2 liter bolus of fat: no hemodynamic changes

I bring to your attention a case report of a patient who received an accidental overdose of 2 liters intravenous lipid infusion and apparently suffered no ill cardiac effects. That is, the patient received fat directly into the blood stream in a quantity equal to a family-sized bottle of soda and didn't have a "heart attack."

Just as certain medications bind to proteins, which binding in the blood stream changes their availability to other tissues, certain medications have an affinity for lipids. This fact has been used as the basis for treating overdoses of these lipid-philic meds. In particular, some medications used for cardiac and cardiovascular disorders have been treated in this manner. For example, Dix et al (2011) report a case of lidocaine toxicity successfully treated with lipids.

Although alternative theories of the lipid's beneficial effects exist, the favorite seems to be that lipids in the blood attract and sequester the toxic molecules. The dosing would be weight-based. Smolin (2010) reports a dosing of 1.5mL/kg bolus followed by 0.25mL/kg/min for 30-60 minutes. For a 220 lbs. man, this would be a 150mL bolus followed by 1500mL over 60 minutes.

West et al (2010) report the case of a 71-year-old woman who overdosed on a calcium-channel blocker. The emergency room followed a protocol that prescribed she should get 400mL of lipid. However, the infusion pump was not turned off, and the patient received a total of 2000mL, or 5 times the recommended dosage. There was so much lipid in her blood that 22 hours after she got the lipids, the hospital could still not get enough blood out of her veins to run lab work properly. She went on to die from the calcium-channel blocker overdose, but West specifically mentions that the lipid overdose "caused no detectable acute adverse hemodynamic effects."

I still hear nurses in the hospital, even in the ICU and cardiac units, talking about having their arteries "clogged" from eating a hamburger. In addition to being incorrect pathophysiology, we can now see that the amount of fat in your burger is not going to kill you.



West, P., Mckeown, N., & Hendrickson, R. (2010). Iatrogenic lipid emulsion overdose in a case of amlodipine poisoning Clinical Toxicology, 48 (4), 393-396 DOI: 10.3109/15563651003670843

Dix, S., Rosner, G., Nayar, M., Harris, J., Guglin, M., Winterfield, J., Xiong, Z., & Mudge, G. (2011). Intractable cardiac arrest due to lidocaine toxicity successfully resuscitated with lipid emulsion* Critical Care Medicine, 39 (4), 872-874 DOI: 10.1097/CCM.0b013e318208eddf

Smollin, C. (2010). Toxicology: Pearls and Pitfalls in the Use of Antidotes Emergency Medicine Clinics of North America, 28 (1), 149-161 DOI: 10.1016/j.emc.2009.09.009

caffè ghettiato, or hacking Dunkin Donuts

A favorite indulgence of Paleo dieters is coffee. For a while I was getting a cappuccino with extra shots of espresso on the way to work. But all that milk is, well, not Paleo-ish. So one day a few months ago I ordered a caffè macchiato at Starbucks on my way, thinking to get all the caffeine with just a hint of the milk to take the edge off the espresso.

Macchiato means "stained," and the drink should basically be espresso with a dusting of milk foam on the topic. Made right, this is a strong drink. What I got served was something sickly sweet made with a caramel flavoring. Ack! So I gave up on Starbucks.

I noticed a couple weeks later that Dunkin Donuts had started serving espresso drinks. Yes, Dunkin Donuts. They've changed the decor and upgraded the offerings. How bad could it be?
They made a slow start in my town. The manager had latte and cappuccino reversed for a while. And they don't offer macchiato. But then I discovered that they offer "Turbo Shots," which are shots of espresso that you can add to any drink. This presented an opportunity for hacking the menu. After all, if you can have a Turbo Shot in a cup of coffee, why not a Turbo Shot in a cup?

You might have to negotiate this. It took me a while sitting at the drive-in window in the middle of the night to explain what I wanted. What we settled on was this: three Turbo Shots in a small paper cup.
The Turbo Shots have a not bad flavor; strong but not charred, like another chain we know of. And if the coffee makes it to work, you can add a few drops of half & half or creamer. I dub this drink the caffè ghettiato. (It may not be the catchiest phrase, but ghettoccino was taken, and macchighetto doesn't work at all.)

