If you're in "florid" pulmonary edema with a high blood pressure, sats in the 60s on room air, respiratory rate in the 40s, and rales bilaterally, this lovely nurse hits the Pyxis and retrieves a nitro drip and places it right up in the room WITH a carrier primed and ready for patient arrival via EMS. Like 'Hi, how are you? Oh, you're in florid pulmonary edema.' WHAM! Nitro drip.
I mean, dude, who DOESN'T order a nitro drip in this situation?
I'll give you the answer to that question: Dr. Controlfreak.
Initial BP was 230/118. Respiratory was setting up the CPAP. Patient's lungs sounded like a construction zone. "Hey, should I plug in my nitro drip?"
No, start a nipride drip.
NIPRIDE DRIP? I haven't hung that since 1985 back when we used to give it to subarachnoid patients. He only ordered that because I thought ahead and had the appropriate medication all ready to go.
Jerk.
Monday, June 30, 2008
Sunday, June 29, 2008
Twilight Zone
We were in the midst of an epic code. Cardiorespiratory arrest with every imaginable heart rhythm, some perfusing, some not, going back and forth..drips, meds, code meds, more drips, lines going bad with no veins, ABGs, tubes, OG tube, foley, drips, someone check a femoral, no femoral pulse, resume CPR, charging, BPs on the thigh, central line, a-line, suction...blah blah blah for like 2 hours.
So, code, code, code, right?
I had two other patients. At some point, they'd both been waiting for dispositions for more than two hours. This coding dude was so unstable that the doctor really couldn't leave the room. He'd get a perfusing rhythm then go back to a PEA or some ugly, post-arrest wide-complex crap or whatever and we'd need to start over again.
Patient 1: "Oh, I understand. I can wait. The doctor has more important things to do than deal with me. I can hear that there's a lot going on across the hall. I'll just try to catch a nap if you don't mind."
No, I don't mind.
Patient 2: "It's okay, I'm tired and want to go home, but I'm willing to wait. The doctor needs to be with that guy."
They never complained about having to wait an additional two hours for discharge and showed empathy toward another patient behind some curtain. Twilight Zone.
So, code, code, code, right?
I had two other patients. At some point, they'd both been waiting for dispositions for more than two hours. This coding dude was so unstable that the doctor really couldn't leave the room. He'd get a perfusing rhythm then go back to a PEA or some ugly, post-arrest wide-complex crap or whatever and we'd need to start over again.
Patient 1: "Oh, I understand. I can wait. The doctor has more important things to do than deal with me. I can hear that there's a lot going on across the hall. I'll just try to catch a nap if you don't mind."
No, I don't mind.
Patient 2: "It's okay, I'm tired and want to go home, but I'm willing to wait. The doctor needs to be with that guy."
They never complained about having to wait an additional two hours for discharge and showed empathy toward another patient behind some curtain. Twilight Zone.
Saturday, June 28, 2008
Illiteracy
A patient's sign-in sheet says the following:
Proleb Bithing
No clue what that meant, but the [non-intoxicated, non-immigrant] patient informed me he wrote "problem breathing." If that's how well you spell, there is probably little hope to get out of the homeless shelter.
Walking by the windows
I was sitting at the front desk, the first reprieve of the night, when I see a guy walking towards the front door being supported somewhat by a teenage son. I saw the guy from 50 feet away through a window for approximately two or three seconds before I said:
"THAT guy is having an MI. I'm going to wheel him right back."
Ha ha ha, the front desk people said. Maybe he just twisted his ankle or something. Um. No people. I'm not kidding.
Who was right? Me. So there.
"THAT guy is having an MI. I'm going to wheel him right back."
Ha ha ha, the front desk people said. Maybe he just twisted his ankle or something. Um. No people. I'm not kidding.
Who was right? Me. So there.
Thursday, June 26, 2008
NOOOOOOOOOOOOOOOOOOOOOOOOOOO!!
Not that anyone cares, but it's 3:40 am (as we all know Nurse K is always awake from 0100-0500 no matter what shift she's on). So, why not start demoing the bathroom? Now, keep in mind that there was impressively butt-ugly floor-to-ceiling wainscoting covering up...something and everything.
The moment of truth...at 3:40 am on June 26, I finally found out what is under the bathroom wainscoting. I've been wondering this for four long years. Is there plaster? Sheetrock? Nothing? Subway tiles? Dead bodies? Who knows. Let's find out.
Oh look, it seems the wait has been worth it. We have water-stained, non-taped sheetrock juxtaposed with some bowel-obstruction brown-painted plaster with a ginormous hole in it. Notably, the sheetrock is on two completely different levels so if I decided to tape them together, there would not be a seam, but a really bitching shelf on which I could place some yet-to-be-determined collection of knick knacks. This is just fucking great.
I have also included a close-up of the bowel-obstruction brown plaster section on the left. Some ass apparently removed some perfectly good subway tiles. My house has be architecturally violated more times than I can count. Poor house probably has some sort of house PTSD variant.
On the plaster, there also appears to be some sort of psychedelic, upside-down bright-blue 6-week embryo looking at an equally-as-psychedelic bright-purple 6-week embryo. Wonder what that's about.
Three more tragic walls to go...
Wednesday, June 25, 2008
Thinking your way through a problem
A few of our ancillary staff members in my department are taking their nursing board exam this year and have been asking me for tips or hints on how to pass it. If you've taken the boards anytime recently, you'll remember being asked a question about a disease you've never heard of or could only barely associate with a factoid or two (oh, I think that's a childhood disease or that sounds like a gynecological problem).
What I always say is something to the effect of know your stuff and do your practice questions, but use your reasoning to try to figure out the best solution when faced with a question on a topic with which you're not familiar. Don't give up because you don't think you know enough about the question to figure it out. Sounds obvious, but if you interned in adult neurology and was a secretary on an adult neurology unit, a question about an orchipexy for cryptorchidism done on a child may freak you out and cause you do eenie-meenie mynie moe or skip the question entirely. Hm, I think orchitis has to do with the crotocologic area of a man, and that sounds like orchipexy...
Now, imagine you know almost nothing about any disease process let alone post-op management of an orchiopexy and have never really gone to the doctor except for the occasional sore throat or cough. Now what?
It's pretty certain you will quickly give up on answering the NCLEX nursing board questions. But wait! There is a question on what to do about hypertension here. I think that means high blood pressure. My uncle had that and he had a heart attack, so it must be serious. The patient should be told to go to the hospital obviously because he might have a heart attack like my uncle.
Hm. Now there is a question about someone that hurt her knee. She fell on it and it hurts a bit, but is able to walk. I know people who have fallen and broke their bones, so she should go to the hospital for that too because everyone who has a broken bone should go to the hospital. There is something here about ice and making an appointment if it does not improve, but who wants to do that if it's broken?
My 80-year-old Grandma had pneumonia, and so I better get checked out for that now that I've been coughing for a day. I mean, Grandma coughed a lot with that pneumonia, and I don't want to get that.
You get the idea. I think many of my patients are using nursing board exam reasoning skills reserved only for the most difficult of problems on more routine issues. A simple class on MS causes an improvement in MS outcomes and a reduced utilization of services. Diabetes education does the same. Telling a patient that there are clinics that will see you on a sliding fee starting at $20 and giving them a map and phone number to that clinic keeps them out of the ER. Telling a patient to call this 1-800 number to apply for help with their prescription drug costs causes them to fill their prescriptions. Telling a patient that it's okay to tell the doctor they can't afford their pills causes them to get a lower-cost treatment they can afford rather than give up because they think there is nothing else out there for them.
If they don't know, they give up. Or come to the ER because everyone they know gave up too.
What I always say is something to the effect of know your stuff and do your practice questions, but use your reasoning to try to figure out the best solution when faced with a question on a topic with which you're not familiar. Don't give up because you don't think you know enough about the question to figure it out. Sounds obvious, but if you interned in adult neurology and was a secretary on an adult neurology unit, a question about an orchipexy for cryptorchidism done on a child may freak you out and cause you do eenie-meenie mynie moe or skip the question entirely. Hm, I think orchitis has to do with the crotocologic area of a man, and that sounds like orchipexy...
Now, imagine you know almost nothing about any disease process let alone post-op management of an orchiopexy and have never really gone to the doctor except for the occasional sore throat or cough. Now what?
It's pretty certain you will quickly give up on answering the NCLEX nursing board questions. But wait! There is a question on what to do about hypertension here. I think that means high blood pressure. My uncle had that and he had a heart attack, so it must be serious. The patient should be told to go to the hospital obviously because he might have a heart attack like my uncle.
Hm. Now there is a question about someone that hurt her knee. She fell on it and it hurts a bit, but is able to walk. I know people who have fallen and broke their bones, so she should go to the hospital for that too because everyone who has a broken bone should go to the hospital. There is something here about ice and making an appointment if it does not improve, but who wants to do that if it's broken?
My 80-year-old Grandma had pneumonia, and so I better get checked out for that now that I've been coughing for a day. I mean, Grandma coughed a lot with that pneumonia, and I don't want to get that.
