Archive for January, 2008
Advice: Don’t stop breathing!
Bread and butter work for a Nurse Practitioner, and lots of other health care professionals, chest examination….and yes I know there is lots of different aspects to it. But at the most basic, it is a case of grabbing a stethoscope and getting the patient to breathe.
How easy must it be?
Well actually it is sometimes incredibly difficult. A strange phenomenon occurs the second your stethoscope touches someones flesh. It is invariably not too problematic in babies, but for the rest of the population it is a major factor that makes me grin/grimace.
What is this phenomenon??? – The patient forgets how to breathe.
This breaks down into several categories:
1: “The Hyperventilater”
Sub divided into 2 section:
1a: “The quickly assessed”…Everytime I move my stethescope the patient responds by rapidly taking another breath in. So I have to move quickly on to the next spot I’m listening to. Consequently the patient feels dizzy, but I’ve finished listening to the whole chest in about 5.343 seconds!
1b: “The classic hyperventilater”: The moment the stethoscope makes skin contact, this patient starts panting like a porn star 
or Meg Ryan over dinner!
I often feel as if my stethoscopes innocents has been stolen, perhaps I should put a condom over it!!
2: “The Throaty rhino”: although perfectly capable of normal breathing during the initial chat with you, this patient will suddenly develop a striddor when the stethoscope makes contact. This can also vary between inspiratory or expiratory or alternate between them.
3: “The mock respiratory arrest”: a well perfused patient, often but not exclusively a child, who actually stops breathing the very moment you start to listen for lung sounds. Category 3 can normally be resolved with a quick chat, (Something along the lines of: “It doesn’t matter what anybody says to you, never stop breathing – it isn’t good for your health”)
Category 3 can sometimes be an early sign of the 4th category…
4: “The need exact instruction”: In this case you end up trying to listen to the chest at the same time as ignoring your own voice saying: “Breathe in…..and out…..and in again……and out”
Instruction leaflet???
(I have to confess that with patients in this latter category I have on occasion taken advantage of these patients by saying: “and now put one hand on your hip, and the other in the air, and now say “I’m a little teapot, short and stout!”)
5: “The sputumiser”: This is typically seen in elderly heavy smokers, and has nothing to do with stethoscope contact. This group of patients sit nicely chatting to you, with no evidence of respiratory problems, then as soon as you say; “Well lets take a listen to your chest”, they start viciously hacking up the tiniest amount of sputum, in an attempt to prove something (God alone knows what!) and “no I really don’t need to look!”
OK then…I’m off to sit in a darkened room and take some deep slow breathes (in and out).
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WTF?
A recent BBC report id’ed that abrev’s pose risk to pt health according to the MDU…..
I’m sorry I’ll read that again
“A recent British Broadcasting Corporation reports identified that abbreviations pose risks to patient health according to the Medical Defense Union”.
The report identifies that it is dangerous and shows cases where death has occurred due to misconstrued abbreviations.
This isn’t really news, fair enough the statistics may prompt some people to stop using abbreviations, but I am fairly confident that all clinicians know they shouldn’t use them but tend to because they are lazy it’s quicker.
This is a second wave to stop clinicians using abbreviations, the first wave was when patients were given increased access to their medical notes, so lots of comments and commonly used abbreviations had to stop.
I thought I’d take this opportunity to document a few of those classic abbreviations:
FLK : Funny Looking Kid.
NFE : Normal for Essex (or other county)
FBAR : F***’ed beyond all recognition. (found in nasty trauma notes)
And a couple of ones that were new to me c/o Wikipedia :
BBMF : “Bone break, me fix” – orthopaedic consent form.
TMB : Too many birthdays (meaning old and very frail)
They also list “DIB” as “dead in bed”, which we used to use for “Difficulty in breathing”, as oppose to “SOB”, which of course is “Shortness of Breath” but is also used for “Son of-a Bitch” and not of course “Silly old bag”. Who said abbreviations are confusing?
Special Olympics Booster
Of course some abbreviations may have gone the full circle and created their own words. “BID” for “Bought in Dead” (The English version of DOA ( Dead on Arrival), may have became known as BID’dies, which is a term applied to old people! Hopefully that’s BS (Bull S**t). “Biddies” is, I believe, a reference to hen’s. Thus used for old folks in the way “old duck” is.
