Bradycardia and The Cough

TINS©, TIWFDASL©, nursing in the ED of this community hospital in Northern The Un-Named Flyover State. A gentleman arrived, somewhere in his forties, and he told his tale of chest pain. He shortly thereafter sported the latest fashions in IVs, EKG monitoring, oxygen, and much blood drawn and sent to lab for analysis.

Two things you should know about me. I am a bottomless well of generally useless trivia, for one. For example, the relevance of which will become apparent shortly, I read a bunch of stuff, including a report, years and years and years ago which asserted that individuals undergoing a cardiac catheterization would be instructed that, should they be commanded to do so, they should cough vigorously and repeatedly. This would, or so the article asserted, increase pressure inside the chest, compress the heart, and thereby expel blood from the heart. This was important because occasionally the catheter, introduced into the heart, could produce irritation sufficient to produce fibrillation. (an uncoordinated trembling of the heart, which produces no blood flow. A Bad Thing.)

Once they drew in another breath preparatory to coughing once again, the negative pressure inside their chest so produced would encourage their heart to again fill with blood, which would be expelled with the next cough. This could temporarily produce enough blood pressure to keep things idling along, until the cath lab staff could intervene and set things right.

The other thing about me, is that I am somewhat chatty. (“No! Say it isn’t so!”). Okay, very chatty. So, there I was, chatting with this gentleman, and noting his cardiac rhythm and heart rate as displayed upon his cardiac monitor.

I noticed that his heart rate, originally in the 90’s, was trending downward. (normal is around 60-80). Once it dropped below 55, I stopped congratulating myself on wonderful patient care, and began to worry.

He began to report feeling dizzy and weak. I directed him, “When I tell you to cough, do not ask any questions, simply do it!”

He, of course, asked me why, but at that point his heart rate had dropped below 30 (Very Not So Good!), and I was a bit terse. “Stop talking, and cough!…Cough!…..Cough!….”

I repeated myself at about one second intervals. Now, I am sure that the other nurses heard me, and wondered what variety of insanity had afflicted me. Once they came in to investigate, and I waved my hand at the monitor, continuing my coxswain like commands of “Cough!….Cough!….Cough!….”, they noted his very, very slow intrinsic heart rate. That, coupled with this guy, eyes fixed upon me, coughing every time I commanded him to do so, told them everything that they needed to know, and things got considerably more active in short order.

He soon received a temporary external pacemaker and and an ICU admit.

And we all lived happily ever after!

WuFlu, Kung Flu, Chinese Flu, or Coronavirus: It IS a big deal, but not for the reasons you likely have been told!

The number of projected deaths, when all is done, is not THE PROBLEM. At north of a million people (that’s one million, or more fathers, mothers, brothers, sisters, sons, daughters, grandfathers and grandmothers. And aunts, uncles and husbands and wives.), that is certainly bad enough. Particularly if someone you love is enumerated in that group. Life changing. Reality altering. Leaves a hole in your heart, your life, that you cannot imagine, unless you have lived through it.

BUT! THAT is not THE PROBLEM. THE PROBLEM, is the follow on effects, as a tsunami of ill inundates our already (on a good day) marginal health “system”, that it is in no way prepared for.

“Just in time” inventory systems will not bite us in the ass. Nope, not at all. Rather, the shortfalls and absent supplies will make us yearn for simply being bitten in the ass. Indeed, the “bite us in the ass” problem will more closely resemble the “bite in the ass” one might receive from a hungry great white shark, or, maybe, a ravenous tiger.

Ragarding the magnitude of THE PROBLEM, you need honest numbers, and then you NEED TO UNDERSTAND THOSE NUMBERS! See Lawdog’s blog, here , for an explanation of testing error (false positives/negatives, and the implications thereof).