You get the idea. I think many of my patients are using nursing board exam reasoning skills reserved only for the most difficult of problems on more routine issues. A simple class on MS causes an improvement in MS outcomes and a reduced utilization of services. Diabetes education does the same. Telling a patient that there are clinics that will see you on a sliding fee starting at $20 and giving them a map and phone number to that clinic keeps them out of the ER. Telling a patient to call this 1-800 number to apply for help with their prescription drug costs causes them to fill their prescriptions. Telling a patient that it's okay to tell the doctor they can't afford their pills causes them to get a lower-cost treatment they can afford rather than give up because they think there is nothing else out there for them.
If they don't know, they give up. Or come to the ER because everyone they know gave up too.
Monday, June 23, 2008
Angina Bonanza!
Buy one angina patient, get a second at 50% off with an in-store coupon. Today only! Long lines anticipated, beat the rush by coming at symptom onset!
I mean, dude, seriously. Here's the deal. For some reason, today's theme was resolved angina. Episode of severe chest pain earlier in the day with risk factors, asymptomatic on arrival. Chest pain only with exertion, asymptomatic in the lobby "because I'm just sitting here." With all the monitored beds full, I kept getting patient after patient like this, not counting the active chest paineurs. Normally, like on nights, I'd just wheel them back after the full triage assessment and be done with it. However, when the entire ER, the hall, and lobby are full, one must be more miserly with beds. If you put all the resolved chest pains back there right away, your acute MI will have to be dealt with in the hallway or beds will need to be shuffled.
We have no capability to do triage-based EKGs unless, for some reason, the patient doesn't mind stripping in front of everyone because there are no exam rooms, only a desk, so that choice is out. I was trying to do the "screening" EKGs in Fast Track for very atypical cases of active chest pain (heartburn with lightheadedness in a healthy 69-year-old lady, for instance, who'd had both before separately), but no one wanted to send them back to the lobby, so doing a screening EKG is a de-facto triage to Fast Track until a regular bed clears up.
I was telling Granma Ethel and Grandpa John to inform me if their symptoms came back and described what symptoms to report. I also got the charge involved to see if people could be shuffled to accommodate them, but some waited (still asymptomatically) up to 45 minutes. So, basically, here's my opinion poll for today:
I mean, dude, seriously. Here's the deal. For some reason, today's theme was resolved angina. Episode of severe chest pain earlier in the day with risk factors, asymptomatic on arrival. Chest pain only with exertion, asymptomatic in the lobby "because I'm just sitting here." With all the monitored beds full, I kept getting patient after patient like this, not counting the active chest paineurs. Normally, like on nights, I'd just wheel them back after the full triage assessment and be done with it. However, when the entire ER, the hall, and lobby are full, one must be more miserly with beds. If you put all the resolved chest pains back there right away, your acute MI will have to be dealt with in the hallway or beds will need to be shuffled.
We have no capability to do triage-based EKGs unless, for some reason, the patient doesn't mind stripping in front of everyone because there are no exam rooms, only a desk, so that choice is out. I was trying to do the "screening" EKGs in Fast Track for very atypical cases of active chest pain (heartburn with lightheadedness in a healthy 69-year-old lady, for instance, who'd had both before separately), but no one wanted to send them back to the lobby, so doing a screening EKG is a de-facto triage to Fast Track until a regular bed clears up.
I was telling Granma Ethel and Grandpa John to inform me if their symptoms came back and described what symptoms to report. I also got the charge involved to see if people could be shuffled to accommodate them, but some waited (still asymptomatically) up to 45 minutes. So, basically, here's my opinion poll for today:
These currently asyptomatic people with pretty clear-cut worsening exertional angina and risk factors should be handled how in the context of no available monitored beds? Is no symptoms at rest, but worsening chest pain and shortness of breath, for instance, with "nearly any walking" considered "stable" enough to chill in the lobby for an hour or whatever? Consider that there are really four choices: (1) Immediate attention/wheeling them back to a room and shouting out that someone needs to be kicked out---use wisely (2) A triage score of "3" where you allow them to wait in the lobby for hours with the caveat of "tell me if it comes back" (3) The screening EKG in Fast Track and let someone else decide what to do, even though no one would ever have the balls to send an old guy with exertional angina back to the lobby and (4) Giving them the same triage score as regular chest paineur ("2") but leaving them in the lobby as a signal to the people in the back that I'm concerned---this may cause them to wait like 45 minutes -1 hr 20 minutes.
Oh, and I'll let you guess what happened. While I'm on the phone frantically trying to figure out where to put all these old dudes with angina and debilitating shortness of breath with "walking to the bathroom", someone comes up and cusses me out saying they're going to "sue the shit" out of the hospital for not giving him a room right away for his chronic abdominal pain, which gave me the opportunity to write "sue the shit out of the hospital" in the patient's chart in quotes. There's always an opportunity to get a little satisfaction out of one's job, no matter what the situation. "Okay, sir, I will chart your intention to sue the hospital if you didn't get bumped ahead of the rest of these people, and that your vital signs are stable, but I will not be bumping you ahead."
Sunday, June 22, 2008
Day/night rotating shift
Me at work this week: "I should just come into work every night from 0100-0500 when I work days because I'm up anyway."
So, it's 4:17 am. How are YOU GUYS doing? I'm too exhausted to do anything, yet can't fall asleep.
Again.
I'm kind of jealous of that lady with the pill on her tongue. Hey, could you help a girl out?!
So, it's 4:17 am. How are YOU GUYS doing? I'm too exhausted to do anything, yet can't fall asleep.
Again.
I'm kind of jealous of that lady with the pill on her tongue. Hey, could you help a girl out?!
Friday, June 20, 2008
Government-run insurance
A patient with a military insurance plan calls up and says that she had a foreign body removed from her eye and was instructed to see an eye doctor the day after discharge, but she made the mistake of calling ahead to her insurance company to see where to go, how much it would cost, etc. She found out the following:
The insurance will pay nothing unless the ER doctor who referred her to the clinic fills out Form X and faxes it to the claims office. It will then take Y days for it to be reviewed and approved.
"But this was an emergency visit, and I can't wait that many days for a review. My eye is patched up, and I need an exam. He is not my regular doctor anyway."
"It doesn't matter, you must have the emergency doctor sign the form and fax it back."
I told her to see if they'd accept the discharge instructions with the referral information on it. Nope, she said, she already tried that. The form had to filled out.
She had apparently been calling three times or so a day for the previous two days to see if the doctor was working, and, as per our policy, no one would disclose to her if he was working that shift or not. Finally, after two days of trying, she got me, and I tried to help her because she sounded like someone who had just been dicked over by the government and nothing more. Obviously, ER doctors don't usually fill out referral forms, but I said to fax the form to our fax machine, and I'd give it to the doctor to sign. I figured he wouldn't care. She said, great, she would go to an office supply store and fax the form.
By the time the form arrived, the doctor was gone for the day.
This poor girl had already gone a week with no eye exam. Maybe he'll sign the form next week, maybe not.
The insurance will pay nothing unless the ER doctor who referred her to the clinic fills out Form X and faxes it to the claims office. It will then take Y days for it to be reviewed and approved.
"But this was an emergency visit, and I can't wait that many days for a review. My eye is patched up, and I need an exam. He is not my regular doctor anyway."
"It doesn't matter, you must have the emergency doctor sign the form and fax it back."
I told her to see if they'd accept the discharge instructions with the referral information on it. Nope, she said, she already tried that. The form had to filled out.
She had apparently been calling three times or so a day for the previous two days to see if the doctor was working, and, as per our policy, no one would disclose to her if he was working that shift or not. Finally, after two days of trying, she got me, and I tried to help her because she sounded like someone who had just been dicked over by the government and nothing more. Obviously, ER doctors don't usually fill out referral forms, but I said to fax the form to our fax machine, and I'd give it to the doctor to sign. I figured he wouldn't care. She said, great, she would go to an office supply store and fax the form.
By the time the form arrived, the doctor was gone for the day.
This poor girl had already gone a week with no eye exam. Maybe he'll sign the form next week, maybe not.
Thursday, June 19, 2008
Emergent chief complaint of the day
45F: "Having sex felt different last night."
Painful?
Nope.
Just. Different.
Painful?
Nope.
Just. Different.
That's not the point
Patient: I'm new in town and can't get into a PMD nor a pain clinic for 2 weeks and 1 month respectively, so I need 18 Percocets, 16 methodone, and 20 flexeril to get me until then.
NP: I'm sorry, I don't refill controlled-substance prescriptions for more than two days. Since you've never been here before, I can give you two days' worth.
**Later**
Patient: I wrote out how many tabs I needed so he will be able to give me the whole week's worth. Here is a list! Can you give him the list and see if he'll give me enough for the whole week? He can call my doctor's office and verify my appointment if he wants! I'm not lying!
Me: Ma'am, sorry, but he does not just give out as many tablets of a controlled substance as you ask for just because you ask for it. Percocet and methadone are drugs with a high abuse potential, and that's just not something he does.
Patient: Well, why not? That's how many I need.
