Thursday, July 24, 2008

Slow Learners

A friend told me that she just got her first speeding ticket -- 2 months after replacing her older, rattly car with a newer, smooth-riding model. Steep learning curve, that one. Not as steep as some people find when they get to traffic court, though.

A few years ago, I accompanied my son to traffic court. He had lost control of his car - we think due to a mechanical malfunction. He was uninjured. His car was totaled - and so was the guard rail that had kept him from spinning into oncoming traffic. The Trooper told him he had to write a ticket so the state could bill our insurance company to replace the guard rail, but that he shouldn't worry about it. When his case was called, the Trooper declined to testify against him and the judge threw him a big enough hint that he realized he should plead not guilty.

Most of the rest of those who appeared before the judge that day fared better by pleading guilty - often guilty with an explanation. The judge lowered fines and points all around. There were a few slow learners in the crowd, though.

The same State Trooper had written citations for about half the crowd in the courtroom that day. For speeding violations, he started his testimony pretty much the same way:

At X time on X date using equipment that I calibrated at the beginning and end of my shift, I recorded a speed of (20- 50 MPH above the posted limit)..........

Most people accepted the Trooper's measurement of their speed, but one defendant wasn't so bright. He started his 'defense' with "Your Honor, I don't know exactly how fast I was going.."


Down came the gavel and the judge said "You may not know how fast you were going, but I have the sworn testimony of an officer of the law using calibrated equipment. He measured your speed at (40-50 mph above the posted speed)." No mercy for that defendant -- maximum points AND fine.

It was hard not to snicker at that one, but 4 or 5 defendants later, another man tried the same stunt -- with exactly the same results. I was glad we were sitting in the back of the courtroom, because I really didn't want to get caught snickering at him.

The third time it happened, only fear of being found in contempt of court kept me from laughing out loud. I can't imagine being stupid enough to try that story the FIRST time if I was caught on radar, but I truly do not understand what defendant #3 could possibly have been thinking.

Thursday, July 17, 2008

Enter the Collective

We're rolling out a new computerized charting system and I was conned into being a "superuser". Flattery will get me to do too many things against my better judgment, and so here I am.

In order to learn the new system, I had to orient on one of the floors already using it. An adult medical floor. My preceptor was a very knowledgeable and very upbeat nurse who'd been using the system for nearly a year. She loves it. She's sure everyone will.

Resistance may be futile, but some days, it's my middle name. Eventually we will all be assimilated.

I have seen and toyed with the system. She's right. We will eventually come to like most aspects of this system. It has a few flaws, but overall it's pretty well designed.

The first part of the system we'll be using is the medication administration record (MAR), so off we went to find, administer, and document medications. Generally this went smoothly as there's no stopping to locate labs before you give medications. Coumadin? Click a button and there's your INR so you know whether it's safe to give the dose. Insulin? The blood sugar is there too - and you have to prove that you read it by entering it as you enter the insulin dose. The system even includes a spot for the second nurse to co-sign insulin and other meds which require that.

Most of the meds given, we were off to see her last patient. She pulled up his MAR and scanned his ID bracelet and the medication. They matched.

"Mr. Jones, we're here to give you your medications."

"What did you call me?"

She knows this patient. He's been on her floor for several days, but she did not simply ignore the question.

"Sir, what is your name?"

"I don't know."

"Do you know where you are?"


"Do you know what year it is?"


To me, "You ask him his name" (so I did)

Again, "I don't know"

To me, "I'll show you his diagnosis later. This isn't unexpected."

To the patient, "Mr. Jones, I have your medication."

"What's it for?"

"It's for your stomach."

"What's it called?"

"Protonix, it's for your stomach. For the acid."

"Why are you giving it to me?"

"Your doctor prescribed it. It's for your stomach."

"I don't know if I'm supposed to be taking that."

And on for several more minutes before she simply asked him to open his mouth, which he did. She placed the pill in his mouth and spent the next several minutes coaxing him to swallow.

THEN she told me that she'd thought about working in the NICU, but didn't think she could do what we do. Right. Those of you who care for confused elderly patients have my undying admiration. I could probably learn to do what you do, but I'm not sure I could learn to love it like she does.

Tuesday, July 15, 2008

Beats the heck out of me

My youngest son asked me a question today. At first glance, it seemed to be a very simple question.

Do you breathe out the same amount of air that you breathe in?

I explained that the volume of individual breaths varies, but that my first thought was that average inhalation must be the same as average exhalation -- because if it wasn't you'd either end up with a vacuum or overinflated. Then I remembered that you actually absorb molecules from the air and return others in the process of respiration. I'm not sure that the quantity is measurable, but I'm not so sure that you exhale the same amount over the long haul as you inhale. So I told him that.

His response?

Why don't you blog about it and see what other people think.

He'll nag me if you don't comment. Facts would be nice, but we'll settle for opinions if that's all you've got.

Monday, July 14, 2008

APGAR 0, 0, 0, 2

The neonatal resuscitation protocols include suggestions for when to discontinue efforts:

Infants without signs of life (no heart beat and no respiratory effort) after 10 minutes of resuscitation show either a high mortality or severe neurodevelopmental disability (LOE 5).106,107After 10 minutes of continuous and adequate resuscitative efforts, discontinuation of resuscitation may be justified if there are no signs of life (Class IIb).
That suggestion wasn't included in the original protocols. Children like Edie are the reason that suggestion was added to the protocol.

Her mom had a normal pregnancy and most of her labor was uneventful. Unfortunately, she delivered in a small hospital which did not, at the time, have in-house anesthesia coverage for emergency C-sections. Something went terribly wrong and he had no heart rate at delivery.

By 1 minute, his APGAR score was still zero - no heart rate, no respiratory effort, no reflex response, poor muscle tone, blue or pale. By 5 minutes, still no heartbeat. At 10 minutes, the pediatrician was still desperately trying to save the baby -- but still no signs of life. Finally, sometime between 10 and 15 minutes, Edie had a heartbeat -- and nothing else.

Edie was a beautiful baby, but she never moved spontaneously. A month later, she might gasp when disconnected briefly the ventilator for suctioning, but generally she didn't even do that. Her parents visited every day. They held her, talked to her, took pictures for their memory book. They hid their pain from most of the staff -- to the point that many believed they were in denial. Those of us who had quit trying to 'orient' them were privileged to share their pain, though. They knew it was just a matter of time and were determined not to waste their precious moments with this child crying at her bedside.

A few months later, Edie got septic and her parents agreed that resuscitating her if her heart stopped would not be in her best interest. She died, more or less peacefully, a few days later.

The other babies I've seen with 0 APGAR scores at 10 minutes survived only a few hours or days. I don't remember another who survived even a week.

It's very difficult to make the decision to stop resuscitating a full term, or near term baby, especially if the mom was in the hospital being monitored so we know the time that the heartbeat stopped prior to that emergency C-section . I've seen many babies respond to the Neonatal Resuscitation Protocol and go on to do very well. Those babies virtually all have had APGAR scores increasing by 5 minutes, and the rest definitely had signs of life by 10 minutes.

That suggestion to consider discontinuing resuscitation if it has been unsuccessful after 10 minutes makes a lot of sense to me as I sit here typing. In the adrenaline-laced atmosphere of a neonatal resuscitation, it's hard to put it into practice. I'm always grateful that the final decision is not mine.