Most ridiculous question from a nurse while on call

[diel]

Pt with brain injury and subsequent diabetes insipidus, peeing 1L/h, high Na bla bla you know. I get him on low dose Vasopressin gtt.
Call 2 hrs later.
-hey, Mr X UOP has dramatically gone down! It was 800ml/h and now I barely got 75 cc for the past hour.
Me: ok, thank you.
Page 30 mins later:
-hey, me again about MrX. we talked about the UOP a while ago and you still didn't address the issue.
Me: there is no issue, I am fine with these findings. Thank you. Click.
Page again in 2 min.
- I really think you need to do something, pt is going into renal failure!
Me: no, he is not. This is vasopressin doing it and I am fine with it.
- I am going to page your senior!
Me: please do.
Senior stands by me, we are admitting a new dude in the SICU.
Sr paged: Him: yeah, Dr Y, whassup?
RN: #$#^&#%*&! Renal failure! UOP was this and now that!
Sr: ????? That is fine. click.

5 min later, I am scrubbing in to do lines. Sr's pager BEEP BEEP.
Sr: Yeah?
RN: #$$&#%%#&!! You guys are making a mistake! Don't you understand? renal failure!
Sr: (goes ballistic) . Son of a %$@^@! Mother f %#&#! Whatta f%#& is your problem? $#&#*@*$@&%@%%^&(!!!! Do you know ANYTHING about DI?????? Get me your charge nurse, NOW!

I almost fell on the floor laughing... btw, worked with my Sr for many months now, the sweetest guy ever, calm and nice all the time.
She popped his cherry.

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[diel]

4AM, trying to catch a snooze in front of the computer. Long ***** night..
Page:
Me: Dr Diel, surgery.
Phone: yeah, are the "GO TO" for central lines?
Me: aaa... go to? ... ok... somebody needs a consult for an urgent CVL?
Phone: well, I really think this pt does.
Me: indications?
Phone: huh? oh! I can't get any peripherals in. Tried many times.
Me: are you the resident?
Phone: no, the RN. I need a CVL. pt has orders for IVF.
Me: IVF? is the pt unstable? Needs resuscitation? Iv Abx? Pressors?
Phone: no, VS are these .... awake alert. has orders for IVF @125/h.
Me: you know I need a Dr.consulting me, can't just put a risky line for some maintenance fluids because RN can't get a peripheral. It does not sound like the pt needs it. Can you get his resident to call me first?
Phone: What ? Why? (getting angry). There is no resident, and the NP is at home, she can't call you AT THIS HOUR!

me: (WTF??)

 

[tncekm]

Pt with brain injury and subsequent diabetes insipidus, peeing 1L/h, high Na bla bla you know. I get him on low dose Vasopressin gtt.
Call 2 hrs later.
-hey, Mr X UOP has dramatically gone down! It was 800ml/h and now I barely got 75 cc for the past hour.
Me: ok, thank you.
Page 30 mins later:
-hey, me again about MrX. we talked about the UOP a while ago and you still didn't address the issue.
Me: there is no issue, I am fine with these findings. Thank you. Click.
Page again in 2 min.
- I really think you need to do something, pt is going into renal failure!
Me: no, he is not. This is vasopressin doing it and I am fine with it.
- I am going to page your senior!
Me: please do.
Senior stands by me, we are admitting a new dude in the SICU.
Sr paged: Him: yeah, Dr Y, whassup?
RN: #$#^&#%*&! Renal failure! UOP was this and now that!
Sr: ????? That is fine. click.

5 min later, I am scrubbing in to do lines. Sr's pager BEEP BEEP.
Sr: Yeah?
RN: #$$&#%%#&!! You guys are making a mistake! Don't you understand? renal failure!
Sr: (goes ballistic) . Son of a %$@^@! Mother f %#&#! Whatta f%#& is your problem? $#&#*@*$@&%@%%^&(!!!! Do you know ANYTHING about DI?????? Get me your charge nurse, NOW!

I almost fell on the floor laughing... btw, worked with my Sr for many months now, the sweetest guy ever, calm and nice all the time.
She popped his cherry.

LOL! Pt has trauma-induced neurogenic DI, you give ADH to correct massive urine output, and RN is bothered by that somehow? That's classic.

 

[glade]

1) The old CYA call. I get paged by a nurse about a patient with "blood coming out of his Foley." What do you mean by that? You mean a tinge or is it -- "No, doctor (condescendingly), not just a tinge. He's actively bleeding into the Foley, you want to come see it or just talk about it?" So I'm actually intrigued to see the exsanguinating pee-pee at this point and go to see the patient. When I get there, the nurse immediately meets me at the door and says, "I don't think it's anything, really, but just check it out." What's that mean? You don't think it's anything but just check it out? So I glance at it and it's just a little concentrated, but no blood. So I say, "yeah, there's no blood." And she nods vigorously and says, "that's what I thought, too." You did? Um, weren't you the one who called me? Then she says, "while you're here, can you check out the dressing?" No. "You don't want to look at the --- doctor? Doctor?" I had already left.

2) The old "try to get another resident in trouble" call. Our nurses play these page games where they try to get residents they dislike in trouble. So one day I'm with an intern, we were chatting for perhaps thirty minutes. I get a page from a nurse about an issue and I go, "uh, why don't you page the intern?" And she says, "I paged him three times already, he's not answering, so that's why I'm talking to you." And I say, "that's interesting. Why don't you page the intern?" And she says, "well, about the -- " and I say, "page the intern." Then I hang up. A second later, the intern's pager goes off. A lot of our residents, when this happens, will ream out the intern for not answering their pages, which the nurses know.