See Aesop’s articles, here, for his description of the second order effects, and how it will make a clusterf…er, HUG! look like a picnic with your Bible study group. I do not know about timing, but, based on 30 + years as an ER nurse, and a dozen as a PA, and several as a medic, well, his assessment of effects is certainly defensible. I pray he is wrong, but I do NOT believe that he is wrong. (While you are there, read his other posts, about the follow on effects, about how this has been mishandled since, oh, 20 or more years ago, and about missed opportunities).

(and, READ HIS COUNSEL [in other posts] ABOUT PREPAREDNESS, BOTH LOGISTIC AND TRAINING! AND TAKE IT TO HEART!)

Good fortune to you all, and WASH YOUR DAMNED HANDS! NOW, DO IT AGAIN! AND AGAIN!

Ham radio at Fort Custer State Park.

So, TINS©, TIWFDASL©…well, Ok, I wasn’t, really. TDW-Mark 1, our kids, and I were away on vacation, camping in Custer State Park, in South Dakota. TDW-Mark 1 had planned on a drive across the northern tier of states, culminating in a visit to Mount Rushmore, The Crazy Horse Memorial, and generally seeing the sights of Not The Un-Named Flyover State. So, there we were, cleaning up after dinner, and the air got surprisingly still, and felt, well, “heavier”. There had been thunderstorm warnings earlier in the afternoon on the broadcast radio, and I figured that a little visit to Ham Radioland was in order.

I turned the car on, powered on the amateur radio, and set the radio to one of the several Ham Radio repeaters in the area of the park. TDW-Mark 1 wandered over to see what her husband was up to.

What I was up to, was taking notes on the “weather net” in progress. There were reports of rotation on the observed thunderstorms, and occasional reports of funnel clouds. TDW-Mark 1 decided that it would be clever to get all the clean up done, and everything put away. She corralled the kids, and set them to work.

One of the other campers wandered over, likely thinking that I had found “The Game” on the radio, and appeared surprised that I did NOT have the broadcast radio on, in my vehicle.

“Whatcha listening to ?”

“The local radio amateurs are weather spotting, and calling their reports. Some of them have seen funnel clouds, others have seen rotation in some of the thunderstorms that they have seen.”

“What’s that mean?”

“That it is very likely that one of these storms may touch down, and the folks near there will have a tornado to call their very own!”

“That sounds like it could be bad!”

“Yep. That could be very bad.”

Right around this point in the tutorial on Weather Spotting In America, And Amateur Radio’s Role Therein, TDW-Mark 1 returned, both to inform me that our campsite had been battened down (or, as battened down as a pop-up camper was going to get, anyhow), and inquire as to what was my brilliant contingency plan in the event that all our little family was to be offered a trip to Oz, by Thor himself.

I had noticed, upon our arrival, that the bathrooms appeared to be very substantially built. Fine brick structures seemed well suited, in my estimation, to the task of sheltering my family from the storm. I so instructed TDW-Mark 1. “If it appears that we are going to get heavy weather, we will hit the showers, select a toilet in the middle of the building, and call it home for as long as necessary.”

“Any sign that things are heading our way?”

“Presently all the funnels, and all the rotation are to our east, and northeast, so we are unlikely to catch any of it. If they close the weather net in the next several hours, we ought to be clear.”

The other camper, overhearing all this, began to turn his head, just like at a tennis match, goggle eyed at our seemingly tranquil acceptance of the potential of holing up in a toilet against some tornado or other. “Aren’t you guys scared at all by this?”

TDW-Mark 1 had his answer. “What good would that do? He’s a medic and ER nurse, I’m an ER nurse, he’s keeping an ear on the weather for us. Tell you what: keep an eye on our campsite. If you see us scurrying to the bathrooms, gather your family and join us, because it is unlikely that we all will catch the trots simultaneously!”

The look on his face was nearly priceless.

Even better? The fact that we heard the Skywarn Net stand down, around a hour later.

Random Thoughts III

Story “A”

You may recall my delight at marijuana legalization, correct? Because, “medical marijuana” wasn’t ENOUGH of a cluster f*&k, right? Of course, there is my recurrent delight at the discretion, great judgment, and common courtesy displayed by the genuii who stroll (nay, stumble) about, reefer fumes pouring from every fold of their clothing, if not every pore, in a nigh overpowering display of Poor Life Choices On Parade.

