History: quick medical history checklist

SAMPLE:
Signs/ Symptoms
Allergies
Medications
Pertinent history
Last oral intake
Events preceding this incident

Pain history checklist

OPQRSTU:
Onset of pain (time, duration)
Palliative factors for pain
Quality of pain (throbbing, stabbing, dull, etc.)
Region of body affected
Severity of pain (usually scale of 1-10)
Timing of pain (after exercise, in evening, etc.)
U: How does it affect ‘U’ in your daily life?

May wish to expand to OPPQRRSTTUVW, with the extra letters representing:
Provocative factors
Radiation (how does pain spread)
Treatments tried
Deja Vu: Has this happened before?
Worry: What do you think or fear that it is?

Sign vs. symptom

sIgn: something I can detect even if patient is unconscious.
sYMptom is something only hYM knows about.

Physical examination

“I Palpate People’s Abdomens“:
Inspection
Palpation
Percussion
Auscultation

ST elevation causes in ECG

ELEVATION:
Electrolytes
LBBB
Early repolarization
Ventricular hypertrophy
Aneurysm
Treatment (eg pericardiocentesis)
Injury (AMI, contusion)
Osborne waves (hypothermia)
Non-occlusive vasospasm

Beck’s triad (cardiac tamponade)

3 D’s:
Distant heart sounds
Distended jugular veins
Decreased arterial pressure

Kubler-Ross dying process: stages

“Death Always Brings Great Acceptance“:
Denial
Anger
Bargaining
Grieving
Acceptance

Coma causes checklist

AEIOU TIPS:
Acidosis/ Alcohol
Epilepsy
Infection
Overdosed
Uremia
Trauma to head
Insulin: too little or or too much
Pyschosis episode
Stroke occurred

Shock: types

RN CHAMPS:
Respiratory
Neurogenic
Cardiogenic
Hemorrhagic
Anaphylactic
Metabolic
Psychogenic
Septic

Fall: potential causes

I’VE FALLEN:
Illness
Vestibular
Environmental
Feet/ Footwear
Alcohol and drugs
Low blood pressure
Low O2 states
Ears/ Eyes
Neuropathy

Subarachnoid hemorrhage (SAH) causes

BATS:
Berry aneurysm
Arteriovenous malformation/ Adult polycystic kidney disease
Trauma (eg being struck with baseball bat)
Stroke

Endotracheal tube: troubleshooting

DOPEY:
Displaced: esophagus, right mainstem, back of throat, etc
Obstructed: secretions, blood, mucus plug, kink, etc
Pneumothorax
Equipment: malfunctions, O2, ETT, BVM, ventilator, monitor
You: your approach, technique: missing something?

Organophosphates poisoning: symptoms

DUMBBELS:
Diarrhea
Urination
Miosis
Bradycardia
Bronchospasm
Emesis
Lacrimation
Salivation

Coma and signicantly reduced conscious state causes: causes

COMA:
CO2 and CO excess
Overdose: TCAs, Benzos, EtOH, insulin, paracetamol, etc.
Metabolic: BSL, Na+, K+, Mg2+, urea, ammonia, etc.
Apoplexy: stroke, SAH, extradural, subdural, Ca, meningitis, encephalitis, cerebral abscess, etc.

Shortness of breath:

AAAA PPPP:
Airway obstruction
Angina
Anxiety
Asthma
Pneumonia
Pneumothorax
Pulmonary Edema
Pulmonary Embolus

Single vehicle accident·

7 S’s:
Suds (EtOH)
Suicide
Sleep
Seizure
Sugar
Stroke (bleed)
Stupidity

Abdominal swelling causes

9 F’s:
Fat
Feces
Fluid
Flatus
Fetus
Full-sized tumors
Full bladder
Fibroids
False pregnancy

You hear a lot these days about ‘patient centered care’ as the health system (on paper at least) moves away from the old disease-centered model that would base treatment decisions largely on the physician or nurses previous clinical experience in response to objective data from various tests and assessments.
The patients role would be passive. The diagnoses of their illness or disease would be ‘extracted’ from them and then the treatment would be imposed upon them.

With the newer model of patient centred care, the patient is empowered to participate much more collaboratively in their care.
It is described as a partnership, where the assessment and diagnosis is explained to the patient and their feelings, beliefs and expectations are listened to and explored by the health-care team. Once fully informed, the patients decision-making is respected (even if the patient decides to take risks or move against accepted management guidelines).

Evidence has shown that patient centered care increases patient satisfaction, improves quality of life, and increases positive health outcomes.

