Take A Look At My Heart

Starting last Fall (09') I became sort of vaguely aware of a change in the way I felt on my bike commutes to work. I pretty much attributed it to the fact there was all this BS going on at work and I wasn't handling it very well. You know, stress. But I figured since I am over 50 now I should probably have it checked out. I had just gone through an insurance physical in anticipation of needing a term policy if I did indeed changed jobs. My rating status for that came back as "Super-Preferred". My financial guy said he had never had anyone get that rating, let alone a 50yr old client. So I'm feeling pretty puffed up with myself. Eventually I get around to seeing a cardiologist. The appointment was pretty much unremarkable. Talked to a cardiology fellow and an attending, the opinion is whatever I'm feeling probably isn't heart related. I'm OK with that, at this point the symptoms I'm having don't really present as cardiac and are fairly nonspecific. They do recommend a stress echo. Yea, whatever.

Over the next couple of months shit gets more specific. Colder weather, less biking, more jumping rope, which has been my indoor cardio work for years. I also started wearing a HR monitor during workouts. After about 15min, with my HR running about 150 or so, I feel the same sensation in my chest as I felt on the bike, with a new twist. When I stop and my HR slows, my heart starts skipping beats. This can't be good. PVCs. Premature Ventricular Contractions. Basically what happens is the ventricle contracts before it's full, ergo, no blood to pump, no pulse. Exercise induced PVC's. Great. I do all the research I can and find out PVCs are common, a lot of people deal with this shit their whole lives and they're mostly benign if there's no underlying heart disease or structural heart defect. In very rare instances they can degenerate in ventricular tachycardia. (that's foreshadowing, do you see where this is going?) Also cardiologists don't take them very seriously. Maybe now is the time for that stress echo.

I go in for the stress test in the first week of January. The set up is a treadmill with all the telemetry equipment and a table with the echocardiogram machine. You get the on the treadmill with gradually increasing rate and incline until your heart rate is crazy high, then they shut it off and hustle you over to the table to take the echo of your heart to get a picture of function during the period of high stress. Some background here. I'm really not much of an endurance athlete. I've never been a guy with a slow HR. Even when I was in great shape ( young, running track, etc) I'd sit around with a resting HR of 72bpm while other guys in similar shape were about 10bpm less. Anyway, fast forward to now, put me a stressful anxiety producing environment and I'm sittin' there about 85pbm without even moving. The test starts and I'm almost immediately at 90bpm, not unusual for me. The woman waiting to do the echo is sitting there watching all the telemetry info and she keeps making comments about how fast my HR is increasing. SHUT UP bitch. After about 30min my rate is 190, the nurse shuts it down and hurries me over to the table for the echo. I'm laying on my side, the imaging tech is doing the echo and I'm starting to recover. I'm catching my breath and my HR is coming down, then the fun starts. I feel the PVC's start up in a big way. Even though I'm laying down I start to get a little dizzy. I hear the nurse say, "oh!". Out of the corner of my eye I can just glimpse the EKG on the screen. Fuck. I'm no expert but I'm pretty sure that's not a normal wave. There's nothing there that even resembles a normal QRS complex. The nurse leaves the room and I can hear him trying to remain calm as he asks the attending cardiologist "can you come here a take a look at this?". I'm recovering a little by now, although my rhythm is not exactly back. The attending looks at the EKG and asks echo girl if she could see this coming. Echo girl says no. Doctor says, "It's just an arrhythmia" and leaves the room. They keep me for about another half-hour until I've recovered completely, then send me on my way. My cardiologist's office calls me the next day, no heart disease and no structural defects. They want to start me on a beta-blocker and need to know what pharmacy to call. They don't even want me to come in to the office. I find out later that there was no printed record of the episode of ventricular tachycardia because the fucking nurse had shut down the fucking machine. What a jackass.