The ghettiato is a good solution for Dunkin Donuts. DD is open all night, ordering the plain espresso avoids getting skim milk or HFCS , and the Turbo Shots are cheap. A splash of half & half smooths out the flavor.

So next time you are on your way to work the night shift or get an after-hours hankering for espresso, remember the ghettiato, the DD hack that's cheap and Paleo-compliant.

Paleo on the roof of the world

My town has a new restaurant started by a Tibetan Buddhist monk. It serves cuisine from Tibet, Nepal, and Bhutan, all countries located in the Himalayan mountains.I ordered off the Bhutan menu today for lunch. I had phaksha kum paa (pork belly with daikon radish cooked with onions, garlic, ginger, chilli powder) and suja (salted butter tea). This was a completely Paleo Diet meal, although it was served with rice (which I felt compelled to eat out of politeness since I hadn't asked them not to serve it).

Bhutan has an interesting array of fauna, including the golden langur, clouded leopard, sloth bear, the barking deer, and an animal called the takin.

I'd be interested in tasting the takin, but the pork belly was quite good. The restaurant only uses meat from local growers: pasture fed beef, heritage hogs, and free-range chicken.

I'll be eating Himalayan again.

Doubling-down on the sorority mentality of nursing school

In the April 2011 issue of AACN's Critical Care Nurse, Susan Luparell suggests that nursing schools need to do more to weed out students with bad attitudes in order to transform the culture of incivility that exists in the nursing workplace.

This is exactly the wrong tactic to use to help nursing develop into a better profession. The assumption that the workplace should be free of interpersonal conflict is not appropriate for a workplace based on openness to enquiry and deference to evidence and reasoning over authority.

Based on my experience of school and the workplace, I would say that a minority of conflict is caused by "bad apples." The majority can be attributed to the stress caused by power imbalances and the desires to enforce or resist conformity. These are what I think of as the "sorority mentality" of nursing, and especially of nursing school, and they are real problems. But the way to deal with them is not to get rid of anyone who doesn't fit in, but to get rid of the idea that we have to like people we work with and to move away from the military model of hierarchies that have pervaded work and school in nursing.

Doubling-down on failed strategies

Although nursing educators want academics in other disciplines to think that nursing is a field on par with history, biology, etc, the reality is that nursing school is more like a cross between college and boot camp. It is part scholarship and part jumping through hoops created by instructors. The fact that nursing schools are accredited is irrelevant, as what exists on paper and in theory can be very different from the reality of school.

Every nurse who had her eyes open in school can tell you stories about students who were or were not cut from their program inappropriately because of instructor biases. This stress combined with the stress of having to meet higher academic standards than other university students is the main cause of poor attitudes among students.

Instructors have an enormous amount of power in nursing school, and the fact that their attempts to wield this power to mold the nursing profession have failed to create a civil working environment should tell us that this is a failing strategy.

Susan Luparell's recommendation does not recognize this fact and actually recommends doubling-down on instructor power. Like a gambler who is addicted to his game more than a winning strategy for wealth creation, Luparell is addicted to the idea that nursing instructors "create" new generations of nurses.

What the workplace needs for civility is more openness and less fear among both staff and management. Rather than asserting themselves more, instructors should facilitate this attitude by asserting themselves less and modeling the type of behavior needed in the workplace.

Marlon Brando, first laptop user

I found this photo of Marlon Brando at, if I remember, the Life magazine website. He's sitting on his couch with a typewriter in his lap. It strikes me how modern he looks. There are two images of the laptop user that drive laptop sales. One is the businessman who can take his work with him anywhere. The other is the uber-relaxed Internet user who doesn't need to sit at a stuffy desk. Here, Brando has pre-figured this last image with his typewriter. Rather than doing e-mail, he is perhaps answering fan mail (probably not).

Dr. Jeffry Life

A long while back, I posted on Cenegenics and their spokesmodel Dr. Jeffry Life. I was a little bit incredulous that it was for real, but I scanned and enlarged a photo I found in a magazine and couldn't find any signs of Photoshopping. Later, I found a video of him that I posted on YouTube.

Time magazine has a feature on longevity, and Dr. Life looks to be still going strong. At 72, he looks fantastic. I assume his overall conditioning is commensurate with his appearance. The photo from the online version of the article is above, and I'll post the photo from the print version of this article to Flickr at some point as well.

