The Big Picture; also why you shouldn't ride motorcycles while drunk

So I get a motorcycle accident from a rural area, a young guy who was drinking and riding (this happens all the time, I don't know what it is about alcohol and motorcycles and no helmet that makes sense), and his family are there. They're asking why he's on a ventilator. It's 7 am and I've been up all night, so I'm struggling with an answer because I feel I can't exactly say his pCO₂ was 69 and his pH was 7.1 (less than 7, you're going to heaven) when he came in, which could be from the trauma or could be from his small brainstem bleed, and we need to ventilate for him to make sure gas exchange occurs and he doesn't suffer more brain injury. So I said something about how he wasn't breathing well enough when he got here, and explained the gas exchange problem, and that we're not going to trial him on breathing on his own until he starts to get healthier.

His girlfriend said something like Oh, so he was breathing on his own then? At the crash? I said possibly, probably—just not well enough.

Then as I'm walking home I realize that's all they probably wanted to know: whether he was breathing at the scene, or did paramedics have to revive him. You know, whether he was dead and brought back. I sometimes try to reduce the complex medical details of a patient's immediate ICU situation into English, but what families seem to want more is 1. what happened that my loved one needs to be in the ICU, 2. how sick are they really, and 3. what chances of recovery do they have? It's hard to step back and adjust your focus, especially when you're still doing your admitting assessments.

A major case in point is that we nurses and physicians, talking among ourselves, will say a patient is stable or easy, when in a real-world sense they're not at all. What we usually mean is that their blood pressure is stable right now, or we don't foresee any critical changes happening in the next, say, twelve hours.

Also we should buy this sign to hang in the ICU, or rather, in the bars in the nearby rural counties:

How We Die

I'm reading How We Die: Reflections on Life's Final Chapter by Sherwin B. Nuland. (Ironically my wife is reading Jennifer Block's Pushed: The Painful Truth about Childbirth and Modern Maternity Care). It's a pretty good book, though I have to say that as a hospital RN there's not much in here I don't know. Still, it's nice to see the knowledge of death in America cohesively organized and shown to be what it is, both in terms of the diseases that kill us (naturally or induced by our diets and lifestyles), and in terms of the cultural weirdness in America of dying in a hospital or nursing home rather than in the care of your family.

Most of the information and writing is accurate, if a little dated or dramatic at times. He does talk about metal paddles for shocking patients and doing chest compressions "at a rate of about one stroke per second", which is about half as fast as any code I've ever seen. And I ran across one thing I didn't really agree with. He describes what it's like to be a code team after a failed resuscitation attempt:

Reluctantly the team stops its efforts, and the entire scene becomes transformed froma vital image of imminent heroic rescue to the dejected gloom of failure.

I've never seen dejected gloom after a failed code. I've occasionally seen anger or sadness, only when we thought we had a chance. But I think most physicians and nurses realize that failing to resuscitate is just failing to forestall the inevitable. People die.

I do agree with what he says following that, however:

The patient dies alone among strangers: well-meaning, empathetic, determinedly committed to sustaining his life—but strangers nonetheless. There is no dignity here. By the time these medical Samaritans have ceased their strenuous struggles, the room is strewn with the debris of the lost campaign...In the center of the devastation lies a corpse, and it has lost all interest for those who, moments earlier, were straining to the deliverers of the man whose spirit occupied it.

I hate the idea of people dying alone among strangers. And the room is always a mess afterward, since every vial, syringe, IV catheter, and bag-mask comes in a disposable container. But I can't say we always lose interest in the corpse. Perhaps physicians do, since they typically feel their work is done and leave the room, sometimes to talk to the family or write their note. But the nurses I've worked with suddenly switch to viewing the room through the family's eyes, removing equipment, quickly changing linens, and cleaning up the room and the person as much as possible to make them have some semblance of dignity. We've managed to get a scene of carnage and garbage cleaned up to being nearly as good as a funeral home, minus the gaudy make-up on the deceased.

At any rate, I do recommend it. The book is divided by what pathophysiological process kills most of us, the first of course being coronary artery disease, with cancer and other killers following suit. I think candid descriptions of the different ways that death proceeds in these cases is valuable in itself, because death is so hidden from modern eyes. And of course I wholeheartedly endorse bringing to the table the discussion of whether we should even be dying in the hospital. Something like 87% of Americans die in hospitals now, often alone. I, like most nurses, tend to think that death happens best at home...with caring professional support, sure, but definitely at home if at all possible. Somewhat like birth.

