have to double verify, take vitals, stay with the patient for the first 15…each time.  So if it is 6 units, you’re doing the same work 6 times, but really only getting reimbursed for the first.  Makes sense to me!

I still believe that every billing person, CMS regulator, TJC auditor and anyone who writes rules and regulations be required to spend at least a week a year, if not more in the trenches.  No cushy units, but units where they would have to work and be subject to the rules they have enacted.  Then they might not be so regulation happy.

One can dream can’t they?

“Ladies and gentleman, boys and girls children of all ages…welcome to the Interwebs Arena for our main event of the  Summer…”

“Fighting out of the Doctor’s Corner wearing the red trunks, the contender from a big hospital somewhere in America.  With a record of 200,000 and 0, years and years of residency training, thousands of sidebar ads and an ego a mile wide, Happy “I’m a Medical Doctor and have my own way of running a code” Hospitalist! …”

“And out of the Nurse’s Corner, wearing the blue trunks, the challenger from a big ER somewhere else in America.  With a record of a million saves, years of being at the front lines of American health care, a chip on her shoulder and Dr. Bloody Gloves in her corner, Nurse “The Snarkinator, can’t believe Happy runs a Code like this” K! …..”

crowd goes wild…

“Let’s get ready to ruuuuuuuumble…..!”

referee…

“OK you two, let’s have a clean fight.  No low blows, no crayzee talk…oh whatever, just come out swinging.”

announcer

Happy and Nurse K are at it again.  Sit back and enjoy the show.

Not going to say who’s right, who’s wrong (although Nurse K is right dude, either wake the patient up for fucks sake, hello, sternal rub ‘em! or pull the cord for the code team), but it sure is turning out to be a real smackdown.  I mean between Happy’s smug aloofness and K’s snark attack, you’ve got a real read on your hands.

Happy’s Post: Michael Jackson May Have Died From Fibromyalgia

Nurse K’s Rebuttal: How to resuscitate a patient Happy-style

Happy’s Attempt to hide the fact he got pwned: Is It Reasonable to Stock Every Room With Emergency Resuscitation Supplies

Would you two just get a room or something…

Edit: K just posted up a rebuttal to Happy’s rebuttal (a double butt-al?)  Face it bro, you’re getting pwned.  Throw the towel.

….I was going to write a bitter polemic about this, but realized that it would just fuel Happy’s ego.  It’s bad enough that I’m linking to it, but I had to say something about it.  So here goes:

1.  More often than not as nurses, we’re not allowed to exercise our critical thinking and judgment thanks to rules, regulations and policies.  Even when we know that it is not necessary to call (thanks to our experience, training and critical thinking), we still have to call, or if nothing more, document why we didn’t.

2.  Some nurses are better/more experienced/better educated/have more common sense than others.  Same goes for doctors.  ‘Nuff said.

3.  We’re not always sure the doctors are aware of the situation (many times they aren’t…) so we call to inform them of it.

4.  Us night shift nurses really love nothing more than to call up a sleeping hospitalist at 3am to report a critical value (that really isn’t, see point #1).  It’s almost as much fun as having to call a cardiologist at that un-godly hour.

Just my view.

First, ventricular bigeminy

In ventricular bigeminy, every other beat is a PVC.  This is usually caused by an irritable foci within the ventricle firing early, in this case, over and over again.

Second, ventricular trigeminy.

As you can see, every third beat is a PVC followed by a compensatory pause and then the cycle starts again.  Once again, an irritable foci within the ventricle is firing off early.

In both cases above, the PVC is followed by a compensatory pause that allows the SA node to rest the cycle.  Also, it appears that in each case, it is a single irritable foci that is firing as the complexes are the same in each strip.  Among the causes of PVCs are:  ischemia, hypoxia, hypokalemia, hypomagnesemia, hypercalcemia, digoxin, cocaine, alcohol, tobacco, cardiomyopathy, MI, mitral valve prolapse and several others.   One of the old school nurses I worked with was saying how back in the day, anytime a patient had more than 6 PVCs a minute, they got started on a lidocaine drip.  Not so much anymore.

If this were my patient, I would double check to make sure they’re maintaining a blood pressure and feeling OK, then make sure their electrolytes get checked.   That is assuming there wasn’t some sort of event, like an MI, occurring.  Typically treatment is either treat the underlying problem, like repleting electrolytes, or do nothing.  Antiarrhythmic medications typically are not used as the side effects can be worse than the problem they are trying to treat!  (See info on the CAST trial for a good illustration.)