 

[fab4fan]

4AM, trying to catch a snooze in front of the computer. Long ***** night..
Page:
Me: Dr Diel, surgery.
Phone: yeah, are the "GO TO" for central lines?
Me: aaa... go to? ... ok... somebody needs a consult for an urgent CVL?
Phone: well, I really think this pt does.
Me: indications?
Phone: huh? oh! I can't get any peripherals in. Tried many times.
Me: are you the resident?
Phone: no, the RN. I need a CVL. pt has orders for IVF.
Me: IVF? is the pt unstable? Needs resuscitation? Iv Abx? Pressors?
Phone: no, VS are these .... awake alert. has orders for IVF @125/h.
Me: you know I need a Dr.consulting me, can't just put a risky line for some maintenance fluids because RN can't get a peripheral. It does not sound like the pt needs it. Can you get his resident to call me first?
Phone: What ? Why? (getting angry). There is no resident, and the NP is at home, she can't call you AT THIS HOUR!

me: (WTF??)

I truly believe you got this call. I just can't believe there are people that dumb out there who actually passed NCLEX-RN. Have I called a doc for an IV? Rarely, but yes, but never, ever in the middle of the night. I mean... The few times I called were pre-op lines when no one could get the pt., and the only resource left was anesthesia.

I don't get people at all, more and more.

 

[AbbyNormal]

My, my. I step away for a day and look what happens. What a lively discussion. So many thoughts going in so many directions; some I agree with, some I disagree with and some leave me lost in the dark.

.

i'll make sure to ignore your advice on an asymptomatic patient in taching away to the 170s. Eventually this patient will require intervention and i'd much rather prefer to treat a patient like this PRIOR a rapid response or a code blue

.

.Eternal, I had to laugh when I read your sarcastic remark. It made me think of Tom Cruise who would say, Eternal, Eternal, Eternal you’re being glib. LOL.

I never said this patient did not require intervention. I WAS intervening. I STAT paged the cardiologist to ask him WHICH intervention he wanted to use.

.

not entirely true. Granted symptomatic vs asymptomatic can alter how you manage someone, you still ultimately view the monitor/ECG to see what the rhythm is in order to perform the appropriate management. There's a world of a difference between the intervention taken if a patient is in SVTs, afib in RVR, vtach/vfib, PEA, etc etc. I think what you wanted to say is "you don't treat lab values"

.

As you say, not entirely true. Sort of.

I absolutely agree that monitors provide information that helps us understand the patient’s condition. The EKG showed VT so I assessed the hemodynamics and found the patient was alert and I used another monitor to assess BP. I never meant to imply that this was a benign problem.

I like having monitors. I would much prefer to have a Swan Ganz catheter and arterial line in a hemodynamically unstable patient than none.

A couple examples to illustrate why I say, don't treat the monitor, treat the patient:

Two cardiac patients were admitted to our telemetry unit at the same time. Somehow the patients EKG monitors got switched and the EKG tech yelled, patient X is crashing in whatever rhythm it was. We ran to the patient’s room with the crash cart and the patient is alert and appears stable so we hook the patient up to the crash cart’s EKG monitor which is not showing an abnormal rhythm. Simultaneously another patient is found lying on the floor unresponsive and several nurses take the other crash cart to him and find he indeed is crashing. Fortunately the patient survived.

Another time I was in OHRU and a patient’s BP alarm began sounding and several nurses ran to him. The patient was alert. I understand that a patient can maintain consciousness for a short time after their heart stops, I have seen it happen. One of the nurses is screaming he’s in PEA, get the cart and the cart comes rolling in and the freaked out nurse begins taking the patient’s gown off him so she can start CPR. I am looking at the monitor and thinking why is the BP waveform flat but the patient’s PA tracings are normal. I assess and find that the patient’s arterial line has kinked off. When patients are alert and off the ventilator after surgery they use their hands to push themselves up in bed and that can cause a line to kink. That is why I say, don’t treat the monitor, treat the patient.

You can’t use a cookie cutter approach to treat patients, regardless if their problem is ventricular tachycardia or else.

An anecdote about ventricular tachycardia, calling codes and residents assuming responsibility for the patients:

One time a patient went into ventricular tachycardia on night shift and they called a code and the nurses and residents shocked the patient and gave a lidocaine bolus and started a lidocaine drip. That was the correct thing to do according to ACLS. But AHA clearly states that ACLS protocols are guidelines for management not absolute rules. ACLS is intended to educate the nurses, residents, dentists, paramedics and attending physicians who are not cardiologists. Cardiologists have a higher level of knowledge of cardiac disease and therapies. So the next morning I was the RN responsible for the patient I described. The cardiologist looks over the code documentation and wants to know why in the hell they had started lidocaine on this patient. He had the patient on an oral medication (forget which) to treat the VT and he was angry because starting the lidocaine would delay determining optimal oral meds for this patient. You can’t send patient’s home on lidocaine drips. The cardiologist DCd the lidocaine and increased the oral med all the while chewing me a new butthole. Never mind that I was home asleep while the clusterf**k was going on. The resident should have contacted the cardiologist to inform him but the resident thought, oh, hey, I know ACLS, and yes he did the right thing by ACLS but the wrong thing because he did not communicate with the attending and the resident did not see the big picture. Lidocaine was correct according to ACLS guidelines but wrong for this particular patient.

Another reason it may be more appropriate to phone the cardiologist rather than page an intern is the cardiologist may want a therapy such as overdrive pacing. I watched a cardiologist use overdrive pacing at the bedside once and he taught me how to do it and later I did the overdrive pacing while I was talking to the doc on the telephone.

.

