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I try all I can, what more is there to do?
Why, lets intubate! And get a ventilator too!
One Pressor, Two Pressor, Three Pressor, Four
There's nothing left to pump into you any more
Five fluids, six fluids, seven bags and eight
yet your foley output shows naught all night.

You lie there listless in bed
and here I am at my wits end.
Surrounded by all of modern medicine's marvels
and with nothing to show for all our travails

The only saving grace, if any
Was that you passed from this world surrounded by family
As cruel and abrupt as was your passing
I can only hope the final battle was worth the living.

I'm tired. My feet hurt. My back aches. My mind is fatigued.
And yet, the thought remains - "what if I'd done this or that or something more?!"
A wise colleague imparts sage advice
"Hindsight never resurrected the dead"...

... and then after a pause, added:
"Go home! Get some sleep. I'll see you back tonight..."

And so I go home to toss and turn
and snatch fits of sleep
For return I must in the morrow
back to earn my keep.

To dance that dance once again
Against that ancient and final foe
We may win or we may loose
But the dance is one we cannot choose

- © Spook, RN [June 2009]

Die erste Pistole

About 10 days ago, I walked into my local shooting range and put down 500 smackers for this little beauty:



The Smith & Wesson M&P 9 9mm semi-automatic pistol. Truth be told, I wanted the Beretta 92fs but apparently there's a serious shortage of Beretta pistols. I also liked the CZ but going by the advice I was given (stick with "tried and true" brand names for your first pistol) - I decided on the M&P. And I gotta say, them interchangeable back-straps was a big selling point to me. The ergonomics of the pistol is superb (which is another reason I really liked the Beretta and the CZ - the "feel").

So yesterday, I went over to the range and sent 200 bullets at this target:



Yes, yes. I know. My aim sucks (12 yards). But that's the whole point of buying the pistol - gotta work on that aim!

All in all, I'm one happy little boy.

Next up:
M1 Garand
Beretta 92 fs

Gotta start puttin' in some overtime at work! :-)

I curse the fact that ...

... my iPhone can't record video and I didn't have my camera around.

I was walking out of the locker room headed toward the ER (ED if you are... well, you ought to know by now) to start my shift when I heard the unmistakable sound of a piano! Our hospital foyer has a grand piano but to date I always thought it was just for show.

My curiosity piqued, I mosied over. And what a sight to behold!

One of our Urology docs was belting out a kick ass rendition of "Bloody Well Right" by Supertramp! Right there in our hospital foyer. He had this big, silly grin on his face as his fingers danced over the keys.

I just had to walk over and ask... I mean, I couldn't believe my ears!

"Hey Doc! 'Bloody Well Right' by Supertramp, right?!"
He just looked at me and nodded, that grin still plastered on his face. He was obviously enjoying himself :-)


So that's that. Along with Uro Doc, that makes 6 other people (other than myself) that I know of, who have heard of Supertramp and who obviously like their music.



Holla at all you Supertramp fans out there!

Confession...

I just rediscovered "Swervedriver"... and fell in love all over again.

The live version of "Duress" absolutely kicks ass.

That is all.

Notice to all current owners of handguns...

EDIT TO ADD:: All future readers of this post, disregard the "(note: concealed/open carry is not an option in my State)" part of the following post.

In other words - I'm looking towards your opinion regarding your recommended "carry" weapons (be the concealed or open); or otherwise.

Thanks!



In any case, here's the original post ------
... that means YOU AD! And LawDog! and... all others :-)

My permit has finally arrived.

Here's the deal -- I'm having a SUPER hard time picking out what I'd like to own (note: concealed/open carry is not an option in my State).

I'm looking for something self-defense-ish (but not limited to). I've shot/tried the following -

* S&W 14 6" barrel 38 special
* S & W M&P (both the 9mm and 0.45 - I prefer the 9... didn't like 45 wasn't too comfortable)
* Colt M1911
* Springfield XD
* Sig Sauer P220 (have to re-evaluate this one)
* Glock 19

That's about it... I have a 90 day window period.


Please recommend your favorites and why.
Oh and anyone who can recommend a place I can get my hands on a good M1 Garand, please let me know!

Thanks!

The Med Error

My first med error (and as things go in ones career, the one I VIVIDLY recall the most) happened when I was orienting on days, my first job as a brand spanking new RN on an extremely busy ortho-neuro-gyne-med-surg floor (years later, my co-workers and I took to calling our unit 'The Dump'. Anyway...)