I’m sure there are plenty of others about, please feel free to let me know!
In the meantime I will try to monitor my notes and ensure I don’t put too many abbreviations in:
“PC: CP.
HPC: CP 1/7, No rad. No SoBoE, No SoB.
O/E: ECG NSR P64, SP02: 99, AE clear & =, BP OK, HS NAD. Abdo: NAD. No Mus/skel pain.
Imp: Atyp. CP.
Mgnt: CE, FBC, UE, LFT, H. Py., ESR, 24hr ECG. Rv PRN/ASAP if SOS.”
TTFNxx
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You called your baby what???
Obviously this post is slightly decreased in potency by the need for confidentiality, enough to say that during my working life I have come across some cracking names, some sweet, some hideous!
When I spent some time in paediatrics in a certain London region, my list of patients would make people think I was a mechanic. In one week we had Mercedes, Porshe, Ferrari and Harley admitted!
How common!!
If spoken in a gentle upper class accent one could get away with such names, however in a rough end of town these names did not have such poetic qualities…
“‘ere, Meer-say-diz- come away from dat firkin’ door, befores I belts ya one!”
Then there are the parents who don’t look into what a name actually means before labelling there precious little darling with it….
The examples that always make medical staff wince are:
Candida: Derived from Latin canditia meaning “white”. This was the name of an early saint who was supposedly healed by Saint Peter as oppose to:
Candida: a fungus which causes infections like vaginal thrush; well that explains the “white” bit – lots of nasty white “cream cheese” discharge.
and
Melina (sometimes spelt Melena): Greek for Yellow/honey as oppose to…
Melena: black, tarry, and foul-smelling stools
A picture of a black stool!!
So why did I decide to write a post about names?
Well despite feeling unloved and under appreciated by my patients in general, (exhibit a), one of my patients has just had a baby, and given it the same name as me…
OK so I don’t have a particularly common name, but it is a name that you hear from time to time. “Coincidence” I told the girls in the office. Then I spoke to the Health vistor who confirmed they had named him after me!
OMG! How am I supposed to react to that?
Well I suppose I should be flattered! Or should I get a court injunction? Answers on a postcard please to:
“I’ve never slept with your wife” competition.
Freepost.
Never-everland!
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Search for the hero…
Subtitle: Mighty Mouse, Melonman and me!!
A little Mousie friend of mine has recently started in the Emergency department. The Emergency department is a great place to work, but as her story tells – sometimes things happen outside the department when you don’t have the team around you.
If you have read her blog, you’ll see she was one of the first on scene to a horrific car accident while off duty. It seems that as a new member of staff in the emergency department, it was a cruel twist of fate that she should find herself there; bad luck, especially taking into account the severity of the accident and the fact she was in uniform.
Luck has a lot to do with things…
I have also been first on scene in nasty car accident, although luck was much more on my side than on Mousie’s. In fact apart from the accident not happening, things couldn’t have really been any luckier…
A nice day, a nice stretch of dual carriageway with a high fatality rate associated with it.
Mr & Mrs M.E. Nurse (both nurses – one experience trauma nurse, one ward sister), little baby Nurse in back. The dearly beloved (TDB) Mrs Nurse was driving. (She is a terrible back seat driver, so I let her drive mostly!)
Over taken by a speeding 4×4.
Max to TDB: “Look at that idiot – he’s got a “Children on Board” sign on his car so he thinks that entitles him to race around like a looooooony”
The 4×4 starts to swerve, looses control and hits the central reservation, does a complete roll across the road and lands on its wheels in a lay-by. (That’s lucky for a start).
Misses us by a few metres, luckily TDB was slowing before the crash, just because she does when a nutter speeds by.
TDB rings the 999 (911 for those Yankee readers) and stays with sleeping baby. Max gets adrenaline surge and jumps heroically out the car. (As Mousie said, we all dream about these moments!!!)
What follows is a little nightmare…(but only a little one). Stupid driver gets out all shook up and is shouting at everyone and generally being aggressive. Front seat passenger has fine shards of glass all over her face and small bleeds from each. Nothing bad but looks scary to the toddler and ~10yr old that were on board and are now walking about zombiefied and crying.
Still in the back of the car is one teenager laying near the door and apparently unconscious. Driver starts to try open the mangled back door to get to her but can’t. He was a bigger chap than me by a long shot, but I have super trained adrenaline power and somehow tear open the mangled door……cooooool!
