When Life Throws You Lemons....

I took care of an unfortunate young man recently who had, to say the least, a sucky year.

Back in January, he began having some intermittent chest pain. A stress test showed some ischemia, so he had an elective heart catheterization.

There is only a 10,000 to 1 chance of having a complication warranting emergent open-heart surgery while having this procedure.

He was the one.

While attempting to deploy a stent into coronary artery, the angio-balloon got caught in the stent. The Cardiologist was unable to deploy the stent, nor remove the catheter.

Although his in-hospital post-operative course was unremarkable, he developed a wound infection a few weeks after discharge.

He followed up, like he should, but the pain in his incision persisted, despite antibiotics.

Eventually, he was re-admitted and put on IV Vancomycin. After a week, he was discharged to home-care with IV antibiotics for 6 weeks.

In late May, he was finally well enough to go back to work, where he was promptly laid off. (Scuttlebutt says the small manufacturing firm couldn't afford the insurance premiums any longer, due to the gentleman medical problems)

Without a job, on unemployment, disillusioned,  and now, depressed, he stopped going to his follow-up appointments.

Soon after, he stopped seeing his friends, kept his family at a distance, and stopped taking his medications.

He went into ventricular tachycardia, which degraded to ventricular fibrillation, and died.

He was only 46.

There are probably a thousand sad stories out there, but this one hit me hard.

I thought I had a tough year.

Some people bitch and moan about how bad things are, well shut up.

It could be worse.

Coumadinization

A physician used that word in his progress notes regarding a patient on Coumadin for PE (pulmonary embolus).

I'd never seen the word, or at least seen it used in  a medical context.

So here I was ready to post some silly definition. So I googled it first, and hell, there's all these websites using the word.

So listen, if you people out there are going to be making up words to use in medical documentation, at least have the common courtesy to let me know.

Thanks.

PS:

In case you were wondering, Warfarinization is out there, too.

A Medical Excuse For Murder?

A recent murder in my area has a lot of medical professionals, well, kinda pissed.
Herbert Lawrence Peck was arrested for shooting and killing his wife after an argument. When police arrived, they found Peck hiding in a closet. The next day, he copped the "my sugar musta dropped" excuse.

I believe the defense will counter with the "liar, liar, pants on fire" gambit.

I wrote defense, meant prosecution.
Lack of caffeine will do that to you.

What Do You See?

I recently had to take my wife, Texette, to the local Urgent Care Center. We were lead to a treatment room and the door was shut.

When the Nurse came in to get a set of vital sign, she swung the door open.

The wood grain on the door made this unusual image.

I *heart* FailBlog

So, Who's The Boss?

This is what can happen when the medical community bends to family pressure:

An elderly lady has been hospitalized for nearly a month due to complications from a severe bout with pneumonia. During her stay, she developed renal failure and proteinuria.

The ever-vigilant family used Dr. Internet to ascertain that a renal biopsy might give them some answers as to why the renal failure occurred.

The Nephrologist disagreed, so the family fired him. The new Nephrologist wasn't to keen on the idea, either.

But the family was persistent, and got what they wanted.

After the procedure, the patient was doing reasonably well...for about an hour.

She had a sudden drop in blood pressure and increase in heart rate. A blood count revealed a drop in hemoglobin from 10 to 6.

Her blood pressure dropped to 60 and she was coded.

During the code, she was intubated, had rapid infusion of blood and blood products, and was placed on vasopressors.

She survived the code, but very nearly died.

I hope her family can forgive themselves.

RT Sing-a-Long: Phlegm

Logical Thinking

These are the thought processes of a male EMT who recognizes the heart attack he is having:

*Don't drive yourself to the Cardiac Center (my facility). It's 15 miles away, and I don't want people to read about the traffic accident caused by the driver with a 'medical condition'.

*Drive yourself to the nearest ER, it's only 5 miles away.

*Don't call 911 from your vehicle, even though the pain, nausea, diaphoresis and dizziness is close to overwhelming you. You don't want to leave your truck on the side of the road.

Lucky for him, and the early morning traffic, he did make it to the ER, was quickly transfered to my facility and got his 99% occluded LAD stented.

The only thing worse than 'man-thinking processes' is 'man-thinking processes' with rationalization.

Reprise: Nailed It!

As can unfortunately occur, "I's has writer's block!"
Not so much writer's block, as lack of blog-worthy material.
But fear not, stupid is as stupid does.
Until then, a blast from the past.