There are no restrictions/guidelines for my workouts so I go back to doing what I have always done, except that now the PVCs start up every time I work out instead of just occasionally. As this progresses I find myself sometimes getting dizzy and having to sit down while I recover. If you miss 2 or 3 heartbeats in a row, it'll fuck with ya. Now we're getting into a gray(er) area. If you pass out from PVCs it's considered to be like dying only with the advantage of waking up. Sudden Cardiac Death (SCD). You know, those guys who fall over dead while they're working out. (he looked fuckin' great 'till he died) I have a scheduled cardiology follow up in March. Pretty much unremarkable again. I tell them the latest stuff and they increase the beta-blocker dosage. The fellow tells me that as PVCs go mine aren't really that bad. Oh, ok.

This uneasy accommodation with my heart continues until mid-April when shit finally comes to a head.

Wed 4/15--I'm at home working out, have finished jumping rope and am doing some light dumbbell work. I have found through trial and error over the past few weeks that my HR recovers faster with fewer PVCs if I bend at the waist while I'm between sets of exercise. That's the position I'm in, standing and bent over, while watching my HR monitor on my wrist. I straighten up. Rubber legs and lights out. I'm aware of myself staggering backwards, but I can't do anything about it. I hit the wall and the weight machine behind me and end up sitting on my ass with the dumbbells still in my hands. I remember saying out loud "that was it". I sit there trying to gather myself. I never really lost full consciousness, but it was close. I took it easy over the next few days and even did a couple light workouts without incident.

Wed 4/22--Been wanting to see Mark Knopfler since the days of Dire Straits. I bought these tickets about 6 months ago. I meet a buddy for a few PVC inducing alcoholic beverages before the show. Dinner and 2 beers later we head off to the concert. We end up parking about 4 blocks away from the venue and walking slightly uphill to the Fox. By the time I get to the theatre the PVCs are rollin'. Bad. I wasn't in a normal rhythm the entire night. The worst night of my life. Probably back and forth between PVCs and V-tach the whole show. By the end of the show I'm kind of settled down. After the show we head back to the car and I drop him back at the restaurant where he's parked. The walk back to the car has lit me up again. I limp home. I have to pull over and stop during the 4 mile ride home. In hindsight I was probably in V-tach the whole way. Why I didn't degenerate into V-fib I don't know. I should have gone to the hospital that night, but I just laid down. I remember thinking there were worse places to die than your own bed.

The next day found me still alive so I called the cardiologist office and they ordered an event monitor for me. It's basically a device that you activate when you feel something strange and it records heart activity and what was happening a minute or so prior to when you activated it. I also made an appointment with my primary doctor. I had only started seeing him the previous October and I was pretty impressed with him. At the time of my first appointment this heart thing wasn't a blip on my radar so I wanted bring him up to speed and get his impressions.

The next 4-5 days aren't very good. PVCs all the time with minimal exertion, like walking DOWN a flight of stairs. I go see my primary physician on Tue 4/28. I fill him in on everything, we talk about it, there's really nothing to be done until the event monitor shows up in the mail. He says "you know where this is headed don't you?" I say yea, ablation or ICD. That evening I start to walk to the pharmacy to pick up a prescription. I get to the end of the library parking lot, about 150ft from my back door, and I can't walk any farther. In retrospect, V-tach. Again.

Wed 4/29--I feel ok in the morning, no PVCs. So it's time to go push it and see what I can do. Right? I start mowing the grass. That's walking behind a self-propelled mower. It becomes quickly evident that this isn't going to work. Again. By now I been in full blown V-tach about a half dozen times and it always resolves spontaneously. I re-challenge myself a couple more times over the course of the day. Same result every time. I call the cardiology office and leave a message. I don't get a call back from the doctor. I call my primary late in the afternoon. He calls me back from his car on his way home from the office. He says it's pretty obvious my body is trying to tell me something. Head to the E.R., he'll call ahead. At this point I figure I'll wait until my wife gets home from work. I'm back in normal rhythm and fine unless I exert myself (i.e. walk more than 50 paces). She gets home, we head to the hospital.

Now, the last thing I want to do is show up at the mess that is the the E.R. with a normal rhythm, wait there for 3hrs with the rest of huddled masses and then tell some nurse that "4hrs ago I was having an arrhythmia" and then hear, "well you seem to be ok now". I make a plan. We're going to park at the north end of the medical campus and do a brisk walk to the E.R. at the south end, about 4 blocks away. My plan works to perfection. About half way there I feel everything in my chest start rolling. We walk into the E.R. and it's packed , they got 'em hanging from the rafters. I'm about fourth in line to the desk. I tell the nurse I'm having PVCs and if they want to see them they need to hook me up right now. She checks my pulse, says it's way too high and hustles me into one of the trauma rooms.