I had an absolute KICK-ASS preceptor who'd been working there for decades. She was smart, talented, hard-working, dedicated and blessed with a dry sense of humor She rode my ass mercilessly all shift long, every single day at work. Her simple rationale: "I'm not trying to be a 'nag' but I'm trying to give you an idea of how really hard this job is. Make use of me, my time and expertise the best you can NOW... because in 6 weeks or less; you'll be ON YOUR OWN".

She scared me poop-less.... but she also made me sit up and take notes.

Now, all "background story" aside:
I was on my last shift of week 3 of orientation. I had a 79 year old post-op ORIF of the Left ankle. I'd gotten through the initial 4-hour period window of post-op patients with their constant monitoring... heck, I'd even gotten 70% of my documentation done. I grinned to my cocky self and thought 'this is going good'.

As are many patients who are post surgery, pt. developed nausea and vomiting. There was a standing order for Droperidol (Inapsine). I drew up the right amount, checked it against the MAR, and showed it all to my preceptor before walking into the pts. room to administer it.

I administered the dose with no hassle, flushed the port and after reassuring the family that the medication should help, left the room to chart.

15 minutes later, as I'm walking by the pts. room, I notice that she seemed drowsy. "Maybe pt. is just tired." I told myself; "After all, pt. has had a long day." I congratulated myself on the quick intervention to resolve pts. nausea/vomiting and my head ballooned with grandiose ideas of what a 'kick ass nurse' I was going to be.

Well, as they say - pride commeth before a fall.

Half an hour later, as I was walking by rounding on my patients, I noticed that the pt. I'd administered Droperidol to seemed to be in a REALLY DEEP SLEEP.

My "still-cocky brain" somehow managed to tarry a tad bit longer to ogle its fine work. Ahhh, she's resting so comfortably....
That was when the "other" brain's screams became more audible.... "she's not breathing! She's not breathing! She's not bre...." (and so on)

!! PANIC !!

Klaxons went off in my "cocky brain" and my bladder did it's best to burst past my sphincter and empty itself in a glorious waterfall onto my shiny new white scrub pants...

I somehow managed to "rush into the room" while also not outwardly appearing to "rush into the room". My mind was racing the speed of light and winning, while all my lungs could do was echo the "Oh my god! Oh my God! Oh my God" chorus... as my heart proceeded to jump out of my mouth and take off for parts unknown.

Outwardly, while I did my best to not appear to be the nervous debris that I was, I attempted a feeble smile at the family as I managed to croak "I'm just here to make sure XYZ is all right"... while my stomach was doing somersaults worthy of an Olympic gymnast medal.

The pt. was a 'little hard' to arouse. But to a noobie nurse like me, anything less that "full arousal" was = "comatose". Even though my heart was incognito, I could feel its rate climb into the Ionosphere. A cold, icy ball materialized in what was left of my stomach....

"Cocky-brain" had been replaced by "Panic-brain". "I killed the patient" seemed to be the medley of the moment - interspersed with "you are an idiot" and "how stupid of you" and various other choice epithets [I'm omitting a few phrases (ok, LOTS of phrases)]....

Miraculously, from somewhere in the depths of my foggy (non panic-ky) brain, I latched onto an idea. I walked outside and brought back a portable pulse-ox machine. This way I'd have an idea of the pts. heart rate and oxygenation while I manually counted the respiratory rate and the blood pressure.

My initial readings were fairly "normal" (i.e. not too deviant from pts. known baseline and previous vitals)... save for the respiratory rate. For the rest of the shift, it hovered around the 12-14 mark (while the other signs stayed stable).

For the remainder of my shift (6 hours), I was in that room as often as I could (sometimes as often as every 5-10 minutes).

Throughout all this drama, my preceptor kept mum - except to encourage me to check in on that patient as often as I could while also hounding me about my other patients.

By the end of that shift, I was a wreck. I was convinced I'd nearly killed the patient. I had worse than a "lowlife no good slacker" opinion of myself. My report off to the night shift was very somber and gloomy.

As I plopped my weary butt down to chart after the shift, my preceptor mosied over and nonchalantly said "you want to talk about it?"
Dejected, head downcast, I mumbled "I'm so sorry. I don't know what happened. One minute pt. was fine but the next minute.... well; I don't know what to say!"
She simply asked "Well, what do you think happened? What do you think caused the pt. to become that way?"
"I really don't know", I stammered. "I wish I did!"; I said, somewhat emotionally.

