Um, Silly?

When I admit a patient, I ask them what they are taking. The nurse asks them what they are taking, and the pharmacist does, too. In the ED (happy, WhiteCoat?) we have a little section where we can mark their medications and enter new ones.

Then, when they go upstairs, I copy the medications from a computer onto an order sheet by hand with a ball point pen, making sure to press hard so it goes through the carbon paper. I then copy it again, still by hand, into a history and physical. Three lists and counting.

I then am supposed to copy it onto the daily progress note by hand with doses and frequencies every day even though we round with a pharmacist with a computer (who, you guessed it, has access to the computer list). I don't do this out of protest. Four lists, and counting.

When the patient gets transferred from the ICU to the floor, or from one floor unit to another, there is a transfer medication list that also gets copied onto a triplicate paper order sheet with a ball point pen, because there is no way to just, oh I dunno, transfer the list. So that's five and counting if there's a transfer.

Upon discharge, the nurse prints a form that has their before admission meds and their inpatient meds as well as a new place to write discharge meds, so we'll call that six. The nurse is then supposed to copy, by hand, that list onto another so-called 'RN discharge'. That's seven. I then dicatate, hopefully from one of these reliable lists, into a discharge summary that is on a different system and not automatically correlated with anything. We'll call that eight.

Eight medication lists for every hospital admission, seven if there's no discharge or transfer. If someone comes out of the ICU and then transfers at all it's up to nine. They all live in different spots. There is no automated updating except at that first step, when there's an EMR.

I know White Coat just posted about a place that uninstalled it's EMR because, admittedly, garbage in is garbage out. But what is garbage copied eight different times, with lists as long as 30? That's, hmmm, 240 chances for error. All in the name of reducing errors.

And we chide our patients for not knowing what medications they're on. We probably don't know, either.

Gassed Out

I have any number of ideas about what to write but I am truly spent, good hearts. I am browning out. It's slower than burnout. I walk slower. The coffee isn't as good at 5 am in a nurse's unit as it is at 7 am on a beautiful morning on the patio with the kids. The iPod works but I get tired of walking the hospital stairs as my only workout, and listening to lectures while filling out forms as my only mental stimulation.

It could be worse, mind you. I have my health. We have running water, plumbing, heat, and food. There's no nearby war. I haven't lost my job or my house. But...

All of us on the current service have our own short-timer's calendar. Somehow we're all looking forward to the 20th because the 20th seems a manageable amount of days away from the end of the month, but that's only half-time, and then it's on to another month of call and scut, then another.

I'm tired of having my family and my relationship come 5th of 5 on the priority list so we can walk around and discuss oral versus IV magnesium supplementation and when to make so-and-so NPO for the cath I won't see except to document normal pedal pulses four hours after return.

This isn't a sarcastic hate the world post, a lot of patients are decent and I'll try to post about them, it's just that I'm 'all done', thanks, as my son would say. All done.

Jaded, Redux

A confidante noted that I've gotten sarcastic. It's a weakness of mine, brought out by paperwork, long hours, and stress. On the way in from the parking garage, though, the birds were chirping, the sun was shining, and the helicopter landed right overhead, which, call me crazy, has always reminded me why I love this job.

Intern year, I will yet conquer thee and remain at least somewhat compassionate. But thanks for the reminder, I need it.

Pearls Before Swine

Which is more--twenty or thirty thousand, or fifty-nine?

The first is the approximate number of deaths over the last few years, per year, from 'influenza and pneumonia', one of the top ten killers in the country. The second, of course, is the number of deaths from the virus formerly known as swine flu, now known as H1N1 flu, which, though unreported, is also the antigen configuration that makes up a goodly portion of the seasonal flu. Now, I'm no public health guru, I'm just a simple resident. Somehow, though, those numbers call recent calls for global action into question just a tad.

We all love a crisis. Me more than most, apparently, since I picked a job where 'crisis' is part of the daily routine. We're good at it; we can pick a discrete enemy to fight.

I must say, though, that the reaction to this pandemic has been just a trifle ludicrous. Fifty-nine deaths? Really? Schools closed, flights diverted, billions of dollars, for fifty-nine deaths?

Not to mention the ED overload with people spreading whatever other gunk they had to each other in order to get tested for swine flu. Awesome. Sterling.

The public health departments actually did the job they were supposed to. They performed surveillance on a new threat and quickly tried to characterize it's mortality rate and epidemiologic characteristics. This work has to, by nature, be paranoid. It's the job of those of us watching and interpreting to avoid mass hysteria, and in this, we failed. I blame mostly the media, frankly, and Joe Biden for good measure as a proxy for elected leaders.

Oh, there's a new virus? Let's cover it for ten minutes of every hour of every day for weeks on end, close schools with no cases, and generally freak out as if the world is ending and make sure people know it COULD HAPPEN TO YOU AT ANY SECOND, especially if you happen to have Mexicans in your neighborhood or even in your time zone. Oh, wait, that's all of us.