The key comes down to this:  how does your patient look?  As with many arrhythmias, sometimes the true measure of what the squiggly lines are saying about your patient is what you patient is telling you.  If they’re doing just fine, then no worries, if not, you need to do some digging!

eMedicine: Prematue Ventricular Contraction

Wikipedia: Premature Ventricular Contraction

20:00, Day 1

So, what do we see? First, Q-waves in leads V1, V2 and V3.  Second, ST-elevation in V1 and V2.  Third, ST-depression in V4 (slight), V5, V6 and flipped T-waves in Leads I and aVL.  Also present is probable left atrial enlargement and  Left Axis Deviation with an axis of around -30°.  Based on this you could theorize that the LAD and Circumflex arteries have some sort of lesion.  The patient is actually hemodynamically stable at the moment.  Previous to this, they had been in atrial flutter with a rate of 110-130′s with some instability.  The cardiologist who was on the floor at the time decided to cardiovert the patient, but as we were prepping to do so they spontaneously converted back to sinus rhythm.  Teetering on the knife edge of stability they enjoyed a nice nap thanks to the Versed we had pushed while prepping for the cardioversion.  It was a reminder to follow the checklist, including ensuring that the patient is still in the rhythm you’re going to shock them out of prior to giving drugs and shocking.  The cardiologist in the last rhythm  check notices that it looks different and at that very moment the tele tech comes running in saying, “They’re in sinus!  They’re back in sinus!”

Next, 24:00 Day 1, patient c/o 5/10 substernal chest pain.

Nothing too different, although you could say that there is a slight elevation in V3.  The other leads actually look a little better, especially the lateral leads.  No change to axis.  This was after one SL nitro though, so that dilation may have helped, one reason we try to get a 12-Lead prior to giving nitro.

06:00, Day 2

Now there appears to be ST-elevation in V3.  The lateral leads have calmed down, with just a touch of depression in V5, V6 and I, with flipped T-waves in aVL.

14:00, Day2

Kind of ugly now, eh?  Now we have questionable Q-waves in V1-V4 (there is a pip right before the wave drops), but fairly significant ST-elevation in the precordials.  Depression and inverted T’s in the lateral leads has returned.  Again this was during an episode of chest pain.

Later that night the patient started to decompensate fairly rapidly.  They had a drop in LOC accompanied by a drop in SPO2 to the low 80′s on 15L non-rebreather.  Lungs we very wet, obviously filling with fluid.  The nurse called the on-call cardiologist who ordered 80mg of Lasix IV, in addition to the 60mg given previously during the day that only got an output of 200ml.  Everything was starting to shut down.  We ended up calling a RRT to get a doc at the bedside, if nothing more than to see if there was anything within the patient’s advanced directive to help.

About a week prior to this, the patient had gone to the cath lab in the failed attempt mentioned above.  Angiography show a 99% occlusion of the left main and distal disease in the RCA, LAD and circumflex arteries.  The left main lesion was so bad that they interventionalist was unable to even pass a wire through, which means it was very, very tight.  They minimal blood flow the heart and absolutely no reserve.  With that in mind, the doc on the RRT realized that we could not fix the underlying problem that was causing the distress.  She spoke with the patient’s family who in the end realized that the patient didn’t have much longer, and made the patient comfort care.  They ended up expiring about an hour later.

Looking at these EKGs one could argue that the ST-elevation is actually LVH with a strain pattern. It certainly fits the criteria, especially when considering the patient had endured previous infarctions and had aortic stenosis, but I’m not completely convinced.  I’m no cardiologist, so I’m going with what I know.  But I am open to other suggestions.  It’s a sad case, especially as the family was still saying how they wanted to talk to the surgeon about open heart surgery the morning of Day 2.  Luckily, we were able to use the means available, notably medication, to give some comfort at the end for the patient, even if we couldn’t’ fix what was wrong.

In the hive mind of CMS, patients should never fall.  Once again, theoretically, not to mention from a public relations standpoint, the argument is sound.  What they and the public tend to forget, that unlesss someone it at the bedside 24-7, falls will occur.  You can follow every published guideline out there.  Scheduled toileting, hourly rounds, bed alarms, reduction of the use of medications that can cause or enhance delirium are all really great ideas and have been proven to reduce falls.  But the bottom line is that when our elders, especially those that may have dementia tned to fall.  Add illness, strange environment, odd noises, unnatural schedules and new medications and you cook up a recipe that could conceivably lead to a fall, in spite of any and all safety measures we as caregivers may take.

But people fall.  Sometimes people fall and there is nothing we can do about it.