"Walk me through it. Walk me through your interactions with that patient during the shift".
And so I proceeded to describe it all, in painstaking detail.

"Do you think any of the medications you gave the patient over the shift might have caused that?"

*Blink* *Blink* "Why, now that you mention it, the whole damned business started after I medicated the pt. for nausea!"
"Well, what did you give?"
"Inaps.... wait a minute!"
"How fast did you give the Inapsine? Did you give it slowly over a good 1-2 minutes?"

I thought real hard. And then it hit me - in my eagerness to relieve my pt. of nausea/vomiting; I might have slammed the medication in too fast. 0.625 mg didn't seem like "a lot" to my dumb-brain... but I'd forgotten to take other criteria into consideration. Not to mention the cardinal sin of administering a medication I wasn't too familiar with - especially with regards to effects AND side-effects.

My face turned a beet red: "I... uh... might have... ummm ... given it a little too fast".

My preceptor smiled and winked at me and said: "Lesson learned".
I was thunder struck!! "WAIT!", I sputtered; "you KNEW all along??!! WHY didn't you tell me???!!!"

"Because I'm here to teach you and you're here to learn. Knowing you, I'm rather confident that after today - you will never give any medication without knowing what it can and cannot do... and how to give it appropriately. Being a nurse is more than charting meds and giving them as ordered - as you've no doubt learned today."

She then reached over and patted my back and said: "Don't beat yourself too much over it. I was observing the patient all along too. Your subsequent reaction to the patient's status is commendable - if a little inefficient. But, you're learning and you attempted to do the right thing; which is what counts any way. Someday, I'll share my own 'learning lessons' with you. But for now, finish your charting and I'll see you tomorrow".


It has a mark left in the only place that counts. No matter how old or how experienced you get...
You never forget it.

"Old Lady With The Low Heart Rate"

I think this one is one for "the books". Y'know? The 'stash' of interesting patients/encounters that you file away some place?

Last week I was assigned to one of our two "Acute side" pods [2 nurses to deal with a theoretical 8 beds.] Naturally, given the state of Emergency Departments these days, those "8 beds" can 'stretch' to 12, 14 or 16 (this is the "acute side", mind you) depending on how many patients you can cram in before you're 'forced' to go on Divert... and of course, you don't get any additional "help" when you're over loaded. Management seems to think that it's ok to staff 2 nurses to 8 beds even when 6 of those patients are on vents...

... but I digress.

Anyway, my partner and I are already dealing with 13 patients (6 in rooms, 7 in hallway stretchers - some "sharing" hallway assignments) when we're curtly informed by the charge nurse that one of our room patients needs to come out because there's a lady out in triage with a "low heart rate and no discernible BP".

My partner and I look at each other and practically play 'Rock, Paper, Scissors' to decide which one of our "critical patients" in our rooms has instantly become 'less critical' so that they can sit out in the hallway while we treat this new patient emergency....

Ok, Ok. Just kidding. We pulled one of our semi-stable chest pain patients (the one we deemed to be at the lowest risk of all our patients) out of his room to open up a spot for our new patient (but we DID play rock-paper-scissors to decide who would pick up the new patient and I DID lose...)

So I walk into the room as the triage nurse and a tech assist the patient to the stretcher. I introduce myself to the patient and her husband (they're both about 90+ years old) and I note that the patient can still walk, albeit with assistance... and that she's still talking.

Triage had told me that the patient's HR was about 30 bpm and she couldn't get a BP.

Not the kind of behavior I'd expect from someone with such a low HR and no BP!, I thought to myself.

As she was settling in, getting undressed and hooked onto the bedside monitor; I asked my questions while surreptitiously assessing the pt. Radial pulse indicated a HR of 28. To confirm, I checked a carotid... also about 28-30 (with super-long pauses between beats). I used my stethoscope to check out her lungs and heart sounds - nothing exceptional other than her irregular bradycardia, with long pauses.

I did a manual BP - she was 55/20!

But she's sitting up and talking to me! Her only complaint is "feeling a little dizzy, like I've been feeling off and on this week except tonight it got worse".

Well, I'll say!

Of course, while this was going on; other things were stepping into high gear. Someone showed up with the EKG machine, someone else started hooking her up to the bedside transcutaneous pacer and a paramedic student started looking for a vein for an IV in her arm. I requested that he get an 18 gauge in her Right A/C and to come grab me if he had any trouble.