Me: Well, many people use the ER to get narcotics to take recreationally or sell for profit, so he limits it to two days maximum if he believes you, no matter who you are.
Patient: Well that's too bad that I have to suffer because people are abusing the ER for their drug habits!
Me: Ma'am, I'm sorry, but that's not the point. The ER is not the place for routine prescription refills no matter what.
NP: I'm sorry, I don't refill controlled-substance prescriptions for more than two days. Since you've never been here before, I can give you two days' worth.
**Later**
Patient: I wrote out how many tabs I needed so he will be able to give me the whole week's worth. Here is a list! Can you give him the list and see if he'll give me enough for the whole week? He can call my doctor's office and verify my appointment if he wants! I'm not lying!
Me: Ma'am, sorry, but he does not just give out as many tablets of a controlled substance as you ask for just because you ask for it. Percocet and methadone are drugs with a high abuse potential, and that's just not something he does.
Patient: Well, why not? That's how many I need.
Me: Well, many people use the ER to get narcotics to take recreationally or sell for profit, so he limits it to two days maximum if he believes you, no matter who you are.
Patient: Well that's too bad that I have to suffer because people are abusing the ER for their drug habits!
Me: Ma'am, I'm sorry, but that's not the point. The ER is not the place for routine prescription refills no matter what.
Wednesday, June 18, 2008
Triage
Patient with PTSD [hyperventilating and yelling]: FUCK! Take it off! It's hurting me! You're hurting me!
Me: Ma'am, that's just the blood pressure cuff. It'll squeeze a bit, but that's it. We have to check vital signs on every patient.
Patient: DON'T YOU TREAT ME LIKE A PATIENT, BITCH!
Me: Sorry ma'am, but you ARE a patient. I have to take your vitals. That is my job.
Notably, this patient was not on Chantix, but was still completely out-of-this-world crayzee. Gee, I wonder how that could be? Maybe it was the PTSD.
Me: Ma'am, that's just the blood pressure cuff. It'll squeeze a bit, but that's it. We have to check vital signs on every patient.
Patient: DON'T YOU TREAT ME LIKE A PATIENT, BITCH!
Me: Sorry ma'am, but you ARE a patient. I have to take your vitals. That is my job.
Notably, this patient was not on Chantix, but was still completely out-of-this-world crayzee. Gee, I wonder how that could be? Maybe it was the PTSD.
Chantix in PTSD
Dude, seriously. If you compare a study to the Tuskegee syphilis study, you better have some mind-blowing evidence of unethical withholding of a decidedly curative treatment for something in study participants despite the public routinely being given said treatment.
Problem is...Chantix IS the most effective anti-smoking treatment out there. So, withholding Chantix from PTSD sufferers because of a fear of a small chance of psychological side-effects would be like Tuskegee far more than giving them the most effective treatment would be.
Smoking is associated with hundreds of thousands of preventable deaths each year, and many of these people I see in the ER on a daily basis. Many can't quit on their own for any significant length of time. Do you want PTSD sufferers to be among those I see with COPD or not? Should doctors say "he's too crayzee to try the effective treatment for smoking, so he should just go cold turkey"?
Should the side effects have been disclosed? Sure. They were after one dude flipped out. End of controversy. Anyone who wants to drop out is more than welcome.
Don't compare studies to Tuskegee if you want me to not be pissed. It's all political spin that's nauseating and annoying. Tuskegee was clearly unethical; giving vets a chance to stop smoking is not.
Problem is...Chantix IS the most effective anti-smoking treatment out there. So, withholding Chantix from PTSD sufferers because of a fear of a small chance of psychological side-effects would be like Tuskegee far more than giving them the most effective treatment would be.
Smoking is associated with hundreds of thousands of preventable deaths each year, and many of these people I see in the ER on a daily basis. Many can't quit on their own for any significant length of time. Do you want PTSD sufferers to be among those I see with COPD or not? Should doctors say "he's too crayzee to try the effective treatment for smoking, so he should just go cold turkey"?
Should the side effects have been disclosed? Sure. They were after one dude flipped out. End of controversy. Anyone who wants to drop out is more than welcome.
Don't compare studies to Tuskegee if you want me to not be pissed. It's all political spin that's nauseating and annoying. Tuskegee was clearly unethical; giving vets a chance to stop smoking is not.
Monday, June 16, 2008
General impression
Most H&Ps offer some sort of kind comment toward the ill such as "pleasant elderly female in no acute distress" or "pleasant, morbidly-obese gentleman" or "pleasant, frail elderly male" or "pleasantly-confused elderly female in no acute distress" or "pleasant, chronically-ill female who appears older than stated age".
Basically, everyone is pleasant, which is at odds with most of my patient assessments, but whatever.
Discovered in a patient's chart recently:
Basically, everyone is pleasant, which is at odds with most of my patient assessments, but whatever.
Discovered in a patient's chart recently:
Unkempt, uncooperative, obnoxious male in no acute distress.
At least someone feels the need to tell the truth in the chart.
Treat the patient!
Today, I went to my yearly, I mean, once-every-five-year gyno exam. As per my usual SUPASTAH time managment skillz, I went to the gyno appointment right after my night shift in one of the hospital-affiliated clinics. I was feeling pretty okay at work, but noticed that I was lightheaded every once in awhile, no big deal.
LPN @ Gyno Clinic: [Bugs out eyes after doing manual blood pressure] You're 84/50 you know.
Me: Yeah, I saw.
LPN: You are normally low like that?
Me: Well, actually, I'm normally in the 90s or low 100s, but remember...treat the patient, not the numbers! I'm not tachycardic, losing blood, nor febrile! My body is just trying to get me to pass out so I'll sleep....
For a couple minutes, I had this awful fear of being one of those people the clinic sends to the ER (ie my work) for a BS one-off reading. No thanks. Signing out AMA from your own ER is somewhat tacky.
LPN @ Gyno Clinic: [Bugs out eyes after doing manual blood pressure] You're 84/50 you know.
Me: Yeah, I saw.
LPN: You are normally low like that?
Me: Well, actually, I'm normally in the 90s or low 100s, but remember...treat the patient, not the numbers! I'm not tachycardic, losing blood, nor febrile! My body is just trying to get me to pass out so I'll sleep....
For a couple minutes, I had this awful fear of being one of those people the clinic sends to the ER (ie my work) for a BS one-off reading. No thanks. Signing out AMA from your own ER is somewhat tacky.
Sunday, June 15, 2008
Bowl
Chief Complaint: "It feels like there is a bowl on my head and one of my toes is tingly."
It's like some of these people show up at odd hours of the night JUST to make me laugh.
It's like some of these people show up at odd hours of the night JUST to make me laugh.
Saturday, June 14, 2008
BOTH!
Me: So, you used alcohol tonight.
Him: Yeah, you can still smell it?
Me: Um. Yeah. What else did you do last night?
Him: Well, I did both!
Me: Both?
Him: Yeah, both. You stupid or somethin?
Me: Oxycontin and adderall? Ecstasy and coke? Meth and heroin? Boys AND girls?
Him: NO, I DRANK AND SMOKED SOME CRACK!
Me: Okay, both. Gotcha.
Him: Yeah, you can still smell it?
Me: Um. Yeah. What else did you do last night?
Him: Well, I did both!
Me: Both?
Him: Yeah, both. You stupid or somethin?
Me: Oxycontin and adderall? Ecstasy and coke? Meth and heroin? Boys AND girls?
Him: NO, I DRANK AND SMOKED SOME CRACK!
Me: Okay, both. Gotcha.
Parasites and depression
As I was writing the article below on the crayzee idea of giving naturopaths admitting privileges and whatnot, I was reminded of the plight of my ex-husband's friend "John".
John was a successful businessman, a sales manager, and was an all-around okay dude to hang around. At some point, John sort of disappeared off the radar, hung around at home a lot, turned down offers to go out, saying he didn't feel like it.
After a few months of this, we went over there to find John in what amounted to a serious depression. He wasn't eating very much, had lost a ton of weight, said he was crying a lot and didn't know why, etc, etc. His mother had moved in with him and said she was having to do things like do his laundry because he would just wear dirty clothes and not even bother to take a shower a lot of the time. He was taking a lot of time off of work and just laying around the house sleeping. She asked us to try to convince him to get help, that the doctor he was seeing wasn't helping him, that he'd been getting worse.
So, I ask John if he was getting help for this stuff. Yeah, he was seeing someone a friend had recommended. Okay, what were you diagnosed with? Well, they said I had parasites in my brain and that's why I was acting this way.
Parasites?
Yeah, parasites.
How do you know you have parasites?
Well, that's what she said it was, that my symptoms are caused by parasites, and I've been treating them so I can get better.
Despite the medical-sounding diagnosis of "parasites", it turned out he was going to a "natural" doctor. Obviously, I told him to talk to a doctor-doctor, but he was insistent on getting treated for the parasites that the woman had deluded him into thinking were causing his rather classic depression.
So, days or weeks later, I hear from my then-husband that John's work said he either had to take a medical leave of absence and get treated for his newfound troubles with alcohol or be terminated. Apparently, he'd pretty much stopped going to work entirely and just sat at home drinking.