Exhibit A:

click for larger size

Anyone who knows EKG tracings can immediately grasp the bad things going on here.  But for those who may be a bit rusty, let me break it down for you.  The patient is rolling along in normal sinus rhythm until they get hit with a R-on-T PVC (a premature ventricular beat the falls when the myocardium is not yet fully repolarized, see below) initiating a run of Torsades de Pointes.  Torsades, meaning “twisting of the points” is a life-threatening ventricular arrhythmia that can rapidly devolve into ventricular fibrillation and death.  It is a form of ventricular tachycardia (VT, V-Tach) characterized by the rotation of the complexes around the isoelectric line illustrated by the increasing/decreasing amplitude of the waves in a near sine-wave pattern.  Treatment in an emergent situation is the following of the V-Tach leg of the ACLS algorithms, although usually a bolus of magnesium sulfate can terminate this as well.  Usually though, when we see this though, the proverbial shit has hit the fan.

In this particular case the patient had been ambulating in the hallway and flipped into Torsades.  The red mark is about where we figure when he hit the floor.  Not for sure, but the timing seems about right.  Now what would CMS say about this?  The patient was awake, alert and oriented x 3, ambulating under his own power when he fell.  So it is still a “never event”.  And this is why a one-size fits all labeling makes no sense.

First, does this mean we shouldn’t let patients ambulate?  They might fall.  Second, should we not give medicatons that may cause arrhythmias like this (more below…)?  They might fall.  Third, should we not anti-coagulate patients who are under treament for atrial fibrillation and thus increase their risk of bleeding with a fall?  Painting in broad strokes doesn’t always work.

Unfortunately, the patient had previously been in atrial fibrillation and been anti-coagulated with warfarin for an INR of 3.2.  He had been cardioverted out of a-fib into sinus earlier in the day and was intiating Tikosyn therapy.  The truly unfortunate part is that when he went down, it was like a tree falling in the forest:  straight back off his heels with his head striking the floor.  CT showed a massive cerebral bleed as a result and family chose to withdraw support allowing him to pass.  So this is a huge “never event”, as per CMS, “Patient death associated with a fall while being cared for in a healthcare facility.”  If he had not been ambulating, odds are pretty good that he would have made it out of the code, as there was a spontaneous return to sinus rhythm right after the scanned strip ends, with spontaneous return of circulation as well.  But since he fell in the hallway and hit his head, the deck was stacked.

As for the medication, Tikosyn (dofetilide) is a Class III antiarrhythmic medication that works by prolonging the cardiac action potential duration.  One major hallmark is that it subsequently prolongs the QT segment.  A prolonged QT interval increases the risk of ventriclar arrhythmias as the repolarization of the myocardium happens at different rates allowing myocytes that have already passed their absolute refractory period to depolarize early and possibly causing a re-entrant phenomenon, kind of like a viscious circle.  The FDA actually mandates that anyone being started on Tikosyn gets themsselves a 3 day vacation on a telemetry floor for this very reason.  Usually we monitor the QT/QTc closely in these patients, obtaining a baseline, then 12-lead EKGs 2 hours post-dose to ensure that the QT/QTc is still within limits.

So was this a “never event”?  Probably.  Could it have been prevented?  Probably not.  There were too many variables in play to do so.  Sometimes shit just happens, no matter what we do.

It says it right there:  MRSA is the fault of hospitals.  If it wasn’t for hospitals, MRSA wouldn’t be so prevalent, wouldn’t be so deadly or such a large issue.  Right.  What a crock of shit.

It mentions nothing abot the over-prescribing of antibiotics.  Nothing of the emergence of the USA300 clone of MRSA in community-acquired infections.  Nothing of the reality that this is based on environmental pressure on the bugs that cause them to acquire resistance in the first place.  No, it’s the hospitals’ fault.

Now I will give due.  We suck when it comes to handling these issues.  And we can do better.  Unfortunately this is a multi-factorial issue and difficult to address whitout pointing fingers.  Wahing hands?  We don’t do it nearly enough.  And nurses aren’t the only culprits.

Physicians can be the most lackadaisical about infection control.

In April 2006, doctors at the UW Medical Center carried personal items from home into sterile operating rooms and dropped them on the floor. These items included backpacks and satchels, made of porous materials friendly to germs. Hospital administrators told inspectors this was “common practice.”

In November 2006, a physician at St. Joseph Medical Center in Tacoma removed his surgical mask during an operation. He had complained it was uncomfortable. Hospital officials told inspectors the physician was a “repeat” violator and had been warned before to keep his mouth and nose covered.

In hospitals, the most common violation is the failure to wash hands upon entering or leaving a patient’s room.