So, TINS©, TIWFDASL© when this braniac arrived, spawn in tow. My poor clerk registered the Named Patient (actually, plural, as in both kids), and then let me know that the chart was ready for me to lay some healing upon them. As if.

So, my first clue that Things Were Not Right, was when the nominally 3 year old child, named Adam, was sitting upright reading some (non picture) book. My second clue was that the nominally 12 year old child, was around 36 inches tall, and appeared to be around 40 pounds. And, did NOT appear critically malnourished.

I asked the reading child, “Please, tell me how old you are?”

The reply was “I’m 12!”

“How old is your brother?”

“Oh, he’s 3!”

I excused myself, and asked my clerk, “Did you know that Adam is 12, and Brady is 3?”

She looked at me, and informed me, “I asked the mother, and asked her twice, which child was which, and who had what birthday. It did not look right to me, but she repeated herself, same birthday both times, for each child. That is what I put down.”

“Well, it is wrong. Please, fix it, and double check it, all over again. Please try to sort out what else she fucked up in registering the kids, please.”

Once the clerk asked the 12 year old for his school id, the mystery was resolved.

My new Life Rule! If you are so stoned that you cannot remember your own gorramned childrens’ birthdays, and you successfully mix the TWO of them up, either stay the Fenomenon home, or WRITE IT DOWN!

Story “B”

Have you heard about Homeopathic Medicine?

“What Is Homeopathy?“

“Homeopathy, also known as homeopathic medicine, is a medical system that was developed in Germany more than 200 years ago. It’s based on two unconventional theories:

*“Like cures like”—the notion that a disease can be cured by a substance that produces similar symptoms in healthy people
*“Law of minimum dose”—the notion that the lower the dose of the medication, the greater its effectiveness. Many homeopathic products are so diluted that no molecules of the original substance remain.

(from: https://nccih.nih.gov/health/homeopathy )

Let’s keep “The Law Of Minimum Dose” in mind for a moment. So, I work in an urgent care clinic in The Un-Named Flyover State. It’s….quirky. Yeah, let’s go with that. So, our cleaners are some folks who are NOT from some national housekeeping chain. I do not know where the owners hired these folks from, but, well, they are, in keeping with the theme of the organization, quirky themselves.

Over the past several weeks, I have been noticing that the hand soap dispensed from pump bottles, has been appearing clearer, and clearer. Similarly, it has seemed less viscous, and less viscous, from week to week.

In keeping with these observations, it has started to require more and more pumps to elicit enough soap to, ya know, WASH MY HANDS!

One of the MA s clued me in to what is happening.

“The cleaners never pour more soap into the dispensers, they just add water. It’s free, unlike the soap that costs.”

I wondered, out loud, “What happens when it is simply only water in the “soap” dispenser?”

She told me, “I dunno, maybe, finally, they’ll buy more soap?”

I corrected her. “NOPE! We will be told, that this is the latest public health innovation! Homeopathic soap!”

Story C

A long time ago, in a county far, far away, I was working as an ER nurse. I overheard one of the clerks engaged in a telephone call.

Now in this agency, at that time, Administration did not want us providing “medical advice” over the phone. I was on board. My stock spiel, when I was trapped into answering some such call, was along the lines of “If you think you have an emergency, you ought to come to the emergency department. If you do not think that you have an emergency, perhaps your problem could wait until (the morning)(Monday), at which time you could arrange for your family doctor to address it. If you do not think that your problem can wait until (the morning)(Monday), well, at this time of night, your only option is to come in to emergency.”

I, myself, often would be the recipient of some query at that point, along the lines of “Well, how do I know if it is an emergency/can wait until Monday?”

My answer would be “You are there, you have sense (Yeah, I was lying through my teeth!), and only you can make that determination. I am not there, and I cannot see what you can see, since you are on the scene, and I am not.”

