icu

Another reason why medicine needs feminism

Because full grown male residents don’t bother to ask a woman if she’s menopausal and make the connection that this is what threw off her otherwise controlled diabetes into DKA. Because estrogen aids in glucose control and protects against rising insulin resistance. 

 And I, as the only female on the team today, asked her, researched this, and defended this theory. With papers. For which I got laughed at repeatedly and told “that’s not a real thing.” Physiology and endocrinology are real things, assholes. We get tested on them. 

 And guess what. The attending, a man with twenty plus years of experience and a great breadth and depth of knowledge of medicine and respect for women, said I was 100% correct. And he straight up told the male residents “duh. It was so obvious. Why did none of you ask her these simple questions? Use your brains!" 

 Moral of the story: Defend your female patients. Don’t discredit them. Educate the ignorant, fight for your patient’s health. Even if it’s with your colleagues. Protect and listen to female patients.

Hey New Nurse

Hey new nurse,

You terrified yet?  Have you wanted to quit or reconsider your career choice yet?  

If not… you probably will.

But, little nurse- take heart.  Please take heart.  You are not alone.  

That confident nurse you admire so much, the one whose work is done on time and is always available to help out.  The one who everyone asks questions and who can usually offer more ideas than the doctors. The one that always gets the hardest assignments and who you hope to see in a code.

That nurse was once where you stand.  They also once shook a little starting an IV.  They were also afraid they put the catheter in the wrong hole.  Their voice also quivered when they talked to their first ‘mean’ doctor.  They also woke up, put on their scrubs, looked in the mirror and thought. “OK…I can do this.”  

The thing about nursing is, you don’t know everything.  You never will.  But, that is both the beauty and the pain of the job- you never stop learning.  So, little nurse, hang in there.  Because that nurse that you admire so much didn’t get to where they are now by quitting.

There’s no feeling like walking into the ICU Monday morning and finding someone else in your patient’s room.

A patient you spent all last week taking care of, playing constant catch-up with the vitals on the monitor. 

A patient you rushed to CT. Holding back tears as the scan came up on the monitor in front of your eyes.

 A patient whose parents know you by your first name and ask you how you’re doing when you step into the room. 

A patient who had improved by the very next day, giving you hope.

 But even then you knew they would still be in ICU for weeks.

Confused, you look up at the board and grab a list, a little panicked now, looking for her name. 

“Where is she?”

A patient who, even after you tried everything, passed away.

With parents who asked your residents to personally thank you.

Residents who understand your tears. Help you debrief and give you time to process.

Just in time to meet your new patient.

Here is a true story for all to read and to share so others may benefit. A while back, there was a 12 year old boy who fell from the merri-go round on the playground at his school. He was dazed for a moment but acting fairly normal. He was taken to the school nurse after which he was brought home by his mother. Once home, the boy complained of a headache but nothing more. After dinner time, his parents noted him to be sleepy and disengaged. Both thought he was just tired and considered putting him to bed early in hopes he would feel better in the morning. But a mother’s intuition kicked in and she knew something was wrong.

She took him to the emergency department to be evaluated. At the emergency department, the child was very sleepy but would arouse, talk, and then quickly fall back asleep. He simply seemed to be very tired. A CAT scan was performed showing a large blood clot over his brain. The blood clot was putting pressure on the brain. I was the Neurosurgeon called to evaluate the boy in the emergency department that evening. I reviewed the CAT scan, examined the child and recommended emergency brain surgery to remove the blood clot. The parents were beside themselves as they had considered putting their child to bed that night to see if he would be better by the morning. If they would have done so, the boy most likely would have not woken up the next morning and could have very well died in his sleep. The child was in surgery within the hour. At surgery, I found an enormous blood clot pressing on the brain which was easily removed. I found a hairline skull fracture which had ruptured an artery and resulted in the bleeding. Post-operatively, the child did well. He was back to his normal self after surgery and was discharged to home with his parents several days later.

His post-operative CAT scan showed the blood clot to be gone. I have seen him back in the office several times since his discharge. He is a normal 12 year boy back to life as usual. With his parents permission, I have included the pre-op and post-op CAT scan images to show you what an epidural hematoma pressing on the brain looks like before surgery and how the brain looks after the blood clot is gone. This real life story nicely illustrates the power of a mother’s intuition, especially regarding her own child. Always trust your gut instinct when you’re not sure of something. More often than not, you’ll be right. This young boy had what’s called an “epidural hematoma” which is the same type of blood clot that actress Natasha Richardson died from in 2009. She was married to Liam Neeson at the time. She died after falling on a bunny hill while taking a ski lesson at a resort near Montreal. She initially felt fine, was awake, talking and acting normally. This is called the “lucent interval”.

