podcast 4: a story I carry

Hey, there, it’s Eve.

This story took a lot for me to tell. I struggled with it for a long while. I worried that other people would be triggered by it. I worried that some people would be offended. I worried that the message of @thosewecarry would be lost.

I tried to tell a different story.

But it wouldn’t let go of me. I feel…I’ve been telling everyone to be brave, to be kind, to embrace their fears and vulnerability. That there’s strength in it. I can’t keep saying that with nothing to back it up. I felt that people deserve to know why I’m so adamant about it.

You deserve to know why and how I know.

So now I’m sharing it with you. I want to warn you, this is hard stuff. If you can’t or don’t want to listen, don’t. I won’t judge you for that. Only you know what you can bear.

Trigger warnings for child sexual abuse, self-harm, suicide.

Resources:

In the US: RAINN

In the UK: Safeline and Mind

In Australia: Blueknot and Braveheart

Podcast (available here and on iTunes)

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podcast 3: resilience

Hey, there. Here’s the link to the third podcast. I got busy and distracted, so didn’t toss it out there like I should have.

Look, listen to me. You know the phrase: “Physician, heal thyself.” How many of you save other people’s lives all by yourself? I’ll wait. 

It’s a lie, you see. It’s a lie we’re told when we’re babies in healthcare, and told again as we grow, and now you tell it to yourself and the next generation. 

You don’t save another person’s life all by yourself. Why would you think you can save your own?

Podcast (available here and on iTunes)

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podcast 2: how we care for each other

Hello there, Eve again. For my second podcast I decided to release a poem I wrote on the same theme, of caring for each other.

Resilience is now a buzzword in healthcare. It carries the idea of self-reliance on its shoulders, once again placing the full burden as a caregiver for others and a caregiver for self upon the person who is already carrying too much.

The song “Found / Tonight” with Ben Platt and Lin-Manuel Miranda: “Have you ever felt like you could disappear, like you could fall and no one would hear?” is playing as I write these words. “Even when the dark comes crashing through, and you’re broken on the ground, you will be found.” We carry each other. No one should walk this road alone.

Any “wellness package” for healthcare providers that doesn’t encourage and foster community is something either worthless or less than worthless. The idea that we can and should carry the weight alone is…it’s shameful.

Here is my story of how a small group of people cared for me when I was in crisis–how they insisted I needed help, and they provided it.

Blog post for the first podcast is here.

Podcast (available here and on iTunes)

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my first podcast

Hey, you.

Welcome to my very first official podcast. It will take about seven minutes out of your day. I know, a lot of people expect the 30 minute to an hour range, but I have ADHD and I really can’t hang in there that long.

This podcast is based on the theme of caring for each other, which–if you follow me on twitter at all–you know is my passion. I firmly believe that the standard you walk past is the standard you accept, and if we want the next generation of medical professionals to thrive, we have to teach them how to care for each other.

Notice I didn’t say they needed to learn how to take care of themselves. That’s an important distinction. The push lately by the healthcare industry has been to encourage self-reliance and self-care and self-advocacy. All of those things matter. They are all important.

What’s more important to me is the community we create around us. The bonds of friendship. The social networks that nourish and feed us. That’s what this podcast is about.

In this, the first episode, I skip the warm fuzzies. Sorry if that’s not what you’re accustomed to. We’re all in this together. Let’s care for each other.

Resources*:

In the US: https://suicidepreventionlifeline.org/

US Veteran’s Affairs: https://www.linesforlife.org

In the UK: https://www.samaritans.org/

In Oz: https://www.beyondblue.org.au/get-support/national-help-lines-and-websites

and: https://mhfa.com.au/mental-health-first-aid-guidelines

*by no means exhaustive. If you know a good resource for your area that you would like to see here, comment below.

Podcast (available here and on iTunes)

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don’t CHEAT a heart

Hey, there. It’s been awhile.

This post is for nurses who care for patients immediately following open-heart surgery, but most of it applies to any patient. I mean, since they all have hearts. Or so I assume.

The top six concerns for patients following open-heart surgery…

C

Cold. Cold is the first problem with open-heart surgery. Cold hearts are bradycardic hearts. What do we see in induced hypothermia? Exactly. Bradyarrhythmias.

Open heart surgeries come back to us with epicardial leads–often both atrial and ventricular, but sometimes they will only have a V lead. Keep your patient connected to the pacemaker, ensuring both capture and sensitivity are appropriate for your patient.

While you’re at it, mark the end of the V cable with a piece of tape. Do not mark both. In an emergency it’s really hard for someone under stress to see the difference between an A and a V.

Mark the V lead only.

If you’re having difficulty maintaining cardiac output and your patient’s heartrate is less than 80, consider turning on the pacer to 90 bpm. Definitely will not work on everyone, particularly if you only have a V lead. Pesky atrial kick, amirite?

Cold doesn’t just increase the odds your patient will be bradycardic. It also increases the odds of atrial and ventricular arrhythmias, and could lower the vfib threshold.

It also causes vasoconstriction. What happens to your hands when you go outside in cold weather? Peripheral vasoconstriction, right? That’s increased afterload (SVR) in action, as well as elevated filling pressures. Another thing cold does–reduces the clearance of anesthetic and sedative medications.

Warm your patient up. Remember, if they aren’t 36 degrees C when they hit the door anesthesia loses their 5%, so they want to hit that mark. Warm blankets or the forced-air warmer are available.

Cold does another thing. It influences coagulopathy. Hypothermic patients bleed more, right?

*Really has no effect down to 35C. Below 35C but above 33C you may see some mild platelet dysfunction. Below 33C the coagulation cascade is affected, but rarely will you ever see an open heart patient come back this cold.

It also precipitates shivering. Shivering increases lactic acid production, CO2 production, and O2 consumption, which brings us to H.

