Asystole will probably make you faint

So the other night I took care of this guy who came in to the ER after having a couple syncopal episodes at home. He was a healthy guy with minimal medical history. Didn't take any meds at home, nothing. He even looked ridiculously healthy... tanned, muscled... looking in much better health in his late 40s than I am in my late 20s.

So he had these two syncopal episodes at home. One was unwitnessed; he just woke up on the floor feeling sweaty, but felt better so quickly he didn't even mention it to his wife. The second episode was witnessed by his wife... she described his eyes rolling back in his head and a period of unresponsiveness for approximately one minute. Again, he returned to normal very quickly, but since this had now happened twice (he told her about the first episode at this point...) the smart wife made him go to the ER.

So why am I writing a whole post about a guy having syncopal episodes? Because as the ER discovered and then I got to witness a bit later... this gentleman's fainting spells were actually 15 to 35 second asystolic events. For real. Legit asystole. Pulseless, apneic, flatline asystolic events. He even got some CPR a couple times.

Like sinus rhythm... sinus rhythm... sinus rhythm ______________ _______________ asystole _____________ ___________________ _________________ sinus rhythm... sinus rhythm...

I saw it with my own two eyes. He didn't brady down. He didn't go into any sort of block. He didn't have any ventricular escape beats or errant P waves. It was just sinus rhythm straight into asystole straight back into sinus rhythm. As if both his SA and AV nodes both just decided to simultaneously take a break and then come back.

We put a transvenous pacer in him ASAP. Then he got a real pacemaker in the am.

What do we think caused this? Seems neuro to me...? Seems like an odd cardiac coincidence for both the SA and AV node to not work simultaneously and come back simultaneously.

I guess it is loud in here

There are many times I wish HIPAA didn't exist, but today especially. That way, if HIPAA didn't exist, I could take and post a picture of my patient for general internet enjoyment. And my personal memory enjoyment.

So my patient thought it was loud in the ICU (which, to be fair, it is), so we gave him some earplugs. This was clearly not enough. I walked in a bit later and clearly he had raided the drawer next to his bed... Not only did he have his ear plugs in but he'd put 4x4s over top of his ears, taped them in place and then covered his ears, cheeks, forehead and scalp with vaseline gauze.

The mental image does not do the actual image justice.

Cocaine is really good for you

So once upon a time we had this young guy who came to us emergently from an outside hospital an hour or so away for an acute Type A dissection. Sucks for him because he was only 33 years old. But even 33 year olds dissect their aortas when they do a lot of cocaine. So our surgeons fixed it and we tuned him all up and he just looks peachy. So out he goes to the floor.

Where, on post-op day 4, his loving and doting girlfriend brings him everything he wants and needs. Including... you guessed it! Some cocaine. A nurse walked in on him doing a line off the bedside table. She appropriately freaked out, the girlfriend got arrested and the patient re-dissected his aorta. No worries. Our surgeons fixed it again for him. He spent a bit longer in the ICU this time because, well two sternotomies and two aortic surgeries in a week is a bit much for anyone. But never you worry, we fixed him again.

 So he goes out to the floor again. And the girlfriend is in jail. And his visitors are restricted. So we figure we're good. And no one can prove it, but he re-dissected his aorta again. Either he's ridiculously unlucky, or somehow he got some more cocaine.

Wouldn't you think you would learn your lesson the first two times???

Don't worry. We fixed him again. 

I have vaginal bleeding... every month...

Ms Menstrual: "I started having some vaginal bleeding today. I'm having a little pain in my abdomen too."

 EMT: "Oh ok... any chance you could be pregnant?"

Ms Menstrual: "Oh no honey, I just had my period last month."

EMT: "Oh you did... so like how long ago?"

Ms Menstrual: "Hmmm... pretty much exactly a month ago."

EMT, with a blank stare and somehow a straight face: "So you think this could be your period this month?"

Ms Menstrual: "Well I better go on up to the ER so they can figure that out huh?"

Chicken and Cheese Crescents

In perusing Pinterest/the weekly search for squad meals... I found this recipe that seemed like good finger food to grab running out the door when the tones invariably go off 30 seconds after we sit down to eat. Which is what happened today. Solely because Marie texted me and ask how the day was, to which I responded, "Not bad, we're about to eat." Cue the tones.

Conveniently though, I had my delicious chicken and cheese crescents fresh from the oven and could run downstairs with 2 hands and a mouth full of (really hot) food to eat en route to the current emergency.

• 2 (8oz) packages of cream cheese (or 1/3 fat neufchatel... b/c I'm so healthy)
• 3 packages of crescent rolls
• 3 cups of shredded cheddar
• 2 cups of shredded Monterey Jack
• 4 large chicken breasts
• 1/2 tsp salt
• 1/2 tsp pepper
• 1 package of ranch dry dressing
• 2 tbsp melted butter
• a few pinches of paprika

Preheat your oven to 350*. Take the big ol' chicken breasts and submerge in boiling water. Keep water boiling until chicken is thoroughly poached. Set aside. Meanwhile, unroll the crescents onto a foil-lined cookie sheet. Set that aside too.