7 myths of practice

AACN's current Critical Care Nurse has an article on 7 myths of practice that nurses continue, although there is evidence against them. The article is free online right now. They include:

1. Trendelenburg Positioning for Hypotension
2. Use of Rectal Tubes to Manage Fecal Incontinence
3. Gastric Residual Volume and Aspiration Risk
4. Restricted Visiting Policies: A Thing of the Past?
5. Nursing Interventions to Prevent Catheter-Associated Urinary Tract Infections
6. Use of Cell Phones in Critical Care Areas
7. Accuracy of Assessment of Body Temperature

Happy Easter

The amount of trash produced by a hospital

Recently I've been thinking a lot more about stuff. No, I don't mean "about stuff," but about "stuff," all those objects bumping around in homes and in and out of our homes. I've been reading books like The 100 Thing Challenge by GuyNamedDave and Unclutter Your Life in One Week by Unclutterer, and I've been watching DVDs like No-Impact Man by No-Impact Man. Google reminds me that today is Earth Day, so let me write a little about this topic.

Everything I own fits in one room, and I feel like I have too many things. I try to cut down on waste and reduce my consumption, but I feel like a spend-thrift mostly. Ultimately, this is personal. The compulsion to downsize, organize, and stop buying--reduce, reuse, recycle--reduce, refuse, rejigger--is innate. It's my default setting, not something learned I do. So for the most part I don't push it on people and don't hold it up as a standard of behavior. However, consumption and waste are economic and social problems, and people should give them some attention even if they aren't ready to make changes themselves.

To get a sense of the amount of waste that is produced, an excellent start is a TED talk by photograper Chris Jordan. Mr. Jordan makes photographs composed of repetitive images of individual objects. To me, the most striking is his photograph of the disposable paper cups used in a day in the United States. The photo can be seen on his website. The U.S. uses and throws out 410,000 disposable paper cups every 15 minutes. This would make a stack every day that would form a wall 42 stories high and maybe a city block wide. Every day! As he points out in his TED talk, if you add an item for scale, the pile of disposable cups the U.S. uses every day would dwarf the Statue of Liberty. Observe:

Waste is nowhere a bigger problem than in health care. As you know if you work in health care, literally every single thing that's used on a patient is packaged in a disposable plastic container, and most of the items are disposable themselves as well. Health care waste management is an enormous industry itself, and will even be having its own industrial conference coming up in early May in Texas.

To give you some perspective, my household of four produces about 4-5 bags of trash every 2 weeks. (Most of this is composed of the individualized and non-reusable packaging of milk cartons, cuts of meat, toiletries, etc.) That means I personally produce about one-tenth bag of trash per day at home (that's 5 bags of trash divided by 14 days, divided by 4 people). In comparison, at work I produce 1 to 2 bags of trash per shift, or 10-to-20 times as much per workday. It's even more of a shock looked at from the patient's perspective. 1-2 bags per shift means 3-6 bags per day. So I estimate the average hospitalized ICU patient produces 30-to-60 times as much trash on a daily basis as a non-hospitalized person.

Let's be generous and assume that the non-ICU patients produce only half of the lower end of this number, or 1.5 bags per day. My hospital is about a 300-bed hospital. Assuming that, on the average day, there are 225 patients admitted, the hospital produces about 340 bags of trash per day just from patient rooms (that's not including offices or the E.R., nor does it count the voluminous trash produced in the O.R.). Including all the other trash in the hospital, I wouldn't be surprised if the hospital produces 500 bags of trash per day or more. This is somewhere on the order of 180,000 bags of trash per year.

How much is that? Well, my city is about 2.25 miles in circumference, or about 12,000 feet in circumference. At this size, if each trash bag is 1 foot wide, the hospital could build a wall of trash around the city that is 15 layers deep every year. Honestly, I don't know where all this trash goes.

