My first bloodied scrubs.

I did chest compressions for approximately 1 hour 15 minutes, with a few breaks, on a poor young soul shot through the chest a few times. He arrived asystolic but was brought back. He coded in the OR, they did open-chest cardiac massage (a.k.a. CPR by squeezing the heart) and direct defibrillation to the heart muscle. Gave who knows how many blood products before being rushed up to our unit with a hemoglobin of 5—so there was still active hemorrhaging—and pulseless again. We gowned, gloved, and donned masks with eye shields as they came up with the patient. They had me start compressions while they set up the rapid transfusion pump, which infuses blood, platelets, and saline almost as fast as a nurse could hang them. They also pushed epinephrine and ran vasopressor drips wide open.

All I can say is it's a good thing I've been exercising.

As I was pushing I kept thinking about all the things I'm learning about hemodynamics and CPR, like: CPR rarely works, you're only pushing 20% the circulation the normal heart can do, most people don't push hard enough or fast enough or let the chest recoil. I didn't sing "Staying Alive" to myself during chest compressions, because that seemed too slow, so I tried to keep a good 150/min tempo on the monitor. That's faster than the 100/min recommended for CPR on the street, but that's how fast I've seen it in ICU codes. I think when you're trying to push meds into veins that have no circulation, you need a faster rate if you're going to move that blood at all.

Eventually I had to kneel on the bed, which meant I was kneeling in blood. During breaks for pulse checks or when I switched out with someone else, I kept throwing towels, blankets, whatever down to cover it, but eventually it soaked through. Searching for the linen room (actually a big complex of rooms) in the basement took me at least 25 minutes. They sent my scrubs to the dry cleaners (I even had to fill out an old-school dry cleaning slip for them) and gave me surgical scrubs.

It's a shame there's so much violence, especially as the Midwest winter breaks and the warm weather arrives. It's like living in a war zone, except it happens on American city blocks not very far from here.

The Joint Commission: Fewer Inductions, Fewer C-Sections, and Exclusive Breastfeeding

The Joint Commission* is the agency which accredits most hospitals in the USA. All of our clinical practice is done with an eye to Joint Commission requirements. These requirements are often housed in what the Joint Commission calls Core Measures, which are "bundles" of treatments that should happen for certain diseases. For us in emergency and critical care, these can be pretty strict. For instance, if your patient comes to the ER with a possible heart attack, you need to give aspirin immediately, run an EKG within five minutes, etc. It's important because these are documented life-saving treatments. If you skip any part of a bundle, you need explicit documentation justifying your decision. When the Joint Commission comes, they follow patients and inspect their charts from admission to discharge. If they don't like what they can see, they can fine you or remove your accreditation, which can then lead to Medicare not reimbursing your services or the state closing your doors.

I'm familiar with the Core Measures for medical patients, but I was surprised to learn that they exist for mother-baby care as well. The new Core Measures for Perinatal Care were released in January 2010 and they began collecting data on hospitals this month. I was additionally surprised at how forward-thinking they are, compared to how I picture obstetric care in this country. Here's what I gleaned from the measures (keep in mind that I don't work for or represent the Joint Commission!):

Measure 1: Elective Delivery. Their goal is reducing the rate of elective deliveries before 39 weeks.

...almost 1/3 of all babies delivered in the United States are electively delivered...compared to spontaneous labor, elective inductions result in more cesarean deliveries and longer maternal length of stay. The American Academy of Family Physicians (2000) also notes that elective induction doubles the cesarean delivery rate. Repeat elective cesarean sections before 39 weeks gestation also result in higher rates of adverse respiratory outcomes, mechanical ventilation, sepsis and hypoglycemia for the newborns

I think this is great, but obviously would like to see a reduction in elective deliveries after 39 weeks, but modern obstetrics is very afraid of 'overdue' births, without (as far as I can tell) very much evidence. However, inductions and c-sections before the 39 week mark are probably one of the major causes of birth complications and NICU admissions in this country, so this is probably a good start.

