As a nurse, I don’t want long posts on social media talking about how amazing we are during this pandemic. I don’t want a round of applause or touching, heartfelt stories of nurses working in unsafe environments and many times to the point of sickness or, yes, even death.
I want anger that people were and are stealing from hospitals as we already dealt with supply shortages.
I want people appalled that in this country our leaders in healthcare ever let it get this far even thought we knew for months this was coming.
So go ahead. Post that picture, share that story about that nurse you know. As for myself and countless others, we’ll be heading into work tomorrow, desperately trying to ration what supplies we have, hoping that people listen and social distance as a much as possible. Because we’re tired, and we’re scared.
(for real though quit stealing from us you assholes)
Nobody signs up for emergency medicine because they have a death wish. We are here because we want to help. We don’t fear stressful situations, we thrive in them. In times like these, when there are so many unknowns, we may question why. Why are we risking our lives for this? Why are we showing up every day when everyone else is home?
We are trained for this. We remain calm when everyone else is panicking. We can help.
Be there for your friends who are scared, your family members who are uninformed. Do your own research and understand the changes happening everyday. Protect yourself at work. Wear PPE. Change your clothes at work before you go home. Turn off the news and social media for a while.
It’s okay to be scared. It’s okay if you panic bought toilet paper. You’re human. We are in this together. We’re all scared. But we’re also all superheroes.
Do you ever take care of a mentally unstable person who happens to be your age and then realize what if you had matched with them on Tinder/Bumble/match/eharmony/farmersonlydotcom?
What if you had swiped right unknowingly? What if that was you sitting next to them while they LOSE THEIR SHIT because the nurse dare ask why they’re in the ER for the leg pain they’ve had for THREE MONTHS?
I’ve been unfortunate to have lost a few good stethoscopes the past year and each time I replaced them, I continued to buy cheaper ones. Sadly, I did notice a drop in quality with the products when I did this. Each time I went to a different brand and try to reason that it really didn’t matter what I got so long as it was useful to me.
Honestly, though, I found that Littman produces some of the best stethoscopes with a wide pricing range based on what you want to spend.
3M Littmann Lightweight II
If you’re looking for something on the cheaper end, but still solid quality, I would always go with the 3M Littmann Lightweight II. It’s lightweight with a flexible hose. It’s fantastic when you’re trying to listen to lung sounds and you can get decent heart tones when necessary. The price is reasonable at less than $40.
You get what you pay for and this is no different with stethoscopes. While I love the 3M Littmann Classic II, I found it lacked a few qualities I needed when working in the emergency rooms or with a variety of patients. It only had the one large bell, which could get me generally sounds quickly, but the sound details weren’t of the highest quality.
3M Littmann Classic III
The 3M Littmann Classic III has a higher quality sound though and has the class two bell system with it. I found it much more efficient when it came to listening to the ranges of high and low pitch sounds that couldn’t be heard in the 3M Littmann Classic II. Also, the clarity of the sound made easier for me to hear those heart tones that may or may not be an S3 or S4.
Another added benefit is with pediatric patients. The smaller bell always helps me gather clearer heart tones and lung sounds, without picking up the tiny adorable stethoscope they hide at the nursing stations in a draw so physicians don’t steal the only one they have. Ultimately the 3M Littmann Classic III is my #1 for affordable and highest quality.
3M Littmann 6163
This last Littman is by the best one I’ve probably every used in my career. The 3M Littmann 6163 Cardiology IV is $170, but it is worth every penny. Higher frequency sounds can be heard with as little as pushing a little hard against the patient’s chest. It had a Dual-lumen tubing, which assisted in the rubbing noises we would hear in another stethoscope. It is made of lightweight material, but extremely durable to wear.
If you’re the type of person that won’t let a single soul touch your stethoscope, or you feel like it won’t go missing, then I would invest the extra money on the 3M Littmann 6163 Cardiology IV.