TSNR: the murse edition

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Sexy Nurse with a capital T

Well, either you're closing your eyes
To a situation you do now wish to acknowledge
Or you are not aware of the caliber of disaster indicated
By the presence of pocket pool in your community.
Ya got trouble, my friend, right here,
I say, trouble right here in your own home.
Why sure I'm a billiard player,
Certainly mighty proud I say
I'm always mighty proud to say it.
I consider that the hours I spend
With a cue in my hand are golden.
Help you cultivate horse sense
And a cool head and a keen eye.
But just as I say,
It takes judgement, brains, and maturity to score
in a balkline game,
I say that any boob kin take
And shove a ball in a pocket.
And they call that sloth.
The first big step on the road
To the depths of deg-ra-Day--
I say, first, medicinal wine from a teaspoon,
Then beer from a bottle.
An' the next thing ya know,
Your son is a playa'
In a pinch-back suit.
And list'nin to some big out-a-town rapper.
Friends, lemme tell you what I mean.
Ya got one, two, three, four, five, six bones.
Bones that mark the diff'rence
Between a gentlemen and a bum,
With a capital "B,"
And that rhymes with "P" and that stands for pool!
And all week long your own home
Youth'll be frittern away,
I say your young men'll be frittern!
Frittern away their noontime, suppertime, choretime too!
Get the ball in the pocket,
Never mind gittin' Dandelions pulled
Or the screen door patched or the beefsteak pounded.
Never mind pumpin' any water
'Til your parents are caught with the Cistern empty
On a Saturday night and that's trouble,
Oh, yes we got lots and lots a' trouble.
I'm thinkin' of the kids in the jeans,
Shirt-tail young ones, peekin' on the web-
sites after school, look, folks!
Right here in your home.
Trouble with a capital "T"
And that rhymes with "P" and that stands for pool!
Now, I know all you folks are the right kinda parents.
I'm gonna be perfectly frank.
Would ya like to know what kinda conversation goes
On while they're loafin' around that DVD?
They're tryin' out hentai, tryin' out FileShare,
Tryin' out bunts like Cigarette Feends!
And braggin' all about
How they gonna cover up a tell-tale breath with Sen-Sen.
One fine night, they leave the basement,
Headin' for the dance at the school!
Libertine men and Scarlet women!
And rap time, shameless music
That'll grab your son and your daughter
With the arms of a jungle animal instink!
Mass-staria!
Friends, the idle brain is the devil's playground!

Mothers of nursing!
Heed the warning before it's too late!
Watch for the tell-tale sign of corruption!
The moment your son leaves the house,
Does he rebuckle his jeans below the waist?
Is there a stain on his palm?
A nympho nurse novel hidden in the corn crib?
Is he starting to memorize jokes
from Brazzers, Bang Brothers?
Are certain words creeping into his conversation?
Words like 'suck't!"
And 'who's your daddy?"
Well, if so my friends,
Ya got trouble,
Right here in your own home!
With a capital "T"
And that rhymes with "P"
And that stands for pool.
We've surely got trouble!
Right here in your own city!
Remember the Maine, Plymouth Rock and the Golden Rule!
Oh, we've got trouble.
We're in terrible, terrible trouble.
That game with the balls is a devil's tool!
Oh yes we got trouble, trouble, trouble!
With a "T"! Gotta rhyme it with "P"!
And that stands for Pool!!!
=================================================

I note that while some nurses are upset over the media representation of themselves as Naughty or Nymphomaniac Sexy Nurses, some nurses are also buying, selling, and trading items like the following, as well as telling bawdy jokes at the nurses' station...

Nurses have no inhibitions...

"Nurses do it with intensive care"

Nurses make the best lovers because…….

• We are so knackered, we fall asleep on the couch right after tea…then you can get on with watching desperate housewives without distraction.
• We know what is what and where is where….and it’s all evidence based.
• We yell “stand clear!” at the appropriate time. So you can…well…stand clear.
• We know the best chocolates… and the millions of uses for sleek…
• We understand the meaning of PRN.
• We can keep a totally straight face when we tell you that you look awesome in that flannelet nightdress and ugg boots.
• Whatever you think is wrong with you, they’ve seen bigger/smaller/saggier/lumpier/furrier/etc making you feel almost like a Victoria’s Secret model in comparison.
• Even tho’ you’re screaming, we are trained to stay focused on the job at hand.
• … we know how to get a girl to the right temperature!
• They can multi-task.
• they read lots of procedure manuals !!!!!!!
• they can present an education folder documenting they are in fact competent.