One of my more unusual patients was a 19 year old gentleman who came to the ED with a complaint of 'Injury at Work'.
The young man was helping his father at a construction site with nailing sheetrock. Back in the old days, when I used to help my dad, we used nails and a hammer. Nowadays, nailguns are the norm.
Apparently, this kid had finished putting up a sheet, sat down, and placed the nailgun on his lap....oops!
You guessed it, the gun went off.

The nail went through the shaft of his penis.

Being the only male nurse in the ED that day, I was asked to take his room to save him any further embarrassment. I introduced myself, asked for his back story and then examined his injury. Nothing bad, just a puncture wound through the shaft, no bleeding, and a puncture wound at the left pubis, also no bleeding.
I asked him where the nail was.

Pt: My dad took it out.
Me: Did he just pull it out?
Dad: "snickering"
Pt: No, he had to use pliers.
Dad: "laughing"
Pt: You think I'm gonna be able to use it again, you know....fuck? I'm supposed to go to California in 3 months.
Dad: 'bent over laughing'
Me: Umm. Lets just wait for the Doctor to examine you and we'll go from there.

Damage: Hairline fracture of the pubis, puncture wound of the shaft of the penis
Treatment: Antibiotics and follow up with Ortho as outpatient

Afterwards one of the younger NAs asked me what the odds were of a nail going through his penis. My reply:

His odds were substantially better than most.

It's A Family Affair

I got a transfer from a neighboring hospital to the Telemetry Unit I was working the other day.

The patient had had a heart catheterization and was found to have severe enough disease to require a bypass. (The other hospital does caths, but not interventions)

Ex-Texette works at the 'Other Hospital' in their Cath Lab.

My daughter, JoJo, is doing her clinical rotation on the same Telemetry Unit and was assigned the same patient.

One patient cared for by three members of the same family.

Very cool!

Get Off Your Ass...

I was working on one of our step-down Units recently, a Unit I don't like working because I feel that some of the staff are lazy.

Thanks for proving me right.

As I was getting ready to round on my patients, I heard the distinctive 'beeping' of an IV infusion pump from the opposite side of the Unit. I went ahead and rounded on my peeps.

As I returned to the Nurse's Station, some 15 minutes later, the alarm was still beeping. I decided to check it out, found the room, and corrected the problem (kinked tubing).

I looked at the patient assignment board to see who the nurse was.

There she is, at the Nurse's Desk....on the computer....on Facebook....tending her Farm.

Bitch!

Waste Not, Want Not

Sometimes what appears as a sad case is, well, funny.
I recently cared for what seemed to be a very sad case. A homeless man, who worked a menial position at a large department store, was admitted for possible stroke.
The man, in is early 50's lived in a tent in the wooded area behind the department store. He bathed in the restrooms at his work place, cleaning his clothed in the sink.
Should he need to heed the call of nature while 'home', the nearest tree or bush sufficed.
He spoke intelligently and stated he had attended college 'up north'.
Alcohol had been his downfall, he drank a fifth of vodka every night, not because he was an alcoholic, but to help him sleep. (His 'stroke' was Wernicke-Korsakoff syndrome, secondary to his alcohol consumption.)

And he wasted nothing.

Every little scrap of paper was utilized. He described his abode as a collection of discarded items.
He said he wasted nothing in his tent.

I can think of only one thing that was wasted in his tent.

ED Sing-a-Long: Ballad of the Frequent Flier

Happy Halloween

Happy Halloween, Ortho-Style

Reprise: The Family Doctor

I've had this blog for 2 years now, so I thought I'd put up an early post, just for the hell of it:

When we think of the family doctor, we have images of the mildly-portly, elderly, wise-looking Marcus Welbish MD. Or at least the quack in the Forrest Gump movie, "His legs is strong, but his back is crooked as a politician." Of course in the ED, we recognize the family doctor just as easily.

No, no, not the MD from the family practice across the street, I'm talking about the family member that not only knows more than the ED doctor, but knows about every illness, surgical intervention and medication of every single family member going back 3 generations.

Yes, I am talking about the dreaded Family Doctor, whom henceforth shall be called Dr.Kia (Know-It-All).

Had a lady show up at the registration desk yesterday requesting her spouse be registered immediately:
"He's having a heart attack!"
"Where's your husband?"
"He's on his way, hurry up. We can't waste time with this registration crap!"
"Is he coming in an ambulance?"
"No, he's driving."