So, I heard the clerk speaking to some Brain Truster. Attempting to explain, repeatedly, how and why she could not tell him whether his laceration needed stitching. Mr. Telephone was persistent, and I could tell, from my clerk’s responses to him, that he was saying stuff like “Well it’s (insert length here) long, and about (insert depth here) deep, and it’s (insert some indicator of severity, like bleeding or suchlike here), so why can’t you tell me if it needs to be stitched?”

She finally had had her fill of his idiocy. “Sir, what color blouse am I wearing?”

“How the hell would I know what color blouse you are wearing?”

“So, how am I supposed to have any opinion worth anything about your cut?”

Suburban Community Hospital (or) Be Careful What You Ask For!

Another time, with dispatch whimsically sending us on a scavenger hunt all over Da East Side of Da City, we had occasion to transport sumdood to Suburban Community Hospital. This was a fairly sizable establishment, even by the standards of the day, and the ED was pretty busy upon our arrival.

We handed Mr. Dood over to the nurses, gave report, and began to prep the cot for the next lucky contestant. One of the nurses ambled over, and engaged us in conversation.

“How come you guys only bring us drunks? We can handle anything TBTCIDC can handle!”

Doug spoke up. “Uh, Ma’am? That’s kind of the majority of what we bring to TBTCIDC, ya know? Most of our runs are sick folks and drunk folks.”

She wasn’t gonna let this go. “Aw, c’mon! How come we never get any good trauma! I know you guys take all the trauma to TBTCIDC! Howzabout occasionally bringing us some of the stuff you always are taking to TBTCIDC?”

We mumbled something that maybe could have been taken as assent, and she meandered off to fight disease and save lives, or something.

As Kharma sometimes deigns, our next run was not too far from Suburban Community Hospital. Indeed, the Grin of Kharma must have been epically large, as the next call was for a very drunk, very loud, very combative inebriate.

Once we had him restrained and in the truck, we conferred. Consensus was, we were about to return to Suburban Community Hospital. After all, they had ASSURED us that they could handle ANYTHING that TBTCIDC could handle.

Well, to paraphrase Bill Engvall, “Heeerrreee’s yer patient!”

When the nurses began to chastise us about our patient selection, as well as our destination selection, our refrain was, “Well, you told us that you were perfectly capable of handling anything TBTCIDC could handle! This fine young man, right here, is completely typical of their patient population!”

And, then we scurried away……

Transfer To Florida

A long, long time ago, in a county very far away, I was a nursing supervisor. I had migrated into supervision after several years as an ER nurse.

One afternoon I arrived at work, and the offgoing supervisor reported that a gentleman had been brought in and admitted for his heart attack. Now, in these far away days, there were no angioplasties, no stents. There was no TPA, no other thrombolytics (“clot busters”). Indeed, the state of the art, outside of referral hospitals, was oxygen, hydration, rest, aspirin, and pain control. We had THAT, in abundance!

So, a couple of days later, one of the CCU nurses took me aside, and informed me that this guy was, to employ her own professional and finely tuned appraisal, “acting kinda squirrely”.

It developed that the attending physician determined that this soul was both having/recovering from a MI (heart attack), but, in addition, was a florid alcoholic, and was entering into DTs. Like, classic, textbook, tachycardic, hallucinating, writhing, pre-seizure tremulous, DTs.

Simply to make everything just nice, the internal med doc that the cardiologist consulted did not believe in using benzodiazepines for alcohol withdrawal. (that would be medications like Valium or Librium, useful both for the sedating effects, as well as their efficacy in protecting the patient from convulsions that might be lethal.) No, he insisted in using antipsychotics, which weren’t altogether effective in addressing his twitching nor his restlessness. Shit.

Well, he survived all this excitement, and, eventually (like, 4-6 weeks worth of eventually) was ready to go home.

