Dr. Mercola pisses me off

What in hell is "Dr." Mercola doing on my linkedin newsfeed? He's an alarmist whackadoodle who takes a sliver of nonconventional/holistic medicine and turns it into  

 dum dum dum dummmmmm


something that will kill you.

You know what's more dangerous than the MMR vaccine?

GETTING measles, mumps, or rubella.  We are so lucky in this country to have not seen the devastating effect of serious diseases.

As for the autism link to vaccines?(the unproven one that Jenny McCarthy announced herself an expert on, you know the one)  I think there's any number of other causes that could be responsible for it-- from processed foods to environmental toxins to Lord knows what else.

Dr. Mercola is an asshat because he takes things that we should think about regarding health and then goes so WILD with "research" (and I use the term loosely) that it... well--- it makes me want to guzzle a gallon of BGH/BST laden cow milk with a side of beef jerky dripping with nitrites while injecting myself with numerous tetanus shots outside his bedroom window while singing "Look at me now..uh... look at me now... Oh.. I'm gettin vaccinated.. look at me now.."

The trouble with oranges

Let me preface this blog latest post with I LOVE MY NEW JOB. In many ways it's the "same church, different pew" but in other ways it's very VERY different. Mostly in good ways, but there are downsides as well.

You know that whole "customer service oriented" patient care trend sweeping the nation? (thanks Medicare and HCAHPS or however the fuck you spell it) Well, I am very pro patient and I go out of my way to be kind and considerate and provide excellent care but this new hospital I'm at? Uses that philosophy of mine and takes it to the extreme.  For example: Our patients are offered iPads to borrow during hourly comfort rounding.  And we have thick, white terry robes for them to wear while ambulating in the halls.  My patients are treated like they are in a luxury hotel.  Which honestly, in most cases makes me feel really happy because I like seeing them comfortable and feel well taken care of. The problem is for some patients, this perpetuates an entitlement mentality and the view that their nurses and doctors are their servants, who are supposed to do their bidding.  The next issue is, while I love providing patient care and exceeding their expectations.. those "expectations" become higher and higher and before you know it, patients tend to lose sight of the fact that they are in the hospital for MEDICAL TREATMENT.

Cue the orange incident.

One of my elderly patients whom the aid and I have been bending over backwards to make happy ALL DAY hit the call bell and I went in.  He held up his orange and said "do you see this?" I said "yes, it's an orange" He said, "I called and told them to cut up the orange for me into slices.  This is what I got.  Now do you understand why I get so frustrated."   Here's what I WANTED to say:

And here is what I DID say, "You must have been disappointed to see that on your tray. I apologize for the miscommunication. I will personally call the diet office and make sure they are aware of this request for next time.  Would you like me to slice it up for you now?"

Patient: "No.. no my appetite is ruined.  Can you put it into the refrigerator for later?" My response "Absolutely!" And I whisked it away to the patient refrigerator. (and said "fucker" under my breath)

A positive? Free espresso and cappuccinos whenever we want for the nursing staff!!  Hm.  How about that. The scanners (for patient ID bands and meds) actually WORK (unlike my other hospital), we have all the latest and greatest state of the art medical equipment and an in house fitness area with our own personal trainer, and what do I focus on? Free coffee.

Maybe I'm not all that different from the codger with the orange after all.  LOL

Today is my last official day on the Cardiothoracic/Med Surg/Lung/Acute stroke Unit

It's snowing like crazy, too.. so hopefully people will be too scared to go out and flood the emergency dept... That also means we will see lots of people out shoveling who spend most of their days eating pies and cheetoes or people slipping on ice because they walk around like a drunken sailor on a good day.

My long time mentor is making cinnamon buns for me and I just know I'm going to cry.  I really learned everything I know about being an RN on that floor. (Nursing school helped pull together what I saw there, but REAL learning? All there)  Any nurse will tell you that nursing school teaches you to learn how to be a nurse but working on an actual floor is where you really develop a true skill set. 

Well.. I'm off to be with my weekend family one last time. I sure will miss them.

If you like my writing style..

