Monday, February 26, 2007

For All the Marbles

Sometime around 2AM a couple of weeks ago, a woman came into the ER complaining of nausea and epigastric pain that went up into her left chest and shoulder. She was old enough to be in the prime age group for heart attacks, and she was having a couple of the symptoms that make us a little nervous. That was reason enough for us to suspect that she was having a heart attack.

Remember the ER chest pain creed, kids? Come on, say it with me... "Every human being who comes through the door is having a heart attack until proven otherwise."

Well, okay. Not every human being. I would exclude those who have not yet been born, and those who have already died. All others are suspect.

Well, guess what? The woman was having an antero-lateral wall ST-elevation myocardial infarct (STEMI). For the laypersons out there, that means the front/side part of the woman's heart muscle was dying because of lack of oxygen. When that happens, it friggin' hurts.
And after 3 spritzes of sublingual nitroglycerin, 325mg of aspirin, the start of a 10mcg/minute nitro drip, 12 mg of Morphine, and 5L/minute of oxygen, the woman was still having 10/10 crushing chest pain. Nothing was helping.

I was just getting ready to place a Foley catheter when I looked up at the patient's monitor and saw her go into what looked like ventricular tachycardia. The patient immediately lost consciousness.

At a loss for words, all I could do was slap the MD on the shoulder with the back of my hand and say "Hey!" as I directed his attention to the monitor.

Okay. I admit it isn't as sexy as saying, "Doctor, I believe our patient has gone into ventricular tachycardia," but it got the job done.

The MD said "Oh, crud," and stepped over to the patient as I moved over to the defibrillator, to which the patient had already been hooked up. After feeling for the patient's femoral pulse, he looked up at me and simply said, "shock her."

I hit the "charge" button on the machine and it made its usual bwooooooooop, rising in pitch until 200 joules (biphasic) was reached. Then it made an irritating warble that could have made Helen Keller wince. The machine was ready.

"Everybody clear!" I barked. Everyone jumped back from the patient and I hit the "shock" button.


The patient jumped, her arms and legs snapping outward. Her heart, having been dope-slapped, decided to get back with the program. That little rhythm strip at the top of this post shows what the defibrillator captured.

Turns out the rhythm was not V-tach, but Torsades de pointes. That's a lethal arrhythmia often talked about, but seen rarely. (Some medicos have never seen it in their entire careers, I am told.) The term is French, and it means "twisting of the points." Click on the picture. If you look closely, you will note that the points of the short, fast waves on the strip appear somewhat twisted around themselves- hence the name.

Be that as it may, the patient's heart found its way back into sinus rhythm, and the patient woke up within seconds afterward.

"How do you feel?" The MD asked.

The patient looked around foggily for a second or two, and finally said, "My chest pain is gone."

"Well, there you go," the MD said.

The patient was hastily packed up, shipped off to the cath lab, had her right coronary and left circumflex artery roto-rootered out, and made a quick recovery. She'll be fine.

That's what it boils down to, folks. Years of education, further years of experience, and hundreds of hours more of training are all packed into what totalled a mere ten seconds of time.

Yeah. It happens that fast. No Hollywood gomer can wrote this stuff. It just happens.

And you know what? I felt pretty damn good walking to my car after that.

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Monday, February 19, 2007

The Stupid Awards, Inaugural Edition

The prizewinner of this week's Stupid Award is a Hispanic woman who brought her child to the ER three times on the same day. The kid had a viral upper respiratory infection and the family's clinic was closed. The first time in, the kid got a chest x-ray (which was negative), a Rapid-Flu nasal wash (which was also negative), and a Rapid-RSV screen (which was also negative). Although the illness was viral, the mom demanded that her son be given an antibiotic. The MD refused. The kid was given Tylenol for a low-grade fever, the family was given a recommendation for an OTC cough suppressant, and the family was sent home with supplemental written discharge instructions in Spanish. She left muttering something in Spanish.

By the way... Who is Ben Dayho?

The second time in, about five hours later, the mother was upset because the kid's fever came back and his cough had not gone away immediately after she gave the kid the OTC cough suppressant; she was also upset that she had to wait to be seen. She was informed that Tylenol can be given every 4 hours, as her previous discharge instructions clearly stated. The MD wrote a scrip for a cough medicine containing phenergan and codeine and the woman was instructed by the MD through a Spanish medical interpreter about how and when to give it. Once again, supplemental written discharge instructions in Spanish regarding the prescription cough medication were provided.

