RobbiRN

Agreed. The Japanese wash before getting in the bath, then sit fully immersed with just their heads out. The water is so hot you feel like it will burn you if you move, so you just hold really still. About ten minutes in one of those definitely raises your core temperature. It's one of many reasons they out-live us by a few years and spend a small fraction of what we do on healthcare. They think we're nasty for sitting in dirty water.

Would anyone really think that one hot bath a day takes the place of washing your hands repeatedly at appropriate times throughout the day? I doubt the authors were trying to clear up that misconception. Nobody suggested prohibiting hot baths. But several of the myth lists and "quizzes" comment on the WHO quote, casting hot baths in a negative light, like"don't waste your time on this."

Don't throw the baby out with the bath water! Multiple lists and quizzes claiming to debunk the myths about Coronavirus are running this quote: "According to the WHO, taking a hot bath will not prevent you from catching COVID-19. Your normal body temperature remains around 36.5°C to 37°C (97.7-98.6° F), regardless of the temperature of your bath or shower." The wording is accurate, because a hot baths do not "prevent" you from getting the virus, but hot baths have multiple well-documented benefits. The quote may be accurate about the average bath or shower, but there is a direct correlation to the temperature of the water and how long you are in it (which is why we die from extremes), so the underlying premises of the statement is flawed. Google "benefits of a hot bath" and "benefits of fever." You will find hundreds of well-documented studies from reputable sources supporting the benefits of heat in fighting infection. The media flippantly dissing hot baths may cause many to skip one of the best basic tools of health.