The nursing shortage

There's been some talk lately about whether we still have a nursing shortage in this economy, e.g. USA Today's New RNs find job market tight. As you can see from the comments, the general idea is that the nursing shortage is still there—it's simply masked by the fact that hospitals in this economy aren't able or willing to hire. Once the economy picks up, and once the baby boomer nurses retire, the shortage is predicted by some to be worse than it was in the 60's and 70's—worse than it ever was before.

I've said it before, but I think that a large part of the nursing shortage derives from a nursing faculty shortage.  Most people don't realize that a typical nursing class requires five to six nursing instructors. Typically one or two carry the didactic portion of the class, giving lectures and tests, and the rest (or all of them together) must be present for the clinical experience.  Because each student RN is assessing patients and passing meds on the instructor's license, it's not considered wise to have more than eight students to a teacher in a clinical setting. At my college, there were up to 200 nursing students at any given time, which means they require at least 25 faculty on hand at all times. Where else in the college do you require that kind of ratio? Nursing is among the most resource-intensive academic programs there are.

And all of these instructors must at least have a master's degree. I can understand requiring a master's degree to lecture and prepare tests. But for clinical leadership, that's a little absurd. There are so many good RNs out there with good knowledge and experience who would make fantastic teachers, except that they don't want to endure the expense and time it takes to get a master's degree, and can't afford to take the pay cut to the sub-par salary which instructors make. If you have to go through more school (even though you already know how to be a nurse) and will make less money than at the bedside, why would you ever teach?

However, despite this, the rumor in the workforce is that pretty soon you're going to need a doctorate degree in nursing to teach.  I don't see how that's going to do anything but aggravate the problem.  I know few nurses who want to pursue a doctorate in nursing, and those that do have their eyes on making $170,000 a year as a nurse anesthetist, not $70,000 a year as some kind of doctor of nursing education.

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15% off maternity scrubs with code "maternity_sale"

Surviving a bullet to the brain

I feel weird talking about specific patients, even de-identified as much as possible, but I thought I'd write about a specific situation. I had a patient who got shot in the head and survived. The bullet passed through the eye, or really between the eye and socket. The eye was collapsed and the socket fractured. Bullet fragments penetrated and came to rest in a few different tracts through the parietal lobe, the thalamus, and caused a hemorrhage in a ventricle. The patient came into the ER awake and talking, but then succumbed and had to be intubated. Everyone figured that traumatic brain injury would result, if the person even survived.

By the time I had the patient we were weaning from the ventilator and sedation. We were even able to surgically fix the eye, though they were only able to distinguish light and dark through that eye. The patient will always have bullet fragments in their brain, but seems to have no evidence of traumatic brain injury. They had fevers, however, but no signs of infection, so it's possible that it was due to damage to the hypothalamus (which regulates body temperature). I'd be interested in seeing if this continues, but of course once patients are out of the ICU I rarely see them anymore!

The patient, incidentally, complained of a headache. 

Disclaimer: this post is not medical advice. Please consult your primary care provider, your priest, or your mom before engaging in activities that may carry the risk of being shot in the head.

Is home birth 3 times as dangerous? New AJOG / ACOG study.

Blogger and Pushed author Jennifer Block wrote an excellent synopsis, complete with links, of the new home birth study being promoted by the American College of Obstetricians & Gynecologists in a stern press release. The walk-away point which they want the media to impart is that while home birth may be better for moms (those darn spa-treatment moms, seeking an admittedly significant lower morbidity!), three times as many babies die as in planned hospital births.

Block outlines the problems with the study, but my walk-away would be her paragraph here:

Here’s what’s particularly curious: Wax and coauthors acknowledge that some of the included studies were not powered to report mortality rates, and when they analyzed the data for mortality and excluded those studies, they found “no significant differences between planned home and planned hospital births,” to quote the study verbatim. But this is not the study’s banner finding. Instead, the authors include the very studies they had excluded and report as their conclusion that “less medical intervention during planned home birth is associated with a tripling of the neonatal mortality rate.”

And yet this is explicitly being promoted by ACOG to alert "public health officials at state and national levels" to the dangers of home birth.

