How To Make a Doctor or Nurse Cry: The Tragic Trinities.

The Happy Hospitalist asked Facebook fans to describe three diseases or patient and family characteristics  that lead to tragedy for healthcare providers when seen in combination with each other and the results were remarkable.   If you are not yet a fan of The Happy Hospitalist Blog Facebook Page, make sure to join now and never miss another status update again.   Every doctor or nurse has their own  tragic trinity combination that brings tears to the very psyche of their soul.

For example, some doctors have pseudoseizures when they see  the tragic trinity of pelvic fracture + observation status + angry daughter watched the 60 Minutes episode on demanding physician write inpatient order.  Some hospital floor nurses cry uncontrollably when they see naked crazy guy in ER +  5 minutes to end of shift + phone ringing with ER ready to call report.  Exposure to these deadly combinations will help doctors, nurses and other healthcare providers survive should they ever find themselves in these dangerous situations.

Is this humor dark and tasteless?  Yes.  So is burned tofu, but you never hear anyone complaining about that.  If you are not in healthcare, you won't understand the crude humor presented here.  If you have a weak stomach, I suggest you stop reading immediately and get some Pepcid.  However, if you are a healthcare provider and you want to learn about potentially deadly combinations you may encounter in your career, I suggest you keep reading.  Study these tragic trinities.  Memorize them and prepare yourself for the day when they show up in your clinic, ER, nursing home or hospital floor.

