Friday, August 06, 2010

"There is a fracture. I need to fix it."

That's our new go-to phrase in the NCCU when dealing with any other service. Those of you who don't know where it came from, watch this, and then read on. (Note: the video will only take three minutes and twenty-two seconds of your life, and you won't regret it.)


The new patient came in late in the evening, after I'd left, from an outside ED. The folks at the ED had done everything right, from a stat CT to offering TPA for his stroke symptoms (which he and his family refused) to doing a 12-lead EKG. It was the 12-lead EKG that caused the trouble: without TPA, there was nothing our services could do but watch and wait to be sure his stroke symptoms didn't get worse, but he was also having a heart attack.

Oops. Well, crud. That's below the clavicle.

So we transferred him to cardiology, because, well, you don't want neurologists and neurosurgeons managing your myocardium. I mean, I'll happily give you all the oxygen and aspirin you can suck down, but I'm really not a heart kind of gal.

A few hours after he'd left my unit and gone to the CVCCU, I got a call from the resident.

Heart Gal: Hey, I'm the resident in the CVCCU, and I had a question about Mr. Jones. How do you know he had a stroke?

Me: Beg pardon?

Heart Gal: Well, you know, he never got an MRI. How do you know he had an acute infarct?

Me: Symptoms.

Heart Gal: But he never had an MRI. How do you know he had a stroke?

Me: His left side went weak and his speech got slurred and his palate wasn't elevating equally. His stroke scale score was 5.

Heart Gal: But...but...without an MRI, how do you know there was an infarct? I mean, how can you tell that there was a stroke without an MRI?

Me: One quick question for you: have his symptoms resolved, or is he still weak and ataxic on that left side?

Heart Gal: He's still weak and ataxic, yeah. But I don't see what that has to do with it. He didn't have an MRI, so you can't tell if he had a stroke, right?

Me: Um. (thinking hard, trying to figure out how to explain this to HG, who's a very nice person as well as an excellent cardiologist) Well, y'know, we don't generally *do* MRIs on people who present with symptoms of an embolic stroke. They take a long time, so we go by symptoms so we don't lose any time in treating with TPA. And Mr. Jones and his family didn't want TPA, so we figured we'd do an MRI once he was stablized. How's his heart, by the way?

Heart Gal: His heart?

Me: Yeah, his heart. We sent him over there with a troponin of 3; how's his heart?

Heart Gal: Oh, it's fine. I'm just trying to figure out how you knew he had a stroke.

et finis



11 comments:

Anonymous said...

And that is exactly why I'm not going to be a cardiologist.

Anonymous said...

Residents make life fun!

Yesterday, I had a patient scheduled for her second attempt for an MRI. The day before she was jut too rowdy and they decided to try again the next day. I get to work and the nurse leaving informs me that the resident ordered 5mh of Haldol pre MRI...

So MRI calls I give her the Haldol and send her on her merry way. Ten minutes later the MRI nurse calls and said, "this ain't happening as grandmas is all over the place, got anything to give her?"

I call the oncall resident and give an update a ask for a touch of Ativan for my 93 year old confused patient. He says, "give her 10mg of Ativan IV".

Me, "I want her calm not dead."

So we changed the order from 10mg to 1-2mg and just that wee bit knocked her out for hours.

messymimi said...

When they specialize, do they quit thinking in terms of a whole patient? If so, why do we make them learn about the whole patient in med school? They are just wasting all of that time with information they will never use...

me said...

My eyes are rolling so much they've given me a HA...

Sx3 said...

I love the single-mindedness of specialists! We really do hold the keys to the nut house!

Molly said...

Well crap, that was probably the poor guy's worst day ever.

Nurse Me said...

Thinking outside the box. Not a quality found in most "specialists"

Anonymous said...

The resident on the cards service wasn't likely a cardiologist in training since cardiology fellowships begin after completing an internal med. residency. She was probably just an overwhelmed but still curious R2 supervising a bunch of interns who were keeping her busy.

Andi, On Call RN said...

hahahaha, this sounds like something that would happen on my unit. Thanks for the laugh!

IowaStudent said...

I don't think I've laughed so hard. Thank you, for the laugh, and the frustration that comes behind it.

Dr. Alice said...

"There is a fracture. I need to fix it."

Awesome. That made my day.