=================================================
Trouble, oh we got trouble,
Right here in the nursing profession!
With a capital "T"
That rhymes with "P"
And that stands for Pool,
That stands for pool.
We've surely got trouble!
Right here in nursing,
Right here!
Gotta figger out a way
To keep the young ones moral after school!
Trouble, trouble, trouble, trouble, trouble...

* Apologies to the Music Man

Colbert points to Sexy Nurse

I hate the Colbert report. Politics by humor has all the charm of the Athenian theatre's effect on Socrates. I saw Colbert live in NYC when he appeared at Radio City Music Hall for the "Legally Prohibited from Being Funny on Television Tour." This was not Conan O'Brien's greatest hour, and Colbert and Stewart showed how inane they actually are. (There's a reason Jon Stewart couldn't keep a big time TV gig until he became a political spokesman.) This clip from March 31 wasn't even funny:


See more from The Sexy Nurse Report series.

Showtime's Battleaxe

I haven't actually watched this show, Nurse Jackie, on Showtime. I don't have cable TV, and I barely watch TV anyhow. But judging from adverts and photos, I am guessing that she fills a special place in the world of nursing stereotypes. I bet she's not Handmaiden, Battleaxe, or Angel. She has a special role all her own: it's called "Bitch." Yes, bitch.
You see, if you are producing a TV show about nursing in the US, you have to choose to build on one of the available stereotypes. Nurse Jackie's not male or English, so the Gay and Matron stereotypes are right out. The Handmaiden stereotype is not PC. The Angel stereotype would make a boring TV show and will never again be used as the basis for a film or TV character unless it's an Evangelical or Catholic production company. This leaves the Battleaxe. It's obvious from the advert above that this is the stereotype the show has used to build their character. Just look at the syringe and needle. It's a dead give-away. Anytime a nurse is holding a needle in a photo, the message is "I'm going to cause you pain." (Incidentally, have you ever seen one of the those old nursing romance novels where the nurse is holding a needle on the cover? No, of course not!)

The problem is that the show needs the support of nurses, or at least not to make nurses' unions its enemies, and no nurse wants to be a Battleaxe. So the show compromised by making her a bitch. Bitch is what the real-life Battleaxe calls herself. Where Battleaxes are partnerless and mostly friendless, the bitch is self-described as "independent." Whereas the Battleaxe lacks social graces, the bitch has "attitude." Whereas the Battleaxe sadistically, or least dispassionately, dispenses pain, the bitch thinks everyone should "man it up" because she's too vulnerable to express empathy. Whereas the Battleaxe is a dominating alpha-female, the bitch just causes people to feel exasperated instead of fearful.

The reason the Bitch is an acceptable variation of the Battleaxe for a TV producer is that many people equate bitchiness with equality, liberation, etc, etc. But Battleaxes, bitches, it's all the same.

Oh, I bet she's a nympho, too, but that's just for ratings.

Sexy army nurse aviation patch

Although nurses help soldiers recover from combat, some soldiers don't seem to notice that these nurses don't wear short skirts and caps. For example, this unit patch from C Co 3-25 Army Aviation:

Here's what a real army nurse looks like:


And here's what an actually cool military patch looks like, from the 498th Air Ambulance:


See more of The Sexy Nurse Report...

Beer face prophylaxis, part trois

Indian lamb saag with nan + beer. No pre-medication. Facial flushing, swelling, and mucous production within 30 minutes post-meal-start-time.

2009 Vogue Paris calendar

Here is the image that started this blog, originally found in Violet Blue. I mean, give me a freakin' break. This girl is nice-looking, but, in addition to any sociological issues, she is not even a sexy Sexy Nurse. How does Vogue magazine ruin sexy? The lingerie replacing the nurse's uniform undermines the fantasy of work-related shenanigans, and it isn't as aesthetically interesting as the iconic white dress (which is almost like a piece of fashion, as discussed in previous posts). Moreover, although she is posed in what I have called the Battleaxe-dominatrix theme, the photographer has completely failed to capture any malevolence--something else which the lingerie undermines--demonstrating a lack of understanding of this fetish.


Pathetic. It does, however, give us a chance to get acquainted with the reality of French nursing. Here's a real French nurse, Luc. He works in Africa:


Here's a real French nurse, Aude. Beautiful, and no high heels required, although she does apparenlty need a watch attached to her clothes:


And here's a real Quebecois nurse, Kathy, from French-speaking Quebec (btw, Montreal is the second-largest French-speaking city in the world, and, for as far north as it is, has its share of babes along with professionally-behaved nurses):

I must say, too, that if you do a Google image search for infirmière, you get a lot more photos and a lot more explicit photos, than if you do an English search.