The patient shoo'ed all us 'men' outside (especially her husband) as we were trying to get her undressed for the EKG/monitor. She managed a wry smile and said "even after all these years, I'm still modest about myself around him". That elicited a chuckle from the two female techs and a grin from me.

"Well, you got nothing to worry about from us M'am. We'll make sure he doesn't catch a sneak peak", I said with a grin; which elicited a good belly laugh from her.

I figured it was time for me to step outside and talk to the husband.

"Hi Mr. Smith. While we're getting your wife settled in, I'd like to tell you what we're planning to do. First we'll hook her up the the bedside monitor so that I can keep an eye on her heart and other important signs even if I'm not in the room. Some of my colleagues are going to do an EKG, a simple electrical "picture" of her heart to see if there is any abnormality. Other colleagues are going to start an IV on her and draw some blood at the same time to test and see if she is or has suffered heart damage in the near past.

Do you have any questions so far?"

"No, I don't", said Mr. Smith.

"What I'd like to ask you though is your perception on things", I continued; "What made you bring her to the ER tonight. Has anything changed over the past week or was it something that happened tonight? Were you engaged in any activity which is not the norm for the two of you? Any strange/different food or drink? Medications?"

When I mentioned medications, Mr. Smith calmly tells me, "I think she took one too many of her BP meds. That explains her symptoms and her bradycardia. I don't think it's anything serious but given her bradycardia, I thought it best to get it checked out".

Now, normally, I don't have 90+ year old gentlemen use the words "symptoms, bradycardia and BP meds" in the same sentence... much less articulate them in a manner as to suggest a medical diagnosis!

Before I could ask the husband where he learned them neat words, out comes the paramedic student with a grin on his face as he hands me a bunch of vaccutainers containing blood samples. "Here you go Spook! 18G in the Right A/C, just like you requested".

As I was thanking him, the student turned around to face the husband and exclaimed, "Mr. Smith! Say, you wouldn't be the same Mr. Smith who was head of cardio-thoracic surgery at Sprawling Metropolis Trauma Center, would you?! I've heard so much about you! My Dad was a paramedic and he used to talk about you all the time!"

I swear I saw the old gentleman in front of me *blush* and mumble, "Yes. I was. But that was a long time ago".

Well, that probably explains him knowing all them words, eh?

Right when I was about to say something, the tech walked out with the 12-lead EKG report. I quietly stopped her and took the paper copy of the EKG to show it to Mr. Smith. I let him take a quick look at it, before I hurried over to the ER doc to show it to him.

Both the ER doc and I now approached the patient and her husband, to explain things as to where we stood. The ER doc was convinced that while her condition was serious, it didn't warrant an immediate pacemaker implant or surgery. Her lab work seemed to indicate no emergent abnormalities and he was inclined to agree with the husband that the pt. had probably taken one too many pills by accident.


The plan was to admit her to remote telemetry overnight - just in case.
While the ER doc was talking with the admitting consultant over the phone, I saw Mr. Smith quietly sneak into his wife's room.

They held hands for a while. Looking into each others eyes. Saying nothing... and yet 'speaking' all that need to be 'said'.

A little while later, I saw him get up, gently lean over and give his wife a heartfelt kiss. He brushed her hair off her face, while they were still holding hands. Then they said something that I couldn't hear and her bent over to kiss her again.

The look they had on their faces was just... well, indescribable.

[I did feel guilty that I witnessed what was obviously meant to be a tender, intimate, private moment between the two of 'em].

Mr. Smith slowly shuffled out of the room, taking care to close the curtains and shut the sliding door. He ambled over to me and said "Thank you for all your help today son. I'm loathe to leave but she insists I do. She says that I need my rest and that the dogs would get antsy without us."

He paused.... and looked down...

"Trust her to be more worried about me and the dogs even as she's lined up in a hospital!"


I walked over to Mr. Smith and bent down on my knees so that his eyes could see mine. I took his hands in mine.

"Mr. Smith, you're wife is as concerned about you as you are about her. But at this point in time, there's not a whole lot else you can do for her. I won't dare to presume to tell you how how things ought to be, but Sir; this hospital has strict visiting hours. As much as I'd love to bend the rules, you and I both know I can't."

He looked up slightly. A striking face; worn by the ravages of time, worry and care. A mist occluded his bright grey eyes.

