Rabbit Trails: ep 1; Ondansetron (Zofran)

Rabbit Trails because there is no defined endpoint or goal, but everything is connected and circles back again and again.

Ondansetron (Zofran) is classified as an antiemetic. It blocks specific receptor sites (selective 5-HT3 Antagonist), which are associated with nausea and vomiting in the chemoreceptor trigger zone, centrally and at specific sites peripherally.

Zofran can be given IV, IM, and PO. The onset for PO is 30min, while the onset for IV is immediate. IV Zofran can be diluted in either 0.9 NS or in Dextrose 5%, it should be infused slowly over at least 30 seconds, and preferable 2—5min.

Adverse Effects: headache, diarrhea, and constipation. A serious complication is EKG changes, specifically prolonged QT interval. (the 32mg dose of Zofran was voluntarily removed from the market for this reason) EKG monitoring is recommended if the patient is suspected to have electrolyte abnormality, bradycardia, or taking other drugs that can cause QT prolongation such as Erythromycin, Methadone, and Haldol (there are many more). Out of respect for potential cardiac arrhythmias, infuse Zofran slowly and keep an eye on the EKG monitor watching for rhythm changes.  (Karch, 2011; Medscape, 2013).

Zofran is most effective if given prophylactically, once the N/V chemoreceptors have been triggered the medication is not nearly as effective. Consider promethazine (Phenergan) which is more effective at curbing N/V once triggered.

Prolonged QT interval

The QT interval represents the time in between ventricular depolarization, QRS wave (ventricular systole) and ventricular repolarization, the T wave. This time period should be no longer than 0.43—0.45 seconds, (two big boxes on the EKG strip).

http://cdn.lifeinthefastlane.com/wp-content/uploads/2011/01/waves-of-the-ecg.gif

*Because the QT interval is rate dependent an accurate value must be calculated through the Bazett formula: QT _corrected = QT/square root of RR interval. It is also possible to get close by considering the QT interval to be 0.4 seconds at a HR of 70, and then subtracting 0.02 seconds for every 10 beat increase in HR, or adding 0.02 seconds for every 10 beat decrease in HR.

During the QT interval the ventricles are actively contracting and do not relax until the end of the T wave when enough potassium (K⁺) ions have left the myocytes; this means that the QT interval can be used as a gauge of the length ventricular systole. Because of K⁺ crucial role in repolarization, a long QT interval is often caused by an electrolyte imbalance, (hypokalemia, hypomagnesemia), or a genetic abnormality in the ion pump, or medication that effects the ion pumps or electrolyte levels. The discovery of an individual with long QT syndrome is almost always only found upon review of an EKG which usually doesn’t happen until the individual presents with a cardiac event such as syncope, aborted cardiac arrest, or sudden death (Medscape, 2013).

A prolonged QT interval, whether it is congenital, drug induced, or pathologic in nature are vulnerable to dangerous, perhaps deadly, rapid ventricular rhythms (Dubin, 2000).

(Gupta et al., 2007)

Torsades de Pointes (Polymorphic Ventricular Tachycardia due to prolonged QT interval)

Torsades de Pointes (TdP) means the twisting of the points, it is one of the most common abnormal rhythms that is a result of a QT prolongation. Treatment for (TdP) that does not spontaneously revert is non synchronized defibrillation for a hemodynamic unstable patient, IV MgSO₄, and the discontinuation of any QT prolonging agent. If the patient is not hemodynamically unstable then a 2mg bolus of MgSO₄ is recommended regardless of serum level; K⁺ levels need to be returned to or remain in the high end of the normal range 4.5-5mmol/L). Short term management can be achieved with HR pacing >70 due to the prolonging effect that bradycardia has on the QT interval, long term management involves avoidance of offending agents, tight electrolyte control, and possibly a pacemaker.  (Gupta et al., 2007)

If someone accidently gives way too much mag sulfate, what should be done?

Reference:

Dubin, D. (2000). Rapid interpretation of EKG's: an interactive course. Cover Publishing Company.

Gupta, A., Lawrence, A. T., Krishnan, K., Kavinsky, C. J., & Trohman, R. G. (2007). Current concepts in the mechanisms and management of drug-induced QT prolongation and torsade de pointes. American heart journal, 153(6), 891-899.