There is more at The Sexy Nurse Report.

Beer face prophylaxis, part deux

I had Mexican food last night, again with beer (mostly to test my prophylactic concoction again). Another success!

After dinner, I logged in to my e-mail and discovered my 23andMe results were ready, and I spent most of the evening browsing through them. According to 23andMe, I have no facial flush from alcohol, and I am at high risk for Celiac disease. I have to look into these results more closely to find out if they have any plausible real connection to "beer face," but at least I think a good working hypothesis right now is that any flushing after drinking is more likely from a non-inebriation reaction.

Beer face prophylaxis

Last night, I may have solved my beer issue, which I like to call "beer face" or "beer head," i.e., flushing, swelling, muscous production, and congestion after drinking beer. (This lasts longer than the drunkenness and takes effect at beer doses below those required for me to get a "buzz.")

As John Durant at Hunter-Gatherer has noted in Beer and inflammation, some people react to beer drinking with less than desirable outcomes. Unlike Mr. Durant, I never drank beer in college because it used to give me intestinal cramping and diarrhea. I never connected this with wheat because I was eating a lot of bread, pizza, etc at the same time.

Then the family went on the Atkins Diet, and I basically haven't eaten bread since. Maybe once a week now, I will eat pizza or a breakfast item such as a "Dutch boy", but this is the extent of my bread intake.
When I do eat pizza, I like to have a beer with it because I don't drink Coke. Since doing Atkins years ago, I have not had so much of the cramping/gas with beer, but I have been experiencing the "beer face" described above.

Uppers and anti-inflammatories

So, last night we had pizza and beer, and I treated "beer face" prophylactically with over-the-counter medications. My OTC meds worked to prevent the flushing and congestion I get with beer nowadays. I have done this before as well, so I now have 3 successful outcomes, although only at an n=1 size.

The medications I used were

• ASA (aka, aspirin)
• ibuprofen (aka, Advil)
• loratidine (aka, Claritin)
• extended-release pseudeoephedrine (aka, 12-hour Sudafed)

This group constitutes two Non-Steroidal AntiInflammatory Drugs (NSAIDs), one antihistamine, and one sympathomimetic. Although Sudafed is often called an antihistamine in common parlance, it is not one and is more or less an upper like amphetamine. Sudafed works by constricting the blood vessels in your nasal passages, not by blocking H1 receptors, like Claritin.

Using this combo of OTC meds keeps my sinuses clear all night after a dinner with 1-2 beers.

Sexy nurse resuscitation: don't try it at home

Reflecting on the video I posted yesterday, it occurred to me that stripping in front of an unresponsive asystole patient may not be the right thing to do. Remember that sexual arousal is initiated by the pelvic splanchnic parasympathetic nervous system. You want to be pushing epi and working on the sympathetic system. So stripping is sort of working at cross purposes...
Cheers!

Coming back from the brink with sexy nurse

Two days ago, I posted a piece on the Sexy Nurse trope. Remember, my point was that the Sexy Nurse is not a stereotype, but an archetypal fantasy of male passivity. Here's a YouTube video that confirms my thesis, although on the surface it appears to do the opposite...

The plot of this commercial plays on the Angel-stereotype-accommodation-fantasy theme. The nurse is so selfless and altruistic that to bring her patient back from the brink of death she is willing to try anything, even stripping off her clothes.

However, in the end, we see that the patient is manipulating his bedside EKG monitor in order to entice the nurse into removing her clothes. This would seem to contradict my contention that in the Sexy Nurse fantasy, the patient is a passive sexual agent. I submit that there is no contradiction. Consider that this commercial is humorous. Without the plot twist at the end, it would simply be the start of an erotic fantasy, not a funny. The joke is that we identify with the patient and laugh at the ridiculousness of our mutual fantasy. After getting the nurse to strip, the patient re-takes a passive role, laying still and letting the nurse stroke his head. This is his fantasy, not taking advantage of the nurse. The commercial is, in fact, a confirmation of my thesis.