So, basically, this 'natural' doctor took his money, made him, most likely highly-suggestible due to his desperation, depression, and embarrassment, think there were things crawling around in his head making him act the way he was. His depression went untreated and he turned to alcohol to treat it, nearly causing him to lose his job (he finally did lose his job the day after 9/11 in a "cost-saving" layoff, or, in other words, let's get rid of the crayzee guy and blame it on 9/11).
This is a case where a patient, who'd followed the recommendation of a "friend", was harmed by a 'natural' doctor (not sure if it was a naturopath, but some naturopaths endorse parasites as causing depression, schizophrenia, and even diabetes, at least on the Internet).
If I'd have been a nurse at the time with a little more knowledge and not a layperson myself, I'd have probably reported this "natural" doctor as practicing medicine without a license. I mean, dude, a parasite is a real thing, and telling someone their symptoms are caused by a parasite is arriving at a medical diagnosis, even if it is based on nothing-in-particular. Toxoplasmosis is a parasitic infection that can theoretically cause behavioral changes, so the concept is not so outlandish as to make it patently unbelievable and outside the realm of practicing medicine without a license.
If someone who was "licensed" and called herself a "doctor" told you that your symptoms were due to parasites in the brain and the treatment was XYZ, would you believe her? Probably. It's likely what John wanted to hear anyway---that he wasn't just some guy who had emotional problems in need of an anti-depressant and therapy, but an unfortunate, unwitting host for a curable parasite infection.
John was a successful businessman, a sales manager, and was an all-around okay dude to hang around. At some point, John sort of disappeared off the radar, hung around at home a lot, turned down offers to go out, saying he didn't feel like it.
After a few months of this, we went over there to find John in what amounted to a serious depression. He wasn't eating very much, had lost a ton of weight, said he was crying a lot and didn't know why, etc, etc. His mother had moved in with him and said she was having to do things like do his laundry because he would just wear dirty clothes and not even bother to take a shower a lot of the time. He was taking a lot of time off of work and just laying around the house sleeping. She asked us to try to convince him to get help, that the doctor he was seeing wasn't helping him, that he'd been getting worse.
So, I ask John if he was getting help for this stuff. Yeah, he was seeing someone a friend had recommended. Okay, what were you diagnosed with? Well, they said I had parasites in my brain and that's why I was acting this way.
Parasites?
Yeah, parasites.
How do you know you have parasites?
Well, that's what she said it was, that my symptoms are caused by parasites, and I've been treating them so I can get better.
Despite the medical-sounding diagnosis of "parasites", it turned out he was going to a "natural" doctor. Obviously, I told him to talk to a doctor-doctor, but he was insistent on getting treated for the parasites that the woman had deluded him into thinking were causing his rather classic depression.
So, days or weeks later, I hear from my then-husband that John's work said he either had to take a medical leave of absence and get treated for his newfound troubles with alcohol or be terminated. Apparently, he'd pretty much stopped going to work entirely and just sat at home drinking.
So, basically, this 'natural' doctor took his money, made him, most likely highly-suggestible due to his desperation, depression, and embarrassment, think there were things crawling around in his head making him act the way he was. His depression went untreated and he turned to alcohol to treat it, nearly causing him to lose his job (he finally did lose his job the day after 9/11 in a "cost-saving" layoff, or, in other words, let's get rid of the crayzee guy and blame it on 9/11).
This is a case where a patient, who'd followed the recommendation of a "friend", was harmed by a 'natural' doctor (not sure if it was a naturopath, but some naturopaths endorse parasites as causing depression, schizophrenia, and even diabetes, at least on the Internet).
If I'd have been a nurse at the time with a little more knowledge and not a layperson myself, I'd have probably reported this "natural" doctor as practicing medicine without a license. I mean, dude, a parasite is a real thing, and telling someone their symptoms are caused by a parasite is arriving at a medical diagnosis, even if it is based on nothing-in-particular. Toxoplasmosis is a parasitic infection that can theoretically cause behavioral changes, so the concept is not so outlandish as to make it patently unbelievable and outside the realm of practicing medicine without a license.
If someone who was "licensed" and called herself a "doctor" told you that your symptoms were due to parasites in the brain and the treatment was XYZ, would you believe her? Probably. It's likely what John wanted to hear anyway---that he wasn't just some guy who had emotional problems in need of an anti-depressant and therapy, but an unfortunate, unwitting host for a curable parasite infection.
Friday, June 13, 2008
Hippies with 4-year online degrees now can admit to the hospital and call themselves "doctor"
If you haven't heard from one of the scienceblogs, Minnesota has passed a law saying those who obtained a 4-year "Doctor of Naturopathy" degree can legally call themselves "doctor" and do things like admit to hospitals, order MRIs and blood tests. Weird, man. It's like giving the dreadlocked pothead down the street who burns incense to "get in touch with nature" admitting privileges. I hope someone at the Star Tribune mis-interpreted the law.
If you have no medical degree, can you legally determine an admitting diagnosis? The answer to that is obviously 'no', since you legally need a license to practice medicine to arrive at a medical diagnosis. Not even an NP can admit to the hospital. If a Naturopath admits to the hospital, then, what? They tie up a room to practice chelation therapy on a patient with unstable angina while the nursing staff gets an ethics conference set up?
If you're interested in what a Naturopath learns in "school", check this link out. It's scary, man.
Here's an example of a Naturopathic treatment for an acute, evolving CVA:
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Um. Yeah. Note the lack of mention of "get your ass to the hospital". Mustard paste and foot baths! So, in summary, you may take a hot bath, a cold bath, or a neutral bath, or just a foot bath with or without mustard paste for your CVA. Also, how would a ND know that a stroke has occurred if he or she can't diagnose a stroke? Diagnosing a medical condition is reserved for those whose medical license allows them to do so. I can tell someone's had a stroke, but I can't legally engage in the practice of diagnosing strokes, yah know.
Any law that gives a group like this any sort of authority is a bad law. This should be obvious.
As my friend Jason says, "You just don't understand non-Western medicine, K! That doesn't mean it isn't just as good as Western medicine." *Sigh*
If you have no medical degree, can you legally determine an admitting diagnosis? The answer to that is obviously 'no', since you legally need a license to practice medicine to arrive at a medical diagnosis. Not even an NP can admit to the hospital. If a Naturopath admits to the hospital, then, what? They tie up a room to practice chelation therapy on a patient with unstable angina while the nursing staff gets an ethics conference set up?
If you're interested in what a Naturopath learns in "school", check this link out. It's scary, man.
Here's an example of a Naturopathic treatment for an acute, evolving CVA:
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“Hydrotherapy” sounds harmless and possibly soothing, until you discover some of its uses:
…if you or a family member already has suffered from one or more strokes, a simple hydrotherapy technique may provide relief, and even minimize long term sequelae…One technique is to lower your body temperature, with a cold bath for example, as much as possible without inducing shivering as soon as possible after a stroke has occurred, or is suspected to have occured. The idea here is that if the stroke is ischemic (temporary restriction of oxygenated blood) the body naturally and preferentially preserves blood flow to the brain, so cooling the rest of the body will cause the blood to shunt rapidly to the brain. However, if the stroke is hemorrhagic, cooling the body rapidly will cause vasoconstriction, thereby helping to control the bleed. Another hydrotherapy technique with a similar rationale is to soak the feet in a hot foot bath, as soon as possible after the stroke has occurred, while applying a cold compress to the neck, face and scalp. If this technique can be applied as a stroke is happening, it may even abort the stroke. Make sure the ice-cold compress touches the skin over the carotid arteries under the jaw bone. Mustard paste or powder may be added to the foot bath to increase the heating effect. Make sure to continue this treatment for at least 20 minutes and keep adding hot water to the foot bath and make sure the cold compress stays really cold. Or, you may take a neutral bath that is neither freezing cold, nor warm. Immersion in water of neutral temperature is extremely soothing to the central nervous system.
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Um. Yeah. Note the lack of mention of "get your ass to the hospital". Mustard paste and foot baths! So, in summary, you may take a hot bath, a cold bath, or a neutral bath, or just a foot bath with or without mustard paste for your CVA. Also, how would a ND know that a stroke has occurred if he or she can't diagnose a stroke? Diagnosing a medical condition is reserved for those whose medical license allows them to do so. I can tell someone's had a stroke, but I can't legally engage in the practice of diagnosing strokes, yah know.
Any law that gives a group like this any sort of authority is a bad law. This should be obvious.
As my friend Jason says, "You just don't understand non-Western medicine, K! That doesn't mean it isn't just as good as Western medicine." *Sigh*
Lamest NH-to-ER transfer ever!
This one has all my lame nursing-home transfer stories beat, except for, maybe, the transfer for "increased left forearm edema" in a patient who has had left arm lymphedema for years. Where's the edema exactly?
Well, maybe guy with "blue skin color with decreased sensation in right arm" who had a Coban dressing on too tight proximal to said color-change was a dumber transfer. Or how about the demented patient who was transferred to us because she needed to be admitted to a new NH after she "signed out AMA" to go back to "her own apartment" in a state 1500 miles away? Apparently, being demented is not a contraindication for signing out AMA and losing your bed at the skilled nursing facility "permanently".