Without further delay, here is the definitive list of The Tragic Trinities of Healthcare.  If you happen to think of any that may have inadvertently been left off the list, make sure to add them to the comments so all doctors, nurses and other healthcare professionals can  prepare themselves.
  • 93 years old + family no longer allowing ativan to be given + patient thinking they're in combat.
  • Frequent flyer overdose (found down naked in her yard again) + schizophrenia + doctor who thinks its funny/appropriate to order 0.5MG haldol!
    •  I might as well spritz it in the air and ask her to inhale! Jeesh! It's 5mg per dose or don't bother ordering it!
  • Pancreatitis + npo + walking off to eat in cafeteria, always back in room when pain meds due with pain and vomiting.
    • Yells at staff to push Dilaudid 4mg and phenergan 50 mg faster (and you were 3 minutes late with the meds). 
  • Moving in with lamp, bath rug, own cordless phone, and pumpkin to carve (along with knife) + on Medicaid + has lawyer, and mother on speed dial and brags about getting disability due to his back issues.
  • Explosive diarrhea + non ambulatory + family left so they 'wouldn't be in the way'.
  • Dementia + UTI + daughter who has spent a little too much time on Web MD.
  • Sleeping meds + bowel meds + unable to transfer without ceiling lift.
  • 91 year old LTAC patient with chronic peg and trach + failure to wean or thrive + full code.
  • Missed period + wants pregnancy test + brought all 5 kids under the age of 4 because couldn't afford a babysitter.
  • 95 years old + fall resulting in hip fracture, SAH and fractured ribs + momma will be fine!
  • Bath salts OD + severe agitation on ketamine drip on a vent + the mom that claims "my baby would have never done those he if knew they were drugs!
  • Viagra + nitro + wife and girlfriend at the bedside.
  • Child with fever for 3 days, no meds + used EMS to come in + no ride home + needs a work note for a shift that starts in 30 minutes.
  • Missed last 2 dialysis treatments + increased SOB + going to leave AMA once emergent dialysis treatment is over.
  • Psych patient on the medical  floor with 1:1 sitter + poops in his hands and rubs it in his leg wounds so he can " die from infection" + decides to walk the unit and has blood dripping from leg wounds + is farting and pooping as he is walking through unit with gown dragging and butt hanging out. 
  • Severe COPD + chronic trach + kicked out if LTAC for smoking through the trach.
  • Confusion + C. diff + family who won't wear the isolation gowns and stand over your shoulder telling you how to take care of the patient.
  • Chronic pain + Substance abuse history + "allergic" to NSAIDS. 
    • But that Dilaudid stuff worked pretty good.
  • Hillbilly trifecta: Hillbilly + ATV + Alcohol/Narcotics.
  • ESRD + severe sepsis + has  son who is a doctor in another state that wants everything done for his mother who is 96 years old.
  • ETOH + GIB + family in denial.
    • "What did you do to make dad crazy.   He doesn't drink!"
  • End stage disease + pain/anxiety + spouse refuses all benzos and  narcs because he'll get better if he's not sedated.
  • Child with mild rash + stay at home mom with multiple rings and Coach purse + cancelled Zumba class.
  • Ivy League grad student + too drunk to go to jail +  JCrew sweater/shorts = douchebag trifecta.
  • Gangbanger with a GSW +  3 baby mommas all showed up at the same time and are not happy with each other + a couple of suspicious looking characters stalking the hallways trying to find this idiot so they can finish the job.
  • Fibromyalgia + ETOH + expert at knowing how to abuse the system.
  • Metastatic disease + comfort care + crazy daughter wants IVF antibiotics, solumedrol and accuchecks.
  • Fainted at home + didn't call doctor + on five blood pressure meds + anemic from chemo + lives alone.
  • Missed probation appointment + dirty urine + "If I'm not admitted, I'll kill myself".
  • Patient npo sneaking water from the faucet + profusely vomiting + legitimately sick with pancreatic issues and a high BAC.
  • Chronic pain + 7 medication and 4 food allergies + 3 Service animals for "stress disorder".
  • Status post five rounds salvage chemotherapy + Hypotensive and tachycardic in oncology clinic + Direct admitted for goals of care discussion and hospice placement.
  • Fibromyalgia + neuropathy + bipolar
  • Middle age divorce + Bipolar + quack diagnosis of adult onset ADHD + dexamphetamine prescription + internet testosterone injections.
  • A non-compliant diabetic, frequent flyer + who does drugs and comes in only to vomit every where because of the DKA + when feeling better demands all sorts of things than signs out AMA!
  • Intubated/near extubation pneumonia + psych patient in which doctor discontinued all psych meds + sedation "holiday".
  • Patient with TIA symptoms that left AMA and came back after you filled out AMA paperwork + wanted TPA when he returned and physician ordered it and you had to administer it + leaving AMA again 3 hours later.
  • Hasn't taken any insulin or done a finger in a month ( cuz they didn't feel like it) + ate whatever they felt like + blood glucose over 1000 + an enabling significant other....
    • I think we could actually keep this one going.
  • Large, former military man + new neuro checks ordered from a fall + extreme Sundowner's with paranoia. 
  • Pre syncope + 35 medications + 93 years old, with very very concerned children if patient will survive the night.
  • On a balloon pump + stands up to poop + what a wonderful day, 
    • Called the cardiologist and they say "Huh, bet you never saw that before!"
  • Multiple fractures + DT s+ Laculose.
  • Trach + pseudomonas + head injury.
  • Numbness/tingling + 15 "allergies" (ranging from vanilla flavor to morphine) +  history of anxiety or headache.
  • Patient with spouse of 8+ years at bedside for hyperglycemia with stated signs and symptoms of high blood sugar being a swollen vagina with blisters + husband also reporting same symptoms when his blood sugar is elevated + RN notes herpes outbreak during straight cath.
  • Patient observed throwing themselves out of their wheelchair + they really didn't need it +  then screaming for help while you are trying to triage a walk in MI
  • Inpatient with severe asthma + walked out on own after less than 24 hours with IV in arm "to brush teeth" +  readmitted to ER via ambulance less than half-hour later.
  • Goody powder + pradaxa + anything.
  • Chronic dizziness + drug "allergies" + borderline personality disorder.
  • Severe DTs + "allergies" to Haldol, Ativan, and Librium + enabling daughter at bedside that says that shes going to take daddy for a smoke and a drive just as soon as he gets released. 
    • And of course, he "don't drink but 6 days a week!"
  • Dementia + chronic fatigue + only daughter is a lawyer in New York.
  • Fibromyalgia + 8 drug allergies + TID Xanax = 3 vials of propofol for anesthesia induction and a rough emergence.
  • Sepsis + DTs/withdrawal + combative and wanting to spit at everyone + RN making it to the back of his head to put a mask on his face while others are restraining his wrists = him spitting on himself.
  • Allergic reaction to lisinopril + steroid allergy + no mental capacity to appreciate the irony.
  • Uncontrolled pain + daily office visits + incomplete documentation, coding and compliance queries provider for documentation. (The coder's perspective)
  • Dialysis + patient is a tree stump (mostly amputated bilateral legs and arms) + unstable arrhythmias.
  • 92 year old family matriarch + full code + 37 family members with sudden onset of acute tachylordia with multiple JC's--except the two that "done fell out".
  • Gastroparesis + narcotic dependence + morbid obesity or anxiety.
  • Acute respiratory failure + acute on CRF + worse CHF = circling the drain.
  • Nausea and vomiting + no IV access+ new resident.
  • Smoker + COPD on home O2 + family keeps leaving room to go on smoke breaks.
  • 600 pounder + refuses the bariatric room + is max assist.
  • OD + opiate addiction + EMS administered Narcan.
  • Gastroparesis + no veins + no brains.
  • Weakness/dressing change/uses a walker + certified by psych for inpatient mental health + unfunded status needs to go to state hospital = 5 month hospitalization.
  • Non-English speaking + terminal illness +family 'wants everything done'.
  • 8 medication allergies + fibromyalgia + on Seroquel.
  • Morbid obesity + chronic joint pain + poor surgical candidate.
  • CHF + advanced COPD + on a ventilator.