Karch, A. M. (Ed.). (2011). 2011 Lippincott's nursing drug guide. Lippincott Williams & Wilkins.

Medscape. (2013) Reference section accessed for Ondansetron and Long QT Syndrome. Retrived 11/04/13 from: http://reference.medscape.com/nurses

Ansel Adams Wilderness—Jackass Lakes, Madera Peak, Chittenden Lake.

       In mid August my dad, younger brother, and I were able to get out on a short adventure. We drove out to Bass Lake, CA and then headed northeast on Beasore Rd. (5S07) for 27 miles. Beasore Rd. starts off nice, but after 10 or 15 miles quickly becomes nearly a one lane road that is made of more gravel, dirt, and potholes than asphalt. We actually had to go an additional three miles out to a small rangers station because we forgot to pick up our wilderness permit in Oakhurst. With our wilderness permit in hand, we drove back and turned north on a dirt road  (5S86) until we got to the trailhead about a mile and a half later. We had decided to hike into the Jackass Lakes via the Norris Lake/Vanderburgh trail rather than the Jackass Lakes trail head, although it would be a slightly longer hike, the elevation gain would be less, and we would pass Norris Lake, and lower Jackass Lake on the way.

The hike took us about 3 hours, which included stopping for pictures every now and then, and second guessing the trail once or twice. We arrived around 5:30 PM and set up camp on the north shore of upper Jackass Lake. The lake is at about 9,150 ft and located at the eastern base of a mountain ridge that shoots south off of the Triple Divide Peak in Yosemite. When the sun dropped over the ridge the fading light was replaced by a quick gust of cold air reminding us that we were up where weather can change quickly. We used my dad’s old 1970s Optimus 99 backpacking stove and heated up some water for hot chocolate.

The chill of the night evaporated as soon as the sun began peaking through the trees. The morning light illumanted a beautiful view of the lake and mountains. I had only ever seen pictures of mirror like reflections in alpine lakes before this.

Now you too can marvel at the beauty of the land in the morning light.

After eating a quick breakfast of oatmeal, we packed our day packs with food and fresh lake water (sterilized with the SteriPen), and began hiking up to Madera peak. Madera Peak (10,509 ft) is the southernmost peak of the south ridge of the Triple Divide, therefore looking north from the summit we were in line with Sing Peak, then Gale Peak, and then the Triple Divide. Looking east we could see either Iron Mt. or the Mammoth Mt. range, and looking south we could see the smoke rising from fires in Kings Canyon National Park.

The hike up was fairly uneventful, although interesting to notice that there were three distinct layers of rock: white, red, then grey. You can see the white and grey layer in the picture below. Also pictured is Lady Lake which we passed on the way back.

After a lunch on the summit we walked the ridge north and dropped down to Chittenden Lake. On the way we had some fun encounters with marmots (mountain groundhogs). It was fun to hear their whistling as the warned each other of our presence as we hiked along. I took some great pictures of the marmots, but have yet to develop the film. Chittenden is much more isolated than either Lady lake, or the Jackass Lakes, and more beautiful in my opinion. It was a much deeper blue, with two little islands in the middle of it. We had about 30min before we needed to hike back, so I set up a hammock and then we took a quick swim; surprisingly it was not too cold. If I ever backpack into the area again, I think I will camp at this lake.

Jordan and I with Chittenden Lake in the back. 

From the summit of Madera Peak, we figured that we could hike around a portion of the ridge, and then cross over near Lady Lake. Unfortunately it is difficult to judge the grade of a slope when sighting from a distance and height. When we got to the backside of Lady Lake, we realized that we could not simply hike over the granite ridge as we had planed. While hoping to cut nearly 1000 vertical ft. out of the hike back, we ended up coming within 300-400 vertical ft. of the summit. Nothing like climbing a mountain twice..

The green is where we thought we could hike.

That night my brother and I set up our hammocks and slept in the trees while dad took the tent.

After a breakfast of eggs and hot chocolate we packed up camp and headed down. The trail back was a little more difficult to find due to the fact that much of the trail travels over sheets of granite and little (and I mean little) towers of stone marked the upper portion. We were never lost, however we had to pause a few times in order to scan the landscape until we saw a trail marker.