In the worst cases, as few as 40 percent of staff members comply with hand-washing standards. Doctors are the worst offenders, according to confidential hospital records reviewed by The Times.

I’ve lost track of times I’ve seen docs walk into isolation rooms and not don any PPE.  VRE?  MRSA?  C.DIff?  Not a problem, it seems their white coats magically protect them from the all but the worst offenders.  Not to mention becoming a vector in their own right.

While measures like presumptive isolation, isolating anyone who has ever had MRSA, screening everyone on admit my help to slow the rise of the germ in hospitals, it does nothing to prevent it coming from the outside.  All of the MRSA patients I have taken care of, have had it on admit.   It’s why they were there.  In a perfect world, we would have private rooms or all patients.  There would be a fast bedside screening tool for MRSA and other community-acquired resistant germs.  Rooms would be cleaned appropriately and thoroughly.  We would all wash our hands or use foams/gels every single time.  But it’s not a perfect world.  Even in our new unit we have double rooms.  Even though our housekeepers do a pretty good job, there is still the risk of acquiring MRSA from a previous occupant just on odds alone.  It is going to happen.

One problem the article doesn’t address is the rise of the USA300 clone that is present in nearly 97% of community-acquired MRSA infections, most notably in skin and soft tissue infections.  This virulent and nasty strain, with its included Panton-Valentin Leukocidin exotoxin can cause necrotizing fascitis, sepsis and pneumonia.  It’s nasty. But again, like any MRSA, good hand hygeine and terminal room cleaning can help to prevent its transmission inside hospital walls.

While hospitals may have covered up cases and mortality due to MRSA, as shown pretty damningly in the Times article, this not just a focused problem.  It is a multi-systemic issue that reaches across disciplines.  Therefore its going to take a multi-system effort to combat it.

“I’m not hurting you?” she asks with a worried frown.

“Nope, just fine.  Keep going.” I said, distracted by the phone ringing on the desk.

“I think I missed.”

Looking down at my arm and the angiocath, “Yup.  Looks like it.  Do you want another go at it?”

So why am I subjecting myself to the unskilled ministrations of this nurse?  Other than the fact I’m a nice guy and an awesome preceptor and charge nurse?  Because her nursing school education failed her.

I’m not saying that her education was sub-par or that she was unable to pass the NCLEX, but that the essential technical skills of a nurse were glossed over.  Nursing school is supposed to be a chance to learn.  Learn pathophysiology, disease processes, the nursing process and a load of nursing theorists.  It should build a theoretical and knowledge based foundation to base one’s practice upon.  In addition to knowledge, it is an opportunity to learn the technical skills that one has to call upon as a nurse.  Things like inserting Foleys and nasogastric tubes, restraining patients, changing beds (with the patient still in it) and starting IVs.  The basic technical skills.  I’m not talking about drawing ABGs, performing EKGs, dealing with chest tube drainage systems or interpreting rhythms, skills that are unit specific and taught in relation to that unit, but basic/slightly advanced nursing skills.

As we were about to begin, the nurse confided in me, “I’ve never started an IV.”

“Never?  Like never at all?”  I ask incredulously.  “Not in school, not in your preceptorship?”

“No.  We weren’t allowed.”

“Why on earth? (actually thinking WTF) not?”

“They said it was something we would learn on the job.”

That’s delusional thinking on the part of the faculty.  Like many other hospitals, ours has an IV team, a dedicated crew of nurses whose sole duty is to place IVs, whether peripheral, midlines or PICCs.  During the day this isn’t a problem, but after 2300, we’re pretty much S.O.L. (shit out of luck).  Sure we still have an IV nurse, but 9 out of 10 they’re busy placing a PICC or at another facility across town.  A new peripheral site does not top high on their priority list.  It comes down to the floor nurse to step up and place a line themselves.  Frequently though, the patients we get the “practice” on in the middle of the night are not the best subjects, hence why I was on the table.

There are not enough educational opportunities to teach our multitude of new nurses the skill, no, art of inserting an IV.  Hell, there’s not enough opportunity for the rest of us to keep our skills sharp (no pun intended…).  I was a lucky one.  I did my preceptorship in a relatively busy ER, where I had multiple opportunities to poke needles into folks in varying states of consciousness and I got adept, not great, but able to start lines.  However, that skill is pretty much rusty and as out of shape as I am due to a lack of practice.  How then are we supposed to provide that opportunity to newer grads?