For those of you that lose your stethoscope like me:
I was in the ER working when I noticed an RN had something attached to his stethoscope. It was a Tile Mate. One of those wifi assisted devices that help you find your car keys were attached to it with a simple zip tie. While it wouldn't entirely prevent theft, it does eliminate the guessing where you left it last.
I got a message to do some toxicology pieces and that kind of reminded me of something I saw over the weekend that I just HAD to research. It is a series of drugs that the news was calling 100 times more potent than heroin or fentanyl, but in reality, it just wasn’t a narcotic.
Warning, due to the limited information out on the drug and its actual effects on a human, I am going to have to go over the pharmacological results for the most part and what I’ve pondered about this drug. I also had to do a Wikipedia search, so not going to say it’s 100% accurate, but not terrible either.
W-18 and -15
The history
First off, these two drugs are being used as a heroin substitute by many addicts. The news has gotten ahead of itself and calling it a narcotic because it originally came from the 1980’s research for analgesic drugs at the University of Alberta. It was actually apart of a series of 32 drugs. The series would later become Schedule 1 narcotics, making them illegal to use in any situation.
Pharmacology
At UNC School of Medicine, a comprehensive pharmacological profile was made of the two major players for this heroine replacement. The major goal of this study was to determine, which receptors the chemicals would bind to, how it was metabolized in the body, and how long would they take to break down.
The most important discovery of this reacher determined that they have no opioid activity. The abstract alone stated:
“Although W-18 and W-15 have been described as having potent antinociceptive activity and are presumed to interact with opioid receptors, we found them to be without detectible opioid activity at µ, δ, κ and nociception opioid receptors in a variety of assays.” (source 2)
Later in the paper, it does state that can bind with weakly binding sigma receptors and some benzodiazepine receptors.
Finally, they found a weak adherence to the H3-histamine receptor, which can play a big role in cardiac function.
Metabolism is done majorly in the liver and there was no change in how where or how the drug affected the receptors after broken down by the liver enzymes.
Excretion is believed to follow common routes of urination at this time.
Personal thoughts
While there isn’t a lot of information, I can honestly say that this fake opioid will NOT work with a standard convention of Narcan, but with the weak affinity for peripheral benzo receptors, maybe a flumazenil may do the trick.
The H3-histamine receptor is another concern. If you find a patient taking this drug, you may find them going into some kind of dysrhythmia. The patient that I dealt with states to have had an allergic reaction, causing his lower extremities to swell up, but had a heart rate of 130 bpm and in a normal sinus rhythm at the time. The patient was hyperthermic and BP was holding up well. Pt was honestly stable, but his last usage was greater than 24 hours and he still had some symptoms. Pt was later admitted to observation to ensure the swelling returned to normal to watch for lab and cardiac changes.
There is quite a lot to be said about the medications we use for patients with arrhythmias. It’s easy to get lost as to what drugs do what and how, but thankfully there was a kind enough person by the name of Vaughan Williams, who actually broke them down into separate classes. Each class effects separate parts of the cardiac cycle, ultimately changing the electrical current of the heart.
Cardiac Action Potential
Before looking at the medications, we have to understand the cardiac cycle and how it actually works.
The above chart presents the four phases of an action potential in a ventricular myocardial cell and how the electrolytes are used to cause the depolarization and repolarization of myocardial cells.
Phase 0 begins with a slight influx of sodium until it passes the potential threshold. Once past the threshold, more sodium channels will open and flood the cell, causing it the depolarize.
Phase 1 is an efflux of potassium from the cell, causing the cell to reach 0mV.
Phase 2 happens at this point. This is when calcium influx happens, prolonging the repolarization period. This period also goes by the name of an absolute refractory period for the cell, since it cannot depolarize during this time.
Phase 3 Calcium channels close again and potassium continues to efflux from the myocardial cell until the internal cell voltage returns to -90mV. Majority of potassium channels then close and the heart enters phase 4, which potassium is allowed to continue to leak into from the cell.
This process happens anywhere from 60 to 100 times per MINUTE!