That's right, drove himself while having a 'heart attack.'

So he ambles in, we get him registered, much to the ire of Dr. Kia. She plops him in a wheelchair, (Paralysis Point strikes again!) and into a treatment room we go.

I walk into the treatment room as the patient is wheeled in and with the help of the CNA and charge nurse, we quickly place him in a gown, hook up the monitor and get an EKG. Hell, for all we know he might be having an MI (not even close). Meanwhile, Dr. Kia starts writing everything down, VS, names, times. Dr. Kia's PA, the patient's sister, is on her cell phone calling the patient's cardiologist in Durham. That's right, some 250 miles away. The ED doc hasn't even walked in the room and Dr. Kia is already arranging a transfer.

ED doc walks in,
"Hello, I'm Dr. ED. What seems to be the problem?"
"He's having a heart attack. He had the same look when he had his heart attack 3 years ago."
"He 'looks' like he's having a heart attack?"
"Yes, I already consulted his cardiologist in Durham and told him he's having a heart attack. He needs to be transferred ASAP."

Off in a corner of the room, Kia PA is frantically dialing on her cell phone, notifying all near and far of the life and death struggle of their beloved family member.

After initial assessment and the determination that no REAL emergency exist, the doc orders some meds and labs. Dr. Kia is not impressed.

"He's had a nitroglycerin already today. Why are you giving him more? And more aspirin? He takes a baby aspirin every day!"
"I don't know," I said, "I've never done this before."

If that wasn't enough, Dr. Kia questioned us as to why we would give a patient with angina, morphine.

"Doesn't it concern you that you may be masking the pain of his heart attack?"
"No," I said, "That's why we have that TV screen with the squiggly lines connected to him. If he starts having a heart attack, the TV says, 'heart attack in progress'."

It also concerned Dr. Kia why we didn't just go ahead and transfer him NOW.
"We haven't gotten all the lab results back yet," I said, "and besides, Durham hasn't called us with a bed assignment."

"It's a 3 hour drive. They should have a room by the time he gets there."

Incidentally, the patient had been 'looking like he's having a heart attack' for 3 days.

A Different Kind Of Pain

The ED night shift has their own pain scale:

ED Sing-a-Long: Paralysis Point

Paralysis Point:
Every ED has one.

Anal-ogy, Part Deux

Some people's religious beliefs can interfere with even the most basic care. I had that problem last week.

I was caring for an elderly patient whose dutiful wife never left the bedside, having taken residence in the room. I had been told in report that their religious convictions forbade a woman to touch him. Doing so equated to intimate relations, at least in the eyes of the spouse. The patient, well, he was too sick to care.

Attempts to conform to her requests were fruitless: There simply were not sufficient male assistance available, especially on the night shift. Efforts were made, but the spouse made demands beyond the capabilities of the staff.

As it were, I was assigned to his care, simply due to the fact that I have a penis.

At one point during the day, the patient soiled himself. I asked the nurse assistant to, well assist. The spouse forbade it.

I attempted to find help from a fellow penis-gendered employee, but one would not be immediately available, and the spouse wanted her husband cleaned immediately.

The solution: The spouse would turn and hold, I would clean and wipe.

It was during this 'our time' moment that the spouse decided to explain her and her husband's philosophy regarding touch, sex and intimacy.

All the while I was wiping his ass.

I began to wonder if my actions constituted anal sex.

Luckily, the patient let out a large watery stool and the thought was lost.

A Little Goes A Long Way

I had the pleasure of caring for a mid-eighties year old gentleman the other day. He was sitting up in a recliner awaiting his morning dose of slop, when I eyed these mini-bottles on his bedside table:

The bottle on the right is Tequila Rose Java Creme Liqueur (15% alcohol content), the one on the left is Malibu Mango Rum (21% alcohol content). The night nurse had mentioned them and told me she had asked the patient not to drink them, due to the medication he was on.

I asked him where they came from.

"A friend brought them."

I went to pick one of them up...empty. So was the other.

"You drink these?"

"No one said nuthin', and I didn't see no harm."

I think he needs to grab one of those batteries off the bedside table.

Update: I'm Pissed

I recently had a post regarding a nurse who allegedly diverted narcotics. I worked the same unit not too long ago and the nurse was marked off the schedule for it's remaining 5 week course.

I asked the Administrative Director very discreetly if things were okay, she replied 'things were taken care of.'

The Unit also has a memo up: Seems a full-time position is available.