It seems a large disservice by that school to deny the opportunity for their students to learn such a vital and practical skill.  I agree, it’s not always the best thing to have legions of eager students roaming the halls to stick unsuspecting patients with large bore angiocaths.  It’s a great way to deter frequent flyers return if they were greeted with such a sight, but alas it isn’t going to happen.  But what happened to starting it on each other?  That’s how we learned.  I won’t soon forget having my classmate John digging around my hand with an 18g trying to poke my elusive dehydrated vein.  That didn’t feel good.   But it was how we learned.

So why the vitriol Wanderer you may ask?  It’s because we recently hired 9 nurses to the the night shift, most of whom are new grads, most without the previous experience of starting IVs.  Some never dropped an NG, placed a Foley, given charcoal or done a large time-consuming dressing change.  It leaves gaps in the team that places a larger impetus on the experienced nurses on the unit to step up and fill the holes while trying to figure out how to get these folks up to technical speed.  And when not everyone is willing to step outside their norm, it makes it a little more stressful.

“So, OK, figure out what you did wrong?” I ask as she arranges a new set on the table.

“No.  No clue.  Any suggestions, words of wisdom?”

“One thing, go in steeper than you did.  My veins are a little deeper, so go in steep, when you get the flash, go just a little further then flatten it out.” I replied demonstrating what I meant.

“OK, you ready?”

“As I’ll ever be.”   Wish I could say it was a successful ending, but I would be lying.  We work together soon, so I’ve resigned myself to be a pin cushion.  If it helps, well, then it’s worth it.  Just wish her nursing school would had delivered so I wouldn’t need to be that pin cushion.

The worst:  slacks, shirt & tie.  I wore this as a cargo loadmaster for an international airline.  For me, being hands-on is an important part of the job, so I ruined numerous dress shirts, countless pairs of pant and a couple of ties as I squeezed in between cargo pallets and into the nooks and crannies of a modern cargo plane.  I was finally able to convince the powers above that as I was working nights, there was no need to wear said uniform.  Khakis and polo shirts became the new dress code.

Second worst: white shirt, bow tie and black slacks.  Worn as a server.  What really topped it off was the full body apron, very classy, especially when you spill food stuffs on it.

The normal:  working as janitor I wore whatever I had been wearing that day.  No changing to go to work, just show up.  Shorts and t-shirt?  Just fine.  Sandals?  Sure.

When I loaded planes, it was jeans and shirts.  Then when winter arrived it was full-on rain gear and insulated coveralls.  But none of these can hold a candle to scrubs.  They are, in my mind, the perfect uniform.  But they are a double edged sword.  Just as you can look good in them, you can also look like a slob.  Dirty, wrinkled, strange color combos and prints, it can all add up to something less than professional.  And many folks don’t care about how they look, they just show up saying, “I’m here.” looking like they rolled out of bed.  Any wonder why image is a big problem for nursing.

A problem I have is finding scrubs I like.  Not a huge fan of the pastel colored prints, for obvious reasons.  And there is not a plethora of “manly” scrubs out there.  While I do agree that this is a female-centric industry, there are more men arriving every day.  For some of the chaps, the unisex scrubs fit great, others not so well.  While there are plenty of scrubs just for the gals, there ain’t much for us boys.  Now I’m not saying we need crazy prints, but prints could be a nice addition.  For now we have to sort through the rests to find those we like.  I’m not completely happy with what I’ve found, an am always on the lookout for different styles, but they do the job well.  I’m still looking for the penultimate scrub set that makes me totally happy.  The search will continue

One thing that scares me though is the public perception.  Recently in a survey at our hospital, a large (>50%) portion of patients identified not knowing who the RN was as a problem.  We all look the same:  RNs, CNAs, Techs, Phlebotomists, etc., all rock scrubs.  Granted, we do look the same, or at least similar.  In the solution portion, in a throwback to an earlier time, 28% responded that whites would be the best way to identify nurses.  Whites?!  Are you kidding?  I have a hard enough time keeping my colors clean and whites would be a nightmare.  I wore white as a student, it was only a top and only for a year, but it was not pleasant.  Not to mention that whites further the image of the nurse handmaiden.  We’re professionals, no longer the pillow-fluffers of yore.  Not that I’m saying those that came before were not professionals, far from it, but that image, the nurse in white is seen as that stereotype.  When you look up naughty nurses (not that I’ve done this…) I’m told they wear whites, not scrubs.  Perception.  Requiring nurses to wear whites, brings this back.  What’s next? Hats?  Candy stripers?  A more palatable version might be profession specific colors, but that could get old in a big hurry.  There may not be a solution to this that works for everyone, but I know that the solution is not whites.