You will love hers!

http://www.amazon.com/Cartoon-Guide-Becoming-Doctor/dp/1105091023/ref=sr_1_1?ie=UTF8&qid=1323646385&sr=8-1

Well done, Dr. Fizzy McFizz.  :)

Floated to ICCU (intermediate critical care unit) over the weekend

Walked in to work yesterday and was given the news that I am being floated to ICCU. I have floated there before and the patient ratios are different on that floor (1 nurse to 4 pts vs 1 nurse to 6 pts on my usual floor).  And let me tell you, the level of patient acuity on my floor is just as intense if not WORSE than the ICCU patient load.  So I was SO HAPPY when they told me I was going there. Yay! :)

Had 4 pts. (one of whom was getting discharged). Two of them had gangrene/necrotic toes. One gangrene dude was on an insulin drip (Q2 hour sugar checks). One lady was 95 and on a protonix drip with a GI  Bleed with a dropping hemoglobin of 7.9 (needed to be transfused with 1 unit of PRBCs), discharge lady was a new onset CHF but now medically stable, so I had to d/c her foley, her PICC line, call report to the nursing home, reconcile her d/c med list, confirm orders with Dr. and help ambulance drivers on arrival.  


It was a great experience because I was not in my "home" environment and yet I did just fine managing all that, and actually kind of enjoyed it. I'm not nearly as scared to go to my new hospital. I think I am finally  ready!! :)

NURSE!! NURSE!!!

Meet *Peter.  Peter is a pain in the ASS.
*Not the patient's real name


Peter came to my hospital from a nursing home for respiratory distress.  Turns out he has an empyema (a bunch of pus outside the lung).. oh and said pus is infected with MRSA. He has a chest tube in to drain it.
Peter is VERY thin.. emaciated, really. And tiny. And paralyzed on the left side. But his voice is very big. So big, in fact, that any given passerby will be sure to hear "nurse.. NURSE...NURSE!!" every 5 to 15 minutes or so.


This is not an exaggeration.  He prefers yelling to using the call bell. And he's forgetful.. Meaning he keeps calling because he keeps forgetting we were in there.


NURSE!! NURSE!!


A pulmonary Dr. went into the room and Peter kept screaming NURSE!! NURSE! Aide went in and said "Do you need something, Peter?"  The pulmonary doc immediately said "Peter ALWAYS needs something"


As the Dr. emerged from the room I gravely said, "You are now an honorary nurse."


NURSE!! NURSE!!
"Move my bed! Move my legs! Turn on my heating pad! Put my head up! Put my head down!"


Then one day, Peter started telling me a story amidst him barking orders at me "I got into a fight on Broad street in Philly years ago.  Guy tried to steal my wallet. I knocked him right out!"


Me: "Philly, Peter?  You like Cheese steaks?"


Peter: "What?"


Me: "Cheese steaks.  Philly is known for them.  Do you like them?"




Peter:  "What are you, POLISH?"


*mental sigh* back to repositioning you and eliminating the small talk it, is.


While at the Accudose med machine, spoke to a Hispanic nurse who had him a few days prior.  She asked him if he liked his oatmeal. He responded, "What the hell do you know about oatmeal? All you eat is enchiladas and tortillas ya damn Mexican!" She just laughed.  Truly, what else can you do?


I learned a valuable lesson from Peter. I learned that when life hands you MRSA, a chest tube, and  hemiplegia, just say whatever the hell you want.  Because people will eventually start to kind of like you.  Kind of..

NURSE!!

Really felt things coming together for me this past weekend

First, a little background on the dynamics of the hospital. (for those of you non hospital employee readers)
When patients are admitted to the hospital, they have an admitting doc/nurse then once they become inpatient, they have a doctor who manages their overall care, then consults are added for various specialty areas.  Then the patient is assigned an RN (bedside nurse) who carries out the orders of the docs, but also coordinates the care between the different departments, administers and educates the patient regarding meds and treatments, and reviews what labs, meds, and treatments the docs order and call them if there are any discrepancies or needs for adjustments.
*disclaimer* Docs have MANY MANY more patients than RNs on a given shift and mistakes can and do happen. (just like they can with an RN). That's why good RNs are invaluable to a doc. We protect their patients by being their last line of defense before a med or treatment is given.  The pt. scenarios discussed in this blog entry highlight instances where a knowledgeable, prudent RN (me, shockingly lol) can make a huge impact on the quality of patient care.

