Tuesday, June 28, 2016

A well-oiled machine.

"What you need to do," the house supervisor said to me, "is learn to lower your expectations."

"Fuck you," I replied, with a sunny smile.

We'd just gotten a patient in, a guy in his fifties who was, according who what we'd heard from the house soup, status post-TPA, hypertensive as a habit, with a dense left hemiparesis. We'd heard that from the house soup because there had been no report from the outside ED from which he'd come. There had been no warning that the patient was on his way; we'd been waiting since early afternoon and it was now five minutes from the end of the shift. Of course.

Luckily, the dude could talk. Peej and Bethie moved him on to the bed and Peej took a first set of vitals.

His blood pressure was 80 over 44.

(Note for the non-medical among us: 80/44 is a perfectly respectable blood pressure for, say, a teenage girl who runs track. It's not good for a guy in his fifties, and it's *especially* not good if said guy has been running, since time immemorial, in the 150's over 90's or higher. Your body gets used to a certain amount of blood going at a certain pressure to all your organs, and something much lower or higher than that usual can cause problems.

A low BP, in particular, can lead to hypoperfusion of the brain, especially after an ischemic stroke. That means that all your stroke symptoms come back and further damage is done because there simply isn't enough blood, at high enough pressure, to fully supply the brain tissue.

To give you some idea of how important perfusion is, we normally allow our patients to run as high as 180 systolic [the top number in blood pressure] and 110 diastolic [the bottom number] after a stroke that's been treated with TPA. We definitely want to keep them above 100 systolic.)

Peej read out the number. I called to Bethie to bring a bag of normal saline and tubing, and started to trend the bed such that New Dude was lying with his head down and feet up. After determining that he didn't, as far as he knew, have congestive heart failure or any allergies, Peej started a bolus of fluid. Bethie called the doctor's lounge, trying to raise somebody--anybody--with an MD after her name to come and check New Dude out.

Just then, New Dude's left side started working again. He said, "Hey! I feel less dizzy! And I have to pee."

And with that, Doc Paul showed up and the night shift took over.

The unusual part of all of this is that both Bethie and Peej are new to stroke. Peej is a new nurse, flat out, having just finished her internship. Bethie did epilepsy stuff for years and worked on an HIV unit in the bad old days before protease inhibitors, so she's experienced, but strokes aren't her thing.

Peej is tall and slender and graceful and serene. She wears her hair in a bun, but that's not why people ask if she's a ballerina--it's her unshakeable poise and excellent posture that makes them think she dances. Bethie is me in a few years: foul-mouthed, fratchety, sarcastic, and with an amazing collection of weaves and wigs. Nobody, looking at the three of us, would ever suspect that we could work together well, let alone be friends.

But we did and we are. It was a minor crisis, not somebody spraying blood all over the walls, but Peej especially handled it beautifully. When I was six weeks out of my training, I panicked when faced with the same situation. Peej never broke a sweat, even taking time to explain to the recently-arrived family what was going on. I am very proud of her.

And we are, in my words, a well-oiled machine.

Or, in Bethie's words, "A fuckin' well-oiled fuckin' machine, man."


Old Fool said...

What a great team.

bobbie said...

Amen!! Life is always better when you work with a great team ~

clairesmum said...

Strong smart women ROCK!
New Dude is lucky he arrived at your unit when he did. Hope he didn't lose too much brain function.

RehabRN said...

Wow! That IS low (even if you're dude was a quadriplegic patient). But thank goodness he got better and a bolus for his trouble.

Nothing like end of shift shenanigans to get the heart racing!

Dr. Alice said...

Good for you guys! I hope the patient is doing better.

Anonymous said...

So I'm old and newly retired but can't pass up a teaching moment so... Trendelenburg is out. Like so out it is at least 10 years past. Unfortunately "evidence based research" still is slow to be adopted into practice. Trendelenburg is out as the baroreceptors in the carotid arteries sense the increased pressure as a false high pressure and work by their feedback mechanisms to LOWER pressure further. Who knew huh?! So the only thing you can do is lower the HOB and raise the feet. Or try a mast suit but I can't imagine anybody uses those anymore either. Just get the fluids and pressors going. I love the blog by the way. You have a great writing style and wry sense of humor. Blog on!

cowango said...

Glad to hear at least some things are working right. Love it when I'm in tune with those I'm working with.

woolywoman said...

Gotta agree, here. Still got orders for it before I retired, but no evidence for good, ample evidence for unhelpful.

AdvancedCardiacRN said...

It's always the most unlikely that make the best teams!