Archive | July, 2009

I am back

28 Jul

Oh! I went on vacation and have been totally out of the loop! I have to play catch up to read everyones goings on–in this sick I-am-not-alone world known as health care. I wondered how it would be to step into the work again after being on vacation as if I would of forgotten how to do my job.

No. Nothing of the sort! I started lines on my patients, managed the drippy drips. Helped people to poop (and pee). Provided emotional support for families. Listened to the hearts and lungs of all my patients and my own heart too! ūüôā Fixed a flash pulmonary edema (again) as realized by: Shortness of breath, Hypertension, Rales 3/4 the way up the lungs, Respiratory rate >30, all in a patient with a cardiac history admitted with rapid Atrial fibrillation on amio drip and getting IV fluids of NSS @125ml/hour for the last 24 hours. I should of known to shut off those fluids as soon as I started working but I hesitated as the patient was dry and not eating and also renally impaired with metastatic cancer to top off the problems. So I let them run and then ended up: fixing the problem by: getting from the MD: (can anyone guess?) Lasix, Morphine, Hydralazine, and of course shutting off the fluids immediately.

Amaryl

6 Jul

I  remember this eccentric endocrine MD who when consulted on patients in the hospital for either high or low blood sugars. He would come in, look at the chart, see the patient on Amaryl, see the trend of blood sugars dropping below 50 and flip out in the nurses station about Amaryl and Kidney function and how patients with increased creatinine should not even be on AmarylРin fact he was so adamant that NO patient in the hospital should be on Amaryl. There are just to many variables affecting the blood glucose of sick patients, especially decreased kidney function as we load many of the patients with antibiotics and lasix and CT scan dye (not to mention the NPO status half of the time for testing)!

I thought at first he was just out-of-the-box, eccentric, passionate, teaching nurses in ways that seemed to me way over my head as I tried to understand his lectures, but really felt lost. The bottom line is that I remembered and learned : No AMARYL for impaired renal function and extreme caution if the attending family doctor is ordering amaryl in any of my patients.

So today here we go……. internal medicine doctor admits patient 5 days ago to tele. Cardio on consult for severe CHF, patient getting massive doses of lasix, BUN and Creat are rising and rising daily. Patient is taking the Amaryl. ooooooooops here we go….blood glucose 27–nurse gives an amp of¬† dextrose–glucose goes up an hour later to 57–it is not enough! nurse calls internal medicine doctor and asks for IV fluids D10—MD says “No, I never have this problem at the nursing home but every time my patients are hospitalized you nurses are always calling me about this–feed the patient!” Nurse says that the patient is 90 years old and does not want to eat. Finally the MD “gives” in to D5%1/2 NSS at 100ml hour. Nurse is upset because the patient is in the hospital for CHF! Nurse is getting upset. Q 1 hour blood sugars are taken and the patients blood sugar is still below 60 and keeps dropping! Finally the nurse at her wits ends calls the House MD and a rapid response to treat the hypoglycemic cool, sweaty, confused patient and the patient gets the appropriate treatment. The patient¬† had to transfer to ICU for q1 hour blood sugar checks and all the while I am thinking, ” This could of been avoided if the AMARYL was never ordered!”

Patient Advocacy: If you are not getting the treatment you need for your patient you have to go elsewhere.

I tried to look for a quick article on Amaryl and renal impairment and could not find one yet, but it does not matter: I SEE this happening again and again! I even heard it could take 3 days to get the medication out of the system if the kidneys are impaired so if your patient has a poor appetite, in kidney failure, and in the hospital: Don’t give the Amaryl! I would rather give the insulin with meals and chase the coverage then to go through that again!

Always Admit to TELE

2 Jul

At the end of my last shift………The ED calls to give report. The diagnosis: peri-prothestic hip fracture, male in his 50s. The nurse tells me that the orthodude tells her to “admit the patient to where we normally admit”¬†¬† So I stopped her immediately. I says to her “This is tele not ortho…Don’t ya think the orthodude wants the patient admitted to the ortho floor?”¬† She actually admitted that her and the ED doc figured the patient should be admitted to tele for the high blood pressure with no history of HTN. What? The patient had 10/10 pain and a blood pressure that normalized after the administration of morphine!

This is one example of a totally inappropriate admission to telemetry. We are not even “set up” for ortho! So of course when the patient required traction–it took hours to get the equipment and then find and ortho nurse to come down and set it up for us.

Pathetic!

I’m sticking to:¬† TELEMETRY/PCU

Ortho patients should go to the ortho floor.

It just seems unfair to us! Imagine the ED nurse calling the ortho floor to give report on a patient in a rapid A fib on a cardizem gtt and heparin gtt. ! All hell would break loose! The cool nurses on ortho would not manage that so why should I have to deal with bucks traction on a patient that is now normotensive with no cardiac history?

The bottom line is this: The ED nurse entered the admit to telemetry orders into the system before she got the order from the attending orthopedic surgeon: and the high blood pressure was the excuse to cover it. The bed was paged before she even got the order!! UNBELIEVABLE ! 

Admit to tele. Admit to tele. Admit to tele.

Don’t ever send me to ortho……….pleaaaaaaaaaase. It scares me!!!