But there is still something missing here.
Whilst there is a much improved flow of information back and forwards between the patient, their families, and the medical staff, and (at least superficially) there seems to be a much stronger collaborative approach to the problems, perhaps in some respects a patient centred model is binding care delivery just as much as the disease centred model.

Off-Centred Care.

In these days of high workloads, a complex structuring of the medical specialties into silos, shortages of medical staff and emphasis on increased productivity (doing ever more…with ever less), doctors, nurses and other healthcare professionals are placed under extraordinary levels of personal and inter-personal stress.
What is often left unacknowledged is the profound effects on patient care outcomes that can result from professional dissatisfaction, physical and mental exhaustion, and any degree of ethical or spiritual dislocation being experienced by the care-givers.

Many many times I have seen all the empowerments of patient centered care and evidence based practice and best practice guidelines trumped by the disempowering actions of an exhausted doctor, or an unhappy nurse, or a depressed manager or a disinterested executive (aside: is evidence based practice actually evidence based anyway?).

Encompassing Care Delivery.

Instead, the focus should be not on the patient, not on the disease, not even on the care-givers, but rather on the field of relationship between them.
No centre at all really, but rather a system of Encompassing Care Delivery (ECD).
For example: ECD would consider the relational effects of the nurse on the patient as well as the patient on the nurse (as well as the patient/nurse relationship on the doctor and vice-versa and etc).
The focus would shift to improving the quality of what happens in the space between the patient and the care-givers be it physical interventions, communications, personal development, or problems. ECD would concentrate on providing tools for the patient, the staff and the so called ‘significant others’ to interact with an increased quality.
Such variables as the environment, staff workloads, debriefing, mentorship, mindfulness, intimacy of care delivery would be seen as important to the healing process as antibiotics and CAT scans .

Professional objectivity would be validated as the thin veneer that is actually inhabits, and deep exploration of the inter-subjectivity’s between all members of the health care team would be encouraged. A sort of therapy going into therapy?
Care for the staff and care for the patient would be seen as two sides of the same coin and evidence based would be just one aspect of delivering quality based care.

I was awoken sometime shortly after 3 am by a noise just outside the bedroom window.
Swiped away from counting M&M’s with Johnny Depp in the map room of a Spanish galleon just off the coast of Havana, it took me a few moments to orient myself to what was going on.
Dink-a dink-a dink-a dink-a dink-a dink-a…..
Then silence except for the sound of a distant dog bark.
Just as I was about to drift off to sleep again.
Dink-a dink-a dink-a dink-a dink-a dink-a…..
What was that?

On the boundary of our back garden, just behind our bedroom there is a tall iron security fence. Lately, we have been having some trouble with a group of local kids who have been scaling the fence late at night and using our garden as a short cut between where they are and where they are not. The fence is slick, has little in the way of foot holds and much in the way of spiked posts. Climbing it is no simple task and this is made even more risky as they usually have alcohol on board.
So words have been spoken.
We have told them that they are trespassing, and putting themselves at a significant risk of impalement. Besides, it is probably quicker to hump up the street 50 meters and cut through an allyway anyway.
And, in their defense, they have told us to go fuck ourselves.
OK…all sorted.

Anyways, tonight someone was outside running a stick or a bar or something along the railings of the fence.
Dink-a dink-a dink-a dink-a dink-a dink-a…..
By the time I had tumbled out of bed, hopped into a pair of pants and opened the lock on the front door, I had made plenty of noise to alert anyone outside that someone was up.
Besides as soon as I stepped outside, I triggered the security lights which totally blinded me anyway.
I padded across the grass over to the fence, and as my eyes readjusted to the darkness, I could see that they were long gone.

Back to bed.
I lay there listening to the night for a while before drifting off again.
Dink-a dink-a dink-a dink-a dink-a dink-a…..
What the frick…? These guys are trying to mess with my mind.
Right! Its on, I’m all over you like lube on a proctoscope my nasty little nocturnal nemesis’s.
This time I was out of bed in a split. Barefoot, silent, night-shift ninja-nurse. Over to the door. Click off the security lights. Open the dead-lock with urgent quietude.
Across the lawn crouched low. Tangled in shadows. Flowing like inky mercury.

Nothing.
No sign of them.
I thought for a moment I could hear distant whispering, but perhaps that was just the wind in the bushes.
I could definitely feel some sort of presence just off in the corner-of-the-eye darkness.
 I withdrew to the side of the house and hunched down behind a low retaining wall. And I waited to catch them.
And I waited.
It was cold, and dark, and it was 4 am, and I had a cramp in my foot, but I sat there wrapped in stillness, determined that no-one was going to out psychologicalize me and get away with it. No way. No how.
4.05 am. Bugger this, Im going back to bed.