Where are all these people for the ongoing threats we have to face on a daily basis? Where's the call for clean water worldwide? Where's the call for increased flu vaccination coverage, which is almost always woefully abysmal? Where's the call to stop diarrhea? Where's the call to actually, shock, have a helmet law or make drunk driving illegal to reduce accidents (no, it really isn't illegal, first time, in some midwestern states. It's a citation). Hmmm, must be too busy spraying down the playground equipment with powerful cleansing agents, because that will somehow stop the kids from sneezing on each other when they come back.

Seriously. Hissy-fit extraordinaire.

Non-Compliance

We have a guy right now that's got it all figured out. He has heart failure, and some sort of cardiomyopathy that keeps his heart from pumping well, and in order to treat this, we need to help him remove more fluid than he takes in, preferably rather quickly so he can re-equilabrate. Simple, right? So why does he roam the halls at night drinking tons of water from outside his room and stealing other people's food?

On the surface, it would seem mad, but deep down it displays the hallmarks not of madness but of mad genius. Each time someone tells him to be compliant, he says, oh, yes, I know, bless you, I'll do better. And then each night he goes and drinks more. A styrofoam cup filled with hospital ice here, someone's leftover milk carton there.

You see, if he's in the hospital, he has free TV, a comfortable bed with housekeeping, a nurse to help him take care of everything, and he gets to stay away from work because he has a decompensation of a serious medical problem. It's a five-star hotel with a craftmatic adjustable bed and an on-demand minibar of narcs.

The team this morning noted, accurately, that even if we discharge him he'll be back in the ED in a couple days 'feeling puffy' and wanting admission, so if we kick him out, he just becomes a problem a few days later for someone else.

Where's our out? Here's the mad genius part. He never openly defies anyone, and he never asks to leave. He says he wants to get better. This takes away the option of letting him leave against medical advice, one out for a troublesome patient. But he doesn't want to leave.

He's always pleasant to the attending and usually to the resident, and always agrees that his health is important, and that he has to save his urine so we can measure it and comply with the fluid restrictions ordered. Thus, we have no options we normally have with a defiant patient. We have no way to restrain or sedate him, or put a catheter in him to measure the urine output he refuses to save. We literally cannot force someone to get treatment unless it's an 'emergency', which, currently, it's not. Further insight can be gained through his one persistent request: a disability letter so he can get out of work. He knows the hospital gig is limited, even in the current climate. He has to have a long-term retirement plan. He's found the gravy train, and it's us. He's playing us. The team knows it.

Our system, for all it's good intention, facilitates this cycle. He has to be seen if he comes back to the ED even if we kick him out. We know if he leaves he'll just drink, do cocaine, and eat salty foods until he 'decompensates' again. I suggest a sitter to make sure he stays in his room, and I'm told that we don't have the staffing for it, because apparently it's better to just have him in the hospital for an endless amount of time. He's totally non-compliant but pleasant, thus we continue, night after night, him wandering the halls undoing everything done during the day. He's been here for almost 2 weeks, and another hospital before that, working on getting his disability in air-condintioned comfort, with top notch nursing staff and a team of dedicated doctors.

It's good to know that if we kicked him out and he got really sick again, there would be a wealth of potential legal advocates to represent his interests. It's great to know that our system supports this poor gentleman in such dire need. God bless America.

Twitter

As you can see by my sidebar, I'm not too sure about what to do with Twitter. My phone is too old to work with it, and me sending updates would be mind-numbingly boring, i.e., going to work, coming home from work, going to work, eating, and so on. If anything actually interesting is going on, I'd better not be twittering, but standing somewhere trying not to pee my pants, remaining outwardly calm, and running the ACLS algorigthms best I know how. So for now, I'm going to try and set a record for longest time between Twitter posts. If I ever get a new phone and a life, we'll see. Sorry. New post below.

Too Many Acronyms

AF w/RVR + AS.

One of our staff calls up from the ED to the floor (gag) where I have to work for three more long weeks with an 'interesting case'. A fib with RVR is common; my first week, we had, like, seven of them, old people with underachieving, scatter-brained atria fibrillating away and ventricles that responded too quickly, leading to usually mild badness like relative hypotension, shortness of breath, weakness, and so on. This one, though...

He came in as a trauma, having fallen off of his bike. EMS did CPR for 'a minute or two' with a stated GCS of 4 initially, and then 9. He was hypotensive with an irregularly irregular pulse, and a harsh, mechanical murmur over the right and left chest. He had old, old fistulas on his right arm for dialysis.

Now A fib doesn't seem so benign. The irregularity keeps the ventricles from being able to pump well; first, they're chaotic, and second, they lose the 'atrial kick' that is often needed to fill them. This gentleman's murmur sounded like aortic stenosis, adding one more problem; the same ventricle that lost it's sidekick atrium also has to push against a tiny, hardened valve.

He comes to the ICU with a rate of 150 or so, and a pressure of 70/48. He won't answer me. He won't open his eyes. He won't do anything. He also doesn't respond to pain. But he's breathing. Thank goodness my ED staff from the department had warned me that he's got mental retardation, too; and thank goodness his mom was there to tell me that he hates hospitals, and ignores everyone. If I hold his eyes open, he looks at me. Cautiously, I decide that he's wide awake, just faking it. Usually this doesn't bother me to assume, but when his pressure is now, hmm, 72/50, it makes me nervous.