Vtach is typically in the 140-180 range, and is almost always less than 200 bpm. You cannot say vtach at a certain rate will most likely be stable, because it's just not true. It depends on the origin, degree of ischemia, presence of valvular disease, etc... <edit> If you see a rhythm strip with vtach at a rate of 250 - 300 please post it here, I would like to see it. I'm not saying it 100% never will happen (it can in a patient with SVT w/ aberrancy), but if you're going to wait until an asymptomatic pt in vtach hits 250 before you call a rapid response you're going to be in trouble. If there are any cardiology fellows here who feel otherwise I'd be interested in hearing.

.

You are absolutely correct that rate of VT is only one factor that influences perfusion. I did not say you cannot have severely compromised by a slower rate of VT. I was simply saying that disregarding all other factors the faster heart rates are more likely to compromise cardiac output and perfusion.

I have hundred of rhythm strips but unfortunately I put a box of them in my Quonset hut and the deck has become unsafe so I can’t get into the building until I build a new deck. But yes ventricular tachycardia can be at very high speeds but don’t take my word for it:.

[Ventricular tachycardia] complex is wide and bizarre, recurs regularly at at rate greater than one hundred beats per minute (usually between 150 and 200 but may approach 300). The Heart, J Willis Hurst

. Another form of ventricular tachycardia that can approach that speed is torsades de pointes. Torsades de pointes is very fast and also very dangerous because it can quickly progress to ventricular fibrillation. When the ventricular tachycardia is an unusually rapid zigzag our cardiologists call that ventricular flutter. I am not certain if that term is used elsewhere. Either of those and I’d be calling everybody I can get to help manage the patient..

It might have helped if I had said that my patient had been known to have sustained VT for some length of time. I can’t recall the details now but I’m thinking he had been in sustained VT for periods of twenty minutes before the day I called the doctor in the rain. I remember discussion about VT and one of the physicians said he had known of a patient who had been in sustained ventricular tachycardia for duration of 36 hours.

I did some searching and found a journal article describing sustained ventricular tachycardia of 70 days’ duration. As you might expect the rate of the ventricular tachycardia was fairly slow. I would attach the PDF but one, I don’t know how to do that and two, I am not sure that is legal. So here are excerpts –

.The American Journal of Cardiology
Volume 11, Issue 1, January 1963, Pages 107-111.
.Ventricular tachycardia of 70 days' duration with survival.

Although ventricular tachycardia has usually been considered to have a poor prognosis,.several cases of prolonged ventricular tachycardia have been reported. The purpose of. this paper is to emphasize again that prolonged ventricular tachycardia does not necessarily lead to death. To our knowledge, this report describes the longest nonfatal attack of ventricular tachycardia recorded in the available English literature.

.Several instances of prolonged ventricular tachycardia have been reported, most ending in death. (Elliott and Fenn,’ 32 days; Marra et a1.,2 30 days; Cooke and White,a 28 days; Weisberg et a1.,4 23 days; Armbrust and Levine,5 23 days.) May@ reported a 59 year old man with ventricular tachycardia, who had coronary artery thrombosis with infarction and involvement of the interventricular septum; he died after 77 days, apparently the longest duration of ventricular tachycardia in American literature. The longest case on record that we could locate in the world literature is that of Moia and Campana.7 A 24 year old man had repeated attacks of ventricular tachycardia for. three years and died of pulmonary complications after an attack of 123 days. There are, in addition, several reported cases of prolonged ventricular tachycardia with favorable termination.(Pordy et a1.,8 57 days) A nonfatal case of ventricular tachycardia of 70 days’ duration was reported in 1959 in Algeria by Raynaud and Bernasconi.

The largest nonfatal case that we could find in the literature was published in 1958 in France by Mathieu et al.17 They reported a 59 year old patient with ventricular tachycardia of 103 days’ duration that reverted to sinus rhythm with treatment.

 

[Eta Carinae]

AbbyN, You do realize the article whose abstract you posted is a CASE REPORT, don't you?

 

[Eta Carinae]

.
Volume 11, Issue 1, January 1963, Pages 107-111.
.Ventricular tachycardia of 70 days' duration with survival.

Although ventricular tachycardia has usually been considered to have a poor prognosis,.several cases of prolonged ventricular tachycardia have been reported. The purpose of. this paper is to emphasize again that prolonged ventricular tachycardia does not necessarily lead to death. To our knowledge, this report describes the longest nonfatal attack of ventricular tachycardia recorded in the available English literature.

.Several instances of prolonged ventricular tachycardia have been reported, most ending in death. (Elliott and Fenn,’ 32 days; Marra et a1.,2 30 days; Cooke and White,a 28 days; Weisberg et a1.,4 23 days; Armbrust and Levine,5 23 days.) May@ reported a 59 year old man with ventricular tachycardia, who had coronary artery thrombosis with infarction and involvement of the interventricular septum; he died after 77 days, apparently the longest duration of ventricular tachycardia in American literature. The longest case on record that we could locate in the world literature is that of Moia and Campana.7 A 24 year old man had repeated attacks of ventricular tachycardia for. three years and died of pulmonary complications after an attack of 123 days. There are, in addition, several reported cases of prolonged ventricular tachycardia with favorable termination.(Pordy et a1.,8 57 days) A nonfatal case of ventricular tachycardia of 70 days’ duration was reported in 1959 in Algeria by Raynaud and Bernasconi.

The largest nonfatal case that we could find in the literature was published in 1958 in France by Mathieu et al.17 They reported a 59 year old patient with ventricular tachycardia of 103 days’ duration that reverted to sinus rhythm with treatment.

note highlighted sentence

 

[Eta Carinae]

And it gets all the more ridiculous.

Then again, I shouldn't be arguing with a nurse...