A short restless sleep broken by periods of laying there listening to the dog snoring and formulating masterful psy-ops missions against this new paedi-axis of evil.
At around 5.30 am I had to get up to empty my bladder. I had just stepped into our ensuite bathroom when:
Dink-a dink-a dink-a dink-a dink-a dink-a…..
What? What?!

Beside our toilet we have this tall metal bin that we use for storing rolls of toilet paper.
Trapped in the bottom of the empty bin was a large, Bogong Moth (Agrotis infusa).
Each time he flapped his wings against the bottom of the bin, the sound was magnified like a kettle drum: Dink-a dink-a dink-a dink-a dink-a dink-a…..

How often is it that we construct this totally fabricated version of what is actually going on around us. We weave together this nice little narrative from unexamined twigs and fragments  and then sit piously in its nest wasting our time being angry at other people for not living up to our expectations.
Oftentimes its not someone trying to piss you off, or ruin your day. Oftentimes its just a moth struggling with its own life.

That’s the thing about hills… you can go up, you can go down. Two directions. 
How hard could it be to get lost?
“Um, Kelly……do you think we’re lost?”

It was nearly nine-thirty by the time we pulled into the small car park at the trail head.
Still in shadow, the parking area was cold and wet underfoot, despite a day stirring to blue sky promise.
From the very first muddy scuffle, the track rose steeply without so much as a warmup.
The guidebook advised us: Rocky Hill Summit Circuit return – 7 km. Please note that sections of this track are steep and slippery.
At 777 meters Rocky Hill is little more than an angular geological blemish, dwarfed by the 2,000 meter snowcaps that surround it.
Bullied up against a curve in the Matukituki river, it sits stubbornly like some giant, over risen layer-cake, having resisted the glaciation of the surrounding valleys during the last ice age.

Leaning into the challenge, it was not long before I could feel my quads pumping out in protest, and by the time we rounded a large outcrop of silver-run schist, we were both breathing hard. We stopped for a time to strip off our jackets and feel the cool morning sun prickle our skin.
The track levelled for a time as it traced the edge of the inky black of diamond lake before rising again through the Weeping Forrest (so named because the trees rise up and then bend over as they search for light through the canopy) in a series of wooden steps and steep acclivities.
Despite the lay of the land a few sheep had found their way up into the rich feedings of these thick green forrest grasses, and being early spring, they had some wobbly legged newborn lambs in tow.

We lingered at a lookout high above diamond lake that jutted like a diving board from the cliff, watching bumble bees swoop and hover on their little outboard motors.
These bees looked exactly how a five year old would paint a bee…big and round and yellow and black.
Leaning from the edge to better see them work, I could feel my cremaster muscle hauling my testicles up into my chest like two novice climbers on belay.

A ways past the lookout, the track up to Rocky Hill now started proper, tacking off on a switch-back varicose up the side of the hill. In places it was so steep that as I came around on the next bend in the trail, I was practically standing on Kelly’s shoulders.
We rose through tangles of bracken fern and bush lawyer and flowering ribbon wood. The air smelt of peppermint and snow. 
At one point the muddy track had recorded the flailing prints of a small hoofed animal, perhaps a sheep, or a goat that had slipped at a particularly tricky twist on the slope. The grass was freshly flattened where it had gone down but there  was no sign of the animal.

Buoyed with the hypoxia of adventure, we marched hydraulically onwards. We were tired and sore, but having a ball.
And there it was. A pyramid of stones raised to mark the summit of Rocky Hill.
Infused with newfound energy we whooped and danced like kids. Just like you are supposed to do when you reach the top of any mountain.
And then after realising where we were, I thought it appropriate to perform my best Rocky impersonation.  Center of an imaginary arial shot, the background sweeping around me as my arms punched the air, Rocky’s theme tune echoing off the mountains in Dolby surround sound. Cool.

Once that was out of my system (which took slightly longer than the actual movie) we found a grassy area to settle in and enjoy a sleepy lunch of cheese sandwiches chased with handfuls of cashew nuts all washed down with ice cold water.
The view was spectacular. Across  an electric blue sky to Lake Wanaka, the Matukituki river, and onwards, to the sparkling 3,033 meter peak of Mt Aspiring.

“Um, Kelly……do you think we’re lost?”
“ Yes Ian….
”
“….I think we might be lost.”¹

1. Ian is currently on holidays….lost somewhere in New Zealand. And loving it.

I will shortly be heading off on an adventure in New Zealand for a few weeks to re-fibrillate the old batteries.