Measure 2: Cesarean Section. Their goal is cutting the c-section rate for first-time mothers who have no complications. This Measure is worded the strongest:

The removal of any pressure to not perform a cesarean birth has led to a skyrocketing of hospital, state and national cesarean section (CS) rates. Some hospitals now have CS rates over 50%. Hospitals with CS rates at 15-20% have infant outcomes that are just as good and better maternal outcomes (Gould et al., 2004). There are no data that higher rates improve any outcomes, yet the CS rates continue to rise. This measure seeks to focus attention on the most variable portion of the CS epidemic, the term labor CS in nulliparous women. This population segment accounts for the large majority of the variable portion of the CS rate, and is the area most affected by subjectivity.

I take "subjectivity" to mean "clinical decision-making lacking in evidence." This, again, is good, though limited (hopefully someday it will extend to an endorsement of VBACs for uncomplicated pregnancies).

Measure 5: Exclusive Breast Milk Feeding. This was the most interesting and surprising goal: Exclusive breast milk feeding during the newborn's entire hospitalization. It lists all the dozens of healthcare organizations which endorse exclusive breastfeeding, and it clarifies what counts as reasons for not exclusively breastfeeding:

Reasons for not exclusively feeding breast milk during the entire hospitalization are clearly documented in the medical record. These reasons are due to a maternal medical condition for which feeding breast milk should be avoided.

Exclusive breast milk feeding is defined as a newborn receiving only breast milk and no other liquids or solids except for drops or syrups consisting of vitamins, minerals, or medicines.

The mother's refusal to feed the newborn breast milk does not constitute a reason for not exclusively feeding breast milk. [bold emphasis theirs]

When determining whether there is a reason documented by a physician/APN/PA or CNM for not exclusely feeding breast milk, reasons must be explicitly documented (e.g., "mother is HIV positive - infant will not be breast fed") or clearly implied (e.g., "mother is currently abusing alcohol - infant will be fed formula"). If reasons are not mentioned in the context of infant feeding, do not make references (e.g., Do not assume that the infant is not receiving breast milk because of the medications the mother is currently taking).

They are also explicit on what medical conditions apply: HIV, active TB, galactosemia, etc. It also allows exemption for drugs which contraindicate breastfeeding.

Two other Core Measures (3 and 4) concern Antenatal Steroids (to avoid preterm labor) and Bloodstream Infections in Newborns which are important, but of more concern to the L&D and NICU clinical environment.

I'm excited by this, because in my clinical world, the Core Measures are important guides to our care, and by and large respected as things that have saved lives. I'm not sure how they are viewed in obstetrics. Hospital obstetrics seems much more dominated by physician's personal views than other parts of the hospital, and it's also much influenced by the outside clinical world: e.g., reducing elective inductions in the hospital will mean affecting how obstetricians practice with patients in their offices. And I heard a lot of "that's nice, but we'll see how it goes in the real world" regarding implementing the Baby-Friendly Hospital Initiative by L&D staff when I was in school. I also don't know how much leverage the Joint Commission has over obstetrics, compared to the leverage it has over the rest of us.

But it's exciting to read.



*It used to be called the Joint Commission on the Accreditation of Healthcare Organizations, or JCAHO—"jay-co" as we still call them. Now they're just The Joint Commission or TJC.

Family Care in the ICU

On a somewhat related note to my post about how patients in the ICU might not get enough psychological support, there was a study published this month by the Society for Critical Care Medicine on the effects on family of having a loved one in the ICU. You probably don't have to read the study to know that distress, fear, and fatigue were going to be major issues. However, another new study published by the SCCM showed that families and patients benefited from having a "family support intervention" specialist to act as a liaison between the staff, the physicians, and the family. I agree with this and think it's a good idea. However, the study authors point out that they weren't able to show that there were better outcomes, decreased costs, or decreased lengths of stay for patients—in other words, it doesn't improve patient health, efficiency or cashflow—which is all anybody really cares about in medicine. The authors hope new studies will demonstrate this effect, but I think it's doubtful. I'm sure there will be dozens of anecdotal cases where a family liaison benefits care, but it won't be enough to "statistically significant."

It's still probably the right thing to do, however.

The effect of a family support intervention on family satisfaction, length-of-stay, and cost of care in the intensive care unit. Crit Care Med. 2010 Mar 11.