Let your cream cheese soften (or stick it in the microwave for a few if you're lazy like me). Mix cream cheese, other cheeses, salt & pepper and ranch together. You need the cream cheese to get soft enough that you can combine everything together well.

Once the chicken isn't so hot that you'll burn yourself, shred or chop it into small chunks. Mix the chicken into the cheese mixture. Spoon a big dollop of the chicken and cheese mixture onto the wide part of the crescent. Roll it up, trying to pinch the sides in as you go. (So your cheesy goodness doesn't all leak out!!) Brush with melted butter and sprinkle each crescent with paprika. Bake for 25m on 350*.

Conclusion: how can you say no to these?? The outside is this flaky pastry and the inside is all cheesy and gooey. They were a hit with my crew. And a hit with the oncoming next crew who ate all the leftovers. I heard there were fights over the last ones. Now, these are not particularly healthy (duh) but sometimes you've got to go that way. Someone suggested the addition of some broccoli which would definitely be good and get you a little greenery. Or I think you could put any number of ingredients in there. Maybe a little taco flavored crescent with salsa, ground beef and some cumin? Or a buffalo chicken one, with buffalo sauce stirred in the chicken and cheese. So many possibilities!

This is NOT the Ritz

Hospitals, like pretty much every other industry, are becoming customer service driven. There's something to be said for that. I like nice people. I like it when nice people are nice to me. I especially like it when nice people are nice to me when I'm sick and feel like shit. But I want to go to the hospital that has the best doctors and nurses and staff, not the nicest. Hospitals are for medical problems. I've been quoted many times saying, "Dr. J is such an ass (he is), but he's the only one I'll let operate on me." That's because he's the best. Dr. J. could probably be nicer. It'd definitely make my life easier at times... But he's good at what he does and since he's a surgeon, whose job is to operate successfully, not be nice to me, I'll take it.

But thanks to the internet and the fact that half the world is fucking entitled, hospitals' reputations can be damaged by any idiot who can type. Newspapers love publishing shit like, "I was so cold and it took the nurses 15 minutes to bring me a blanket." Poor you, that's sad. The U is obviously a terrible hospital. You missed the part where the nurse, on her way to get said blanket, walked past the room where Grandma was trying to escape from her bed and about to fall and decided to prioritize that over immediately returning with your blanket. This makes my boss' boss' boss send me email likes "Today's employee goal of the day is: Smile at everyone in the elevator." I'd rather stab myself in the eye, thanks.

So last night my orientee, Georgia and I were taking care of Mr. Clog. He had an endovascular carotid stent placed, putting him in my ICU overnight. This procedure gets you an ICU admission post-procedure for q1 hour neuro checks for 12 hours and then you get to go home in the am. Angio to ICU to straight home. Rarely even go out to the floor. Which, pretty much by default, made Mr. Clog the least sick patient in our unit. He wasn't on oxygen. He had two PIVs... no central or arterial line. Yet he complained about everything. His IVs were "touching" him. He didn't like having cardiac monitoring leads on. But he slept most of the night and seemed to understand our explanations why he had to keep his leads on and IVs in.

So I was a little surprised in the morning when he started screaming at me and calling me a bitch. (Disclaimer: I have my moments, but I'm generally pretty nice to patients. Not top 10% on the nurse niceness scale, but definitely top quarter.) He asked for our manager and said he wanted to file a complaint. When I asked him what the problem was he said, "I come to the hospital to be pampered. Your only job is to pamper me and do everything I tell you to do. I didn't feel pampered last night and your manager should know that."

Seriously? Pampered? This is a hospital! This is NOT the Ritz. And I'm very highly trained at a lot of things that don't include pampering you, but keeping your sorry butt alive another day. (Also, an 60ish obese country white guy asking to be "pampered" is just weird in and of itself...)

Fat people have sex too?

So there was this obese women in the ER. And I'm talking like OBESE. I'd give her a rough BMI of 55? 60? Weight pushing 500lbs? This was a big girl. Luckily, along with her weight, she retained her sense of humor and was spending most of her time in the ER joking around (read: oversharing...) with the staff. Now mind you, this woman could not climb up onto the stretcher by herself and could not spread her legs independently for us to put a foley in. Yes, her thighs were so big that as far as she could spread her legs out to the side from the hip, they were still touching. It took eight nurses to put that foley in her, mostly holding her legs and pannus out of the way. EIGHT. That's another story in and of itself.

Ms Thighs: "You girls having trouble down there?"

Nurses: Grunt. Groan.

Ms Thighs: "Get in the gym girls. Cousin Thighs does this by herself."

Nurses: collective quizzical stare

Ms Thighs: "What? Oh you mean what's she doin' down there? Well once a month me and Mr Thighs like to have ourselves a nice night you know. Mr Thighs doesn't have enough hands to get up in there, so we pay my cousin $20 to make a little path for him."

O.M.G.

I love my cousins. I love my friends. I love my siblings. I love a lot of people. I don't love none of y'all bitches enough to hold your fat out of the way so you can get some. Not a chance. Not even with headphones and a HAZMAT suit.