To read Part 1 of the story, go to Epinephrine Error - Broken Heart Syndrome, Part 1 How did you feel when you got the accidental IV push epinephrine?“The effects were instant. I thought I was going to die–people say that all the time, but I really did. When the doctor ran in, I actually asked him to intubate me. I felt a massive amount of pressure on my chest, trying to take a deep breath felt impossible. My hands started to get numb, and I couldn’t even move them. After about 30-40 seconds I couldn’t talk anymore. At that moment, I truly thought I was going to die. My father was visiting his dad out of state so it was just my mom and me in the emergency room. I wondered if my dad would blame himself for not being here to stop it, and I worried if my mom would be able to live with herself after watching her daughter die. I thought about a lot of things I regretted and things I wanted to do that I would never get the chance to. I don’t remember much after that until waking up about 10-15 minutes later in the trauma bay. I had mild chest pain and a terrible headache, the worst I’ve ever had.” What is it like going from the provider side to being the patient?“It was very strange having my coworkers take care of me and probably even more strange for them to be taking care of me. In a way I think it made it worse that I knew what was happening. A heart is not designed to sustain such high rates. I was hypoxic which comes with its own set of serious complications. Knowing that I was in a very critical state was scary enough, but knowing the number of things that could get worse because of it was even scarier. I wore a monitor for the entire month of February, and the first day the company called several times to warn me that my rate was 200. After a while, they quit calling because it was happening all the time. My EP cardiologist said there was nothing more to do and I’d eventually outgrow it.” How are you now, a year later?“I have been very up and down since the incident. I would improve for a few weeks then get bad again, improve then get bad. Some days are good, some are bad. I can be asymptomatic with a heart rate of 180 or symptomatic–weak, light-headed, short of breath–with a rate of 130. Overall, I’m better than I was the first couple of weeks following the incident. I’m currently taking Cardizem and Corlanor which have been the best medications I’ve been on yet. Beta-blockers made me very tired, dropped my blood pressure, and never controlled the rate well. I still have random rapid rates, even at rest, but I don’t feel nearly as run down as I did on beta-blockers. I still struggle to exercise because it doesn’t take much for my heart rate to get past 180 with minimal exertion.” What have been your greatest disappointments along the way?“Although the medication changes, doctor appointments, and heart monitors have been difficult and inconvenient, the emotional aspect has by far been the hardest. It’s extremely frustrating and depressing. Between the cardiologists and cardiac electrophysiologists that I’ve seen, no one really seems to have a clear understanding of what is exactly wrong with my heart, and some have clearly thought it’s all in my head.” “Probably the greatest disappointment was an EP study two months ago when the cardiologist said he didn’t find anything to ablate. It seems like there must be some irritable focus near the SA node that we could ablate and I’d go back to normal. Nothing else was working. When he said he didn’t find anything he could to ablate, I just cried. I’d pinned a lot of hope on an ablation being the fix. I felt like I was back to square 1 with no hope in sight. After the study, he said the same thing he’d said all along, that since I started with a young, healthy heart, and since the repeat echo had shown a resolution of the takotsubo and my ejection fraction had normalized, ‘ten months isn’t a long time to wait for the rapid rates to resolve.’ I’m seeing a new EP cardiologist now who says he can fix me, but he’ll have to crack my chest open to do it.” How is your life different now?“Prior to this incident, I was very active and healthy. I loved dancing. When I felt anything–anger, sadness or a passion about something–dancing was my outlet. Not being able to run or dance like I used to is hard, but even daily life is very different. It’s embarrassing when I have to pause halfway up the stairs at school, or need to ask for a break during a long-distance walk. I always feel like I need to explain myself which is hard for me to do, and it’s even more difficult for people to understand. I do often feel like an inconvenience to my family and friends when I can’t participate in things like I used to. Going to Disney was one of my family’s favorite things to do. Now walking around the park alone is hard for me, but I can’t go on rides anymore either because they could trigger a lethal rhythm. I’ve lost friends because of this, mostly because I cancel on plans when I didn’t feel good. Eventually, I just stopped getting invited.” What kind of support, or lack of support, have you gotten?“I’ve been shocked by the amount of both. I’ve received a good amount of negativity which is unfortunate. On the outside, I look very healthy, so I understand how people could think I’m being dramatic when I have symptoms. The low point was when a charge nurse who knew how my heart was damaged had the gall to say, “Let me explain Munchausen’s to you.” My heart rate was 180 at the time, and I was lightheaded, but she judged me to be lazy and dramatic. On the flip-side, I’ve also received so much love and positivity from others–it’s amazing, and I’m beyond thankful. I am so grateful that I have the support system I do have. Are you still hopeful that you’ll get back to normal?“I have remained hopeful from the very beginning that I will get back to normal. That’s not to say I don’t have days where it seems like I won’t ever get better. If this new round of medications doesn’t work, we will discuss surgery. If we have to crack my chest to do an ablation from the outside for me to be able to run again, it’s worth it. I know I will eventually get there.” Author’s Note: In March of 2018, a team of researchers led by Caroline Scally of The Aberdeen Cardiovascular and Diabetes Research Centre, University of Aberdeen, United Kingdom, published the results of a study representing a major paradigm shift. Their findings soundly refuted the general assumption that because there is an apparent rapid recovery of left ventricular ejection fraction, ongoing patient complaints of continued symptoms are due to anxiety or mental problems. Scally’s group studied thirty-seven patients who had experienced takotsubo cardiomyopathy, comparing them to a carefully chosen control group matching the patients’ ages and comorbidities. They concluded: “In contrast to previous perceptions, takotsubo cardiomyopathy has long-lasting clinical consequences, including demonstrable symptomatic and functional impairment associated with persistent subclinical cardiac dysfunction. Taken together our findings demonstrate that after takotsubo cardiomyopathy, patients develop a persistent, long-term heart failure phenotype.”1

A good outcome is a good outcome, but I wonder how long ago this happened? The dose is 3x the current recommendations I've seen. Do you know if that protocol is still in place and what it's based on? Cheyenne's outcome is clearly a bad one, validating the strong warnings about potential cardiac damage with IV epinephrine. I'm curious if you have any knowledge of your patient's outcomes over time? Cheyenne's reaction also cleared. One might argue that had the epi been given IM as ordered, it would have been insufficient. We'll never know. It was given rapid IV push, and Cheyenne faces an uncertain future with a damaged heart. Do you know how well your patient did after you dropped her at the hospital? Even though she did well initially, are you certain there were no ill effects later?

I think it's best to start with the idea that we only give Epinephrine IV push during a resuscitation, and seriously question pushing it in any other setting. The recommended IV dose for refractory anaphylactic shock is 0.1 mg over 5 minutes = ultra slow push. In Cheyenne's case 0.3 mg was pushed in less than 5 seconds.

So far, the system remains firmly entrenched.

It is very real and close to home. The writer did write all those things. Everyone is not okay. But, there is still hope for healing. Stay tuned for part two.