(no offense).

 

[Eta Carinae]

Now that that's said...

Alright, we've now beaten one anecdotal horse to death, and the tone of the thread is teetering on the precipice. Please bring it back on topic with some sense of collegiality and humor.

Please...

 

[Eta Carinae]

AbbyN, Still love you though

 

[AbbyNormal]

AbbyN, You do realize the article whose abstract you posted is a CASE REPORT, don't you?

Yes, I do. Your point is?

It shows that ventricular tachycardia is not always a lethal rhythm. Often it is. It is likely fair to say it is fatal more often than not.

Some (not all) of the posters seem to think that it is a hard and fast rule that you code and shock everybody who presents in ventricular tachycardia. I posted this to show VT can be stable even when it occurs for extended length of time. (thus showing why a RN might seek treatment options from the cardiologist rather than an intern.)

Eta Carinae, is English not your first language?

 

[AbbyNormal]

AbbyN, Still love you though

Love you too.

Now will you make me some cookies?

 

[tncekm]

Yes, I do. Your point is?

I think HER point was to err on the side of caution. I.e. if you want to treat the patient, give the patient the treatment with the highest probability of desired outcome. lol. Most cases ended in death, this one didn't. Lucky him, he beat the odds.

edited for:

If that ^^^ was in reference to me, I'm a she.

 

[Eta Carinae]

Now will you make me some cookies?

Umm, that's your job.

And I prefer coffee, make sure it's hot. Thanks.

 

[Eta Carinae]

I think his point was to err on the side of caution. I.e. if you want to treat the patient, give the patient the treatment with the highest probability of desired outcome. lol. Most cases ended in death, this one didn't. Lucky him, he beat the odds.

If that ^^^ was in reference to me, I'm a she.

 

[Eta Carinae]

I give up. This is like arguing with a dummy.

Wait, did I say, like?

 

[tncekm]

Well, I'll remember that, She-person. I even corrected my original post for you!

 

[AbbyNormal]

.
make sure it's hot

There you go talking dirty to me again.

You are a little tiger, aren't you?

 

[filter07]

Can you medical students stop being obnoxious to the nurses in this thread? You will hopefully grow out of it in a few years but until then keep your snide comments to yourselves instead of broadcasting to everyone how emotionally stunted you are in your mid to late 20s.

As for the middle of the night call for a CVL, isn't that just classic? I don't understand why someone needs to protect the sleeping people at home who are actually supposed to care for a patient. Instead, especially as an in-house general surgery resident, I would get called to do all sorts of random crap for virtually any patient in the hospital.

Also, the comment about people lying to get you in trouble is so true. I remember in my more foolish intern days, when I was curt with someone over the phone(but never really crossed the line), occasionally my attending would be notified about how I was verbally abusive, ignored 3-5 pages, was yelling... all sorts of fabrications. Some people just have no conscience. It's really a shame. They play their immature games and don't know who they are hurting with these lies. They think we just get a one-time tongue lashing and that's it, but these comments can potentially get us fired or worse.

 

[group_theory]

Pt with brain injury and subsequent diabetes insipidus, peeing 1L/h, high Na bla bla you know. I get him on low dose Vasopressin gtt.
Call 2 hrs later.
-hey, Mr X UOP has dramatically gone down! It was 800ml/h and now I barely got 75 cc for the past hour.
Me: ok, thank you.
Page 30 mins later:
-hey, me again about MrX. we talked about the UOP a while ago and you still didn't address the issue.
Me: there is no issue, I am fine with these findings. Thank you. Click.
Page again in 2 min.
- I really think you need to do something, pt is going into renal failure!
Me: no, he is not. This is vasopressin doing it and I am fine with it.
- I am going to page your senior!
Me: please do.
Senior stands by me, we are admitting a new dude in the SICU.
Sr paged: Him: yeah, Dr Y, whassup?
RN: #$#^&#%*&! Renal failure! UOP was this and now that!
Sr: ????? That is fine. click.

5 min later, I am scrubbing in to do lines. Sr's pager BEEP BEEP.
Sr: Yeah?
RN: #$$&#%%#&!! You guys are making a mistake! Don't you understand? renal failure!
Sr: (goes ballistic) . Son of a %$@^@! Mother f %#&#! Whatta f%#& is your problem? $#&#*@*$@&%@%%^&(!!!! Do you know ANYTHING about DI?????? Get me your charge nurse, NOW!

I almost fell on the floor laughing... btw, worked with my Sr for many months now, the sweetest guy ever, calm and nice all the time.
She popped his cherry.

Reminds me of a few years back when this kid with central DI was admitted for dehydration/rotavirus. She's on a stable regiment of ddavp (managed by peds endo) for her central DI.

Anyway, during this particular night, her nurse decided that she didn't like this kid's urine output so held off her evening scheduled ddavp dose and charted it as "not administered, not appropriate at this time due to low urine output". As expected, her urine output "picked up".

Morning comes, and a rapid response is called because this kid starts to seize. Serum sodium in the 170s. But at least we have acceptable urine output

*never quite understand the obsession with urine output - yes it's important but it's important to evaluate it in the context of the patient.

 

[Substance]

Reminds me of a few years back when this kid with central DI was admitted for dehydration/rotavirus. She's on a stable regiment of ddavp (managed by peds endo) for her central DI.

Anyway, during this particular night, her nurse decided that she didn't like this kid's urine output so held off her evening scheduled ddavp dose and charted it as "not administered, not appropriate at this time due to low urine output". As expected, her urine output "picked up".

Morning comes, and a rapid response is called because this kid starts to seize. Serum sodium in the 170s. But at least we have acceptable urine output

*never quite understand the obsession with urine output - yes it's important but it's important to evaluate it in the context of the patient.