H

Hypoxia–tissue ischemia–is the next consideration. This may or may not be reflected in the ABG alone due to the way oxygen dissociates from the hemoglobin, the amount of circulating hemoglobin, or the presence of methemoglobin.

Here’s where I reference that horrible oxyhemoglobin dissociation curve we all remember being dense about in physiology.

No, it’s not that bad. In fact, I’m not even going to bring it up. How about that. Important thing to understand is that hypoxic patients are more prone to dysrhythmias. An ischemic heart is an unhappy one.

E

No, it’s not exanguination. Although that would be bad. Everyone remember the old saying, “Surgical bleeding is bleeding you can hear”? It rushes, dumping in the chest tubes.

If you hold the chest tubes level with the insertion point and blood fills them, that’s an indication for urgent return to the OR. All roads lead rapidly to a resternotomy.

Electrolytes. The heart simply adores magnesium and potassium and calcium. Typical goals in a post-op heart surgery:

K+ >4.2 mEq/L

Mg++ >2.2 mEq/L

ionized Ca++ >4.7 mg/dL.

Low-normal levels of potassium and magnesium predispose an irritated heart to dysrhythmias, which is why our goals for replacement are a touch supratherapeutic, but not high.

Ionized calcium is the amount of circulating calcium not bound to albumin, which means it’s the bit of the electrolyte that’s free to do work–clotting, muscle relaxation, contractility–and this last function is the one we’re interested in.

Most open-heart protocols require you to check these electrolytes with an ABG and CBC fifteen to twenty minutes after arrival and four hours later. Because things change, yeah? Sometimes quite unexpectedly. If your open-heart protocol doesn’t require ionized calcium, check one anyway. Tell ’em Eve said so.

Nah. Tell them that, in light of blood product administration and relative tenderness of the myocardium following surgical manipulation, you wanted to ensure there were adequate amounts of calcium ions to do the work. Tilt your head to the side, wink and smirk as you say it. Or not.

A

This next one is a biggie. Acidosis. Obviously acid-base balance affects heart function. Acidosis impairs contractility. As it turns out, the body requires the blood supply to be a certain pH for proper functioning. Even oxygen…oh. Yes. There we are again, at the oxyhemoglobin dissociation curve. Yes. I promised I wouldn’t bring it up. Ok, fair.

Let’s not be acidotic. Query me this: what is the fastest way to correct an acid-base imbalance safely?

Did you say by increasing the respiratory rate? DING DING DING. Yes. And the tidal volume. Which is…what Kussmaul respirations are. You guys remember those, right? The deep, rapid respirations of metabolic acidosis? Oh, DKA is the classic example. But our patients, our immediate cardiac post-op patients, the ones who are anesthetized and chemically paralyzed, they are unlikely to be capable of mustering said response, correct? Which means we must help them.

Except maybe not blow their lungs with high tidal volume. So. Rate is the way to go.

Oh, and by the way–let’s not give a ton of sodium bicarbonate. I mean, every amp you give you’ll pay for later. It dissociates in the serum to make NaCl and CO2…so…yeah…

T

Touch. We fiddled with that heart. Hearts don’t like to be touched. Just sayin. And yes, it’s almost Valentine’s Day. Take it from the twice divorced mom of five. Hearts are tender. They can’t take a lot of rough handling. Most post-ops experience myocardial depression for 6-12 hours after surgery, with a drop in ejection fraction of 10-15% even when hyperdynamic on pre-op TEE.

You think the LV is the whole story?

Got another think coming. If the LV is occasionally fussy, the RV is a straight bitch. Any intervention on the right side, affecting the right side, and you need to consider primacor or dobutamine for forward flow. Low-dose epinephrine will also work, say, 0.02-0.05 mcg/kg/min.

Know your surgeon and your patient.

a little rant

***WARNING***

The podcast doesn’t contain any profanity, but it may be difficult for some people to hear. Be kind to yourselves.

Paralysis and PAD–pain, anxiety, and delirium–protocols have consumed me lately. Notice pain comes before anxiety on the scale. Address your patient’s need for analgesics prior to adding sedation, or you are merely hiding their need for pain control beneath a blanket of lethargy.

I know it’s easier to hang propofol than administer bolus fentanyl doses, especially when you’re initiating hypothermia or sending your patient emergently to cath lab, or running to CT, but consider the process that brought them to the point where they required intubation. Trauma, hypoxia, acidosis, CPR–painful states.

I notice with a lot of PAD protocols that while the sedation is ordered as a continuous drip, the pain medication requires a certain number of bolus doses to be administered in a certain narrow timeframe to justify initiation of a drip. This is, to my mind, fucking stupid. This shows a certain lack of good clinical judgment on the part of the people who designed the protocol. It’s the opposite of a delirium-avoidance approach. And while I am by no means insisting that every single patient requires pain medication and sedation while on a ventilator, I am most definitely suggesting that each paralysis requires adequate narcotizing prior to sedation, and prior to placement on a maintenance drip.

With the new guidelines for ARDS and the renewed emphasis on therapeutic paralysis, it is vital that we understand the difference between pain control, sedation, and paralysis.

Another concept, and to me, one of even greater importance, is the care we show people who are undergoing therapeutic paralysis. This is the subject of my podcast. It’s a short listen, but important.

This was hard for me to say. I know I pause a lot. I considered editing those pauses out but decided to let them stand, so you could hear what I felt, trying to explain what it was like.

PAD and paralysis

Have you ever cleaned tear tracks from around the eyes of a patient who is paralyzed?

Many of you have heard my healthcare story. Here’s an opportunity to hear a little bit more about what I believe about caring for patients undergoing mechanical ventilation, particularly in the context of paralysis.

Head to the PHARM for more…