What to do? He gets a fluid bolus. He gets pads put on. Now I'm stuck. If I give him too much fluid, that floppy heart pushing against the valve will get filled like a water balloon and lose it's strength from being stretched. The rhythm I can try to fix with a shock, but I don't know if he has a clot in there that could shoot up into his scon-box and infarct a bunch of brain. Even if I shock him, he has a fixed outflow obstruction from the valve--a class of problems that can cause shock because blood is blocked. Other similar lesions include massive PEs, and tension pneumothorax, although the obstructing mechanisms are vastly different. He has two IVs, so we just watch him. Watch him, and worry.

I start explaining to his mother how he'll probably need surgery, and he yells 'no!' from the bed, then 'no, no, no!' just to make sure. Ironically, he looks strikingly like a bald Dustin Hoffman, making the comparison to Rain Man complete. I feel much better with my retarded, hypotensive, irregularly irregular, stenotic, and syncopal patient who is now vociferously negative. Thank you for your lack of cooperation, sir. Keep it up.

Review his labs; the EKG is irregularly irregular but no ST elevations; the chest x-ray, unfortunately, has a hugely wide mediastinum, but 'no!' is also the answer to my inquiry about chest pain, so perhaps this can wait. His troponin is 0.5, which is elevated but not yet in the NSTEMI territory (that is, he doesn't have a heart attack, yet).

As the Fat Man says, the delivery of good medical care is to do as much nothing as possible. So we do nothing. We watch. We wait. And at 7 am, when the team arrives, and the post-call sigh of relief occurs, my retarded, stenotic, hypotensive, irregular, contrarian friend is in a regular rhythm (on his own), has a pressure of 94/62, and still shouts 'no!' whenever surgery is mentioned, now opening his eyes and sticking out his bottom lip to make the point. More to come. I want to see that valve when it gets hacked out (he NEEDS it).

Communists

The old demented Lithuanian is upset because I wanted to get an EKG for his heart block and bradycardia. He gets upset. He gets ornery. He raises his voice.

'Ah, you,' he says, 'you're a communist, aren't you?'

'You forgot your Red Star.' 'Where are we?' I ask.

'Where are we? Hah! You know! Where are we!?' OK, so it wasn't the most delicate way to ask about orientation. I think I know where he is; thirty years ago, in some Gulag. It dawns on me that this may be very real for him, and the EKG pads, Lord knows what he thinks those are.

I go sit next to him. 'How can I make this easier for you?' I ask, since he's been roaming the halls, and since we can't give haldol to someone in heart block.

'I don't have to talk to you,' he says. 'You're nothing.' It makes me wonder about his story. But since I don't have my Red Star with me, I suppose I can't very well interrogate him.

Like Butter

So far, I've had three really sick people this month--one sepsis, one status, and one angioedema. At the end of each, the staff has said it went smoothly. The last one even said, 'from my perspective, that was like butter'.

Which reinforces my sense that, if an Emergency Doc knows exactly what's wrong with you and knows exactly what to do, you're a sick, sick puppy.

All those other folks that confuse the heck out of me with wierd shooting pains in their foot and some shortness of breath and a headache and oh, yeah, I'm sleepy--nothing too terrible seems to happen to them.

"Then You'll Get One Case..."

Staff and I were sitting at the tracking board when a new patient popped up, that I signed up for. The chief complaint was 'allergic reaction'.

"That should worry you," he said. "You'll get all these people with rashes and minor stuff and you might get cavalier, and then you'll get one that's true anaphylaxis, or true angioedema, and from then on that chief complaint will cause a lot of sphincter tone." We walk to the room.

He draws back the curtain and the lady's lips are HUGE, both of them. He turns and says to the nurse, benadryl, cimetidine, and solumedrol, please...no audible stridor but she is uncomfortable, worried.

0.4 mg of epinephrine, 1:1000, IM, is given. The language phone reveals nothing--no known allergies, no medications, no recent changes. Her hands are swollen, as well, and she has hives on her chest. No wheezing. Still no stridor. At the end of the phone call with the translator, through which she has said nothing as her cousin translates because she can't talk, she says, 'my throat feels tight'.

She is wheeled back to the trauma bay, where we do all our airways and lines, nurses hurrying, which is often a great predictor of how sick someone is. Surgery is there with three other traumas but the trauma chief is very intent on this lady. Another predictor of how sick someone is.

I am tempted to ask if this is a 'learner airway', but it's assumed that I will take it. I've seen her posterior pharynx, it's not swollen, she's young, it should be easy, but the impact of lips the thickness of two fingers across each is daunting. The trauma chief has the cric kit and is gowned.

Etomidate, sux, and I walk the mac blade down the center of the tongue, posterior pharynx, epiglottis, and a grade I view of the cords at which point I know she's safe because if I can't get it someone will, then the tube is passed gently, and she's truly safe. All over but the sedation, and the workup. No labs ever drawn. Under it all, she was an easy airway--which means we did it at the right time.

These are rare. I remember those prophetic words--you'll get cavalier, and then you'll have one...