The ProblemDear Mr. Thornton, I’m writing in response to the specific questions from your email this morning. A full investigation of the tragic event in our Faster Care area is in progress. You will have access to the complete report by tomorrow afternoon. I cannot deny or confirm several specifics, but I can agree this is undoubtedly the most heartbreaking incident during my tenure at Sarnia Shores. In response to your first question, I was attending our mandatory monthly performance review, so I was not in the department Thursday afternoon. Second, you asked how we could have such an incompetent nurse working in our Emergency Department. Michelle, the RN responsible for the accidental IV administration of epinephrine, is a Certified Emergency Nurse with an eighteen-year track record of excellent reviews, four awards for exceptional service, and multiple letters of appreciation from our customers in her file. She has no previous documented errors or formal patient complaints. You stated that the nurse failed the patient. Yes, she did–but first, the system failed the nurse. When you took over as the CEO of Sarnia Shores Healthcare, I was hopeful that we would find ways to increase our efficiency. Some of the initiatives have been helpful. You will likely remember that I strongly opposed the directive to move from a triage system to a direct bedding approach in which no patient waits if a room is available regardless of patient acuity. At the time of the incident, every room in our main area was occupied, and two rescue units were waiting to off-load new arrivals. Twelve of the patients occupying our main rooms had minor or chronic conditions. Ten of those twelve patients had arrived in the hour preceding the incident. Under our previous system, some of those patients would have waited in the lobby for a Faster Care room to open. The twelve patients who did not need acute care will likely increase our satisfaction scores, but their placement in those rooms removed immediate access to limited resources from those whose lives were on the line. The triage nurse identified Cheyenne as having an emergent, life-threatening anaphylactic reaction with her airway quickly closing. She notified the charge nurse but was told to send her to Faster Care because no main rooms were open. Faster Care is not designed to handle critical patients. There are no monitors. The nurse to patient ratio is 6 to 1 with a 45-minute door to door target time. It is designed for rapid discharges after minimal testing or treatment of non-emergent patients. A 56-year-old with active chest pain was also sent to Faster Care four minutes before Cheyenne, so Michelle already had a new potentially critical patient. The PA in Faster Care immediately recognized that Cheyenne needed emergent intervention and pulled the Michelle from the chest pain patient to Cheyenne’s room. The PA gave Michelle verbal orders to start an IV and give three medications, one of which was an I'm injection of 0.3 mg of epinephrine. Every emergency room RN knows that we only give epinephrine IV push during a resuscitation, but, while Michelle was preparing to administer the medication, her Vocera came on, informing her that one of the rescue units was also headed to her last open room. She protested that she had two critical patients in the past few minutes and she couldn’t take another one. During the distraction of the Vocera exchange, she accidentally pushed the epinephrine IV. She immediately recognized her error, called the PA back to the bedside, and paged overhead for a rapid response. You asked why the error was not stopped by our bedside bar-code scanning process. In many life-threatening or resuscitation situations, ER staff still work based on verbal orders and chart after the fact. Even if the medication had been entered in the computer system and scanned at the bedside, the nurse would have ultimately been responsible for the route of administration. The computer can confirm the medication matches an order for a specific patient, but it cannot control how the nurse gives it. There is no question that the medication was ordered to be given I'm. The rapid response was appropriate, and no other deviations from standard practice have been identified. I can confirm the results you noted as they are in the permanent record. Cheyenne’s heart rate shot to 200 beats a minute before slowing to 130 over the next nine minutes. The EKG showed she remained in a sinus rhythm. She experienced severe tightness in her chest and shortness of breath. The troponin drawn immediately after the incident was 0.01 while the repeat level three hours later was elevated to 0.36, consistent with damage to the heart muscle. The echo cardiogram clearly demonstrated a reduced ejection fraction of 40% and atypical Takotsubo cardiomyopathy, an abnormal ballooning of the left ventricle. A cardiac catheterization did not find any blocked cardiac arteries. After starting two medications, Cheyenne continues to experience random rapid rates over 150 at rest and up to 180 with minimal exertion. As I stated at the outset, the full report will be available tomorrow. I need you to know Michelle is mortified. She hasn’t slept and struggles to eat. She will carry her part of this tragedy for the rest of her life. I personally share the sadness and pain of this misfortune on several levels. Cheyenne has excelled here in her role here as a Health Unit Coordinator/Patient Care Tech in our department over the past two years, and I have become very fond of her. She is well-liked by her co-workers, and many here are devastated. We share the fear of her uncertain future. We will support Cheyenne in every way we can. She is our family too. I am deeply sorry. I didn’t know she was your niece until I received your email this morning. Sincerely, Sharon Goodwin Author's note: Takotsubo cardiomyopathy and the subsequent IST (Inappropriate Sinus Tachycardia) are often poorly understood, misdiagnosed, and marginalized. In Epinephrine Error, Part 2,we’ll look at Cheyenne’s ongoing quest for healing a year after the epinephrine error.