Next time I would like to bring more food, a fishing pole, and stay a few more days, never the less it was a great dad and sons outing.

Shenandoah National Park—Skyline Drive

When driving out to the East Coast for nursing school my dad and I were planning on driving Skyline Drive, unfortunately we were running short on time, and decided to skip that attraction.

Spring finals wrapped up last week, and I took the opportunity to visit the park via bicycle.

Skyline Drive is 105 miles long built over the course of 8 years from 1931 to 1938; it was commissioned through the Work Projects Administration, part of the New Deal agency. There is a lot of good stuff about the park and the drive, like the views and the wildlife. You can go there yourself, or look it up online.. I am pretty tired and I would rather tell you why I am so tired.

Today was the first day of the Amgen Tour of California; stage one was 102 miles with 11,100ft of climbing. I figured I would give something similar a shot. My ride along Skyline Drive was 100 miles with 10,200ft of climbing. The professionals are MUCH MUCH better than I am. The winner took the yellow jersey in 4:31:23. It took me almost three hours longer to cover less distance, less vertical feet, and in cooler weather. They averaged around 22.5mph where as I was around 14mph. Making the jump from a 50-mile ride last week, to a 100-mile ride this week may have not been my brightest idea. You can see the details of the ride at the link below.

http://connect.garmin.com/activity/311967615

Riding a bike for hours at a time is bound to create some issues. My yard sale find from 05’ or 06’ has treated me very well, however I am beginning to wonder if it is not quite the best fit for me; at times my back, neck, and arms were hurting just as much as my legs. Wearing my camelbak may not have helped the situation either; it was full of over 2L of water, two spare tubes, a hand pump, patch kits, tire irons, food, phone, camera, more food, wallet, keys, and plenty of bike tools.

My mom has been fortunate to attend the Sea Otter Classic over the past few years. She has been a competitor, a volunteer, and lately worked a booth in the vendor’s section for Mt. Hermon Redwood Canopy Tours.

Pretty crazy weekend of racing.

Not only does she have a great time while there, she is also great at getting free goodies and bargain deals. I was grateful for this care package she sent me, and took most of it with me on the ride.

The only things that did not come with me on the ride was the hat and the sticker.

The ride did confirm one thing for me: A pair of good shorts or bibs with a good chamois is important. The pervious two weeks I had been having some chaffing issues down under and I wasn’t sure if it was due to my saddle, ridding in the rain, or wearing hand-me-down shorts that I have no idea how old they are. I figured that it was worth spending the money and buying a bit of new riding gear. I wasn’t sure what to get, so I read up about bibs vs. shorts.

http://cycling-review.com/clothing/bike-shorts/

I got some bib shorts, and they worked out marvelously; where as before I was having trouble with 30mile rides, I had no issues on this 7-hour ride. Well that is not exactly true… Bibs are kind of like wearing a onesie with a dipper, expect you can’t use that diaper… going to the bathroom can be a challenge.

My friends often ask me what I think about when I go for these long rides or runs. I never seem to have good answers, so this ride I spent some time thinking about what I was thinking about. I realized that I don’t have too many profound thoughts when riding my bike; here are some that I remember:

“I wonder if I am going out too hard?”

“Why did I pick this for my first century ride?”

“That’s a nice view.”

“I’ve only gone 8 miles?! This is going to be a long day.”

“Oh my Lord, these sunglasses seem to drain all the sweat from my face straight into my left eye.”

“Hughes River Gap, hey I know the Hughes.”

“I think I can go downhill faster if I tuck rather than pedal, ooh, careful, speed wobbles.”

Heinrich Haussler probably going much faster than me.

“Shut up legs!” –Jens Voigt

Side note, here are a few more funny ones from him:

-      If it hurts me, it must hurt the other ones twice as much

-      Maybe they just think I am a pretty face

-      No, I do not accept defeat here. I do not accept this

-      Shut up legs! Do what I tell you to do

-      Of course I am blessed with a little bit of talent

-      Oh, you poor thing, you’ve got no chance, you’re already beaten

-      You’re all beaten; I am just laughing at you

-      I get paid to hurt other people, how good is that?