She declined medical attention at the resort because she felt fine and subsequently returned to her hotel room. Within hours, she fell sick complaining of a headache and was rushed to the hospital where she was declared brain dead many hours thereafter. She never made it to surgery. She was not wearing a helmet at the time of her fall. An autopsy revealed that she died from an epidural hematoma. Natasha Richardson’s death may have been preventable if she or anyone else around her would have had a higher degree of suspicion for injury or if she had accepted treatment when she had the chance. There is power in knowledge. Unfortunately, no one strongly suspected an epidural hematoma or brain injury when she was initially acting fine. Obviously, hind sight is 20-20 and I don’t have all the details surrounding her death to make any conclusive statements but you get the general idea. Always have a higher degree of suspicion for injury when someone hits their head, especially if they are complaining of a headache or acting tired afterwards. Epidural hematomas cause increasing pressure on the brain as the blood clot enlarges.

The most common symptoms include headache, sleepiness, nausea/vomiting or altered mental status. If you note someone having these symptoms after hitting their head, you should have them promptly evaluated at your local emergency department. And remember, always follow your natural instincts on these matters because usually they are right, especially when it pertains to a parent’s intuition. On a final note, always encourage, and if you can, make your children wear a helmet when they are riding their bike, skate boarding, roller blading or skiing. That one simple measure, which they will certainly fight you on, can save their life. If you have found this post interesting or helpful, PLEASE SHARE for others to read. And stay tuned for more Real Life Neurosurgery stories to come a www.BrianMatters.com.

- Brian Hoeflinger, MD

Things they don't teach you in nursing school

This I’ve seen time and again over the past couple of years: When your critically ill patient’s vitals suddenly get better for no apparent reason and without you changing anything, it’s not time to celebrate. It’s time to get the crash cart. Bad things are about to happen.

The living will a nurse...

Dear Colleagues, 

If there is a situation when I end up admitted here, this is what I ask….

1. Please make sure (unit creeper) is not in the room when you put my foley in.

2. Never let (list of unit dumb-asses) be my nurse.

3. I’m sorry for my mother.

4. and my sister.

5. I want to remember none of my stay. Sedate me to the gods.

6. I swear to God, if you motherfuckers give me c.diff, you’re dead to me.

7. Yes, I want a warm blanket.

8.  Also don’t let (nurse-frenenemy) be my nurse, she will def. try to kill me.

9. Please do not turn me every 2 hours. That shit’s annoying.  

10. If my “story of how I got injured” is embarrassing or humiliating, y’all better fucking lie.

11. I’ll pretend to be confused disoriented & combative just for the opportunity to punch some of you.

Tuesday

Doncha just love it when someone comes in to your office as a walk in actively dying from like 4 different serious conditions? Sounds like it would be some big, rare, exciting event in a rural primary care office. 

I calls it Tuesday. 

So there I was already 2 patients behind because I was following up with a patient who had been admitted with a septic joint and bacteremia from a bug I’ve literally never heard of (and the ID doc admitted he had only seen once before), and then this dude stumbles in to the office. And I mean stumbles. He can barely make it to the chair. 

The front desk alerts my nurse that there’s a dude in the waiting room who doesn’t look like he can wait. She helps him into a room, lays him on the table, and gets his vitals. She then calmly comes and knocks on my door and gave me a stern, “I need you in 6 now please. 

I headed to 6. There I found a man with a through-the-roof blood pressure, fast-enough-to-kill-you heart rate, kussmaul breathing, teetering-on-the-edge-of-respiratory-failure O2 sat,  and hey-at-least-something’s-normal temperature. Dude was gray. 

From the moment I walked into the room I knew he was leaving in an ambulance. I just had to figure out why. While we waited for the ambulance I got a blood sugar (400ish, of course) and an EKG which showed some heart strain, but no active heart attack, thank goodness. I did a thorough physical exam. 

I started to form a differential: A fib with RVR, SVT, sepsis from pneumonia, possible PE, diabetic ketoacidosis, stroke, hypertensive urgency/emergency, MI, intoxication, and the list went on. As I did my exam, I couldn’t really rule out anything on my list except SVT and A-fib. His vitals said sepsis. His lungs said DKA and pneumonia. His legs said CHF. His mouth said severe dehydration. His mannerisms said delirium

The patient asked me what I thought was wrong. I answered honestly: “I think you have 3 or 4 different things going on, and any one of them is enough to cause some serious damage.” I explained my thoughts. “So you gonna start me back on my medicines?” he queried. “Nope, but the hospital will when you get there.”

“Oh really, which hospital?” he asked. “The one that has an ICU,” I fired back.

This man truly had no idea how sick he was. He had one foot in the grave and wanted to go home. Luckily some friends with him convinced him to go. 

On the following tuesday we got a stack of hospital records. New diagnoses were being added every day. He had had every test the hospital could have possibly run, I thought. I called him in his ICU room and he updated me on his myriad new diagnoses and lengthy medication list. He was now almost back to normal and hoping to go home in a few days. 

The next tuesday I saw him in hospital follow up. His discharge summary read like a soap opera. Pulmonary embolism. Pneumonia. Heart attack. A fib. Heart failure. Renal failure. Liver failure. DKA. Everything failure, essentially. 

And yet this man sat before me looking perfectly well, no longer gray or delirious, now back from the brink of death. Just another tuesday afternoon.