I think the discussion has moved on to various other situations, but my concern in the original post was that those attempting to help were preventing the woman from moving herself from an extremely award position even though she was alert, denied pain, and asked them several times to allow her to sit up. There is a huge difference between allowing (or in this case disallowing) an alert oriented, oriented person from moving herself and actively moving the person.

I think I'd take the ICU RN over the radiologist to help with mom, but, hey, if we're ever on the same plane together, let's do this. One of my most vivid childhood memories is of my mother doing an emergent c-section with a framing saw and a butcher knife when one of our cows died during calf-birth. She directed my dad and I to help. We got the calf out too late to save him, but the courageous effort ignited my passion to heal. For better or worse, I have a strong genetic disposition to go for it and deal with a jury later if necessary.

Yes. Thank you. This has been a source of grief on our end for decades. Patients who from minor fender-benders who were ambulatory at the scene were back-boarded after complaining of neck pain. Their complaints multiplied en route due to the backboard, and they arrived angry and sometimes outright hostile until we could get them off it--which used to require someone higher than RN. EMS is using them less often, and our lives are better. Pixie, you mentioned previously that log rolling is no longer indicated? Can you elaborate on that?

A couple of others have noted the danger of trying to help when several people with various levels of ability are jockeying for position. That was the other reason I bowed out of the first situation. Along with the medic and the pharmacy employee, there were several others already trying to help. On the plane, I was the only one who responded, which made it prudent and easy for me to intervene.

I ran the scenario of the lady who fell in the street by three different paramedics who are currently working on local EMS crews as they passed through our ER today. Each of them quickly responded they would let her sit up. In her case, the significant factors were that she was alert, oriented, denied pain, and wanted to sit up. They stated they would apply a collar after she sat up due to the head injury prior to transporting her, but they would not put her on a backboard.

This is the part that really bothered me intuitively. I felt they were restraining her against her will and she was lucid and communicating. I'm not discounting guarding c-spine, but there were several clear advantages to allowing her to re-position herself, primarily improving her airway, reducing risk of aspiration, and decreasing intracranial pressure. After my suggestion, the medic did allow her to roll onto her right shoulder (from the awkward position described above) and a bystander supplied a rolled blanket which he placed under her head to improve the alignment. I appreciate your thoughts and those of all who choose to engage on the topic.

You go Pixie.RN. That's the courageous spirit I'm hoping to find. You have EMT-P and TCRN, so can you clarify what "hold c-spine" means? Align and maintain, or maintain the position the patient was found in?

You are right. You don't know what you are responding to and by responding at all you are putting yourself in a position of responsibility. I have no reservations about responding on the plane because clearly I was the most capable person willing to respond--no one else did. I also have no fear about defending my advice in the extremely unlikely event that it should become necessary to do so.

There's a strong current of reluctance to get involved running through many of the responses here. Has our litigious society trumped all moral imperative to help when we are confident of our skill and knowledge? The irony is that if we turn away, the vacuum will be filled by those more willing but less capable. What if the person needing help is you, or someone you love, instead of some stranger? Wouldn't you want the most capable person available to step forward?

The quotation marks around medic were not intended to be diminutive or pejorative. I emphasized his stated title because I'm not sure what "medic" means in the UK. I've heard "medic" used in the armed forces, but in the US we have EMTs and Paramedics in our EMS systems. My uncertainty about his level of expertise was one reason I chose not to assert myself further. It's true that my descriptions were general, but his version of maintaining c-spine was forcing the patient to remain in the awkward position I described with her head lower than her torso (please read it again) despite her denying pain, asking to sit up, and trying to sit up. She was alert and clearly moving all extremities in her attempts to sit up during which she was physically restrained. Log rolling was not option because she was not on her back. EMS maintains c-spine after aligning the head and the body. They do not maintain the tortuous and unnatural position in which the patient is discovered.