-      You have got to be as insane as the insanity around you

-      In the hierarchy of the family, I’m just above the dog. But I like it that way

-      Having things organized is for small-minded people. Genius controls chaos

-      Oh man, it’s going to take days to kill all these people

-      While I’m not very talented at cooking, I am very talented at eating.

-      I am confident that when I get really old, the human lifespan will be extended

-      Everybody has to suffer, suffer, suffer until they’ve all had enough

-      Every time I race, I will race so fiercely my legs cry

-      I get paid to inflict pain and terror, for other people!

-      If you go (with a break), you can either win or not win. If you don't go for it, you definitely won't win

-      I'll burn, I'm ready to die for you on the bike

-      Cycling is not rocket science

And here are some more:

http://www.youtube.com/watch?v=U5F6rE0wovc

Ok back to my thoughts:

“Oohh, 30miles out, I could turn around now, that is respectable.”

“45 miles out, ooh I’vs got it now.”

“Halfway there, and my legs are shaking, what was I thinking..”

It was both encouraging and discouraging to have these every mile.

“There are no lights in this tunnel, I can’t see anything.”

It was fine on the way down because I was going around 30mph, but it was sketchy on the way up, especially when cars didn't use their headlights.

“I haven’t gone pee since I this morning, I wonder if my urine output is less than 30ml/hour… that wouldn’t be good.. I better check that when I get home.” (I did, it was 725ml for 10hr)

So as I got more tired my thoughts shifted from G rated to PG-13 or R, I wont repeat them here, but if you want to you can add a few choice vulgar expletives to the these last few thoughts.

“Where is the end of this hill?”

“Why isn’t the road smoother?”

“Wind really?! Really?”

“Where is the down hill, there is suppose to be down hill now.”

“I am never going to do this again.”

“Y’all can just wait behind me, I doubt you would be taking these corners any faster.”

“Hey there is the car, that wasn’t so bad now was it?”

I don’t know when or if I will ever get around to doing something like this again, but I think I enjoyed it in the end.

Ashburn, West Virginia, Appalachian Trail - 55 miles

Short Version: I rode my bike from Ashburn, VA to the Appalachian Trail in West Virginia and back again. It was awesome. There are some pictures below.

55 miles is a long ride for me

Longer Version: Sometimes I get as creative with my writing as I do with my adventures, but there is really nothing too interesting about the Washington & Old Dominion Railroad. It ran about 72 miles from Bluemont, VA to Rosslyn, VA. The first tracks were laid down in the mid 1850s. The rail line had no strategic part in the Civil war, it was sold, bought out, and put out of service many times until 1968 when it ceased operation all together. However it has now become a wonderful and frequently used bike path that runs from Purcellville, VA to Arlington, VA.

I hopped on the bike path in Ashburn, VA and rode it out to its west end in Purcellville. I have done out and backs to Purcellville a number of times, and always make it a goal to never get passed, however this time I took a few stops for pictures.

Once I got to Purcellville I had to do a bit of gravel road riding, now I love mountain biking, but gravel roads are awful especially when they have those washboard bumps in them. My road bike does not handle them well.

Although the road conditions did not improve for riding, the scenery did improve dramatically.

I almost turned back about 3 times, there were no trespassing signs everywhere. Usually this is not a problem for me, but for some reason today the signs were really speaking to me. I thought someone was going to come out with a gun wondering what I was doing on their road. I would turn around, walk or ride away for a minute, then stop, say to myself: “I’ve come 27 miles already, are you really going to turn around? I am sure it is just around the corner..”

And then I would see something like this and second guess myself again

At the end of the day I made it just fine, and found a spot along the Appalachian Trail at Wilson Gap to eat some banana chocolate chip muffins.

The ride back was initially much more fun because I spent the first few miles descending out of the Appalachian, but then it was the long haul back home.

I am not sure if I will do this particular adventure again, but it was fun while it lasted.

Coffee Bible and Prayer

Look at the proud!
  They trust in theirselves, and their lives are crooked.
But the righteous will live by their.
   faithfulness to God.