Self-titration of antihypertensive therapy boosts BP control....duh?

You won't be able to see this unless you register for a free log-in at theheart.org, a gigantaur professional cardiology website, but they have an article on how patients who monitored their own blood pressure and self-titrated (self-adjusted) their medication doses according to a simple scale reduced their own hypertension when  normal, fixed-dose treatment had failed to do so.  In other words, they take their blood pressure daily, adjust as necessary, and call their doctor's office if they go above or below critical pressures. I wonder if there could be variations on this, like weekly checks instead of daily, which would make it easier for patients (i.e. increase compliance) but still be more effective than seeing your doctor once every six months and finding out you've been blowing aneurysms in your brain in the interval.

Call me a crazy hippie with too many (four many) home births under my wife's belt, but self-care and self-monitoring, which many midwives encourage and educate you to do, is such a great idea. I work with patients whose high blood pressure causes strokes, kidney failure, heart attacks, etc. Sometimes they're completely noncompliant with medication, but sometimes they're just taking their dose and it's not enough.  We should be enabling people who are interested in taking care of themselves to actually have the tools and knowledge to do so.

Do we need doulas in critical care?

Rixa over at Stand and Deliver wrote a post about an obstetrician practice banning doulas. (See here for info on what is a doula?) Of course, I think it's bad that doctors would want to eliminate the kind of professional who can provide checks and balance in a world of high intervention and c-section rates. But then again, I think it's a little weird that we need doulas at all—why seek an obstetrician if you need someone to defend you against them? Or is there a two-part role here, the scientific professional who can help you in emergencies, but who can't help you emotionally, so you need a doula? At any rate, we never used doulas with our midwives, because our midwives acted as doulas, and of course we were informed patients (so if, for instance, the midwife began doing something dangerous or stupid, we'd probably be able to tell. Not that this was ever an issue.)  It seems like in the perfect world where you have informed patients and caring, competent birth practitioner, why would you need a doula?

Then I thought how weird this would be in the ICU. Can you imagine having a privately-hired patient advocate in the room while you're taking care of a patient? Questioning your nursing care or the doctor's orders? My first thought was that this would be intensely irritating to most clinicians, especially the docs. They'd go nuts. I guess they'd have some right to, both because of the paternalistic mindset they have toward "their" patients (which, in most cases, helps the patients!) and because they can easily lose their license and get sued.

But I think we could use it. I work in a teaching hospital now, where inexperienced residents are often checked by the experienced nurses. But what happens when the nurse isn't experienced? Or when the supervising physician is too busy to really supervise? Entire twelve-hour shifts can go by before someone realizes that something is wrong: wrong meds, wrong dose, oversedation, neurological changes that could've been addressed, etc. And regular hospitals with experienced specialists have essentially the same problem: twelve hours can go by between physician visits, which last an average of ten minutes and often refer their exam to another physician's or the RN's documentation. This is why the nurse in ICU is so essential and critical to patient safety. Usually we are the patient's only advocate against factory-style medicine. But there are bad nurses and overworked nurses, sorry to say.

Do we need ICU "doulas"? Having an experienced third-party RN would benefit a lot of patients. The unfortunate reality is that in a hospital, in which you have hundreds of clinicians seeing thousands of patients a year, errors happen, people fall through the cracks, and bad clinicians with bad judgment keep practicing. But realistically, the expense would probably prohibitive. Being a birth doula is not simple, but it's not critical care; it's simpler because it's a physiological process, not a pathophysiological one. So you'd need someone with a medical license and experience, and that won't come cheap. There's also the probable situation that the only people who would hire these ICU advocates would be people seeking fuel for litigation.

However, as I've said before, critical medicine strives to be evidence-based, and has a relatively low risk of litigation, while current obstetric practice seems to be fear- and tradition-based, due to a high risk of litigation. So I think if you're going to brave giving birth in a hospital, you should really consider seeking the services of an experienced, independent doula.

Why my kids aren't going to school with your kids

A couple of coworkers (not from my unit) basically had this conversation:

Coworker 1: My son totally tricked me into buying this game where you blow people's heads off and explode their guts and stuff. Lolz, sounds like a great game for an eight-year-old huh? It cost $65 too!

Coworker 2: I just buy my kids whatever they want, I don't even care.

Me: (to myself) yeah...that's partly why I'm homeschooling my kids.