Doctors are trained to understand illness.

Nurses are trained to follow protocol, algorithm, and habit.

 

[Paseo Del Norte]

I truly believe you got this call. I just can't believe there are people that dumb out there who actually passed NCLEX-RN. Have I called a doc for an IV? Rarely, but yes, but never, ever in the middle of the night. I mean... The few times I called were pre-op lines when no one could get the pt., and the only resource left was anesthesia.

I don't get people at all, more and more.

It's called euboxia, a chronic inability to think outside of the little check boxes and "normal" numbers and appreciate the larger situation. This is sometimes a hallmark finding I see among my fellow nurses.

To this day I still see nurses loose the plot when a patient is respiratory distress or failure is wheeled into the ER in respiratory distress. Something about hypoxic drive, bla, bla, bla. I'm doing a LEMON assessment, pulling tubes and backups, and pulling meds for an RSI or calling RT for an hour long neb and/or BiPAP while the nurse continues to spout off crap that was questionable back when T-Rex was the new kid in the block.

One of the best was when I got a 0600 call for our ER doc (family doc who had pts admitted under him). The floor nurse was calling because she held the patients insulin for a blood sugar of 90 mg/dl. The doc was speechless, you have a normal blood sugar, the patient will be eating soon, and insulin is being held.

I remember taking a travel assignment in a hospital where this behavior was put of control. Doing triage one night when a traumatic SAH came in. Doc wanted pancronium, none in the ER and the nurses were freaking out. Frantic calls to house sup and pharmacy on call, pretty much the works. We had several bottles of Roc, I told the doc we could continue to freak out or he could let me give Roc and I would have more than enough time to make an ICU pancronium run. Easy critical thinking scenario IMHO? He wrote orders stating that I was one to one only with the patient until we flew the pt out. With bad weather, I had an easy night.

Again, euboxia. Unfortunately, I see this occur on the physician side of the house as well. Being a nurse, I tend to be harder on my own.

 

[J1515]

But yes ventricular tachycardia can be at very high speeds but don’t take my word for it:.

[Ventricular tachycardia] complex is wide and bizarre, recurs regularly at at rate greater than one hundred beats per minute (usually between 150 and 200 but may approach 300).

I know the definition of ventricular tachycardia. I graduated medical school. You were trying to educate an MS4/resident earlier in this thread that vtach is "not so fast" at 180, and they should start worrying when it hits 250. The fact is, vtach will rarely reach 250. I already told you there are rare exceptions. The next time you see vtach on the floors between 250-300, please scan the strip and post it here.

. Another form of ventricular tachycardia that can approach that speed is torsades de pointes. Torsades de pointes is very fast and also very dangerous because it can quickly progress to ventricular fibrillation. When the ventricular tachycardia is an unusually rapid zigzag our cardiologists call that ventricular flutter. I am not certain if that term is used elsewhere. Either of those and I’d be calling everybody I can get to help manage the patient

I mean this in the most respectful way possible and I'm not trying to be mean...you are fighting a losing battle...just stop. Torsades has nothing to do with the argument at hand. Whether the new onset vtach is monomorphic or polymorphic, a rapid response needs to be called especially if the patient is hypotensive - end of story. In the time you were on the phone with the cardiologist (and he was bitching about his new house) the patient could've died. Already having the team standing by can be the life saving factor in the future.

 

[J1515]

Some (not all) of the posters seem to think that it is a hard and fast rule that you code and shock everybody who presents in ventricular tachycardia.

No. Nobody said that. ACLS guidelines state that if the person is STABLE and asymptomatic, then you can try pharmacological therapy and waste time experimenting.

If the patient is hemodynamically UNSTABLE (including hypotension or altered mental status) then you sedate and cardiovert.

The fact that the patient in question here was hypotensive is the problem I and many others have with your decision to not call a rapid.

 

[Speculatrix]

I didn't care either way until you said the above..... now you've decided to throw in a few specialty bashing statements on the side? Your arrogance is getting disturbing. Or maybe you didn't mean that the way it sounded....

Yes, the specialty attacks were completely out of line and unprofessional, I apologize. I felt that smq had to instinctively incise into my preferred management (and the one that currently standard of care), repeatedly without taking into consideration the full story - then backtracking. You know when you read the line "Clinically correlate" in any sort of radiology report? That's the sort of feeling I got. Anyway, as weird as this sounds, part of that passion arose because I'm deeply involved with the plight of the patient- I always view them as a potential family member, and try to do my best.

 

[Speculatrix]

No...you're right...she's an arrogant douche.

And she has a PhD and is an MS4 and is therefore the smartest person on earth...for a couple of months anyway. Never mind the total lack of experience in medicine.

As a comparison, I too have a PhD and and am a PGY4. I have never felt as ignorant as I do now.

The more you know, the more you know you don't know.

Listen, like you, I am very well aware of what I don't know, to the point where I keep a moleskine reminding me of the limits of my knowledge and the wonders of medicine. It's the sort of thing that keeps me reading, learning, and trying to achieve the best for myself. My research went well, I was interviewed by every single top program, and ranked to match at several of them. Nevertheless, you're right, I don't have too much experience as the one directing the show at the hospital, that's obviously what residency is about. However, I do know what I know well, and fortunately can retain and apply a lot of information, and also know my (low) place on the totem pole. I don't comment on things I have no idea about, I have pretty good insight into the way I come across in person, and generally get along well with everyone in the hospital. I'm not going to make any apologies for my confidence, and I refuse to adopt a self-effacing, ho-hum attitude because false humility (also very common in medicine) is even more disgusting. If that makes me an arrogant douchey b*tch, then so be it. All I say is- Bring it On.

