Friday, June 25, 2010

Here's a good idea:

If you have a patient without IV access and with a blood glucose of twelve, who is having a prolonged seizure because of that hypoglycemia, do not call casually down to the NCCU and ask me to mosey on up "when I have a minute" and put in an IV for you.

Call the response team instead.

I arrived to find a patient who'd been burned over about 40% of her body when her meth lab took a wrong turn, with a nurse and doctor standing at the bedside like calves at a new gate. The doctor was beseeching the patient to breathe slowly and deeply as her eyes rolled back in her head and she seized. The nurse was doing something, I don't recall what, but it wasn't what needed to be done.

So I grabbed a start kit off the cart and found the only place I could without fresh grafts: her left ankle. Her daughter started protesting that she'd "had tumors in that leg" and trying to stop me from inserting the IV. The daughter got told to get out of my way. As I found one decent vein and stuck it, I asked, "What's her CBG?"

"Uh....low" said the doc.

"How low?" I pressed.

"Twelve."

I looked up from the blood flash I'd gotten and turned to the nurse. "Call the response team" I said, low and forcefully.

"What?" she said.

"Call the fucking response team. Dial ninety-nine and tell them you need a response team stat."

Back to the IV. I heard the call go out. The catheter hit something and wouldn't budge any more, so I tried floating it in. No go, and I lost blood return. I eased the catheter out about a quarter inch (about half of the length it was actually in) and got blood.

"Give me the D50" I said.

The nurse fumbled around for a minute and managed to give me an amp of D50 with the needle guard removed. At that point, thank God, the response team showed up and included a nurse I'll call Stoya because, well, she looks like Stoya. She got the needle guard back on the dextrose and managed to push the amp through a 22-gauge that was only about an eighth of an inch in the vein. It blew as she finished off the amp.

The response team chief was looking at the doctor, expecting some sort of explanation and perhaps a brief history of what was going on. Doctor Moo stared back, speechless. "Forty-five-year-old female, brittle type I," I said to the chief, "who was given 125 units of NPH this morning and hasn't eaten since. CBG of twelve, no access. Why the hell doesn't this patient have a central line?" That last was to the doc.

Meanwhile, somebody showed up with Glucagon, and that got into a muscle somehow, and Stoya handed me a 20g to start another IV. A couple of CCU nurses were working on the other leg, but nobody was getting anything. After several minutes of this (it felt longer), Stoya said, "Oh, fuck yeah" under her breath and turned the woman's leg to the side.

A huge vein had popped up out of nowhere on her ankle. I slid my right hand under Stoya's arm and, with her stabilizing the vein for me with one thumb, watched the entire universe collapse down to this one scene: right hand with a needle, blood on my ungloved left hand (I'd taken off the glove to try to feel something; don't tell me you don't do that too), a single vein popping out of a bony ankle. Stick, flash, fumble for a flush, yank the cap off the flush with my teeth. Get the access flushed and taped. Push another amp of D50.

The patient's blood sugar had come up by this time to the point that she was no longer seizing, but instead was actively fighting. She took a swing at one of the nurses and began to scream. Her daughter, at the head of the bed, started screaming back. "Get her out of here" I said to the biggest respiratory tech we have, and he did. A patient care aide who weighs somewhere around 220 laid down across the patient to keep her from coming out of the bed.

"I need a milligram of Ativan, stat" I said, to one of the dozen people clustered around the door. "Uh...I don't know if we have that on the floor..." she started to reply. "Then get it out of the code cart. A milligram of Ativan. MOVE!"

Working with those nurses was like working with a group of sedated turtles in Jell-O. I'm proud that the only time I raised my voice was when I said "move" to the nurse who was impersonating one of the more languid varieties of rock.

Through the whole response (twenty minutes, total) the doctor at the bedside never said a damn word. He simply had no clue at all what to do. The nurse was new, so I'll excuse her for not knowing: knowing what to do in the classroom and doing it automatically in a crisis are worlds apart.

The pharmacist came to visit me the next day. "I liked the way you handled that response the other day" he told me. "Nice work."