Related posts:
What's So Scary About Healthcare? Putting Strangers in Charge
Why I Like Open ICUs
Open ICUs Are Good for Patients

A Crash Course in Trauma Psychiatry

There's a lot to think about with trauma patients even after they're stabilized: their blood pressure, their lungs, the ventilator, multiple drips, pain control, sedation, restraints, wound vacs, infection, sudden hemorrhage, compartment syndrome, kidney failure, and sometimes most difficult of all, their neurological status (are they going to wake up disoriented and combative? or not wake up? and why? drug coma? brain damage?). Trauma patients are different from other patients in the ICU, because they were presumably healthy before their incident (though there's always the chance of drug and alcohol abuse—that might be why you're giving them enough fentanyl to kill a horse), but now anything could fail.

Aside from these physiological problems, however, I find myself worrying about the people themselves. Many of these people are pretty awake while they're going through all this. They may be casted, on a vent, trached, pegged (having a feeding tube), in traction, spinal immobilization, etc, but still awake. It seems like there should be some psychiatric team or something we can utilize to help them cope. Granted, we sedate many of these people with IV drips, but we sedate them for their health, for instance so they breathe better on the ventilator. So if there's no physiological reason to sedate them, they're awake. It's not as horrifying as it sounds (I think!) because they come into this conscious awareness slowly, and they're sick and groggy, but still. Often it's the busy RN who alerts these patients, and their families, to what's ahead: their chances of survival and disability, the rehab plan, how many weeks or months this might entail, what it means for their family or job.

There are more extreme psychiatric problems, too. For instance, one young gang member was shot more than 10 times, through every major internal organ; yet, barring disaster, he'll survive and walk again after rehab. What does this do to his psyche? Does he reform himself? Does he think he's invincible? What about his brothers who come to visit, sobbing, or his multiple young male 'cousins' who might not really be family? It seems like a good time for anti-violence intervention for the visitors and some kind of reformative intervention for the patient.

Or another gang member was shot and got in a wreck trying to drive to our ER. He is paralyzed as a quadriplegic. How do we help him cope? Can we help him cope? Is there even any hope, if he's just going to live out his days in substandard conditions in some public health nursing home?

These personal issues are on the back-back-back burner in everyone's minds in trauma. The nurse is busy keeping the patient alive. The physicians are in and out in five minutes, unless a patient is critical. There are other ancillary staff like dieticians and physical therapists, but these issues are not strictly their concern.

I know this is a pipe dream, that a hospital which is already spending hundreds of thousands in pro bono money to save and recuperate gang-bangers with no insurance, is also going to devote time and money to rehabilitating their souls and trying to make them into good citizens. But I'll at least try to keep this in mind during my nursing career.

The vials of Versed (midazolam), which is often the extent of critical care psychiatry, were photographed by Jmh649.

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15% off tall scrubs with code "tall_sale"

Panicky Births: Why I Wouldn't Give Birth In A Hospital (Had I a Uterus)

The Healthy Birth Blog Carnival is up and its topic is staying off your back (i.e. lithotomy, or the 'stranded beetle' position) during the second stage of labor. The second stage = the birth: the baby is actively coming out. And in most places in this country, that's when everybody freaks the heck out.



What I witnessed in school was, when birth is imminent, the mom is typically helped, flipped, tossed, or otherwise forcibly put on her back, her legs are thrown up into stirrups or held aloft by nurses (or family, innocent bystanders, Simon of Cyrene—whoever's handy), and everyone starts hollering at her. Now, I'm not an OB nurse. But in critical care, when you urgently need to give clear commands, ONE PERSON DOES IT, whether you're getting a patient out of bed or coding them. This is so the patient doesn't fall on the floor as three nurses tell them to go three different ways; it's so the code efforts proceed in an orderly fashion; it's so the combative patient has one professional to listen to rather than a room full of hostile voices. But from what I saw, this doesn't happen in obstetrics. It's a free-for-all. The stories in the carnival reflect this; it's really worth covering. Even home births attended by midwives aren't always exempt from this practice.