I like your answer because it pretty well backs what I did. 1. I watched for a couple of minutes to get a feel for what they were doing, then identified myself as an ER RN on holiday. I suggested that since she was alert and denying pain, allowing her to sit up would reduce intracranial pressure, reduce her work of breathing and the potential for aspiration. That's when the man identified himself as a "medic" and stated he wanted to maintain her c-spine until their EMS people got there. I chose not to assert myself further. 2. On the KLM flight, I told them I was not a doctor but I would give them my opinion that there was a high probability of cellulitis based on the appearance and history with a low possibility of a blood clot, neither of which required immediate intervention. I told them to stop the cool compresses which reduce blood flow, keep the leg warm, elevated, and to re-position it frequently. The fight attendant came by my seat later and gave me a $100 voucher for a discount on my next flight for my help. I initially declined, but he insisted "this is what we do." Interesting side note. I checked later and most US based airlines do contract with an agency for in-flight direction if there are no volunteers who respond. Some airlines outside the US do not have medical backup on the ground, but licensed medical professionals on a plane in EU countries are required by law to respond to overhead pages.

I thought that was the case, but I asked the attendant if they used a service or had any doctor they could contact for direction if they failed to get help on board. He said no.

Thank you for your thoughts. Stay tuned. I wanted to start with an open-ended presentation to get other's ideas based on the situations before adding what I did and how it went. I will throw out the carrot that I did not simply observe in either situation.

While on vacation outside of the US a few days ago, I had two chances to intervene in medical situations. I'm curious what you would have done if you had been in my situation. Case 1: In a southern coastal city in the UK, an elderly woman reportedly "just fainted and fell" while crossing a street. No one there knew her. Several bystanders were trying to help, including a man who identified himself as a "medic" and woman who worked at a pharmacy. The injured woman was obese, lying awkwardly on her right hip with her torso twisted, her upper chest on the pavement and her head twisted toward her left shoulder. Her head was lower than her body, and she was bleeding from a scalp laceration. The medic knelt beside her and held pressure on the scalp wound. She denied any pain and tried to get up several times, but they held her down even when she vomited, insisting that she should not move. Her breathing was heavy. EMS had been called, and I could hear a distant siren. Case 2: Halfway between Amsterdam and New York, they paged overhead for a doctor to come to the back of the plane. No one moved. I went back and told the flight attendant I was an ER RN, not a doctor. Apparently, I was their best option. He took me to an elderly man who was worried about moderate swelling and mild redness in his right lower leg and ankle. With his daughter translating, I learned the swelling had started during our flight, but he'd been on a plane for three hours prior to ours. He had a large scab on his lower right lower shin from a scrape three days ago but denied any pain. He was sitting on a jump seat with his leg propped up on a window well, straight and level with his hip. They were applying cool compresses. I've second guessed myself a bit on one of these two. What would you have done?

I'm going to swim upstream on this one. I don't lay out or tan, but I've lived a lot of my life outdoors. I do wear a visor and limit my mid day exposure to harsh sunlight. When I was at a dermatologist for a routine check, she started lecturing me for not wearing sunscreen. Half tongue-in-cheek, I quipped: "I think someday we're going to find out that sunscreen was more dangerous than the sun." She froze for a second. "You may be right. We started with 2 to 3 chemicals. Now we're up to 8 or 9 and we really have no idea what these do to people long-term."

Or, just like the doctors before us, we are surrendering the throne. . . The raging dissatisfaction voiced here can be nebulous raging or a spark to kindle a revolution. The irony of the paradigm shift to paint-by-number medicine is that doctors are rapidly becoming obsolete while more and more reassessment and treatment is managed by bedside RN's. We have the Nation's lives in our hands. Never underestimate our power to force constructive changes. If we back down, we, and everyone we care about, will suffer in the the pathetic system that is evolving while a few wealthy business people bask in their extravagance. I'm 25 years into ER staff nursing and mentored my current manager. I will fearlessly fight the lunacy at every level while I stay at the bedside, saving lives and doing the things that only we can do.