Yep. ERNursey's story is worse than all of those.
Well, maybe guy with "blue skin color with decreased sensation in right arm" who had a Coban dressing on too tight proximal to said color-change was a dumber transfer. Or how about the demented patient who was transferred to us because she needed to be admitted to a new NH after she "signed out AMA" to go back to "her own apartment" in a state 1500 miles away? Apparently, being demented is not a contraindication for signing out AMA and losing your bed at the skilled nursing facility "permanently".
Yep. ERNursey's story is worse than all of those.
A letter
This letter is to EE at Backboards and Bandaids.
Dear EE,
Hi? How are the husband and fetus? My, what weather we're having!
I thought you'd be interested in knowing that I assisted the doctor as she did an I&D on a gigantic inner-buttcheek cyst. There was an immediate, unholy gush of bloody, purulent drainage pretty much all over the cart. Right about the time the dude screamed "MOTHERFUCKIN A! BE NICE TO THAT ASS, GIRLS!", I thought of you.
Just thought you'd like to know.
Have a nice day. Or some shit.
Peace out,
Nurse K
Thursday, June 12, 2008
Stroke patient reads neurology textbook
I had a patient the other day with an acute left-sided CVA (or, if you want to be really anal, a TIA because it's not a CVA until 24 hours after symptom onset). He had nearly 100% expressive aphasia and a good chunk of receptive aphasia as well. His right arm was weaker than the left, but not flaccid.
In addition to the right-sided weakness, he had some right-sided neglect. He looked only towards the left side and didn't turn to look at me when I approached him from the right, for example.
I was explaining neglect to one of the aides who was in nursing school, and I offered to let her watch me do an assessment to see how it manifested. She seemed interested in this patient, so why not?
I asked him to squeeze my fingers with his left hand only and he did so without difficulty. I put my fingers in his right hand and asked him to squeeze. He did nothing. I asked again. Nothing. I asked a third time, and he grabbed my fingers with his left hand and squeezed them while they were still in the right hand. Sad for him, cool to watch though.
In addition to the right-sided weakness, he had some right-sided neglect. He looked only towards the left side and didn't turn to look at me when I approached him from the right, for example.
I was explaining neglect to one of the aides who was in nursing school, and I offered to let her watch me do an assessment to see how it manifested. She seemed interested in this patient, so why not?
I asked him to squeeze my fingers with his left hand only and he did so without difficulty. I put my fingers in his right hand and asked him to squeeze. He did nothing. I asked again. Nothing. I asked a third time, and he grabbed my fingers with his left hand and squeezed them while they were still in the right hand. Sad for him, cool to watch though.
Check out the losers in your 'hood
Check out the felons in your neighborhood with Felon Spy. You'll be surprised how many sodomites, rapists, kidnappers, child abusers, and burglars are within a mile of your house.
My favorite neighborhood charge is "attempted stalking in the first degree." If you are merely attempting to stalk, doesn't that, by definition, mean you're not stalking? To me, seeing as stalking is a pattern of behavior, either you're stalking or you are not. It's hard to intimidate someone when you consistently F up your stalking attempts.
Did Dude's car break down on the way to his ex-girlfriend's house every time he intended to follow her to her hair appointments? Did Dude write a whole bunch of threatening letters and then forget to mail them? Did he intend to stand outside that pretty bartender Sally's house, but keep forgetting where she lived and just stand outside a different house each time, hoping it would be the right one?
Also, I just noticed that there is a link from Felon Spy encouraging people to help stop "medical adoptions." A medical adoption is not about adopting children with medical needs. Check it out and be disgusted here. Be sure to read the client testimonials on the right sidebar. Can't be real...
My favorite neighborhood charge is "attempted stalking in the first degree." If you are merely attempting to stalk, doesn't that, by definition, mean you're not stalking? To me, seeing as stalking is a pattern of behavior, either you're stalking or you are not. It's hard to intimidate someone when you consistently F up your stalking attempts.
Did Dude's car break down on the way to his ex-girlfriend's house every time he intended to follow her to her hair appointments? Did Dude write a whole bunch of threatening letters and then forget to mail them? Did he intend to stand outside that pretty bartender Sally's house, but keep forgetting where she lived and just stand outside a different house each time, hoping it would be the right one?
Also, I just noticed that there is a link from Felon Spy encouraging people to help stop "medical adoptions." A medical adoption is not about adopting children with medical needs. Check it out and be disgusted here. Be sure to read the client testimonials on the right sidebar. Can't be real...
Wednesday, June 11, 2008
Coming out both ends!
Chief complaint: Two-day history of productive cough with green sputum and green penile discharge.
Tuesday, June 10, 2008
Hardass ER nurse gets visibly upset
It was one of those days where the board looked like a night shift at 0300, but it was the middle of the afternoon. The ER doc who has 6 kids asked us if he could go take a nap because sleep at home was impossible with crying babies and whatnot. Nary a vaginal discharge, back pain for a decade, nor a rash since Eisenhower was president was to be found within 250 yards of our facility.
One of the aides tried to start something by squirting me in the tit with a syringe. As I was plotting my revenge, I saw on the computer that someone signed in to be triaged. The last name was familiar for some reason. A frequent flyer, probably. No. How do I know this name? Then it hit me.
That's the motherfucker who stole my car!
Yep. Early-on in my ER career, I went outside to go to work, and noticed my car that was just there a minute ago was gone. What the Hell? Luckily, not more than a couple seconds later, a cop comes around the corner with his bright search-light thingies on. What good timing! I stand in the street and wave my arms.
"I don't know why you're here, but someone stole my car just now!"
Dude immediately gets on the radio and starts putting out alerts to everyone in the county to be on the look-out for my car. Turns out the cops had just arrested a guy for breaking into one of my neighbors houses. My badass neighbor stopped the burglary and caught one of the guys. The other two people were seen running in the direction where my car was parked.
Ergo, my car was the burglary getaway vehicle.
This occurred in the worst part of my divorce process. My ex had cleaned out my bank account and had been breaking into my house himself to steal various items. I still haven't fixed one of the windows he kicked out so he could cut my phone lines. I wasn't getting any child support (nor have I ever). I had no money. No savings account. My credit cards were maxed out. In a time where I needed some hope that it was all going to be better and that I'd be okay, those guys made it markedly worse.
Finally, my car was recovered, and the city charged me $170 for the tow plus $30/day fee, including the days that the police held my car to dust it for fingerprints. Yeah, you heard it right. The police refused to release the car to me until their investigation was complete, which was fine, and I had to pay to have it stored there for the investigation. Ninety bucks. Total bullshit.
I didn't have the money to get my car out of the lot. I had to use everything I had left to my name (like $100) and borrow the rest from my mom. No money for food, gas. Nothing. The three guys who burglarized my neighbor and stole my car were charged with various bullshitty things and put in jail for a suboptimal period of time, given their history of repeated arrests for similar things. They were not ordered to pay restitution, and I was allowed to submit a "victim impact statement" that was considered as part of their sentencing.
They told the judge they were robbing the house so they could buy meth. Dirtball meth-heads were driving my car. Disgusting. I couldn't even afford to get the thing detailed.
So, this dirtball gets out of jail and shows up in my ER. Before he was even done being triaged, I was cussing, crying, and causing a scene with my one wet tit. He violated my space. He made me hate my neighborhood and want to leave. He made me fear even something as simple as walking from my house to my garage at night.
And now I was expected-by-the-ghost-of-Florence-Nightengale to treat him just like anyone else because he decided to show up? He thinks he can show up and expect us to be good to him when he stole from one of them?
Incidentally, a month after my car was stolen the first time, my car was stolen again and vandalized on the inside in a failed attempted to steal my stereo. It was assumed, based on the fact that it was ditched in approximately the same place as the first car theft, that the same people stole it again. The patient was one of the people who hadn't yet been caught, so I assume it was him specifically. The Neighborhood Watch people and the neighbor were very good at keeping me updated on the whereabouts of the suspects, by the way.
Finally, one of the travel nurses agreed to take the patient because someone had to (everyone else had also refused to take him in a show of solidarity or something), and I see the motherfucker walk by. Scraggly. Pale. Skinny. A thousand eyes in a desolate ER stared upon him as he walked down the hall to his room with the travel nurse. He was not mean, angry, nor rude to anyone. He told her about his pain and said he only wanted toradol due to his probation.
No matter what, he's still the guy whose victimized me to pay for his drug addiction. If I see him again, I'll look his ass in the eye and tell him what he did to me right before I put a #14 right in the top of his hand. I hope for his sake that he decides on a different hospital.
At the very least, I deserve an apology, and I never so much as got that.
One of the aides tried to start something by squirting me in the tit with a syringe. As I was plotting my revenge, I saw on the computer that someone signed in to be triaged. The last name was familiar for some reason. A frequent flyer, probably. No. How do I know this name? Then it hit me.
That's the motherfucker who stole my car!