Our discharge planner discovered that our new friend was a resident of Florida which we, in The Unamed Flyover State, were not anywhere near. He had wrecked his vehicle in the initial confusion, and therefore had no vehicle to get him home. In any event, what with his MI, and his lengthy stay in Thorazine Land, was in no sort of shape to (a) drive home to Florida, nor (b) master the intellectual challenges inherent in navigating the interstate home, even if he was strong enough to physically do so, Which he was not.

Her investigations revealed that none of his family was in any sort of position to happily drive up here and retrieve him (which of course begs the question of what was he doing here, with his pleasantly confused self, something like 1200 miles from home? And alone?)

So, once the dust settled, he was still our problem, and The Suits determined that springing for a flight home would end the financial drain that he represented, since no insurance company in the Western World would pay for him to reside at the Grand Hotel De Our Little Hospital, once his medical need had resolved. I did mention that he was squirrely, right? Well, our discharge planner hypothesized that his heart attack, and DTs, had trampled his previously marginally sufficient coping mechanisms, and he was, now, fully senile. Therefore, putting him up, unsupervised, in a hotel, would not work out at all well.

So the plan was laid. Our discharge planner purchased a plane ticket. He had specifically purchased a ticket on a nonstop flight, determining that there would be fewer opportunities for him to wander off, and get lost Ghawd Alone knew where. Then, she dumped it in my lap. I called A Competing Ambulance Service, and spoke to a supervisor.

“I have this guy, and we are going to fly him home. He is not altogether there, and so he needs both supervision, and a chain of custody. The flight is at 5 pm, so I want him at the gate at 4 pm sharp. I want your crew to physically deliver him to the boarding gate, physically observe him belted into his seat, and obtain a signature as a receipt from the flight attendant who seats him. Can you do all that?”

“Sure. You just have to set it up with the airline. OK?”

“Outstanding! I’ll set it up, and call you back.”

So, I called the airline. I spoke with a supervisor, and laid out my problem, and my view of the solution. “Sure, no problem. We can do that. Anything else?”

“Yep. Can you get a receipt for my guy, from the folks who pick him up, and then call me with the fact of safe arrival, please? Then, mailing us the receipt would be wonderful!”

“Sure, can do. Gimme your name and mailing address!”

I called the Competing Ambulance Service back, and brought the supervisor up to speed. “Oh”, I added, “One more thing. We’ll hand the plane ticket to your medic, and also hand him or her the chart. That HAS to go with him, and is part of the chain of custody business. OK?”

“OK!”, was the response.

So, on the appointed day, I was at the nurses station awaiting The Competing Ambulance Service crew. Once they arrived, I reviewed all the foregoing. Both medics nodded, and one opined, “Yeah, that’s all according the the briefing we got from the supervisor. Where’s the chart, and the ticket?”

The charge nurse handed both items over. The medic made a show of placing the ticked into the inside pocket of his jacket, turning so both his partner as well as the nurse and I could see it settled deeply into it. His partner tucked the chart beneath the pillow, and they were off!

Around 1630, I got paged to pick up a phone call. “Mcfee!” was my greeting.

“Mr. Mcfee, this is Bob from The Competing Ambulance Service. My crew just radioed me to let me know that your patient is on the flight, seatbelt secured, and they have a signature form one of the flight attendants. So far, so good. That attendant has you phone number, and will phone you once he has been handed over to family at the other end.”

And, as promised, around 1930, the crew from The Competing Ambulance Service arrived, hunted me down, and handed me a copy of their trip sheet, prominently featuring the name, signature, and employee ID number of the flight attendant accepting Mr. Man for his flight.

To frost my cake of WIN!, the next day the night shift supervisor relayed via days, that our patient had successfully, and uneventfully, been handed off to his family at his destination.

Hallelujah!

“Little Mary Sunshine is NOT a Force Multiplier!”

Once upon a time, long ago and far away, I was nursing in an ER in a medium sized city. For some reason, I was unable to evade being placed in charge.

Lord Knows that I tried! While I have established that I can be reasonably effective in a supervisory role, I really do not like it. For one thing, it places me in overly close proximity to Suits. I do not enjoy proximity to suits. Hell, my Suit Aversion Disorder led me to work midnights, in the first place! (well, that and shift differential, as well as seven-on-and-seven-off scheduling, to be honest.)

