Seeing Zebras

Which is more interesting...or at least more entertaining?

• A GI doctor diagnosing and treating labyrinthitis? OR

• His partner proclaiming, "It's the fucking flu!"
  

Swine Flu Vaccinations -- A Day in the Trenches

I spent some time helping vaccinate kids for the local school district. Some observations:

• Afternoon is rough in the elementary schools. The pm kindergarten kids walk in the door smiling, all fresh & shiny. Once they learn about what's in store for them, their eyes turn into sauces, and they look at you like you're the devil. Of course, once it's over, most were easily plied with stickers & a snack.

• The hardest to vaccinate were the ones who had Mom there for emotional support. Stage 1: Rational Discussion -- The more Mom tried to talk them through their fear with rational discussion, the more they feared the inevitable. Stage 2: Bribary -- The little buggers never fell for this ploy. It might have worked if Mom had the bribe ready & within view, but no such luck. Stage 3: Threat -- During this stage, Mom underestimates baby girl's intelligence. She KNOWS that you already bought the Miley Cyrus tickets, so the threat of not going is a bit hollow. Maybe if you had held firm on punishments in the past, this stage would work. Stage 4: Force -- This is clearly the stage we've been working up to. Had Mom just given baby girl a great big bear hug in the first place, we'd have gotten things over with and moved along to stickers & snack. Unfortunately, Mom feels guilty at this point, so this stage drags out longer than necessary. Every parent should learn the basket hold restraint -- and don't forget to get that head down, or you'll get a broken nose.

• My son was right -- the assistant principal at his middle school is truly whacked. She meant well, but she was more dramatic than the kids. Plus, she must have never learned to avoid interfering with a nurse in action. I had a system for dealing with nervous kids -- worked like a charm every time. She had a system for talking over me, lying to them ("this won't hurt!") and making them more nervous. Plus, she didn't win me over when she loudly stated, "He is autistic!! We don't want him to act out!" Uh...dude just wanted some details, and he wanted to watch. Not a problem - once I could talk to him myself.

• The high school boys were motivated by one of the following: 1) reading the potential side effects and using them to get out of class, 2) impressing the girls with how cool or funny they were, or 3) getting sympathy from the girls by acting fearful (in a humorous way...).

• I learned from the school nurses that frequent fliers start at a young age. Instead of getting out of work, they have symptoms to miss class or go home early. Instead of being narcotic seeking, they have to settle for Tums or Tylenol. One such young man made himself known during vaccinations: "Mrs. HS Nurse, I'm feeling dizzy. You got some Tylenol or something?"

• I only tortured one young man. My usual method of needle insertion failed miserably. His muscle must have still been tense because the darn thing felt like it was hitting a wall. After that, I made sure that every muscle was LOOSE...
  

Fun experiences, but I was happy to get back to dealing with adults.

A Need for Fresh Air

Young, whiny Dude: Can I go outside? I really need some fresh air.

Me: No - you're hooked up to an IV and telemetry - you'll need to stay in the hospital unless the doctor says we can unhook you.

Young, whiny Dude: Ohhhh...but I really NEED fresh air.

Me: Are you a smoker?

Young, whiny Dude: Yeah.

Me: Uh, no...go chill out until the doctor rounds, because I'm not making a phone call so that you can have a smoke.

Young, whiny Dude sulked back to his room. He found an outlet for his nicotine jitters, and it wasn't a nicotine patch. The aide reported that his girlfriend took him to the bathroom, locked the door, and gave him a "sponge bath." Time for dude to go home.

Quote of the Day

Family Dr.: I'm concerned about the surgeon's orders. Can you call and talk to him about my concerns?

Stupid Doctor Tricks

I was having trouble waking up this morning, sipping coffee throughout report, nodding my head as I took notes. Once we reached the last victim, I mean patient, I was jolted awake. Recent chest xray found increasing CHF. His lungs had crackles, audible wheezing, and he was coughing. I was told that Dr. Meek believes that the patient is dehydrated, not in CHF. It took a long time to pick my jaw up off the floor. Check the chart, no BNP ordered. Time to make some phone calls to Dr. Meek:

Nurse DT: Can we draw a BNP?