Probably wont be posting too much during this time (after all…adventures are for letting all this sort of stuff drop away, no?)

But I do hope to post the occasional log of our trip which you will be able to read here: Not Just a Nurse.
And I have a favor to ask…..whilst I’m gone, would someone mind watering my blog from time to time?

Take some time to think of the funniest medical related story you can remember and drop it in the comments of this post.
Maybe it is a story that actually happened to you….or to a colleague. Could be a link to the funniest story you have read on-line. What about your experiences as a patient?
Perhaps it is an anecdote or simply your best medical joke. Let rip.
I will be checking in from time to time to get my hit of comment crack …. and in this case hopefully a little comment crack-up!
And as a little incentive, when I get back, there will be a prize for the funniest story¹.
Make us laugh.

Take care,
Ian.

1. I would love to make it something excellent, but unless there is a company out there that wants to donate a wee prize….it will have to be an impactednurse t-shirt of your choice. I did say it would be a little incentive.

A picture may paint a thousand words, but 40 mls of Mylanta, 60 mls of iced water a dusting of Talc, and something blue, paints one word….mischief.

Emergency Department nurses: professional, compassionate, hard working, cool under pressure, and…um….whats the other word I’m looking for?
Help me out here guys…….

But if you really want to know what horrible is, you must be prepared to go somewhere very different. 
Horrible is a place far darker and dense than any simple bright-red spatterings of physics. 
You must be prepared to be taken to some deep, disturbing places. Places that hook in, and bother you, and quiver your preset smile, and make you wish you had’nt asked after all.
And so it is usually best to toss out little porn, scratch the itch, and move the conversation on.

Just the other day I looked after a young man who collapsed whilst talking to a used car salesman. He was fit, and had no pre-existing medical conditions.
One minute he was leaning against an old Datsun discussing money and mud flaps…the next he collapsed into something asphyxiatingly horrible.
No reason.

Initially, his only movements were repeated lunging of his left arm. Like a man who has fallen through a hole in the ice, and was desperately grasping to get out.
But even as we worked on him, he slid below. All fell still except for his dread-full darting eyes.

Locked in syndrome, also known as cerebromedullospinal disconnection, de-efferented state, pseudocoma, or ventral pontine syndrome results following some insult to the brainstem in which the pons is damaged, or perhaps a stroke at the level of the basilar artery occluding bloodflow to the pons.
In French the condition is described as”maladie de l’emmuré vivant”, literally translated as walled-in alive disease. 
The person experiencing locked in syndrome may be fully cognisant but unable to move any voluntary muscles in the body except for the eyes¹. The result is a quadriplegia, with lower cranial nerve paralysis and mutism (unable to speak).

It is estimated that several thousand patients suffer this syndrome each year, however the very concept of being locked-in is quite a misnomer, for unlike a lock, this condition has no key. At present there is no cure.
Up to 90% of these people will die within the first four months, although a small percentage will make some improvements in motor control and ability to communicate with the outside world.
This is quite different to patients who suffer brain injury. These people often recover to be as mentally alert as they were before the accident.
Except that they are trapped in a shrink-wrapped prison, denuded of all activity and interaction. For ever.

And yet it is not as simple as that. Despite existing in a condition that many of us think would drive us insane, there remains some vital spark that can on occasion prove some expansion of fullness and passion that forces the rest of us to examine what it is exactly that makes us human and how we should relate to each other.

Locked in syndrome was recently raised in the general public awareness following the release of the Oscar-nominated film: The Diving Bell and the Butterfly. Adapted from the French memoir of Dominique Bauby a 44 year old former editor-in-chief at Elle magazine who, following a stroke in 1995 that left him locked in, went on to dictate the entire book by means of blinking his left eye.²

The British Medical Journal has a 2005 article: The Patient’s Journey: Living with locked-in syndrome in which ‘Nick’ provides a thought-provoking narrative of his own experience of locked-in syndrome following a rugby accident in 2000.
I urge you to read the entire article.