15 comments:

Steve said...

WHOA!

As a "Frequent Flier" at several hospitals, I really appreciate a nurse who knows her stuff and can keep her wits about her when the shit hits the fan.

You freaking rock, Jo.

Steve
Adventures of a Funky Heart blog:
http://tricuspid.wordpress.com/

Dr. Alice said...

Great Scott. What was it with the doc? Intern, or just generally clueless?

Moose said...

You do, in fact, rock. When I'm very very sick I want you as my nurse. If not you, your clone, or twin.

Also, 125u NPH!?!? Cripes, I know I take a lot and I've never taken more than 70 units of *any* insulin in my LIFE.

Also, also, will glucogen even work on someone with that much burn space and a massive blood sugar crash? Doesn't the body's reaction to the burn interfere with the whole glucogen mechanism [I mean, having it do the sugar release et al]?

Either way, icky situation, and, FWIW, I think you totally rule.

Jo said...

Steve: Thank you!

Dr. A: Brand-spanking new doc, not on any service that would normally have to deal with blood glucose (phys med). Poor guy. He was quite shaken.

Moose: I don't know jack about burns and glucose metabolism. Whatever we all did worked, though, thank Frogs.

Annie said...

Man. When I enter the medical workforce I hope I have your presence of mind.

Jo said...

Annie: I wrote this without mentioning the internal panic I had (doesn't make a good story). Dealing with stuff like this is only a matter of practice.

A NURSE said...

I've had days like that on OB. And ya, I need one glove off...from the days we wore NO gloves at all for IV starts... ya just can't feel those veins that like to hide properly......

messymimi said...

I am in awe.

You keep calm and do the work, pacifying the screaming self on the inside. Then you relax after and let that scream out.

Exactly as you should.

me said...

Yikes.

To hell and back.

Good job.

Maha said...

I want to grow up to be like you :)

woolywoman said...

God I hate July. Our herd of young hopefuls has arrived. I know everyone has to start somewhere but it makes for a long month. I finally got enough seniority to take the first 2 weeks of new intern season off.

It always sucks when your fellow nurses are acting stupid. I hate calling out fellow nurses, but, damn, girl, there are sometimes it must be done.

Felix Kasza said...

"... one of the more languid varieties of rock" -- ROFL!

And I agree with Moose: Unless this patient was a 500 lbs type 2 who was planning to pig out on Jelly Beans, why the F would she get a 125u (!!!) dose of NPH? Not to mention that NPH is the worst crap to hit diabetics since that U-40 brown sludge made from the crap stuck to the underside of a pig's feet?

Please mention to the physiatrist that one may not expect a doctor to be expert in all things ... but glucose or glucagon for a blood sugar less than 50 mg/dl should not require a textbook to figure out. And if he has a good day, perhaps he could look up "flexible insulin therapy" (known as MDI, multiple daily injections, hereabouts).

@Moose: Glucagon works as long as your liver has a reasonable reserve of glycogen (a storage form of glucose). Once that is depleted, Glucagon fails. Personally, in my before-the-pump days, when I used to fall off the bicycle with some frequency, I preferred glucose over Glucagon; most first-responders will give the full milligram of the latter, which makes me puke all over. (.5 mg, followed by the other .5 mg after 15 minutes if necessary, is much easier on the stomach.)

Cheers,
Felix.

nurse XY said...

You're my hero Jo. I only hope to be half the nurse you are some day, (not to mention the writer...).

Drew said...

Fascinating. I'm not a medical professional, just a lowly English teacher, though I've always had an interest for all things medical after having grown up with a somewhat hypochondriatic mother.

This reminds me of a scene straight out of House, but with the detail and the emotion of a real story instead of a fictional one.

If I ever go belly-up, I hope to have someone like you as my nurse.

Sue G said...

I do my best learning from hearing or witnessing stories like this. Or from being one of the sedated turtles and reviewing what went down. One of those turtles will one day save a life because of your example.

"Dr Moo" LOL