Vaughan Williams Classifications
The major purpose of the medications in this class effect they way the cardiac action potential works in the cells of the heart. The drugs usually help to slow down specific phase to the heart and allow the heart to fix itself a bit.
Class I - Sodium Channel Blockers
These medications are designed to disrupt phase 0, causing a prolongation of it. There are 3 subcategories (a,b,c) that are broken down into moderate, weak, and strong.
This article won’t go into great depths, but the major goal of the class is to prolong the QRS complex and prolong or shorten QTi.
Medications include:
Lidocaine
Verapamil
Procainamide
Propafenone
Class II - Beta Blockers (-olol or -alol)
Quite commonly used out of hospital for patients with hypertension, beta blockers are actually a common antidysrhythmic. The basic pharmacology is: by blocking the beta-1 receptor sites, it prevents stimulation of the cardiac muscle to beat faster. The increase of sympathetic tone will decrease the rate the heart will beat.
Medications include:
Propranolol
Metoprolol
Carvedilol
Class III - Potassium Channel Blockers
Similar to the Class Ia medications, potassium channel blockers are used to prolong APD, which can cause a prolongation of ERP. This class of medication is commonly known to treat different ventricular dysrhythmias (Vtach or Vfib). The most common medication for this class is Amiodarone and deserves a post of its own.
It’s most common use is during CPR, when the patient is in pulses Vtach or Vfib rhythm and is then followed by a drip with ROSC is achieved. An important note to make about Amiodarone is it can take 16 weeks to leave the system.
Medications include:
Amiodarone
Sotalol
Ibutilide
Class IV - Calcium Channel Blockers
Commonly uses for Afib with RVR and PSVT, a calcium channel blocker will prolong phase 2 of the action potion in the cell. The goal is to slow the conduction through the atrioventricular (AV) node, slowing the ventricular tachycardia that is occurring. By prolonging the ERP in the AV node, the heart is able to regulate the rate better.
Calcium channel blockers are commonly prescribed by physicians to assist in the care of such arrhythmias. One side effect of these drugs is it may drop the patient’s BP, so ensure you have an SBP >100 or a MAP >65, prior to administering the medication
Class V - Others
This is the mix bag class. These drugs do not truly fit in any category but are still highly important to mention anyways. Two of these medications are Adenosine and Digoxin.
Adenosineprevents the re-entry of a signal in a sinus rhythm, preventing SVT. A warning though is for patients that have WPW syndrome may cause an increase in heart rate instead, so make sure you’re reading the rhythm correctly.
Digoxineffects vagal tone and is seen less as an emergency drug and more as a maintenance drug for chronic heart issues. A major issue with this drug is it holds a very narrow therapeutic index. Toxicity is quite possible if given too much.
Summary
Each class works in its own way on the action potential in the cardiac conduction system. How they affect the heart greatly determines when and how the medication should be used in different medical scenarios. The point of this article is to help a bit with the pharmacodynamics involved with the medications and to hint at the situations a person in the medical field would use them?
Remember to check out my facebook page. Feel free to send suggestions for possible article ideas, it might pop up some time. Always remember that medicine is an art, just as much as a science.
We all know this age group when our young ones begin to learn to talk and feed themselves. They learn to use the potty and start making new friends. This is when they love the word, “No!”
A lot of development occurs during this period of time and the growth in children, both mentally and physically are key. Here are some brief notes for you to look at for reference to what is to come with this age group:
Increase in illness, due to being around new children and playing with them.
Immune system will begin to grow in new environments
Neuromuscular growth occurs as they begin to develop finer motor skills
Brain will weigh 90% of an adult’s
Renal development is important as they begin to learn toilet training.
12 to 15 months feeling of fullness is known
18 months ability to control bladder muscles for excretions
Separation anxiety peeks 10 – 18 months
Basic language is mastered at 36 months
Age 3 – 4 most can understand full sentences.
Children begin learning sexual differences by observing their role models and siblings
Tip: do no try reason with children this age as to why a procedure needs to be done.