Yep. Early-on in my ER career, I went outside to go to work, and noticed my car that was just there a minute ago was gone. What the Hell? Luckily, not more than a couple seconds later, a cop comes around the corner with his bright search-light thingies on. What good timing! I stand in the street and wave my arms.
"I don't know why you're here, but someone stole my car just now!"
Dude immediately gets on the radio and starts putting out alerts to everyone in the county to be on the look-out for my car. Turns out the cops had just arrested a guy for breaking into one of my neighbors houses. My badass neighbor stopped the burglary and caught one of the guys. The other two people were seen running in the direction where my car was parked.
Ergo, my car was the burglary getaway vehicle.
This occurred in the worst part of my divorce process. My ex had cleaned out my bank account and had been breaking into my house himself to steal various items. I still haven't fixed one of the windows he kicked out so he could cut my phone lines. I wasn't getting any child support (nor have I ever). I had no money. No savings account. My credit cards were maxed out. In a time where I needed some hope that it was all going to be better and that I'd be okay, those guys made it markedly worse.
Finally, my car was recovered, and the city charged me $170 for the tow plus $30/day fee, including the days that the police held my car to dust it for fingerprints. Yeah, you heard it right. The police refused to release the car to me until their investigation was complete, which was fine, and I had to pay to have it stored there for the investigation. Ninety bucks. Total bullshit.
I didn't have the money to get my car out of the lot. I had to use everything I had left to my name (like $100) and borrow the rest from my mom. No money for food, gas. Nothing. The three guys who burglarized my neighbor and stole my car were charged with various bullshitty things and put in jail for a suboptimal period of time, given their history of repeated arrests for similar things. They were not ordered to pay restitution, and I was allowed to submit a "victim impact statement" that was considered as part of their sentencing.
They told the judge they were robbing the house so they could buy meth. Dirtball meth-heads were driving my car. Disgusting. I couldn't even afford to get the thing detailed.
So, this dirtball gets out of jail and shows up in my ER. Before he was even done being triaged, I was cussing, crying, and causing a scene with my one wet tit. He violated my space. He made me hate my neighborhood and want to leave. He made me fear even something as simple as walking from my house to my garage at night.
And now I was expected-by-the-ghost-of-Florence-Nightengale to treat him just like anyone else because he decided to show up? He thinks he can show up and expect us to be good to him when he stole from one of them?
Incidentally, a month after my car was stolen the first time, my car was stolen again and vandalized on the inside in a failed attempted to steal my stereo. It was assumed, based on the fact that it was ditched in approximately the same place as the first car theft, that the same people stole it again. The patient was one of the people who hadn't yet been caught, so I assume it was him specifically. The Neighborhood Watch people and the neighbor were very good at keeping me updated on the whereabouts of the suspects, by the way.
Finally, one of the travel nurses agreed to take the patient because someone had to (everyone else had also refused to take him in a show of solidarity or something), and I see the motherfucker walk by. Scraggly. Pale. Skinny. A thousand eyes in a desolate ER stared upon him as he walked down the hall to his room with the travel nurse. He was not mean, angry, nor rude to anyone. He told her about his pain and said he only wanted toradol due to his probation.
No matter what, he's still the guy whose victimized me to pay for his drug addiction. If I see him again, I'll look his ass in the eye and tell him what he did to me right before I put a #14 right in the top of his hand. I hope for his sake that he decides on a different hospital.
At the very least, I deserve an apology, and I never so much as got that.
Stupid head scan
10/10 wrote about the ethical reasons for not ordering a clearly unnecessary head CT, and that reminded me of this case.
An employee came down to our ER after bumping her head while working on the floor. Pretty standard head-bump, something all of us do every once-in-awhile. You stand up, the shelf is there and ---yeoch--- you bump your head. She was complaining of a headache a day later and so, for some God-awful reason, her boss sent her to us.
Yes, after bumping your head, you may feel some pain at the point-of-impact even--gasp--less than 24 hours later. The patient had no visual changes, nausea, nor neurological deficits of any kind and wasn't on a whole pile of blood-thinners. Just an average hospital employee who bumped her head. Not even a lac nor a goose-egg. No ibuprofen nor ice was tried prior to her arrival.
So, yep, you guessed it. Head CT! She waited 4 hours in the department's lobby and waiting for her scan. She socialized with the staff, walked down to the cafeteria to get some lunch, etc. She received her scan, paid for by our workman's comp insurance, and was on her way.
Why the scan? "Because she had head trauma and a headache."
Another great-workup, care of Dr. Marvin.
An employee came down to our ER after bumping her head while working on the floor. Pretty standard head-bump, something all of us do every once-in-awhile. You stand up, the shelf is there and ---yeoch--- you bump your head. She was complaining of a headache a day later and so, for some God-awful reason, her boss sent her to us.
Yes, after bumping your head, you may feel some pain at the point-of-impact even--gasp--less than 24 hours later. The patient had no visual changes, nausea, nor neurological deficits of any kind and wasn't on a whole pile of blood-thinners. Just an average hospital employee who bumped her head. Not even a lac nor a goose-egg. No ibuprofen nor ice was tried prior to her arrival.
So, yep, you guessed it. Head CT! She waited 4 hours in the department's lobby and waiting for her scan. She socialized with the staff, walked down to the cafeteria to get some lunch, etc. She received her scan, paid for by our workman's comp insurance, and was on her way.
Why the scan? "Because she had head trauma and a headache."
Another great-workup, care of Dr. Marvin.
Semantics
A patient comes in with his second seizure of the day, and is back to his usual state of being upon arrival.
Is it normal for you to have two seizures in one day?
"No, I normally have only about one a month, but they've been getting more frequent lately, I guess."
Did you miss any of your medication doses today?
"Nope."
Drink today? Sleep-deprived?
"Nope and nope."
So, we go through whatever, give him a load of Keppra or whatever, and he comes back at me with this, "Oh, Keppra."
Huh?
"Oh, I got this prescription for Keppra a month ago after I saw my epilepsy doctor, but never filled it."
Well, you just said you never missed a dose.
"Well, I never filled it to begin with. I figured that wouldn't count as a missed dose."
*Sigh*
Is it normal for you to have two seizures in one day?
"No, I normally have only about one a month, but they've been getting more frequent lately, I guess."
Did you miss any of your medication doses today?
"Nope."
Drink today? Sleep-deprived?
"Nope and nope."
So, we go through whatever, give him a load of Keppra or whatever, and he comes back at me with this, "Oh, Keppra."
Huh?
"Oh, I got this prescription for Keppra a month ago after I saw my epilepsy doctor, but never filled it."
Well, you just said you never missed a dose.
"Well, I never filled it to begin with. I figured that wouldn't count as a missed dose."
*Sigh*
Monday, June 9, 2008
Impending sense of doom
So, I've been doing various home projects this past weekend, and one of them was to peel off two layers of ugly wallpaper in the kitchen and wash all the walls so I can paint later this week. The previous owners of the house were smokers and the white walls and especially the ceiling had that yellowish crap all over it. I thought this whole time my house had old water damage and that's why the ceiling was yellow, but no, it was just yellow smoker-residue. I went through bucket after bucket of cleaner, but now the ceiling is white and shiny.
F'in nasty. If you haven't heard it before, don't smoke. All that crap that's on my ceiling is in your lungs too, only a lot more of it. Oh, and that cough isn't bacterial bronchitis either. You don't need antibiotics, you just need to stop smoking.
But yeah, I've lived here for 4 years and never washed the ceiling. Bite me. When's the last time you washed YOUR kitchen ceiling?
Moving on.
As I take a break from this tedium, I just realized something: I may have removed my old house's protective coating. I wonder if the kitchen is going to catch on fire now.
F'in nasty. If you haven't heard it before, don't smoke. All that crap that's on my ceiling is in your lungs too, only a lot more of it. Oh, and that cough isn't bacterial bronchitis either. You don't need antibiotics, you just need to stop smoking.
But yeah, I've lived here for 4 years and never washed the ceiling. Bite me. When's the last time you washed YOUR kitchen ceiling?
Moving on.
As I take a break from this tedium, I just realized something: I may have removed my old house's protective coating. I wonder if the kitchen is going to catch on fire now.
Saturday, June 7, 2008
It ain't made by Kellogg's
MonkeyGirl has a theory on the origin of her respiratory ailment. Is this a public health concern for nurses? You be the judge.
Saturday morning CRAYZEE!!!!!!!!!!!!!!
Here's a comment that just came in on an old post:
Every time I see some scraggly-looking dudes buying pills off the homies dealing at the liquor store down the street, I'll just get out my tiny little violin and play it for their untreated chronic pain because obviously that's why they're buying drugs at the bus stop outside the liquor store, not for some desire to "get high".
When I go to graduate school, I think I'll do a thesis on the effects of drug dealers (not to be confused with doctors) informing their clients about working, sliding-fee clinics, and health savings accounts with every drug deal because obviously these people just have a knowledge deficit on available resources for their chronic pain and are turning to the streets instead.
Every time I see some scraggly-looking dudes buying pills off the homies dealing at the liquor store down the street, I'll just get out my tiny little violin and play it for their untreated chronic pain because obviously that's why they're buying drugs at the bus stop outside the liquor store, not for some desire to "get high".
