Something to do with all those extra SARS facemasks you have lying around.

Thanks to Medpundit, who credits The SARS Art Project.

As someone so nicely pointed out, you may not want to view
this while at work. But I think that if you work in a place that doesn’t find this picture even just a little bit amusing, well… maybe you should :-)

Sorry to have not posted in awhile; it’s been busy around here what with all the home improvement projects we’ve been undertaking :-)

At work, we’ve had a few patients that we’ve withdrawn treatment from. It’s always a really sad sort of affair. Usually a patient will come into the hospital after some sort of catastrophe, we work really hard to get them back for about a week, and if no significant improvement occurs, we “withdraw” treatment (with the family’s consent, of course!)

Withdrawing typically consists of discontinuing any pressors that we’re using to keep the patient’s blood pressure up, extubating (removing the breathing tube; taking them off life support, “pulling the plug” so to speak), and stopping antibiotics. The family always wants to have an answer to the one question that is most important to them, and the hardest to answer for us: “How long will it take for the patient to die?”

I’ve had patients on maximum doses of pressors when the decision is made to withdraw. Usually pressors (Dopamine, Neosynephrine, Levophed, Epinephrine) are weaned off. We “titrate” the dose to get the desired effect (usually a blood pressure over 90) and then try to fix the cause of the low BP. Once that occurs and the patient starts to stabilize, we wean the pressors off little by little. Turning them off cold turkey could cause a relapse. We always wean according to how well the patient is tolerating the process. It can take hours to days to wean drips off. When withdrawing a patient from treatment, we shut them off cold turkey.

I’ve had two responses to this: patients have both died very quickly (within ~10 mins) and very slowly (days). So when families ask me how long it will take when the pressors come off, I can’t honestly tell them. It’s frustrating for all.

The ventilator is another component. When withdrawing, we shut the vent off and extubate no matter how much support the patient is receiving. It could be maximum support, or it could be just a little extra pressure to completely inflate their lungs with each breath. This follows a more predictable path – the more support a patient is getting for ventilation, the more quickly they will pass away when the vent is removed. I myself have only been involved in withdrawing treatment from comatose or semi-comatose patients. Semi-comatose patients are those that usually appear to be “sleeping” unless they are touched or talked to… then they might stir a bit or open their eyes. They rarely talk or answer in any way.

Sometimes when the vent is removed, patients have a hard time breathing (hence the need for it in the first place). To help relieve this, we typically give Morphine IV. Morphine helps relax the smooth muscles of the respiratory tract and depresses the drive to breath. It can be given both intermittently and as a continuous infusion that we titrate for the patient’s comfort. We can assess how a patient’s doing by their breathing pattern. Some breath just fine, some don’t. It’s usually pretty hard for the family to watch. Fortunately, morphine works quite quickly. Soon, the patient’s carbon dioxide level rises and if they weren’t already unconcious before, they certainly are now.

There isn’t much of a point to this post beyond what I’ve already written. Like I said, we’ve withdrawn from several patients lately and it’s always a tough thing to deal with, even if the only place you’re dealing with it is in the back of your mind.

I have a confession to make: I LOVE STORY SUBMISSIONS! Even if you already have a blog where you could pontificate about general medical happenings, here you can pontificate anonymously! Just click “Submit Your Story” off to the left there, and go to it.

That being said, I have a story submission from RPMcMurphy, RN. Enjoy!

I saw a previous story about a pain med seeker and it brought to mind a patient I once had on the med-surg floor. This guy complained of vague but intense abdominal pain. He writhed and wiggled and moaned. Demerol was prescribed. I had my doubts about him, but chose to assume that he was indeed in pain.

This went on for almost 2 days with no diagnosis. Of course, the dosages escalated and the call bell went off more frequently as well. Anyhooooo…..he goes in for exploratory surgery (this was 1988). I spoke with the operating surgeon post op and he shows me something. In a little zip lock bag is a small (about the size of a silver dollar) plastic spider. Made in China…you know. This guy ate it to induce pain and get meds! Not the end though:

After all this, he sues the hospital claiming sciatic nerve damage from all the IM (intramuscular) Demerol injections! I never found out the outcome, but one can only imagine that in this day and age, he got the $$ anyway and probably blew it on street drugs.

(This is me again now) Starting out as a nurse on med-surg, I once had a patient who’d had multiple surgeries and to my now more-seasoned eyes, was obviously drug seeking. He got so many Demerol shots that one night I couldn’t find anywhere to give him a shot – every single muscular place was hard with scar tissue from all the previous shots. He was there for months. I used to be irritated with him because he’d always ask for his meds a little early – and I’d always have to tell him that he’d have to wait. And he’d continue to call and annoy me.

I knew so little back then.

We have a guest columnist! DaGoddess:

Okay, so some of you may not know this….but, I’m a nurse. An RN to be precise. I currently work in pediatrics but have worked Labor and Delivery, and general adult Medical-Surgical as well.

You know, there’s an interesting phenomenon with caregivers that I see time and time again. They lose themselves in their efforts to care for their loved ones.

(more…)

One night I was helping out an RN who was assigned to a rather fresh open heart patient. The patient needed blood, and transport was called to go fetch it.

