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Cutie MD

22 Aug

Check for orthostatic blood pressure, laying, sitting, and standing once each shift. These are the best hand written cardiology orders we will ever see.

Fast Atrial Fibrillation

3 Aug

It is Atrial Fibrillation with a rapid ventricular response. The atrial rate can be more than 300 beats per minute followed by the ventricular rate of up to 170 beats. That is fast. I like to say in my mind Fast AFib. It just sounds cooler.

The intravenous cardizem is infusing giving a better control, or not.What about the or nots? I bet EPS Dr Wes, could give us the facts.

Why does it always have to be intravenous  cardizem?  I have seen Multaq post cardioversion sustain a nice sinus bradycardia. I have a love/hate relationship with Amiodarone.

I am a fan of the digoxin added to a beta-blocker.  I am starting to dig digoxin more and more because it does not drop the blood pressure.


cat FIGHT?

15 Oct

I have been feeling this vibe throughout my patient care when it comes to certain internal medicine MDs and a certain cardiology group where I work, aka: the best place to work in the whole world. I thought at first that it was just me, that I was just imagining this rift due to an over active imagination and high tendencies towards drama. After last weeks shift work I have come to the conclusion: I am not imagining this, I am feeling it, seeing it, stuck in the middle of it, and my patients although safe, could have better outcomes if it were not for this rift going on. Can you imagine? Health care providers alert: this really is happening. I am not sure why or when it started but here is one example, that I am not even sure I should be blogging about. I mean it feels taboo to even write about. It feels like protected  going ons of inside hospital information. I have to get this off my mind though AND want to know if anyone else has experienced this AND how to best advocate for my patients during this what appears to be a cat fight.
(thinks about how to twist the facts and still provide an accurate description of what I am trying to describe)

This is not just one internal MD, it is a few of them and the cardiology group is a pretty big one and they stick together like a well trained military unit.

Example: Who is managing this patient?

Patient comes in for a urinary tract infection (besides the point really until the end of this example). IMD (internal medicine admitting MD)  admits this patient. The patient comes in with lethargy, and change of mental status from home. The patient is found on admission to be in a rapid Atrial fibrillation is started on Cardizem IV in the ED and admitted to telemetry. The urine sent from the ED reveals a UTI. So the patient also gets treated with antibiotics. IMD consults the cardiology group. Cardio does their job: Patient on Cardizem IV bridging to oral Cardizem, Heparin bridging to Coumadin all while checking diagnostics to determine perhaps why this patient has a new onset of atrial fibrillation, stroke risk, anti-coagulation risks versus benefits, etc… The IMD IMD “>presribes the antibiotics at a low dose for only 4 doses and then discontinued. The patient is well controlled on IV cardizem without any side effects or complaints. So the Cardio MD prescribes oral cardizem and discontinues the drip. (usual right? yes.) Unfortunately the patient who does not trust the medical profession does not want to take the cardizem pill. Why? Do not know, she just does not like it, does not want it. So the IMD comes in every day (after the cardiologist is long gone)  and takes the patient off oral cardizem because he knows the patient does not want it, and prescribes digoxin orally for the patient. The patient only trusts IMD and if IMD were to explain to the patient: “You did well on IV Cardizem the oral will be good for you and you are being treated by knowledgable experts of cardiology and I trust your care with their prescribed interventions for you.” Here is the problem. IMD does not load the patient with IV digoxin. The  pre=”The “>cardizem drip has been off for a while, then BAMM right back to Atrial fibrillation with a rapid ventricular response. Here we go…this is where it gets fun. RN calls Cardio right? Tells the Cardio MD:  uhhhggggg. I have to tell you that patient so and so of IMD that you are the cardio consulting specialist is back in rapid a fib….and….IMD discontinued the oral cardizem after you left today, started the patient on oral digoxin, the patient has gotten one dose. The patient is symptomatic, uncontrolled and now hypotensive and from shift report the nurses tell me that this is the third time this week for this same patient. RN says: what do you want me to give this patient to control this rate? Cardio MD says: I want this patient on Cardizem. UGHHHHHHHHHHHH! Cardio MD says: “call IMD and ask why he keeps discontinuing the cardizem or ask him why he consulted cardiology in the first place.”

 He then says, “Ask him if a cardiology consult just looks good on paper even though you rescind the prescribed intervention?”

NO. I am not getting in the middle of this. I am tired of it! (this is one example of a few just from lately from these doctors)

See in my humble nurse opinion:

3 times cardizem IV went up on the patient. The cardiology knew that IMD kept discontinuing the oral cardizem at the request of the patient who is not mentally intact by the way. IMD kept ordering digoxin orally. They both see this and know what is going on. They are both taking a stand against each other but no one is managing the patient. The IMD could of let the cardiologist manage this, the IMD could have called the cardiologist and said, “the patient does not like the cardizem, is there an alternative solution? (of course there is). The cardiologist could have seen that the IMD kept prescribing digoxin and could have written orders to load the patient with IV digoxin and maybe some atenolol on the side to go with it, but hey: I am just a sort of new nurse that notices the trends in what medications control heart rates. And guess what else the IMD did? Discontinued the IV antibiotics after four doses and 2 days later the patient is febrile probably exacerbating this fast heart rate even more. (RN cries for help) Why?