I think this public health doula put it best:

The second a woman is judged to be "complete", everyone in the room suddenly gets license to, quite frankly, be a total jerk to her...if before there was lots of murmuring and support and encouragement, all of a sudden she's treated she's constantly failing. Generally, directed pushing involves a lot of yelling directly into her face, telling her to try harder no matter how hard she is already trying, forcing her to hold her breath, exhaust herself, and then ordering her to relax as soon as pushing is over. This happens even if she's making great progress: a primip who pushes out a baby in 20 minutes still gets this treatment. It also recruits all-too-susceptible support people into this aggressive treatment. They get the chance to do something! take action! after hours of labor in which they often didn't feel very useful.

This reminds me of the at-term pregnant patient we had who stayed in the hospital for a week because of high blood pressure (really, because she didn't agree to come in for frequent BP checks) and one L&D nurse said "Why don't we just deliver her already?" How much does boredom and impatience have to do with it?

Not that I understand what is so urgent anyway. There are second stages of labor when the baby urgently or emergently needs to come out; but that's not the norm. It seems like standard practice to assume it is, though. I suppose it has a lot to do with the fact that all our medical safeguards are gone in the active second stage; the fetal monitor probably starts getting fuzzy and unreadable, there's no IV medication you can give to stop it. It's an unmanageable process, which scares practitioners. But it's supposed to be unmanageable; that's how it flows smoothly, if you let it. Typically the baby is coming out whether you want it to or not, and you don't have to shout at the mom; her body compels her to push, using (if I remember right) the same reflexes her body uses to make her want to defecate. Nobody shouts at pregnant women when they're trying to move their bowels.

We've had four home births, and things only became urgent when there was evidence that things needed to be done urgently. Otherwise, they were calm and let things proceed as they should. The midwives used what we nurses call our clinical judgment: not proceeding rashly, not making assumptions, but using our eyes, our heads, and our assessment skills and tools to have a good idea of what's going on. It was never a free-for-all.


Related posts:
Crash Birth
How My Wife Had An 11+ Pound Baby At Home and Didn't Die (my submission, because it involved an upright delivery)

Rest In Peace, Grandma

My grandmother died yesterday of pancreatic cancer. She was only diagnosed in January. A month ago I was talking on the phone with her, and she was still planning the family reunion which she plans every year. Her only complaint (that she verbalized, anyway) was being tired all the time.

We spent five days over Easter visiting her. She was in a hospital bed in her house, but she did get up the wheelchair for maybe twenty minutes at a time. She had lost so much weight. Regardless of that, her mind was still sharp as a tack. She remembered things nobody else could, as everyone sat around discussing the past. Everything from phone numbers, events, and birthdays, to the names of corner stores and restaurants and bars from fifty years ago—my uncles were recollecting how they used to take their dad's empty gallon beer jug to be filled up: two twin boys, aged seven, going into a tavern, heaving the bottle up onto a bar they could hardly see over, and then walking through the city with the jug full of beer! She laughed when my uncles said nowadays they would've been turned over to foster care and she would've never seen them again.

She really liked seeing us, talking with me and seeing my wife and her four rambunctious great-grandkids. My son informed her that God makes people old and sometimes brings them up to heaven. And the kids gave her a chocolate Easter cross (the stores were clean out of bunnies by Saturday!). Another visitor who was there when we were said that when his relative had pancreatic cancer, sometimes a little sugar kick or some chocolate would make them feel better. Something with the pancreas—I assume it starts to fail to secrete insulin, but maybe it also fails to secrete glucagon, which maintains & increases your blood sugar.

She was very realistic about what was happening. She asked me if I got to spend time with my other grandmother before she died (seven years ago). I didn't really; I saw her a couple months before, but not right at her death, and now I regret that a little. I'd rather be with someone while they're awake (or even half-awake). Not that I think funerals are unimportant, but they're not as good as spending time together. I actually got to say goodbye to my grandmother, which I'll always value. We left last Monday, and my dad called me yesterday to say she passed away peacefully. (My dad and my aunt are both nurses, and hospice was with her, so I assumed it would be peaceful!) It goes without saying that I'm thankful she was able to die at home, rather than a hospital.

She wants a simple funeral: a viewing at the church, not a funeral home, then the funeral mass, and then straight to the cemetary. That's how I would want it, too.