When I go to graduate school, I think I'll do a thesis on the effects of drug dealers (not to be confused with doctors) informing their clients about working, sliding-fee clinics, and health savings accounts with every drug deal because obviously these people just have a knowledge deficit on available resources for their chronic pain and are turning to the streets instead.
Friday, June 6, 2008
A retarded thing that made me happy that is totally off topic, but you'll have to deal with it
I am looking in to doing a historically-accurate-as-possible bathroom remodel, um, on a budget, and I just randomly went into my garage and climbed up in the rafters [SCARY!] to look at the scrap wood that the previous owners of my house stacked up there to see if there was any of the original baseboard or anything that I can use.
What do I find hiding up there? The original muddaf'in bathroom door, old stain and all, from the 1920s which had been replaced by the current cheap-o white shit-door that is currently up there. Twenty-six inches across just like my door opening. Original oxidized metal doorknob, bathrobe hook and everything. If you have an old house that you've ever re-done, you'll know how cool this is. It's like buttah...or some sh*t.
Oh, and if you have an old house that you're re-doing and you paint over the woodwork like the previous owners who "re-did" my house did? I'll kill ya on general principle. Be warned.
Now, I'm off to the architectural recycling store to try to hunt down some 80-year-old baseboard. Yawn.
What do I find hiding up there? The original muddaf'in bathroom door, old stain and all, from the 1920s which had been replaced by the current cheap-o white shit-door that is currently up there. Twenty-six inches across just like my door opening. Original oxidized metal doorknob, bathrobe hook and everything. If you have an old house that you've ever re-done, you'll know how cool this is. It's like buttah...or some sh*t.
Oh, and if you have an old house that you're re-doing and you paint over the woodwork like the previous owners who "re-did" my house did? I'll kill ya on general principle. Be warned.
Now, I'm off to the architectural recycling store to try to hunt down some 80-year-old baseboard. Yawn.
Thursday, June 5, 2008
Costs and a simple solution?
*Remember, this is not medical advice, people. Consult your own doctors with what to do!
In the thread below, Kacey tells me the following:
My question was...why are you paying even $75 for a proton-pump inhibitor? Prevacid is a brand name and, to my knowledge, there is not yet a generic equivalent. There is a generic Protonix and an over-the-counter Prilosec. The Cleveland Clinic did a study review and found that there was no real difference in efficacy when comparing proton-pump inhibitors and recommended cost should be the #1 deciding factor when deciding which to prescribe. Prices for these drugs varied by at least a hundred bucks in the study with no real difference in efficacy between them. I would go so far as to say that it could be unethical to prescribe a drug that you know is more costly and no more effective than a generic or over-the-counter drug.
I'm sure the doctor who prescribed it had no clue how much it would cost, however.
Of course, many say that for most people, your standard H2-blocker (Pepcid, ranitidine, etc) is good enough if you have excessive stomach acid and is, for certain, better-than-nothing if the alternative is not treating your ulcer or obnoxious GERD. Many of these are $4 at WallyWorld or over-the-counter.
If you have occasional heartburn, there is probably no need for daily therapy and TUMS will serve you up right.
At least in my department, doctors have no clue how much drugs cost, nor do the nurses. I certainly have no clue how much any IV medications cost because there is no way for me to look that up as I'm not a pharmacy employee. All I know is Factor VIIa needs to be hand-delivered by a RN to the ER in a special portable cooler like the Ark of the Covenant because it costs a bajillion dollars. I heard a rumor that a bag of IgG was $7000, but I don't know the cost of a syringe of morphine nor zofran, and I give those all the time.
Our outpatient and inpatient pharmacy employees use the same EMR system that we do, so they can look up previously-entered insurance information, a patient med list, etc.
Wouldn't it be slick to have an option for the full cost of the medications (at your hospital's outpatient pharmacy for instance) to be integrated into your EMR and displayed right there on the screen where the discharge meds are ordered? If you want to, you can click a button and get a list of suggested alternatives and their prices?
For double slickness, the full cost (ie if you didn't have insurance) of the inpatient medications with suggested alternatives (if you wanted alternatives to be displayed) could be displayed as well.
After a little while, doctors would have memorized the prices of the drugs they routinely order and be able to do a little cost-containment if necessary. The goal would not be to get the exact price, but a rough estimate or average price.
Alternatively, in a doctor's office setting, computer or Palm Pilot programs such as the free Epocrates could be used to quickly check prices. I only see the bright-eyed residents flashing a Palm Pilot to check drug prices, but more doctors should be doing it at least for drugs they routinely prescribe.
I think to contain costs of medications and reduce overall spending on health care without compromising quality to any large extent, the first thing you have to do is teach the dang doctors how much things cost and make that information readily available to them in some standard and easy-to-use format. There is some unspoken cultural rule that cost of medical services should be hidden to everyone but the billing department, but this needs to change and should change now.
In the thread below, Kacey tells me the following:
-
Kacey said... [Blah blah blah about McCain, then:]
We went to the drugstore yesterday and filled the hubby's Prevacid Rx for $75.00. The price on the bag said, "504.00". I know the insurance company did not pay $429.00 for this, but without insurance.... we would have.
My question was...why are you paying even $75 for a proton-pump inhibitor? Prevacid is a brand name and, to my knowledge, there is not yet a generic equivalent. There is a generic Protonix and an over-the-counter Prilosec. The Cleveland Clinic did a study review and found that there was no real difference in efficacy when comparing proton-pump inhibitors and recommended cost should be the #1 deciding factor when deciding which to prescribe. Prices for these drugs varied by at least a hundred bucks in the study with no real difference in efficacy between them. I would go so far as to say that it could be unethical to prescribe a drug that you know is more costly and no more effective than a generic or over-the-counter drug.
I'm sure the doctor who prescribed it had no clue how much it would cost, however.
Of course, many say that for most people, your standard H2-blocker (Pepcid, ranitidine, etc) is good enough if you have excessive stomach acid and is, for certain, better-than-nothing if the alternative is not treating your ulcer or obnoxious GERD. Many of these are $4 at WallyWorld or over-the-counter.
If you have occasional heartburn, there is probably no need for daily therapy and TUMS will serve you up right.
At least in my department, doctors have no clue how much drugs cost, nor do the nurses. I certainly have no clue how much any IV medications cost because there is no way for me to look that up as I'm not a pharmacy employee. All I know is Factor VIIa needs to be hand-delivered by a RN to the ER in a special portable cooler like the Ark of the Covenant because it costs a bajillion dollars. I heard a rumor that a bag of IgG was $7000, but I don't know the cost of a syringe of morphine nor zofran, and I give those all the time.
Our outpatient and inpatient pharmacy employees use the same EMR system that we do, so they can look up previously-entered insurance information, a patient med list, etc.
Wouldn't it be slick to have an option for the full cost of the medications (at your hospital's outpatient pharmacy for instance) to be integrated into your EMR and displayed right there on the screen where the discharge meds are ordered? If you want to, you can click a button and get a list of suggested alternatives and their prices?
For double slickness, the full cost (ie if you didn't have insurance) of the inpatient medications with suggested alternatives (if you wanted alternatives to be displayed) could be displayed as well.
After a little while, doctors would have memorized the prices of the drugs they routinely order and be able to do a little cost-containment if necessary. The goal would not be to get the exact price, but a rough estimate or average price.
Alternatively, in a doctor's office setting, computer or Palm Pilot programs such as the free Epocrates could be used to quickly check prices. I only see the bright-eyed residents flashing a Palm Pilot to check drug prices, but more doctors should be doing it at least for drugs they routinely prescribe.
I think to contain costs of medications and reduce overall spending on health care without compromising quality to any large extent, the first thing you have to do is teach the dang doctors how much things cost and make that information readily available to them in some standard and easy-to-use format. There is some unspoken cultural rule that cost of medical services should be hidden to everyone but the billing department, but this needs to change and should change now.
Choices
Here's a political post. Skip if you wish. You have been warned.
Let's say you work for a small company...maybe you're the secretary for an insurance agent and go to a megachurch on Sundays. Your boss is too small to offer reasonably-price health coverage. If he was forced to buy you insurance due to a "mandate", he'd simply fire you and do the secretarial work himself. If you demanded insurance, he'd tell you no and to find another job if you needed insurance because he couldn't afford it.
However, your megachurch has 10,000 members and could easily get a low-cost group insurance plan where the premiums would be partially financed by its usual donations. Maybe you, in fact, have work insurance, but the church plan is better than your work insurance, giving you an additional choice/competition for your health care. Luckily, you're also a cyclist and your chapter of the cycling club has negotiated a bottom-basement price on a health insurance plan due to the low risk of the group being insured. So you can choose between an individual plan, a work plan, the church plan, and the cycling plan.
There is one candidate which would make such expanded coverage with less government involvement-type situations feasible and that's John McCain.
Let's say you work for a small company...maybe you're the secretary for an insurance agent and go to a megachurch on Sundays. Your boss is too small to offer reasonably-price health coverage. If he was forced to buy you insurance due to a "mandate", he'd simply fire you and do the secretarial work himself. If you demanded insurance, he'd tell you no and to find another job if you needed insurance because he couldn't afford it.