Can anyone believe this?

It is not all internal medicine MDs, just a few and they are only doing this to this one cardiology group (not to any of the other cardiology groups.) So I do not know what their problems are (well yeah I know) but it does not matter! My patients need better management and I am begging for it, stuck in the middle crying. I understand cardiology making their statement: “If you want us to manage on consult: LET us do our job.” I sort of understand the Internal Meds: but not when it gets this far out of hand and not when your patient comes in with a UTI and only 4 low doses of antibiotics are given, and the patient is febrile, with mental decline and hypotensive, and I ASK for orders for antibiotics and IV fluids and you tell me no AND the patient is in uncontrolled atrial fibrillation and you tell me let us just monitor the patient. Uh no no. Sorry. Not me today. I will get the Cardizem bolus and drip up per cardiology AND some IV fluids for hypotension  per cardiology AND I will not tell you that I am at this moment: Getting blood cultures times two, a urine sample (that we already know is positive!) a CBC, Chemistry, Lactate level, and coags!

And guess what! 2 hours later I call you with these results and interventions: Your patient has a lactate level >4, is hypotensive getting normal saline per the cardiologist, the heart rate rhythm is still uncontrolled (although a bit better thanx to cardio), the white blood cell count has doubled since yesterday! Your patient is febrile refusing tylenol because he thinks we are trying to slip him a cardizem pill (did someone tell this patient not to take oral cardizem or what?) and anyway the patient is probably to lethargic to take pills now,  AND the house physician has transferred the patient to the intensive care unit  AND would you like to consult a critical care MD for ICU management or are you coming in to see the patient?

Anyone out there understand  or relate ? because I am just shocked by this childish mis-managed behaviour. We are health care providers, not big egos waiting to be stroked! (or what ever the heck the problem is)

*Disclaimer: I feel better getting this off my mind but if any patients or future patients are reading this please note that this is not normal, not the usual, and not all MDs no matter what specialty.

dictation dream

12 Oct
wow! listen to that rhythmic dictating voice!

wow! listen to that rhythmic dictating voice!

Oh dear Radiologist. My day was going smooth. The usual, nothing out of the ordinary. Found myself performing nursing assessments, medication administration, monitoring signs, changing a wet pad here or there, educating patients, providing emotional support, titrating heparin, hanging cardizem drips, checking labs, calling doctors, the same old same old. Wendy, the medical surgical nurse of 5 years who is new to PCU nursing and acts like fresh grad sucks me dry cause she can not keep up and drowns every shift within her insecurity and lingers on tasks and symptoms of a lesser priority and I pity her cause I remember my first six months of my nursing career. I start her IVs, listen to her worries. Yesterday while she was drowning consumed by family members, she asks me to call the dictation line and get the results of a CT scan on one of her patients.

It goes like this: patient gets testing, radiologist dictates into the phone the results, and someone in some dark office transcribes the verbage and it appears in the computer hours later. When you can not wait hours for this to happen, you can call the dictation line and listen to the report recorded straight from the radiologists mouth. Sometimes if it is urgent: like MRI for stroke, you might call the radiologist yourself or if the radiologist calls you, well then you know the results are not good.

It is just the process.

Yesterday lost in my own mind, I call the dictation line for Wendy. I have my finger on the number 3 button on the phone for short rewind because usually they talk, dictate so fast you have to keep rewinding to make sure you hear it right and write it down because you will most likely be calling the MD with the results.

I hear his voice, calm and steady, speaking in paced controlled intervals and I see him in my mind starting at the top and looking at the scan and hear him describe the anatomy from the chest to the pelvis, landmark to landmark. His descriptions force visualization in my mind.

it goes chest (findings findings findings) space (findings findings findings) period (findings findings findings) comma (findings findings findings) period. (findings findings findings) next paragraph(findings findings findings) comma (findings findings findings) period next paragraph

abdomen (findings findings findings) period (findings findings findings)  comma (findings findings findings) period next paragraph

pelvis (findings findings findings) comma (findings findings findings)  space (findings findings findings) period (findings findings findings) period (findings findings findings) comma (findings findings findings) period

impression  one (findings findings findings) comma(findings findings findings)  period  two (findings findings findings) period  three (findings findings findings) period dictation number blah blah blah blah