 

[Rendar5]

I'm responding again because I don't find it appropriate to second guess someone without knowing the full situation/environment the decision was made in. In your hospital with this situation, I'm sure you're dead on right JL as is everyone else apalled at Abby's call to consult expert consultation before calling rapid response. It doesn't mean it's correct in all situations. So I have three points that I'd like everyone getting on her case to consider. If you've considered it and still want to get on her case, fine, I'm not gonna argue with you anymore. No need to quote me and respond in that case

1. I find it hard to blame her for not calling a rapid when we don't know the environment of the hospital. We don't know who the rapid response team is made of (it could be someone with less experience than the RN), we don't know if rapid responses are even called in her ICU (they aren't in mine, you get the resident/fellow/attending), we dont' know how long it would take for the rapid response team to get to her unit (it may take 5 minutes depending on the elevator situation), we don't know how long it takes Cardiac ICU attendings to be reached by phone (perhaps they have their personal phone numbers and it takes less than 30 seconds to reach them).

If you were in a situation where calling a rapid response meant waiting 5 minutes for a respiratory tech and an RN vs. calling the attending, grabbing the nearest respiratory tech and the ICU nurse 2 patients down, and getting paddles out and onto the patient in 2 minutes tim, would you really think that rapid response was the correct move? Hell, this call to expert consultation could've taken less time than it takes to figure out the correct sedative and dose, get it, and deliver it to the patient in preparation for a shock)

2. I have my ACLS book open. Depending on whether or not this hypotension is new or baseline for pt, there are two possible pathways. One (new hypotension) is Expert Consultation + Cardioversion. Two (baseline hypotension) is Expert Consultation + Amiodarone vs. Adensosine (if this VTach is actually SVT with aberrancy) with standby Cardioversion. Expert Consultation in some places is most definitely Rapid Response Team. Expert Consultation in other places is most definitely Cardiology Attending.

3. I've seen patients unnecessarily treated with excessive amounts of fluid leading to dangerous volume overload because they were "hypotensive" with SBP in the 80s when this is actually their baseline.

 

[Speculatrix]

Yes, I do. Your point is?

It shows that ventricular tachycardia is not always a lethal rhythm. Often it is. It is likely fair to say it is fatal more often than not.

Some (not all) of the posters seem to think that it is a hard and fast rule that you code and shock everybody who presents in ventricular tachycardia. I posted this to show VT can be stable even when it occurs for extended length of time. (thus showing why a RN might seek treatment options from the cardiologist rather than an intern.)

Eta Carinae, is English not your first language?

The fact that you, in this post, and other posts, ignore the contributions of interns and residents as being irrelevant shows your own deficiencies and disrespect of what a teaching hospital is about. My guess would be that you're the sort of nurse who groans when a new crop of interns comes in and antagonizes them whenever you can... or goes above them inappropriately in cases like these. This in itself is troubling.

As for the case report - those are about rare occurrences in medicine - not standard of care. It's unclear whether you knew about that case report before you called that cardiologist, or just googled it just now to "bolster" your weak, nonexistent argument. Judging from the number of responses on this topic, I bet a fair number of housestaff would have know how to manage that situation, especially on a rapid-response team, as opposed to some academic cardiologist at his gold club or moving, as it were.

 

[Droopy Snoopy]

Give it a f*cking rest people.

 

[MedicoBoomstick]

Give it a f*cking rest people.

+1

I am a lowly pre-med student and I need funnies to keep me going. They sustain me. For those with a dog in this fight, take it to PM?

 

[tncekm]

Reminds me of a few years back when this kid with central DI was admitted for dehydration/rotavirus. She's on a stable regiment of ddavp (managed by peds endo) for her central DI.

Anyway, during this particular night, her nurse decided that she didn't like this kid's urine output so held off her evening scheduled ddavp dose and charted it as "not administered, not appropriate at this time due to low urine output". As expected, her urine output "picked up".

Morning comes, and a rapid response is called because this kid starts to seize. Serum sodium in the 170s. But at least we have acceptable urine output

*never quite understand the obsession with urine output - yes it's important but it's important to evaluate it in the context of the patient.

Ugh, I was really hoping the case before the one you posted was a freak incident. Now I'm starting to get scared!

 

[diel]

Oh my god I love this emoticon!
It's awesome!!!!!

Yeah, pls give the poor horse a rest, or get off this thread, get a new one titled "I am the shizzle in ACLS and this is what I know".

 

[jdh71]

Yes, I do. Your point is?

It shows that ventricular tachycardia is not always a lethal rhythm. Often it is. It is likely fair to say it is fatal more often than not.

Some (not all) of the posters seem to think that it is a hard and fast rule that you code and shock everybody who presents in ventricular tachycardia. I posted this to show VT can be stable even when it occurs for extended length of time. (thus showing why a RN might seek treatment options from the cardiologist rather than an intern.)

Eta Carinae, is English not your first language?

Love the drama, but am in a TL;DR mood . . . I assume you are not talking about idioventricular rythms aka "slow vtach", which requires nothing, as opposed to real v-tach.

You are kind of correct if you mean that you don't have to shock every v-tach, because you don't. It's rare, but asymptomatic v-tach gets amiodarone first (anyone who doubts can look at your ACLS). I've seen one case of asymptomatic v-tach that we successfully "coded" with amiodarone alone, no shocks.

Calling the blue is the most appropriate action because stable can go into unstable in a hurry.

 

[jdh71]

Why do nurses always want you to look at the poo?