I guess I can put the Vaseline away.

ED Sing-a-Long: Burn Out Blues

Medical Acronyms

Folks in the medical field love acronyms.
We got 'em for just about anything ranging from diseases (CAD, PE, COPD) to surgical procedures (CABG, TURP, TVH) to lab and x-rays tests (BUN, MRI, US) to patient descriptions (GOMER, PIA, CTD).

Last week I had a patient, whom through a series of unfortunate events, had gone for 7 days without a bowel movement. Why it had not been addressed is another story, but I notified the Medical Doctor regarding this when he came to examine her.
His main concern was ileus, so he ordered an abdominal series.

In his progress notes he wrote:
'No BM for several days, will get abdominal series to rule out ileus vs (+)FOS'

That's Dedication, Part Deux

I posted about a patient's need for a cigarette, but he was confused.

This dood wasn't.

He had come in for an elective outpatient laparoscopic procedure. Unfortunately, the hour long procedure went for 4 hours as the the surgeon encountered unforseen scar tissue.

Still, the patient was expected to be discharged home the same day, but he was in excruciating pain, despite large doses of IV Morphine, Demerol and Fentanyl.

So the surgeon opted for overnight admission for pain control: PCA Dilaudid.

The patient wasn't in the room for 15 minutes when his spouse came to the desk asking if she could take him outside for a cigarette.

Of course we said no: No smoking on hospital property. But this isn't a prison, we can't stop you, but we can not provide a wheelchair.

So clutching his abdomen, he shuffled out his of room, making his way towards the elevator.

Suddenly, getting his Dilaudid drip set up took a backseat to everything, including my lunch break.

Anal-ogy

My facility, as well as many other, employs staff from varying backgrounds. We have several physicians from India, the Philippines, Africa, etc. Although they speak English, at least well enough to be understood, they have some difficulty with our colloquialisms.

When I work, I like to stay organized. I stake out my territory at the desk, I line up my charts in order.

Yes, I know, but it helps me work more efficiently.

So anyway, one of our foreign doctors, a sweet lady from Africa, came to desk looking for a chart, saw my little display and asked who did it.

I replied, "Those are mine, I guess you could say I'm a little anal about my charts."

She said, "That's OK, I like anal, I like anal better than anything."

PSA: Hygiene

To the twenty year old chickie who has made her fourth visit to the ER in 3 months with a complaint of abdominal pain:

You have a UTI, a bladder infection.

#1: Tell your scummy boyfriend to clean his fricking wacker or wear a condom

#2: Front-to-back, you idiot, wipe front-to-back

'Nothing Runs Like A Deere'

To the drunk idiot the police brought to our ED the other night:

The slogan John Deere likes to tout has nothing to do with it's tractor's ability to elude the police, but rather their ability to work hard and long.

Driving your tractor in circles to evade capture doesn't work either.

ED Sing-a-Long: Narcan

Special thanks to EMTB2RN for the suggestion.

Jury Awards Man $9 Million After ED Treatment Leave 'Permanent' Scars

I saw this headline and thought about Whitecoat's insistance that the ER should be called the ED.

Maybe we should stick with ER, at least for now.

I'm Pissed

I know that drug abuse runs rampant in the Medical Field: nurses, doctors, hell even the housekeepers for all I know, and I have known.

Just keep me out of it.

So I go to get some pain medication out of the Pyxis for my patient... specifically IV Dilaudid.
Now for those that don't know, or haven't noticed, when you log into Pyxis, chose a patient and see their list of medications, you can also see the last time that medication was accessed for that patient.
Low and behold, the patient had been accessed not 10 minutes before by another nurse and Dilaudid was removed.
The nurse that the Pyxis says accessed that patient and medication had just going off shift.
I asked her if she gave anything to the patient, she denied it, as did the other nurse on duty. The off-shift nurse then went home.
The patient denied being given anything.

FUCK!

I showed the entry to the Charge Nurse, then to the Administrative Director.
I was told not to worry about it, and that I shouldn't fill out an incident/occurrence report (WTF). She would take care of it.

I know I did as I should: I went up the chain of command, but no paper trail? I don't have definitive proof, I mean, I didn't actually see her take the vial, but should I report it to the Board of Nursing?
Will the hospital find reason to reprimand me if I do report it to the Board?

DOUBLE FUCK!

Something tells me that either way, I'm a gonna need some Vaseline.

Zombieland

Must see.

That is all.