"I've never been away from her. Ever. She'll be terrified. I know she will!"
That last response sounded less like a statement and more like a plea...

It nearly broke my heart.
"Hold on Mr. Smith. Let me see what I can do to..."

Just like that, I saw him shake his head. Take a few deep breaths in. Then he looked down to meet my eyes - his steel grey fiercely boring into my liquid brown.

"You take good care of her. She's all I have left!" I felt his hands clench mine, as if reinforcing his desperate plea.

"We will, Mr. Smith", I mumbled; "I promise".

He nodded assent, and then slowly shuffled off.


Leaving me all alone, to contemplate the loving bond that is shared between a man and his beloved wife....

Spoke my mind

Sent to me via email:



[Click image to zoom]

If you created this image, lemme know so I can credit you.

Be careful when taking walks

One of our ER docs told me this story:

Many years ago, when I was doing my residency near The Other Big City, police brought this elderly gentleman in to the ER. They said that they'd found him wandering around and when they stopped to question him, he responded with incoherent words and neither one of the officers could figure out what the man was saying.

And neither could we. His vitals weren't normal but they weren't off the wall either. One of the nurses thought she detected some AoB (Alcohol on Breath) but for the most part this guy appeared benign. Lungs clear, good heart sounds, no apparent signs of trauma.

Then, one of the cardiology residents who happened to be down on a consult happened to pass by the ER room while we were trying to figure out what the hell to do. He stopped, poked his head in and asked one of the nurses what was going on. Upon being told the gist of the story; the resident shook his head and said: "He's not mentally confused or unstable. He's speaking a different language. I don't know what it is but I know it's not gibberish." Apparently this cardiology resident was of Indian extraction and had heard it before.

This set of a flurry of activity... and before long, they managed to find an Indian-American nurse who was called down to help translate.

Apparently, this gentleman had recently arrived in country; visiting his son's family for the holidays. He'd had a glass or two of wine in the afternoon and had decided to stretch his legs with a walk and take in some fresh air. That was when the police found him and the poor man spoke not a syllable of English. Fearing that he'd been injured/lost and wanting to make sure he was ok health-wise, the police brought him in and that's where all the fun started.

What's in your RSI box?

Nurse K posted a random bleg a while ago about RSI boxes. I must admit that when she mentioned that her ED didn't have a RSI (Rapid Sequence Induction) box, I was slightly surprised. I thought all EDs had something similar - I mean, having one makes a lot of sense.

But then again, my old hospital's ED didn't have one either.

So Nurse K, here's what we have in our ED:
- Meds in the box:
* Atropine Sulfate (1 mg/10 ml) prefilled syringe X 1
* Etomidate (2 mg/ml) 10 ml vial X 1
* Ketamine Hydrochloride (50 mg/ml) 10 ml vial X 1
* Lidocaine Hydrochloride 2% (100 mg/5 ml) prefilled syringe X 1
* Midazolam (2 mg/2 ml) vial X 2
* Succinylcholine (20 mg/ml) 10 ml vial X 1
* Vecuronium (10 mg) vial X 1

- Dilutants:
* Sterile Water for injection (10 ml) vial X 2

- Tools:
* 60 ml syringe X 1
* 20 ml syringe X 2
* 10 ml syringe X 2
* 3 ml syringe X 3
* BD 18G 1.5 inch IV needle X 2
* Easy Cap II Carbon Dioxide detector X 2 (no longer used. Now part of intubation bag)

- Misc:
* Alcohol swabs x 15
* Controlled substance documentation form

Some piccys:


RSI Box against a standard computer keyboard (to provide scale for sizing).


Closer view of RSI (notice the red pharmacy lock indicating a stocked, ready to use box).


Naturally, no nursing job can be complete without "documentation". A typical pharmacy use/waste form. Two RNs (or an RN and Pharmacist) to initial waste/use before restocking and locking the box.

We have 3 such boxes in our ED. Our airway/intubation kits are separate (they usually hang out in the trauma/code rooms near our crash carts). A while ago we decided to switch out CO2 detectors from the RSI boxes to the airway boxes. There are separate kits for peds intubation (in separate boxes as well). We also have our own anti-platelet/thrombolytic boxes (tPA, tnkASE, Integrilin).

Once a box has been used, a nurse (or tech) walks the box down to pharmacy and it gets re-stocked.

So, what's in your RSI box?