Wealth is treacherous,
  And the arrogant are never at rest.
They open their mouths as wide as the grave,
  And like death, they are never satisfied.
In their greed they have gathered up many nations
  And swallowed many peoples.
- Habakkuk 2:4-5

Pride and greed are killers that sneak into the unexpected areas of our lives. So insidious are their ways, we are often caught defending that which is separating us from God.

MS wk 5 Journal

MS wk 5 Journal—Williams

This past Friday was a unique day at the hospital. The overall census at the hospital was down due to the holidays therefore they were consolidating patients in order to shut down a portion of the hospital to save money. 7A, the stroke, neuro unit was the unit to go dark until needed again. The last mother of the last family that I lived with worked as a nurse at a very small hospital (25 bed) up in Northern California. She was a night shift nurse and it was common during different times of the years for her to be called and either placed on call, or given the whole night off. The fluctuations in census made sense to me due to the small tourism town, however I didn’t really expect to see it at such a large hospital.

The day provided us with a unique opportunity to see multiple discharges and transfers. I was able listen in on the phone conversations from one nurse to another that had to be done prior to the new unit receiving the patient. I was also able to see some of the difficulties that come with either transfer or discharge. The patient, the nurse, and the family could be ready to leave, however they could be stuck waiting on the doctor to enter the discharge orders into the computer. Or perhaps the orders for transfer to a new unit have been made, the patient is ready, yet the nurse assume that they are waiting on a call from the new unit before the patient moves, when in fact the new room is open, and they are waiting to hear from the nurse with the patient. I believe that double-checking, and making reminder calls is better than doing nothing, even at the risk of getting on someone’s nerves. If problems can be avoided simply by better communication then it is worth taking a bit more time to clarify instruction, or lack thereof.

I believe that I had written one of the previous weeks regarding the potential for medication errors, and this week I had the opportunity to see the effects of one first hand. The order for TPN was not re-entered by the doctor, and neither the pharmacy nor the night shift nurse caught the mistake, or questioned why a new bag was not going to be sent up. Through this mistake the patient was without food for a period of time, somehow placed on a mechanical soft diet, and then placed back on the TPN without an alteration to the PO diet. It was interesting to watch the circle of blame, go from the nurses blaming the doctor, then blaming the pharmacy when the doctor was in the room, and the doctor blaming both the nurses and the pharmacy. I can see how it was perhaps the initial fault of the doctor for not reordering the medication, however the checks and balances in place (nurses and pharmacy) failed to catch the mistake, and the error was carried out to the patient’s detriment. Fortunately it was not a mistake of a greater magnitude.

I was a little frustrated with the seriousness with which the nurses were taking my concerns. I originally pointed out the rise of WBC from 14 to 26.9 in a period of two days while in the presence of antibiotics, which were discontinued that day. I understand now that the rise in WBC is not likely due to an acute infection, however neither nurse one, or nurse 2 could give me a straight answer for the WBC increase or the d/c of the antibiotics. Perhaps they were playing devils advocate, and making me think critically about it, but I don’t think so. I understand that I am very very new at nursing, so perhaps a level of 26.9 when the range roughly 4-10 is not that bad, but some indication as to why would have been helpful.

I also found that my concern over the growing abdominal ascites was not taken seriously. I mentioned it more than once, and the greatest response I received was, “Go get me a set of vitals, and we’ll see what that tells us.” The vitals were within the patient’s normal, however that does not change the fact that the pt stomach had gown much larger in the course of the day. I wish I had measured the pt’s abdomen somehow so that I could have given some concrete evidence. The best evidence that I had was that his respiration rate had bumped up 5 breath/min since the morning, even though he had received a narcotic for pain that afternoon which may cause slight respiratory depression. I had the opportunity to see a paracentisis while doing pt contact hours when I was getting my EMT license, and I watched 3L of fluid get pulled out of an alcoholic’s abdomen. Every person is different, yet his abdomen was not as large as the pt on Friday. I don’t know what more to say about this, in my opinion his stomach had doubled its volume in the course of 8hrs.