I staggered to the sideline, the coach asked me “What’s wrong”? He said I told him I just felt sick and to put me back on the field in 10 minutes. Then I collapsed and was rushed to hospital (unconscious) in an ambulance with the staff struggling to keep me alive….
…..Words can’t describe the situation I have been left in—but this is as close as I can get it: an extremely horrific experience that I wouldn’t wish on my worst enemy. The incredibly immense frustration levels at times have eased slightly over the years because of physical and health gains I have made.
It felt like I was in a really bad nightmare constantly for about the first three months. I could only just hear (I couldn’t even open my eyes or breathe by myself); without them even knowing that I still could hear, the doctors and specialists in front of me said to my mum that I would die. They even asked my mum if she wanted them to turn the life support machine off after a few days….
…I’ve always thought, fuck what they [the doctors] think and say—or I would have been dead at the start. Most specialists and doctors with whom I’ve dealt since my accident have been so extremely negative…

And in a case report from the Journal of Neurology, Neurosurgery, and Psychiatry in 2007, examined the poetry written by a Polish cartoonist who was locked-in following a stroke 4 years prior.

“You return week upon week with no pain of which to speak
A carbon copy of carefree spring
The sunny summer feelings that you bring
A clearing full of flowers
Lost in a forest of emerald green towers
A burst of joy for Christmas time
A mindful eye for harder rhyme”

Despite such abysmal situation, this man continued to produce a prolific outcalling of poetry. Ongoing expressions of love and beauty, fear and grief, humour, optimistic thinking, and reflecting upon memories.

So perhaps after all, what is far more horrible is not those who are locked-in from the world, but those of us who are locked-out.

1. in Total Locked-in Syndrome even the muscles controlling eye movements are paralysed
2. A transcriber would say each letter of the alphabet until Dominique ‘chose’ that letter by blinking. It is estimated that the book took 200,000 blinks to complete over a period of 10 months.

And whilst we are on the topic of things stuck on fingers.
From time to time we get young male dudes presenting to our emergency department who think these wheel bearing thingies (see picture above) might make some pretty hardcore jewelery.

Of course if they end up presenting to the ED the thing will be stuck on their finger ( and you had better hope its just their finger…seriously ), and they will have pulled and yanked and twisted until the finger is super swollen and painful.
Now, these bearing things are seriously thick and would be a nightmare to have to cut off if you don’t know the trick.

Go out back and get a big hammer.
You do have a hammer in your department don’t you? 
I thought so.
Take the patient outside to a solid concrete surface¹ and explain to them that the best way to get this thing off is to shatter it.
Reassure them it will be painless. Unless you miss of course.
Place their hand on the ground, fingers spread, so the outer curve of the bearing is resting against concrete.
Cover the top of the bearing (and their hand) with a towel to stop any fragments from flying.
You are then going to hit the top of the bearing with the hammer. 
Actually, all you need is one or two firm taps really.

The bearing simply breaks apart and the thankful dude will leave wondering why he never thought of that.
ED nurses, more hardcore than a ring of steel.

1. we use our ambulance parking bays…which just happen to be located in plain view of our waiting room. Watching a nurse walk out with a big hammer and whack a patient on the back of the hand is guaranteed to generate more than a little interest.

One of the most common bite wounds we see in the ED¹ is that caused by our fellow human beings (Family: Hominidae. Characterised by superior intelligence, articulate speech, and erect carriage.
Except when a) in love, or b) in toxicated.).

Human bites may result from an intentional chow down some chunk of another persons anatomy, usually during an altercation (although I have seen some pretty carnivorous  love bites in my time).
Or, it may be an ‘accidental’ bite when  the momentum of one persons fist, enacted upon by the forces of alcohol and anger,  intersects with the inertia of another persons teeth.

The latter are known as fight bites.
They occur most frequently in the early hours of Saturday and Sundays (which are fight nights), which gives you the fight night bite.
Fight bites usually involve the knuckles of the dominant hand and may result in a laceration to the extensor tendon, the superficial and deep fascia, and the joint capsule.
Serves you right.

Unfortunately human bites are amongst the more nasty in the animal kingdom. Human saliva contains at least forty two species of bacteria, far exceeding that of a dog which carries a measly two or three.
And at a concentration of around 100,000,000 organisms per mL,  it is not so surprising that bite wounds contaminated with human oral flora are very likely to become infected.
The most common organisms cultured from human bites are Streptococcus, Staphylococcus aureus and Eikenella corrodens.

And if you are lucky enough to avoid the 10% to 50% chance of an infection, human bites may potentially transmit diseases such as hepatitisB, hepatitisC, herpes simplex virus, syphilis, tuberculosis, antinomycosis and tetanus (and yes, you could theoretically be infected with HIV, although this is overwhelmingly improbable)².

So, never underestimate the seriousness of a human bite. Even a superficial one.
They need careful assessment, meticulous wound care, and consideration of antibiotics and tetanus cover.

1. Human bites come in at number 3, preceded by Dogs and Cats. And just in case you are worried…the odds of getting bitten by a shark are about 1 in 5 million
2. Reference: emedicine