"How to make a nurse cry:  chronic pain + 14 food allergies + 3 service animals for stress disorder."

How to make a nurse cry:  chronic pain + 14 food allergies + 3 service animals for stress disorder photo humor meme.

Lasix Changes Name to Lasixtoeight. "Lasts Six Hours" Called False Advertising.

Bridgewater, NJ -- Sanofi-Aventis was forced to change the brand name of its loop diuretic furosemide from Lasix to Lasixtoeight yesterday after the drug maker admitted knowing all along Lasix lasts six to eight hours and not six hours as the name implied.

Attending nurses, pharmacists and physicians have been telling students for decades that  Lasix stands for "lasts six hours".  This teaching moment has helped propel brand name Lasix to cult drug status, unmatched by any other medication in the pharmaceutical world, except perhaps the excitement of the adenosine pause.

Generic furosemide is rarely prescribed because the story of brand name Lasix has been universally enjoyed on rounds by medical, pharmacy and nursing students for decades.   As most students mature, they naturally prefer Lasix over furosemide and all other diuretics.

"What the Hell is furosemide.  Never heard of it," said Dr Mark Fleming, Director of the Internal Medicine Residency Program at Harvard Medical School, who also admits telling the 'lasts six hours' story at least seven thousand times during his tenure at Harvard.  "Sometimes I'll order Lasix on a patient just so I can tell the story again," said Dr Fleming.

Very few attending pharmacists and nurses are comfortable dispensing furosemide because of their lack of familiarity.

"If our 3 a.m. chart checks discover an order for furosemide, I have instructed our floor nurses to call the doctor immediately and get conversion dosing to Lasix before the morning dose is due hours later on the next shift,"  said Nancy Parkman, Director of Nursing at Lakeview Nursing Home in Bridgewater, New Jersey.  

As students mature, most tire quickly of the excitement attending physicians display in telling Lasix lore.  "As a resident, I only write for furosemide, out of spite," said Sandy Wigham, a first year intern who also enjoys going straight to 12 mg of Adenosine inside of 6 mg.  

Internal documents obtained from the US Food and Drug Administration confirm the drug maker has known for  decades that using the name 'Lasix' would give the drug an unfair marketing advantage over competing loop diuretics, Bumex and Demadex.

"Who's going to order Lasixtoeight?  I can't even pronounce it," said Pamela Stevens the Sanofi-Aventis drug rep who lost her job selling Lasix as a result of the name change.  "Most doctors won't presecribe something they can't pronounce."

Feeling the heat from investors, Sanofi called $4-a-month generic furosemide a garbage drug and responded by offering a one month supply of  Lasixtoeight for $80 instead of the normal $300 charged for brand name Lasix.  

Shortly after the Lasix name change, Roche Labs, owner of competing diuretic Bumex, filed an FDA application to change the name of Bumex to Lasix after fudging data to show diuretic activity was actually just six hours instead of six to eight hours like Lasixtoeight. They are hoping nobody at the FDA will notice the change. 

CDC Ebola Isolation Protocol Deficiency Discovered

Atlanta, GA --  The Centers for Disease Control and Prevention (CDC) apologized Monday for blaming a protocol breach as the source of hospital acquired Ebola infections in two healthcare workers at Texas Presbyterian Hospital in Dallas, Texas shortly after discovering major deficiencies in their own Ebola isolation protocols.

"We apologize to all healthcare workers personally offended by our protocol breach accusation resulting in Ebola transmission.  It turns out it our protocol needed updating,"  said Tom Frieden, CDC director since 2009.

Mr Frieden came clean after a CDC intern discovered a copy of the The Official CDC Ebola Isolation Protocol on Google and reported his concerns to Mr. Frieden immediately.

The CDC hopes to have an updated Ebola isolation protocol available for all healthcare workers early next year.  Until then, they are requesting all hospital workers, who come into contact with an Ebola patient, draw a giant E in permanent black marker on their right shoulder so everyone around them can act accordingly.

Official CDC Ebola Isolation Protocol for Healthcare Workers
Official Ebola Isolation Protocol for Healthcare Workers 

You can buy your own isolation protocol shirt or other assorted isolation protocol gifts only from The Happy Hospitalist's Zazzle store.