            The last thing that is related to assessments was the level of thoroughness that I have seen with physical assessments on the unit. I was impressed to see that the new nurse, nurse one did things like asses grip strength, muscle ROM and strength, took the socks off to find pedal pulses, and inspect the feet, as well as listen to the heart in two different places, and correlate that with a radial pulse. It was the most in-depth assessment that I have seen by a nurse in the hospital yet. However as I did my own assessment alongside him, I noticed that he did not mention an irregular heartbeat. The admission history as well as the patient hand off sheet said that the patient had normal S₁ and S₂ sounds with a normal rate and rhythm, however the patients heart rhythm was clearly not regular. I went back and checked three times over the next 30min to make sure I was not making things up, I would check apical pulse along with a different peripheral pulses at the same time. It was likely nothing more than A-fib, which is fairly common, and frequently presents with no symptoms or adverse effects for the patient, however a-fib is correlated quite strongly with cerebral ischemic events. (5 times more likely according to AHA, and National Stroke Association). Maybe it is of no big concern at the end of the day, however I think it is of greater concern that two individuals got two different results. If it was a scientific study both sets of data would be tossed until consistent, and independent results could be presented. Here again I probably should have said something but it is difficult to come up with the courage to contradict both the previous paper work as well as another more experienced nurse’s assessment.

One of my biggest struggles right now regarding clinicals is not knowing the level at which I should be involved. This past Friday I sought to function slightly more like a nurse on the unit. I organized a blank paper in the same manner that one of the other nurses did in order to keep track of 4 patients at once. I would take notes at each beside report in the morning, and I attended the 9am meeting with the case manager, other nurses, PT, and the doctor. I sought to fill my role as a student and understand the role of a floor nurse with multiple patients. I think I may have gotten in the way a little bit.

I honestly think I did a fairly good job this last Friday, I don’t think that I would change much, except for perhaps taking to the clincal instructor regarding conflicting assessments, or patient concerns that I feel are not being appropriately addressed.

Four pears: $1 My baking: Priceless

I really love food, I enjoy the process of making it just as much as eating it.

Friday was the end of a semi stressful week, which included our first lab competency test, our first test in Health Assessment, and our first test in Pharmacology. I say semi stressful because when looking at next month we have seven tests, more lab competency, and since clinicals start this Friday, every Friday for the next 15 months will probably be booked from 5am till 7pm. That will be a bit more stressful.

Friday evening arrived and I really didn’t feel like studying, so I baked. I had recently bought 4 pears for a dollar at a local store (there were about 12hrs from being rotten), I decided these would worked well in a baked good. Even if there was some nasty bacteria or mold in the mushy parts, cooking them in the oven at temps between 425 and 350 is well over the temperature at which surgical equipment is autoclaved at. (121 C for 20min)

I started by trimming off the really nasty parts of the pears, and then diced all four up into irregular shapes. I had quite the pile of pears, so much so that I figured that I could probably do two different things with them. I decided to bake both muffins as well as some loafs of bread.

Unfortunately I have yet to acquire proper baking tins, bowls, pans.. therefore the muffins were mixed in a stove pot, and then cooked in the only muffin tins I had. Tiny ones.They turned out really well despite their small stature. The muffins contained the typical ingredients of butter, eggs, sugar, flour, soda, powder, and milk, but what really made them tasty was cup of diced pear, 1/2 tsp of cinnamon, and ¼ tsp of nutmeg.

They were easy and fun to make. Since they were so small it only took 12min to bake them, and since they are so small I can eat ten of them in one sitting and not feel bad about it. It is like eating ice cream with a small spoon. Always better.

The second tasty treat was indeed tasty. Baking loafs is slightly more complicated than muffins, and I wanted to change things up a bit.

Again for want of a proper mixing bowl I mixed the dry ingredients in a stovetop pot. Once the typically dry ingredients had been mixed together I decided to add a few handfuls of dried cranberries, and followed that up with a few handfuls of chopped walnuts. I mixed in the wet ingredients and placed it all into the pans available to me, a loaf pan, and a cake pan.

The bread turned out great. I wish you could have some. The dried cranberries give it a sweet tang, which is only accented by the unmistakable flavor of walnuts all the while surrounded by the taste of almost overripe organic pears. Not too light, not too dense, one of my best works. It is delicious.