Was on rounds early this year and we're all at the nurses station, gettin' our lean on, holding that sucker up, while discussing a patient, and I notice it suddenly smells bad, I mean really, really, really bad, like a portapotty combined with an anaerobic abscess - the smell was so bad I knew it couldn't be a med student fart. The smell is coming out of a room that nurse just came out of . . .

She hurries over to me and says, "Aren't you taking care of Mr. Soandso?"

I say, "Yeah, he's one of ours, what's up?"

She says, "I think he has c-diff, maybe something more - there's blood in his stool!!"

Me, "That's not good, how's he doing otherwise?"

Her, "Not good, he's altered, tachycardic to the 130s, tachypnic, and dropping his pressures, and he has bloody diarrhea"

Me, "How long has he been like this?"

Her, "I just took his vitals now, I was going to page you."

Me, "Give him a 1.5 L bolus of NS now, send an CBC, CMP, ABG, and a lactate, and I'll start the transfer paperwork to get him back into the unit."

I tell my intern to go in and take a look at him, while I run the case by the attending, who agrees with the transfer. (This guy had WAY more going on than this just, was a corpse we kept doing our best to keep alive 2* to an interesting social situation and that is all I will say)

As I'm going to get the paperwork together, her, "Aren't you going to look at the stool, there is blood in it!!!"

Me, "I promise, I believe you," and I turn back to finish my paperwork, she storms off in huff to get the saline.

 

[diel]

Sitting here, writing some notes. Came to this RN note:
(literally copy paste)
Paged and informed Trauma team that patient had gum in his mouth this AM. Nursing asked patient to spit out gum. No new orders were received from trauma team at this time. Will continue plan of care.

la la la la..............

 

[AbbyNormal]

Sitting here, writing some notes. Came to this RN note:
(literally copy paste)
Paged and informed Trauma team that patient had gum in his mouth this AM. Nursing asked patient to spit out gum. No new orders were received from trauma team at this time. Will continue plan of care.

la la la la..............

Was the patient scheduled for elective surgery that day? I have known anesthesiologists who delayed the patient's surgery for several hours simply because they were chewing gum. Gum "may" increase gastric secretions but medical journals conflict about this.

 

[diel]

Was the patient scheduled for elective surgery that day? I have known anesthesiologists who delayed the patient's surgery for several hours simply because they were chewing gum. Gum "may" increase gastric secretions but medical journals conflict about this.

Nope. Just NPO, awaiting bowel function.
But I guess you are right, it would increase gastric secretion.
But is this really a reason to page an MD and not handle it yourself?
What "new orders" can we give for this ?

 

[AbbyNormal]

Nope. Just NPO, awaiting bowel function.
But I guess you are right, it would increase gastric secretion.
But is this really a reason to page an MD and not handle it yourself?
What "new orders" can we give for this ?

It really depends on the particular physician. Some will continue the surgery as scheduled and others will delay from two to six hours.

If I were in that situation I would notify the anesthesiologist and if he made the decision to delay, I would call the attending (if the anesthesiologist did not).

I agree this is not an emergent contact, but still would want the anesth to be aware.

 

[J1515]

Nope. Just NPO, awaiting bowel function.

Studies have actually shown that chewing gum might shorten the duration of post op ileus. I'm surprised the nurse didn't read any of those articles

 

[AbbyNormal]

Studies have actually shown that chewing gum might shorten the duration of post op ileus. I'm surprised the nurse didn't read any of those articles

I guess I didn't read enough of the articles. I just now read a a couple and read: "our clinical trial suggests that gum chewing, although safe, does not reduce duration of postcolectomy ileus".

But really now what do you expect from "just" a nurse? Amazing that I can even read...

 

[J1515]

I guess I didn't read enough of the articles. I just now read a a couple and read: "our clinical trial suggests that gum chewing, although safe, does not reduce duration of postcolectomy ileus".

But really now what do you expect from "just" a nurse? Amazing that I can even read...

And this is what separates you from someone who went to medical school. You googled something and simply spouted out what came up. There are many types of post-op ileus - you chose a single study after a specific procedure. Stop trying to one-up people who actually know what they're talking about. You are derailing this thread with your attempts to prove how much you <don't> know.

Originally Posted by J1515 View Post
Studies have actually shown that chewing gum might shorten the duration of post op ileus. I'm surprised the nurse didn't read any of those articles (note my original post said "might" as there are a minority of studies that point out this is controversial - but regardless that gum chewing poses no harm and thus the nurse making a big deal of it was pointless)

http://www.ncbi.nlm.nih.gov/pubmed/20228654 - "Results of meta-analyses support the use of chewing gum for treatment of postoperative ileus. Chewing gum was consistently found to reduce time to passage of flatus and stool."

http://www.ncbi.nlm.nih.gov/pubmed/20013603 - Bowel sounds were 5 hours earlier in the gum-chewing group (mean 18.2 hours) than in the control group (mean 23.2 hours). Passing flatus was 5.3 hours earlier in group G (mean 34.6 hours) than in group C (mean 39.9 hours). Patients having mild ileus symptoms were 9% less in group G (mean 12%) than in group C (mean 21%). The difference between the two groups were all highly significant ( P < 0.001). Gum chewing was easily tolerated without any complications. Gum chewing is an inexpensive, convenient, and physiological method in enhancing the recovery of bowel function./19884293"]

http://www.ncbi.nlm.nih.gov/pubmed/19884293- In five such trials in patients undergoing colon resection, gum-chewing shortened the time until first flatus and bowel movement, but made no significant difference in length of stay.


http://www.ncbi.nlm.nih.gov/pubmed/19763686- Chewing-gum therapy following open gastrointestinal surgery is beneficial in reducing the period of postoperative ileus, although without a significant reduction in length of hospital stay. These outcomes are not significant for laparoscopic gastrointestinal surgery.