About 10 minutes later, the bag of packed cells arrived, and I brought it into the RN to do the crosscheck with the patient’s ID band. When that was finished, the nurse spiked the bag… and instead of going into the bag, the spike went through the bag. Fortunately, the RN was standing in the opposite direction, and the shower of blood that ensued didn’t get on her – just the floor, counter, sink, bed, and IV pump.

Well, this necessitated another trip to the blood bank to get another unit of blood, so I volunteered to do this to save time. I filled out another blood card and walked briskly over to the blood bank. When I got there, I explained the situation to the technician, who gave me a look that a parent would give a small child who’s just spilled their milk onto the floor, counter, sink, bed, and IV pump and said, “I’ll fix you another bag to take, but tell your coworker that she should consider being more careful.”

Huh!? Having an unstable open heart patient needing a unit of blood is the perfect time to start being uncareful, don’t you think?

I couldn’t have said it better myself!

California has enacted a law (AB 394) that will change nurse-to-patient ratios. Because I work in Critical Care, Title 22 already mandates that I must only have 1-2 patients in CCU at any time. Even if my patient has transfer orders to a stepdown unit or med/surg floor, I still must only have 1-2 patients, because I am working in a critical care setting.

Henceforth, I’m not sure what the current working ratios for med/surg are. I floated once to telemetry and had 5 patients. I thought that was okay, but one in particular took up a LOT of my time, thus leaving less time to deal with the other 4. AB 394 puts forth minimum staffing ratios. Critical Care will remain 1:1-2, but most other floors (excluding nursery, ante- and post-partum) will eventually phase to 1 licensed nurse to 4 patients. I believe this to be fair.

However… did you notice I said licensed nurses, not registered? There are two classifications of nurses – RN’s and LVN’s. LVN’s (or LPN’s – they’re the same thing) are Licensed Vocational (Practical) Nurses. I have searched for quite awhile tonight to find out just exactly what the difference is between RN’s and LVN’s and haven’t really come up with anything concrete.

From what I’ve heard over the years, LPN’s can’t do as much clinically as an RN. I’ve read sources saying that LPN’s cannot assess patients, and sources saying that they can. Most LPN’s cannot give IV medications, but some can if they are specifically trained to do so. As a rule, an RN is to thoroughly assess their patients and formulate a nursing diagnosis for each, devise a plan, implement the plan, then evaluate the outcome and change the plan as needed. Nursing care plans are the bane of a nurse’s life. But more on that another time :-) It is my understanding that LPN’s may assess patients in more of a “fact gathering” capacity than an “assessment” capacity and are not able to formulate a nursing diagnosis. Big deal, I say. Nursing care plans are overrated!

Unfortunately, I’m also getting the idea that LPN’s can only work under the supervision of an RN. THAT is distressing to me. Say that AB 394 is implemented in January 2004, and hospitals must then staff their floors at 1 RN for 4 patients (1:4). Theoretically, this means that hospitals can hire LPN’s – after all, an RN’s scope of practice is wider than that of an LPN, so RN’s cost more. Hiring LPN’s to pick up the staffing slack would make a lot of sense. However, this also means that because an LVN works under an RN, it is possible to assign one RN to 10 patients, if the LVN takes 5 of them. This would meet staffing ratios, but would then require the RN to care for her own 5 patients and supervise the care of the LVN’s patients as well.

Most RN’s I know hate supervising anything. After all, if you want it done and done correctly, you do it yourself! Certified Nursing Assistants are invaluable to nurses in helping them turn and clean up patients, empty foley bags, and check fingerstick blood sugars. Other than that, it’s Me RN who will be control freaking on every other aspect of my patient’s care. If I had to o.k. an assessment that an LPN under me does, or determine that one of their patients can have some IV pain medication and then have to go give it, what is the point? It still takes up my time.

I know that there are many areas that are perfect for an LPN/LVN. CCU will never be one of these, but I doubt that that would happen anyway – I’m more concerned about the above happening on med/surg and telemetry floors. There is also a raging debate going on regarding how RN’s treat LPN’s (as though they aren’t “real nurses.”) Regarding LPN’s, I say go for it – use them if that’s the best fit. Just don’t ask me to supervise.

I’m off to NTI in San Antonio for a week. Bye!

I’ve been a charge nurse now for almost 5 months. It’s been quite a learning experience in several ways. Until the other night, though, I had not been responsible for being “code leader” during a cardiac arrest.

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This has nothing at all to do with medicine, but I have to ask.

We were in traffic yesterday, and decided to use the carpool lane. It
got me to thinking: What makes people NOT use the carpool lane? I see
all kinds of one-person cars out there – what makes them not just kind of
scoot over a little for a few miles or so?

I rarely see police cars around. When carpool lanes “came out,” were
there stiff penalties for using the lane alone? Does riding solo in the carpool lane elicit ridicule from other drivers? Being newish to the area awhile back, I
was driving in the carpool lane one night by myself during the posted times,
and no one seemed to notice or care.

Anyway – not a pressing topic for sure, but one I’m curious about nonetheless. In a society where the road becomes a parking lot for hours every day – why aren’t more people tempted to break free and use an
almost completely empty lane?