ER Ebola Quarantine Screening Tool: A CDC Guide for Healthcare Workers

Atlanta, GA --  Just one day after the viral release of Who To Blame When You Get Ebola, the CDC has released a follow up ER Ebola screening tool to help emergency departments determine which patients need to be quarantined immediately.  Fear continues to grip the country after two nurses at a Dallas, Texas hospital contracted Ebola virus in the course of their normal workday activities.

"We know, without a doubt, this  all inclusive and fail proof ER Ebola screening tool will help healthcare workers know when to immediately initiate quarantine protocols.  There's no way anyone will be missed if this protocol is not broken,"  said Tom Frieden, Director of the CDC, being careful to avoid use of the word 'breached'.

The CDC has been under constant attack after blaming a breach in protocol as the cause of Ebola  transmission at Texas Health Presbyterian Hospital.  The White House has since responded by  organizing Ebola SWAT teams ready to travel anywhere in the country and hunt down healthcare workers who call in sick after Ebola strikes their hospital.    The White has even appointed a lawyer, Ron Klain, as this nation's  Ebola Czar to help triage lawsuits against community hospitals for failing to keep their yellow gown supply closet fully stocked during an outbreak of Ebola.

Not everyone is convinced the quarantine tool goes far enough.  "They should have just quarantined the whole country of Texas," said Rusty Bender, a college graduate living with his mother despite a Bachelor of Fine Arts degree.



In response to public criticism, the CDC has updated their Ebola ER quarantine tool to yield a greater net of protection.

"Retrospectively, we realized our original protocol failed to account for the possibility of some folks traveling out of Dallas to other communities, which we just didn't think of at the time," said Tom Frieden, in a hastily called news conference while wearing full barrier protection at his home.

The CDC is asking healthcare professionals to ask ER patients if they have come in contact with Ebola in the last 3 weeks.  The CDC understands most patients will have no idea and have accounted for this possibility in their updated guidelines.

"We want to be as thorough as possible and not have people who may have Ebola infecting our planes, trains and automobiles." said Mr. Frieden.

The CDC offered little guidance regarding the risk of coming into contact with Ebola, except to say anyone who witnesses a healthcare worker wearing scrubs at a grocery store should keep a large perimeter distance and to yell 'EBOLA", then call 911 if they see them coughing or sneezing.

 Updated ER Ebola Quarantine Screening Tool from the CDC (algorithm)

Ebola Halloween Hazmat Costumes Sell Out: CDC Found Hoarding Them.

Atlanta, GA --  Hours after Mark Zuckerberg donated $25 million dollars to the Centers for Disease Control and Prevention (CDC) to fight Ebola virus, Amazon sold out of Ebola hazmat costumes and thousands of Halloween shops from Los Angeles to New York confirmed brisk sales for Ebola gear ranging from age 3 months to XXXL.

Ebola Halloween Costumes Seen Helping Hospitals
After telling reporters his agency must 'rethink the way we address Ebola infection control', CDC Director Tom Frieden has confirmed he authorized spending all 25 million dollars on over-the-counter Ebola costumes.

In a news conference yesterday, the CDC proudly announced their well planned protocol to protect healthcare workers using Ebola costumes, describing them as 'full barrier protection gear with a Tyvek suit, eye protection, 2 Surgical masks, 2 Pairs of gloves, booties, Duct tape and plastic bin for easy storage.'

"We want doctors and nurses to be like, 'Damn. love your Ebola gear!" said the reliable source high inside the ranks of the CDC.

Some CDC employees knew a major policy shift was planned days before details were confirmed at the news conference.   Sarah Stenson, a CDC employee laid off yesterday for saying the word 'Ebola' out loud during work, a no-no, confirmed seeing several employees playing with bright yellow Ebola Hazmat outfits that looked identical to the ones she bought her 3 and 8 year-old boys for Halloween.

"My boss asked me last week how to sign up for Amazon Prime and now these Ebola costumes  show up on his desk complete with goggles, air mask, gloves and full body suit.  Coincidence?  I think not."

The CDC has acknowledged a need to better protect hospital workers against Ebola as a second healthcare worker at Texas Presbyterian Hospital tested positive for Ebola virus after caring for Eric Thomas Duncan, the Liberian who has since passed away of this deadly disease.

Rapid response teams within the CDC are now prepared to travel anywhere at a moment's notice to drop off enough Ebola costumes for 14 of the required 21 days of isolation.  However, due to the national shortage in Ebola costumes, the CDC is asking hospitals to recycle the gloves and suits by "turning them inside out' when supplies run low.

"We are also asking hospitals to return their Ebola costumes to CDC headquarters once the coast is clear so we can wash them out and give them to other hospitals that are in dire need of barrier protection," said Mr. Frieden proudly.