For another, I get subjected to all the bullshit from other departments, which, invariably, appears to consist of interacting with slothlike souls who manifest only one burning desire: skate through their shifts, while expending as little effort as is needed to maintain their receipt of a paycheck. Notice, I did not attribute to these chuckleheads the desire to actually do something resembling their jobs. That wuld be different.

Finally, when in charge, I get to cope with all the malignant and ill considered decisions regarding staffing the aforementioned cursed suits have enacted.

So at this point I was working in a relatively urbanized area, with a sixteen bed ED, in a town with three total Eds of various sizes. We had been short staffed for an extended time. This, of course, made me oh, so very happy. Or, not. I had been bitching, complaining, protesting and generally making known that not only was this sort of staffing insufficient, but, into the bargain, was considerably short of their own goddamned published staffing parameters, written by the goddamned suits themselves, and for which I would be written up should I let someone go home leading to staffing short of these parameters.

Well, as it developed, one of the Junior Suits (our assistant director) was compelled to show her smiling face up to work some of the short midnight shifts. She was, let us say, “entertaining”, to work with. She would “help out” by triaging. Well, when you triage someone, it is helpful if you (1) obtain and record vitals, (2) ascertain, and document allergies, medications, medical history, as well as (3) history of present illness, typically elicited by asking something along the lines of, “So, Mr./Ms/Xr X, what motivated you to come out in the dark of night to join our happy little party?”. You did notice how much fun I seemed to think it was, to, ya know, DOCUMENT, the aforementioned items, right? Sort of like that was, oh, I dunno, a GOOD THING, or something?

So, it develops that Little Mary Sunshine did not document (or even obtain; it was difficult to sort that one out) vials, allergy/med/history, or present complaint information, at least, not consistently. In addition, it seems that an ED physician with, say, a dozen patients, really, really gets petulant if these items are not there in the chart to be found. Slows him/her down, considerably.

Then, there is the part about both bedding the patient, as well as noting such fact on the greaseboard, as well as reporting off to the the nurse who would, oh, I don’t know, maybe BE CARING FOR THAT PATIENT.

Finally, it was established practice to start the needful IVs, collect the blood, and send it to the lab, along with a requisition for the bloodwork the physician was going to be desiring to see. None of which had penetrated Little Mary Sunshine’s cranial vault.

She was no more helpful as a “floor” nurse, Which is to say, she would half ass do things, not tell anybody at what point she had grown disinterested and wandered of Ghawd alone knew where, let alone document anything that she, by some miracle of random happenstance, completed.

As my partner, Andy, opined, “Ya know, she is not really a very effective force multiplier!”

Much more nicely phrased than the tsunami of profanity that was boiling away, waiting for me to spew forth as my OWN opinion of her “efforts”!

So, visiting as she was from the warm climate of Daytime “Suitworld”, Little Mary Sunshine was chilly most of the time. (she might have been warmer, had she been moving about as briskly as the rest of us, but, then….) Andy, once again demonstrating the situational awareness that made him a fine nurse and great partner, noted this fact, and brought it to my attention one long, long night during a missing Mary moment.

He implemented a plan based upon this observation, and turned the department thermostat down to around 60, from the typically balmy 70 where it normally rested.

Well, time passed, Mary Sunshine wandered around, fucking things up, and soon the HVAC system equibrillated at the new set point. Mary zipped up her sweatshirt, and began to complain that it was cold.

Nice of her to notice.

Shortly thereafter, she loudly opined that “You guys seem to have things under control. I’m gonna go back into my office and do some paperwork. Call me if you need me!”

Once she was safely away down the hall towards her (independently heated) office, we returned the thermostat to the baseline setting.

The rest of the night passed as the typical clusterfuck of shortstaffed jackassery, fortunately not exacerbated by halfwit half assed managerial fumble fingering.