http://www.ncbi.nlm.nih.gov/pubmed/19261555 - . RESULTS: We identified nine eligible trials that had enrolled a total of 437 patients. The intervention was well tolerated and complication rates were low. There was statistical evidence of heterogeneity for the three main outcomes. Pooled estimates showed a reduction in time to flatus by 14 h (95% CI: -20 to -8h, p=0.001), time to bowel movement by 23 h (95% CI: -32 to -15 h, p<0.001) and a reduction in length of hospital stay by 1.1 days (95% CI: -1.9 to -0.2 days, p=0.016)

http://www.ncbi.nlm.nih.gov/pubmed/18158012The time to flatus was shorter in patients who received gum compared with controls (2.4 versus 2.9 days; P <0.001). Also, time to bowel movement was reduced in patients who received gum (3.2 versus 3.9 days; P <0.001). There was no significant difference in length of hospital stay between gum-chewing patients and controls (4.7 versus 5.1 days, respectively; P = 0.067). Gum chewing was well tolerated in all patients.

 

[Ashers]

0036 in the middle of staffing an admission.

"Regarding pt [mispelled name]: She just some how clocked herself in the nose and had/is finishing up a bloody nose. Please come assess."

When I spoke with the RN, I asked if she was putting pressure on the pt's nose. She said "No, because it stopped, but I still need you to come to take a look because mom said the last time she had a bloody nose she had to come to the hospital in an ambulance."

I'm thinking: 1) it's stopped. 2) she's already in a hospital.

I went to see the pt -- still no blood. Mom said, "There's probably blood in her nose. Do you want to look up her nose?" This patient is an older kid with a movement disorder who is hysterical and uncooperative with any exam, so I figure if I were to stick anything up her nose even for the fun of it to see if there was blood, I could cause more damage. "Yes, but she's not actively bleeding, and her nose isn't bruised, so she is fine for now. Let me know if anything changes."

 

[smq123]

I'm thinking: 1) it's stopped. 2) she's already in a hospital.

This reminded me of a page I got from the triage nurse in our outpatient clinic. One of the patients had apparently called the office and said that he was feeling sad and suicidal and "at the end of his rope." She was sending him in to the ER, but wanted to let me know that he was coming in.

This was all very confusing to me because he was already IN the hospital. For some reason, rather than tell the nurse that he wasn't feeling well, he just decided to call the clinic instead. Strange guy.

 

[diel]

It really depends on the particular physician. Some will continue the surgery as scheduled and others will delay from two to six hours.

If I were in that situation I would notify the anesthesiologist and if he made the decision to delay, I would call the attending (if the anesthesiologist did not).

I agree this is not an emergent contact, but still would want the anesth to be aware.

Again, pt was NOT sched for any surgeries.
Just NPO.
But, we can stop .
(Man, I love this emoticon!!!!!!!!!)

PS: I appreciate your work, and concern about the pts. I really do.
But before you page for something that THERE IS NOTHING I can do or should do about (chewing gums, temp of 37.9, necessity of having a bowel movement in the middle of the night etc...), just remember, I have about 90 ppl on my list (trauma is an exhaustive service). You have 2-4. How do you think I feel about a page about a chewing gum when I am in the ED, on the floor intubating, putting lines, adjusting epinephrine and levophed drips on crashing patients, dealing with endless consults about ppl with brain injuries, pelvis fractures and so on?
At that point, I don't give 2 pieces about studies on chewing or anything that irrelevant.

I don't have the GOD syndrome that I am an MD and "whoa whoa, don't bother me". Please do bother me, but only after you stop and think to yourself: "I think I have done all I could. Only an MD can solve this problem now, and this problem needs to be addressed now."

Every time you will do that, we, the residents, get to live few hours longer, because of less blown neurons in our head.
I humbly thank you in advance.

 

[diel]

Another funny one:
BEEP BEEP.
Me: yello, Dr. Diel,TRAUMA SURGERY.
Phone: yeah, calling ab pt X, he's in HDU now, he is pt with ESRD, (something something)his pressure went down but he is alert bla bla bla (talking very fast).
Me: ... stop

Phone: (ignores, continues) bla bla...
Me: WAIT! Stop!
Phone: (stops for 0.02 sec but then again verbal Niagara) ...
Me: (my eyes just popped, phone is killing my timpanic mb) STOP! Who is this pt? What are you talking about?
Phone: (finally kinda stops). Huh? Pt X. In HDU.
Me: I don't know this guy. I'm sorry.
Phone: Are you nephrology?
Me: ........no...I told you I am trauma!
Phone: Trauma? are you sure?
Me: (starring at my coat.. says surgery...hmm). Yes , trauma.
Phone: so you are not covering for nephrology?



Morale: I know it's easy to page the wrong number, so ask the person on the other line if they cover for your pt before waisting your breath.
I swear to God , she spent 2 minutes telling me something, and DID NOT like to be interrupted.

Still funny.

 

[AbbyNormal]

Again, pt was NOT sched for any surgeries.
Just NPO.
But, we can stop .
(Man, I love this emoticon!!!!!!!!!)

I do indeed believe you love that emoticon. It suits you well.

I suggested a patient scheduled for surgery "might" have surgery delayed if chewing gum and that would be an appropriate reason to inform the physician that the patient had been chewing gum.

Thank you for informing me that was not the case TWICE already. I understood this was not a pre-op patient the first time you told me but please keep repeating this endlessly in a loop just in case I forget.

 

[diel]

Hey, you asked for it.
You stated your point twice . Just scroll up.

 

[AbbyNormal]

 

[diel]