The girl comes around and the driver gets her out the back of the car, against my wishes, but I take over and support her neck. She obviously had not been wearing a seat belt and had been thrown around.
A young woman from another car is now on scene, we seem to have an instant bond. The youngest child is crying, the driver is shouting at her to stop and thus making her worse. I ask the new woman to take a look at the girl as her head is bleeding, she brings her near me and together we take a look. Pretty big cut, so she uses something as a pressure pad and cuddles the girl. The others all seem fine, but wound up. My brilliant assistant and I talk to everyone and calm the whole situation down. Everything is in control. The driver lights a cigarette, and gets shouted at in no uncertain turns by my new friend and me to put it out.
In the distant the melodic chiming of fire engines. My new friend turn to me and says: “You handled this well”. I return the complement.
“So what do you do?” she asks. I answer, she smiles. I return the question.
“Oh me, I’m a Police woman!”
The ambulance arrives. I was expecting to get barged out the way. I must have been oooozing coolness and experience, as they left me where I was and let me lead the log roll. This was not my town, these were not my old buddies, never met them before. Really quite flattered, shame about the crippling leg cramp I’d got from being stuck in the same position on the cold road!
All cleared up, I return to my car, to find my daughter awake and being amused by a fireman – good job they came then really!
The next day I ring the hospital, all were discharged the same day. Nasty accident, landed in a lay-by, the right way round, Police woman and experience emergency nurse on scene immediately… Lucky….very freaking lucky.
So my little mousie friend, experience is nice and something you will gain (already have gained and learnt from), luck however you have no control over.
You don’t become Mighty Mouse over night….,%20LITTLE%20GOLDEN%20RECORD%20%20R-217_%20The.JPG)
If I’d been on your scene, the tragic outcome would have been the same.
If you’d been on my scene, the lucky outcome would have been the same.
And what is this about a melon man…
…the 3rd car on scene contained someone a little less experienced, who really wanted to help, so he ran around the dual carriageway collecting pieces of watermelon that had been flung out of the 4×4 when it crashed. I saw what he was doing and it put a smile on my face. I had to try not to laugh when he came up to the scene, prior to the ambulance and asked me….
“What shall I do with the bits of melon I’ve collected?”
I gave a suitable calm friendly answer….honest!
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2008….
Well ‘appy-new-year!
I have a little catching up to do…
Firstly my blogging buddy Peter from downunder tagged me. Hmm…the proudest moment of my life….I am a hugely proud dad, but that’s me being proud of my kids, rather than proud of myself. So? Proud of myself….there was that precordial thump that directly there and then saved someones life. Actually it wasn’t that streight forward….
Picture the scene, a heaving emergency room, a relative yelled, I ran in, glancing at the monitor, the patient was definitely “out”. I did a precordial thump, SPACK!!!
Nothing happened, I turned into adrenaline surged super hero strengthed nurse and ripped off the string vest bringing the patient up with it, as I let go of the vest the patient fell back onto the bed with a “
“…. and that was the bang that got him started!
Proud to be where I am today: happily married (mostly), nice job, good friends, still relatively sane (despite a few years that would make some of my reactive depressed patients crumble if they’d been through it).
Generally proud chap I suppose….but could I do better….well it is a new year, so some resolutions wouldn’t be out of place….
I must…(try)…to…
1: Do more self directed studying. There is loads of stuff I don’t know, I’ve started a new blog for notes and hardly touched it. I must sit in with the diabetes team. As an emergency nurse who found himself in primary care my chronic disease management definitely needs some work. (The problem is I should be looking in books instead of blogging)
Urg Nursing books!! Thank god I am not a student nurse anymore!
2: Get more exercise. It goes in waves. Must make a set time to do exercise and stick to it.
3: Have realistic expectations of others. (3 year olds included).
4: Not loose tapes I’ve dictated letters onto!!!!
5: Try to tolerate my mother, despite the fact she can’t tolerate her mother!
The main problem is I don’t have enough time! Perhaps I should stop this blog! Mind you I think I would miss it and everybody around it. So perhaps just a little less time on that retched Facebook. I’ve got to keep this running until March, so I can have my 1st Bloggiversary.
I would like to say thanks to Elaine and my other reader(s) for there attention and wish you a happy new year.
It shouldn't happen in health care 