However, your megachurch has 10,000 members and could easily get a low-cost group insurance plan where the premiums would be partially financed by its usual donations. Maybe you, in fact, have work insurance, but the church plan is better than your work insurance, giving you an additional choice/competition for your health care. Luckily, you're also a cyclist and your chapter of the cycling club has negotiated a bottom-basement price on a health insurance plan due to the low risk of the group being insured. So you can choose between an individual plan, a work plan, the church plan, and the cycling plan.
There is one candidate which would make such expanded coverage with less government involvement-type situations feasible and that's John McCain.
John McCain Will Reform The Tax Code To Offer More Choices Beyond Employer-Based Health Insurance Coverage. While still having the option of employer-based coverage, every family will also have the option of receiving a direct refundable tax credit - effectively cash - of $2,500 for individuals and $5,000 for families to offset the cost of insurance. Families will be able to choose the insurance provider that suits them best and the money would be sent directly to the insurance provider. Those obtaining innovative insurance that costs less than the credit can deposit the remainder in expanded Health Savings Accounts.
Tuesday, June 3, 2008
Dumb nursing-home ER transfer of the week
A patient comes in from the English-as-a-second-language training center (AKA Local Nursing Home) via EMS with no chief complaint herself. She was admitted that day to the transitional care unit for short-term rehab after a hip fracture repair.
The reason for the transfer after only an hour or two there? The very first set of her vitals like the minute she set foot in the door were "unstable". Now, this is not unheard of. The patient is sent to the NH, they arrive, and a day or two later are febrile with a low BP or something. So, let's see what her unstable vitals were:
BP 163/84, HR 75, Sats 99% on RA, and Temp of 97.4.
Um. Those aren't unstable. We called and asked what vitals were unstable (were we missing something?), and the "nurse" declared her to be dangerously hypertensive with a blood pressure of 163/84! She needed to be seen and stabilized before being admitted back to the TCU.
Did they re-check the vitals before calling 9-11? No. Did they leave a note to maybe recheck it again and call the doctor if it was persistently elevated? No.
Our initial BP was 150/85 or something like that. The patient felt fine. So we sent her right back in less than 20 minutes, most of which was spent filling out the required forms for her to do so.
The reason for the transfer after only an hour or two there? The very first set of her vitals like the minute she set foot in the door were "unstable". Now, this is not unheard of. The patient is sent to the NH, they arrive, and a day or two later are febrile with a low BP or something. So, let's see what her unstable vitals were:
BP 163/84, HR 75, Sats 99% on RA, and Temp of 97.4.
Um. Those aren't unstable. We called and asked what vitals were unstable (were we missing something?), and the "nurse" declared her to be dangerously hypertensive with a blood pressure of 163/84! She needed to be seen and stabilized before being admitted back to the TCU.
Did they re-check the vitals before calling 9-11? No. Did they leave a note to maybe recheck it again and call the doctor if it was persistently elevated? No.
Our initial BP was 150/85 or something like that. The patient felt fine. So we sent her right back in less than 20 minutes, most of which was spent filling out the required forms for her to do so.
Mr. Smith isn't dead
A month or so ago, I asked around to see if anyone'd seen Mr. Smith, made famous for signing in for chest pain then going about town to run errands (AKA 'snort coke'), kindly letting us know at what time he would be back in full-blown coke-enhanced chest pain. I mean, if your dealer wants to meet you at 4pm and you just signed in with chest pain to the ER at 3:55 pm, you have to leave to see your dealer because obviously dealers aren't known for being very reliable timekeepers and your addiction can't afford another day of waiting. You miss your chance, you miss your chance at least until tomorrow, noamsayne?
Anyway.
Someone told me he was dead. I was a little sad. Despite being a total manipulator and a classic drug-seeker, he was always reasonably nice, would tell you about what was going on in his life, and wouldn't pitch a fit if we called him out on his bullshitting. "You're here all the time and your EKG is still normal. Time to go home." Then he'd thank us, and just go back to wherever he'd come from that night and try again a week later.
I learned that he wasn't dead afterall! He was just in jail. A day after he gets out, guess where he ends up? You gots it, our ER asking for dilaudid because nitro doesn't work. When I saw him rolling down in his stretcher, I smiled.
Anyway.
Someone told me he was dead. I was a little sad. Despite being a total manipulator and a classic drug-seeker, he was always reasonably nice, would tell you about what was going on in his life, and wouldn't pitch a fit if we called him out on his bullshitting. "You're here all the time and your EKG is still normal. Time to go home." Then he'd thank us, and just go back to wherever he'd come from that night and try again a week later.
I learned that he wasn't dead afterall! He was just in jail. A day after he gets out, guess where he ends up? You gots it, our ER asking for dilaudid because nitro doesn't work. When I saw him rolling down in his stretcher, I smiled.
Monday, June 2, 2008
Sub-par care
A young, otherwise-healthy patient with a high WBC count (19.5 or something), flank pain, low-grade fever, slight tachycardia, and UTI symptoms (ie pyelonephritis) refused admission to the hospital due to child care concerns. She was encouraged her to make some calls to see who could watch the kid, and was even told about the crisis nursery as a last resort. Nope, she wanted to sign out. She asked the MD to write her for some oral antibiotics instead.
He explained to her that either it was admission or no further care, including oral antibiotics. He explained to her that both he and the admitting physician thought oral antibiotics and outpatient treatment would not be sufficient for her kidney infection and he would not agree to sub-par care for her convenience.
Would the doctor really be liable for malpractice if he gave her some oral antibiotics with the [well-charted, well-explained] caveat that he did not think it would be sufficient, encouragement of close follow-up and to return for admission if symptoms worsened? Is there an ethical duty to at least attempt oral antibiotics even if you truly feel that there isn't a great chance they will work? In other words, should the doctor have agreed to provide, as he described it, "sub-par care" instead of providing no care?
He explained to her that either it was admission or no further care, including oral antibiotics. He explained to her that both he and the admitting physician thought oral antibiotics and outpatient treatment would not be sufficient for her kidney infection and he would not agree to sub-par care for her convenience.
Would the doctor really be liable for malpractice if he gave her some oral antibiotics with the [well-charted, well-explained] caveat that he did not think it would be sufficient, encouragement of close follow-up and to return for admission if symptoms worsened? Is there an ethical duty to at least attempt oral antibiotics even if you truly feel that there isn't a great chance they will work? In other words, should the doctor have agreed to provide, as he described it, "sub-par care" instead of providing no care?
Sunday, June 1, 2008
When the 'It's all about me' attitude pisses me off the most
A drug seeker who I hadn't seen in awhile with chronic "back pain" comes in by ambulance. Oh, she is pregnant now. How pregnant are you? Oh, first trimester, how excellent. Congratulations. Or something.
She blew a 0.11 on the breathalyzer.
It's on now, bitch.
Patient with embryo with small, developing brain cells: But nurse! You don't know what I go through with this back pain!
Me: You are legally drunk and pregnant, ma'am. However bad your pain is today, it is not worse than what your baby will go through its whole life when he or she is born retarded from fetal alcohol syndrome.
You know what the worst part of all of this was? She never once acknowledged the fact that being drunk early in the morning to "help her back pain" while pregnant was a bad thing. She just kept making excuses for her behavior. I countered each excuse with something like "however you feel now does not warrant harming your baby". Maybe she caught the hint. If not, the child protective services people had another go at it.
She blew a 0.11 on the breathalyzer.
It's on now, bitch.
Patient with embryo with small, developing brain cells: But nurse! You don't know what I go through with this back pain!
Me: You are legally drunk and pregnant, ma'am. However bad your pain is today, it is not worse than what your baby will go through its whole life when he or she is born retarded from fetal alcohol syndrome.
You know what the worst part of all of this was? She never once acknowledged the fact that being drunk early in the morning to "help her back pain" while pregnant was a bad thing. She just kept making excuses for her behavior. I countered each excuse with something like "however you feel now does not warrant harming your baby". Maybe she caught the hint. If not, the child protective services people had another go at it.
I don't like taking pills
Overhead in triage
Young man: I got this back pain!
Triage nurse: Did you try anything for it?
YM: Well, you see, my girlfriend offered me some eye-boo-pro-fin but I didn't take none cuz I don't like to take pillz. I thought I betta get it checked out.
Triage nurse: Well that was stupid! You'd rather wait here for 4 hours to see a doctor instead of taking an ibuprofen because you don't like taking pills? That doesn't make much sense now, does it?
YM: Well like I said, I don't like taking pills.
Young man: I got this back pain!
Triage nurse: Did you try anything for it?
YM: Well, you see, my girlfriend offered me some eye-boo-pro-fin but I didn't take none cuz I don't like to take pillz. I thought I betta get it checked out.
Triage nurse: Well that was stupid! You'd rather wait here for 4 hours to see a doctor instead of taking an ibuprofen because you don't like taking pills? That doesn't make much sense now, does it?
YM: Well like I said, I don't like taking pills.
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