Dr. Meek: yes, but I feel that the patient is dehydrated.

BNP = 1420 Another call to Dr. Meek.

Dr. Meek: oh...okay...

Nurse DT: I was holding the IV fluids you ordered. Can I cancel that order?

Dr. Meek: oh, yes, and write that order was not initiated. Uh, yeah...no problem there.

Nurse DT: Would you like to order anything else, maybe some Lasix?

Dr. Meek: no, I believe that the patient is dehydrated.

Note: BUN = 33, Creat = 1.1. I may be just a nurse, but last I checked, an elevated BUN can be indicative of CHF. The creatinine is barely elevated.

Echocardiogram was ordered -- can't wait to see those results.

"You're the person who keeps the doctors from killing me"

The title is a quote from my favorite patient of the day. He was a patient of Dr. Knight, so he was in good hands. But, even a good doctor is only human, so being an assertive and attentive nurse is important. Some examples:

• Told in report that TSH = 0.03 (well below normal). The weekend doctor didn't make any adjustments in the patient's synthroid, nurse didn't ask him about it. No mention of lab value in progress notes. Synthroid given for the day, so no point in calling that evening, but note left for doctor's attention in the am. Synthroid lowered. Primary care MD rounds on Monday and increases synthroid to original dose. D'oh! Call him up, back down it goes.

• Young GI patient has been on telemetry for days, running sinus tachycardic in the 120's at rest, 150's with mild activity. No cardiology consult. No TSH level. No EKG. Again, asked & received. Though, the initial response I was given was to discontinue the telemetry.
  

• GI bleed patient has order for 2 units of blood to be transfused for low hgb/hct. Levels were low, but not critically low. Patient was asymptomatic. One unit had already been infused when I received report. Blood pressure was creeping higher & higher -- no bp meds on board. Scheduled for endoscopy that morning. Call & receive order to cancel second unit & bp meds ordered.

• Patient has been experiencing unrelieved back pain (on top of other, more urgent concerns). We had some heavy duty meds on board to treat it, but they doped her up, leaving her sleeping most of the day. Asked if a lidoderm patch would be a possibility. Worked wonderfully! As a result, patient responded better to other interventions for primary concerns.
  

None of these examples are life & death issues. Passive nurses would have let each one slide by, going with the flow. Routine becomes their priority. Assess, pass meds, chart. No time for thinking. What's the point of telling me in report that TSH is low if you're not going to do anything about it? It's meaningless to repeat that number just for the sake of showing that you looked at labs.

We're taught to use critical thinking rather than just accepting the orders we're given. I realize that I only have a fraction of the knowledge/training of these doctors; but I spend more time with the patients, and feel that it's my job to point out problems. These moments end up being great learning opportunities. If the doctor agrees with my concern, this reinforces the thought processes that got me there. If the doctor disagrees, I ask for the rationale (respectfully -- to learn) and learn more on the subject. I have yet to have a doctor upset with me for asking questions. Most seem to appreciate the opportunity to teach.

Academy Awards -- Seizures

And the Academy Award for Best Actor goes to........................the patient behind door number 1. He managed to occupy a hospital bed for many, many days while test after test, and doctor after doctor tried to determine the origin of his seizures. Sure, many suspected they were fake, but this was CYA medicine at its best.

Best Supporting Actor is..........................Mrs. CoDependent. Mrs. CoDependent is fake seizure guy's wife. She LOVES spending time at the hospital. LOVES chatting with the nurses about her husband's many health problems. LOVES hanging out at the nurse's station, trying to schmooze the staff. Oh yes, she has a lot of time & effort invested in these "seizures."

Ah...but yours truly should have received an award for spoiling this plot. Fake seizure guy is hooked on narcs due to chronic pain. I noticed that a "seizure" came on minutes after I refused to push dilaudid at his request. My response? Pretend to prepare a syringe of ativan, tell him that it would help him to relax, and push normal saline into his IV. The placebo worked. Plus, I documented every last motor movement that proved that they were psychogenic seizures. Psych placement requested, case closed.

I do believe that he had some major psych issues, and hope that he gets some real help. It will only work if they sort out his wife's issues as well.