It was so competent, so complete, I was impressed amazed and happy. I hung up the phone and announced at the nurses station. I think there is a new radiologist in town and his voice is a dream that I almost stopped writing while listening verbatim. I did not get his name at the end of dictation but I know he  is hiding in that dark room reading images right now and I think I am about to go down there and tell him “I love your voice and your dictation skills are awesome.” Of course I have no time to bust into the dark room and actually do that and it would appear insane anyway, so I think about calling on the phone and the unit clerk says “I think you should call him and tell him, so many times calls are only made to complain, do something random!” I look at the four digit number on my clipboard: the direct line to the dark reading room. I pull out my hospital cell and get ready to dial…..the telemetry monitor starts screaming, some patient appears to be in SVT or a rapid atrial fibrillation ( can not really tell with a rate that fast)  up to the 200s. I look and find it is my patient alarming. Cell phone goes in the pocket. I walk briskly to the room. My patient is hardly responsive, hypertensive, febrile, and the bed is soaked with urine.  The family at the bedside has that worried look. The nurse aid escorts her to the hallway. I take out my cell phone and call for assistance. Everyone comes, the code cart is rolled in. Another nurse brings supplies that might be needed to save someone from unnecessarily opening the code cart. The patient is stabilized and rate controlled with a cardizem bolus leaving her in a better controlled atrial fib but the MD still wants her in the unit. I try to change her wet pad before she is rolled up to the unit (priorities!) but the critical care RN begs me to stop so I do. They wheel her up for me, cause it is shift change and the nurse relieving me is waiting for report. I sit down in my chair, it is over. I look at the four digit number to the reading room. Give report and go home. Never did make the call.

up to speed

7 Oct

Since everything has basically gone paperless at the greatest community hospital in the world aka where I work, I wonder when and who is going to bring some of the physicians up to speed. Dr. Wants To Be Spoon Fed by the nurse who is on my annoying doctor list (the list is not that big really) stands far far away from nurse Jane, yells across the nurses station, “What medications is the patient on?”. I say “it is in the computer” so of course he does not go to the computer to look, he fills out the discharge medications section: same meds as at home and leaves. Really? The patient was on coumadin and came in with a hemoglobin of 5 bleeding out the rectum and he writes same meds as at home? Now in total irritation and major frustration I have to call him on his cell phone and read the list of medications from the computer and take telephone orders for the discharge medications to be totally compliant with the discharge policy and to prevent the patient from actually following those instructions.

Interventional Radiologist you do not rock

6 Aug

Unbelievable. I had always heard stories of those maniac, big baby doctors who throw charts, curse out nurses and generally act like big brats. I have had some brief experiences with jerky– like MDs but nothing to the point of actually becoming upset about it until most recently.

Last week I get a patient from the night nurse who received the patient from the ED around 0300. The patient is emmaciated, chachetic, dehydrated, hypotensive but with a normal mentation and normal heart rate.

The problem: the patient has no intravascular access and not a vein in sight ANYWHERE. Great for us, there is an order for a PICC line insertion in the morning. What? I would think that the ER doc should of at least put in a central or given us some type of access.

Anyway the patient also needs a lumbar puncture as the patient was immuno-compromised with a history of meningitis just last year.

So the interventional radiologist is consulted for the lumbar puncture.

PICC line nurse is as the bedside all sterile and ready to insert the line. The sign on the door reads: Sterile procedure in process, DO NOT ENTER.

So I am in the room across the hall with another patient and I see the interventional radiologist pound on the closed door with the clear warning sign. He opens the door and demands that the IR nurse stop what she is doing and bring the patient down to specials immediately for the lumbar puncture.

Ha! Who the hell did he think he was? She told him no, I am inserting right now and will be done in less than 30 minutes.

The jerk comes to the nurses station. Demands in a loud manner to see the primary nurse (me) and when I reveal myself he begins to tell-me-off, verbalizes that my supervisor should be fired, and if the patient is not down in the specials dept in the next 15 minutes—he is leaving! All of this done by him in a HUGE rant about how he has other places to go, things to do, his time is valuable, he does not need this crap, why are we (nursing) so unorganized?

I begin to tell him that…the patient has no vascular access and did he really want the PICC line nurse to stop the procedure and send the patient to him like that? He says put in a peripheral, I says if that were possible the patient would not be getting a STAT central line. He says it should of been done earlier. I says sure in a perfect world, but you are more than welcome to insert the central line yourself and then do the lumbar puncture if-you-like. Oh that tickled him pink, he was boiling mad. Then I says do you want the attending on the phone, we can call him on his mobile phone if you like and then you can explains yourself that you-are-gonna- leave without doing the lumbar.

He storms back to his little department where he can apparently abuse the interventional rad nurses and techs.

Ewww*vomit in my shoes* … apparently he is well known for these outbursts of immaturity.

He made an ASS of himself in front of all the cardiologists who were at the nurses station–working.

They were all like wondering who the hell was that jerk? And I gladly told everyone his name! That was Dr. Nasty Pants Interventional Radiologist.  No-More-Consults-For-You-Dr-Nasty! At least not from any of the Doctors that witnessed your immaturity on that day!

Dude you suck!


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 Amaryl– in 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!