First patient.  84 year old woman with frequent PVCs and PACs and periodic atrial fibrillation presents with a CVA in the frontal region of her brain. (A fib can be responsible for strokes because when the heart beats ineffectively (as with a fib) blood clots can form from the pooled blood in the heart.)  The docs were unaware the pt had any history of a fib until I looked at the monitor and realized it and called them.. (it later became apparent on her EKG).  As soon as the stroke was diagnosed on the MRI, she was ordered aggrenox (it's like super aspirin).  After the afib diagnosis, they started her on Pradaxa (prevents strokes in pts with afib, specifically).  But two different drs ordered it. and I have never given those two meds concurrently, so I called the dr to clarify and make sure he knew she was taking both.  He said it was okay to take them both.  Printed out literature and handed it to her  Ok great.  Next day they start her on betapace/sotalol (beta blocker for arrhythmias) Great.  Print out patient education, review it.. says right on it not to give to patient if they are on amoxopine.  I called the pharmacy, they tell me it's a class D interaction and can cause a prolonged qtc interval (which can lead to Torsades de Pointes, which lead to dizziness, fainting and potentially a deadly cardiac rhythm).  I called the Dr. and he was not aware she is on amoxipine and he said to hold the dose until he comes in tomorrow. (he wanted to think about some alternatives before giving it).

Next patient. 78 year old gentleman with a history of a coronary artery bypass graft presents also with a stroke. Has a history of renal stents, creatinine level (lab that tests kidney function) 1.9 on admission (around 1.1 is normal), drops to 1.2 after getting IV fluids (but only 500 mL at a time and at 60 mLs and hour so as not to fluid overload him) few days later, creat jumps to 1.7. Call Dr., get another 500 mLs ordered.  Look through the orders, see the cardiologist sending him to the cath lab in the am (to see if he has any blockages in his heart since his CABG was 20 years ago and his ejection fraction was half of what they originally though it was)). What do they use when doing a cardiac cath? DYE. what does dye do to kidneys? It fucks them up! Which is why we use a sulphur based med called mucomyst routinely as a prophylaxis on our patients-- even ones with GOOD kidney function. (Studies have shown is has a protective quality on the kidneys when patients have the dye injected into them in the cath lab.) Patient had no mucomyst ordered!  Called the attending (really like him) and let him know this. His response?  "Holy shit! Has renal been consulted?"  Me "no, renal was not consulted...that's another reason I am calling you.  He has kidney stents. He needs a renal consult" He added a consult and a stat dose of mucomyst. (I doubt the cardiologist realized this guy's creat was 1.7 otherwise he probably would have said to hold off on the cath.  I am thinking he probably was not cathed today, but the mucomyst/acetylcysteine is something that should be dosed for several days prior to being cathed in a pt with renal compromise anyway, so it was still a good thing I called).

Next patient was a woman in her late 40s with a dissected internal carotid artery (99% blocked) presenting with EXTREMELY bad neck pain, unequal pupils, difficulty swallowing, and a left facial droop. Usually this type of dissection can occur after a trauma of some sort but the patient was a very good historian (she's extremely intelligent and has a high profile type of job, but I don't want to say much more about her than that) had no injuries to her neck.  I don't know if I ever mentioned this in the past, but in my patient with dissecting aortic aneurisms (ones that are growing in size) they experience excruciating back pain that radiates from the site of the aneurism.  So, it did not surprise me at all that this woman was having horrible pain at the base of her skull.  She was getting morphine 2mg IVP Q4, Dilaudid .5mg IVP Q8-- it wasn't cutting it.  She actually started vomiting after her morphine dose so I had to give her Zofran (I always automatically get a zofran dose out with morphine when I know a pt. is even the tiniest bit queasy). Called the Dr. got her changed to dilaudid 1mg Q3, and added 1 percocet Q4.  Finally her pain was much better managed. Treatment plan for a dissection like hers is to anti-coagulate the blood with a non weight based heparin infusion and coumadin until her INR level is between 2 and 3, then the Heparin can stop. She will probably stay on the coumadin for 3-6 months until a follow up scan of the carotid shows that the dissection has resolved on its out. There are surgical options I heard the vascular surgeon talk over with her, but they are hoping the coumadin therapy and time will help it to resolve on its own. Meanwhile we were closely watching her neuro status to be sure her stroke symptoms do not progress. The risk of a carotid dissection rupturing are about 2% so that fear was much less for me after I read up about her condition.  She was a WONDERFUL patient and I hope her pain stays away.  She was a pleasure to talk with and take care of. :)

I was doubting my knowledge base and getting impatient with myself for a while there, but this weekend proved to me that I know more than I thought I did and it felt wonderful to be able to help my patients not only with direct patient care but with knowledge.  Being a nurse can be the most rewarding and wonderful job in the world. :)