The third time around, about four hours later, they came back. This time, the kid was carried in his dad's(?) arms, while mother stormed angrily into the ER ahead of them. The kid's head was lolling back and forth and his eyes were staring dazedly off into the great whatever.

When questioned, Mother stated that she had given the phenergan/codeine cough medication as prescribed. But when the cough did not go away after a half-hour, she gave him another dose, because the kid's coughing was keeping her awake. A half-hour later, the cough was still there, so Mom gave the kid a third dose. Without a pause, she then accused the MD of writing a prescription for too weak of a dose. Mom found the kid curled up in a ball on the floor in front of the bathroom.

The kid was simply stoned out of his gourd. He turned out fine. Mom, on the other hand, won a complementary chat with the social worker and an expenses-paid referral to CPS by the MD who had seen her all three times and had at last grown weary of Mom's BS.

Wednesday, February 14, 2007

Let Me Re-Phrase That...

Language is the capital that drives the economy of human communication. Each social or professional culture presides over its own unique lexicon. The observer will also note further subdivisions related to slang or specific specialty.

Nurses and physicians often use abbreviated terms among ourselves. We do this for two reasons:

1: It saves time;
2: The other person knows what we are saying (as long as the speaker is not just making something up in order to sound cool, which happens from time to time).

But I was reminded this week about how easy it is to fall into the terminology rut in front of patients, and about how important it is to communicate clearly and understandably with my patients. It was a simple matter, really, and not life-threatening at all; but the misunderstanding between the patient and her nurse (yours truly) might not have happened had I been more careful. And I would not have become fodder for the comic enjoyment of my fellow nurses.

The patient came in during the "dinner rush" (between 6PM and 11PM) complaining of bilateral lower abdominal pain. She was well within childbearing age. She was also suffering from a self-care deficit which was related to her lifestyle choices. She had a poor grasp of basic concepts related to her health and hygeine (namely, bathing). Her ability to communicate her chief complaint and her history was poor. Her education level was poor.

The standard practice related to any woman of childbearing age who presents in the ER with a complaint of lower abdominal pain involves ruling out female disorders such as ovarian cysts, pelvic inflammatory disorders, and so on by means of a pelvic examination. (We also perform other tests and draw blood to rule out other possible differential diagnoses.) In my ER, we have many beds available than are designed to facilitate pelvic exams. Unfortunately, my patient was not on one of them. I finished my nursing assessment of the patient and then called an ER Tech over. Then I spoke the words that set the scene about which I now write.

I told the tech, "The patient needs a pelvic stretcher."

In front of the patient.

The patient's lack of understanding related to my terminology was evidenced by her sitting straight up in bed and bellowing, "THE H*** I DO! YOU AIN'T GONNA STRETCH MY PELVIS!

The following silence was oppressive. I heard a snicker from the nurse's station.

I turned to the patient and calmly explained to her what a pelvic stretcher was. She straightened her blankets, tossed her hair, and said, "Well, alright then."

I had a very hard time summoning the courage to exit the patient's room and walk red-faced to the nurse's desk, where I was greeted by hoots of laughter.

I don't know if this could have been avoided, but it reminds me that I need to be more careful about what I say in front of my patients. Very humbling, indeed.


Friday, February 02, 2007

For Nurses: A Great New Online Forum

I tend to avoid advertising on my blog because I dislike clutter and do not wish to bombard my dear visitors with extra stuff. However, when I see a good thing I like to let my readers know about it.

As a nurse, I look for online forums in which I can connect with other nurses in a professional and collegial atmosphere. I envisioned the ideal nursing forum to be free of clutter, easy to navigate, and without any of the trashy advertising and sexual overtones that are so prevalent on sites such as MySpace (which I detest). I had yet to find that ideal forum and was tired of other nursing sites that seem to have devolved into forums for debate on such merry-go-round issues as whether or not nurses should revert to wearing starched whites. I had essentially given up on my search.

Until now.

Allow me to introduce NurseLinkup, a brand-new online community and forum for nurses. It's free, it's easy to navigate, and it appears to focus on issues and discussions that are driven to enhance nursing knowledge and to strengthen collegial communication among nurses. The site allows for blog posting, internal communications, email, and chat. It also allows for total privacy of information should the nurse so desire. And it is free of charge.

If you are a nurse who is looking for a better way of communicating with other nurses, I invite you to take a look at NurseLinkup for yourself.