We say no for a reason

As I've mentioned before, the U operates on a lot of people that other hospitals wouldn't dream of operating on. Frequently, us nurses can be overheard questioning the sanity of our surgeons for approving this or that patient as an operative candidate. So when they do turn down a patient for being "too high risk," believe me when I say, that patient is so high risk that their chances of surviving surgery are negligible.

So the other day, there was this lady who was turned down for just such reasons. She absolutely did not qualify for a traditional surgery and was even deemed too high risk for our clinical trial alternative that is currently only enrolling high risk candidates. Her list of co-morbidities was not the longest I have ever seen, but they were significant and serious. She saw all of our surgeons and several related medical specialists who were consulted in her case. Everyone told her she would not survive the surgery, could not be optimized medically to be able to survive the surgery at a later date, and had no palliative surgical options.

This lady was adamant she was going to have surgery though. Not only did the U turn her down, but so did every other major medical center in several states. From what I have gathered, this lady was not used to being told no. With her family's connections and money, I assume few people have ever told her no for anything. Maybe that's a snarky assumption on my part. But it seems to be true.

So after being told she was not an operative candidate at a handful of top ranking medical centers by a myriad of well-respected physicians, what does she do? Go home with optimal medical therapy to spend the rest of her life (which was in danger of ending in the next year or two, but not imminently...) with her friends and family? Call hospice for assistance with symptom relief? Check out the swanky surgical digs in Mexico or Thailand? Nope.

This lady called the FDA and petitioned to get included in the trial. Like straight up told the FDA she should have surgery even though all the experts said she was not a candidate. The FDA is smart. They said no.

So what's next? Give up? Oh no. This lady is important remember. So she talked to her buddy the Senator (or Congressman or something...) and he petitioned the FDA for her. And somehow, this politician convinced the FDA that she should have surgery. (How does that even work?!)

So back on down to the U she comes. We do surgery.

And guess what? She fucking died. She didn't survive 24 hours out of surgery.

There are so many things wrong with this story. But mostly I keep coming back to... this is a prime example of why politics and medicine don't mix. The patient and the politician made this decision contrary to the advice of the people whose job is to be an expert in this subject matter!

Furthermore, their reckless arrogance has now not only affected this woman and her family who could have spent more quality time with her, but also potentially screwed the results of a major clinical trial.

Angry face.

Where do we find these people?

The U does a lot of surgeries that the other hospitals in a rather large area wouldn't touch with a ten foot pole. It's good and bad. We give hope and frequently, success and positive outcomes to people who get turned down by everyone else. At the same time, sometime we give a bit too much hope I think. Some people just aren't operative candidates. Or even if they are, albeit incredibly high risk candidates, the more humane thing to do would be not to operate.

It leaves us wondering where our surgeons find some of their patients. For real... I literally have no idea how they find some of these people.

Like Friday, when one of our surgeons operated on this lovely gentleman. A redo-redo surgery. Oh and he's a hemophiliac, with end-stage liver failure. Who's an inmate in the middle of serving a 10 year sentence.

I couldn't come up with a worse candidate (medically and socially) for open heart surgery if I tried. You can't make this shit up.

Maybe the surgeons troll the prisons, looking for a challenge? Got to keep them on their toes.

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!