The next 15 minutes were impressive as the trauma nurses sprang into action. I've had some less than stellar visits to this E.R. from a patient care standpoint, but these nurses were great. In a matter of minutes I had 18 gauge bilateral IV access and a 12 lead EKG hookup in place. This is a teaching institution and obviously I was the most potentially interesting case in the house at this time. A crowd soon gathered. At one point the E.R. attending came back to check in on me, sees the mob of onlookers and says, "WHY is everyone standing around staring at Mr. Haynes?". They were just waitin' for me to go into V-Fib so they could break out the paddles. Sorry to disappoint. The amiodarone bolus did its job. I was in normal rhythm. Move along folks, nothing more to see here. I was left literally, completely alone while they tried to figure out what to do with me. What a difference an hour makes.

They put me in the CCU. Probably overkill, but all they really knew was some guy showed up in the E.R. in V-Tach. I knew as long as there was no exertion I was fine. I was the healthiest guy in the cardiac care unit. My wife said that was like being the tallest midget. The intern doing my work up loved how I managed to be in V-Tach when I came into the E.R. He told the story that night to the cardiac fellow on call who then walked into my room, said "Don't do that again", then turned and left. The story had legs and was retold numerous times during my stay until pretty much everyone in the unit knew about it. Like any good tale it became a little more fantastic with each retelling, until I had sprinted to the hospital from somewhere in the Central West End.

They have some good pictures from the V-Tach in the E.R. The electrophysiologist decide cardiac ablation is the best option. I'm not going to go into great detail on the procedure. You can look it up on any number of sites.

http://www.mayoclinic.com/health/cardiac-ablation/MY00706 is a good one. Also a cyclist named Craig Cook did a much more thorough blog a couple years ago while he went through this (v-tach.blogspot.com). However, I will say that if I never have to have another foley inserted it would be OK with me. Also the part where they say you will be sedated and not feel/remember much is bullshit. I was awake for the entire procedure. The current thinking is that sedation makes it more difficult to keep the foci active for mapping and ablation. The area where they were working on me is apparently sensitive because it stung like a motherfucker when they burned it. I went to the E.R. on Wednesday night, ablation on Friday and home early Saturday afternoon.

So how am I now, 5 months post procedure? Well, it wasn't a magic bullet for me anyway. June was a great month with no PVCs. In July/August I began having a few "resting" PVCs, which I had never had before. Then in September some mild runs post exercise and during stress situations, but the resting PVCs have pretty much gone away. Alcohol definitely lowers my threshold, more than it seemed to prior to the ablation. To date no V-Tach and I'm working on managing the whole thing better. More moderate workouts with max HR 130-140. No more balls to the wall stuff. Still it's a disturbing trend for me. Interesting thing about the stress/anxiety PVCs is the thing I'm most anxious about is having and extended run of PVCs or slipping into V-Tach. So it's a chicken/egg thing. I've relayed the resurgence of the symptoms to my EP, but as long as there's no V-Tach there doesn't seem to be much interest. Remember what I said about cardiologists and PVCs. A big part of my problem is I don't know what the new "normal" is or even if there is one. Probably shit changes week-to-week or month-to-month from here on and I just deal as it changes. Mayo Clinic has a sports cardiology clinic and I'm thinking about taking a run up there to see what they say. So all in all--we'll see.

Max an' Annabelle

Treatsie

I feel it necessary to comment on the current state of the 5900 satellite and express my concern over the issues of workflow and staffing.

When the BMT service moved to the north campus the initial pharmacist staffing was as follows: 3 RPh 0700-1200, 4 RPh 1200-1500, 3 RPh 1500-1700 and 2 RPh 1700-2200. While the BMT service as well as Med Onc have continued to expand, the number of pharmacists responsible for these areas is down, and now stands at 1 or 2 for the entire day with the exception of approximately 1-1.5hr from 1200-1400 when there is an overlap of a third pharmacist. By way of contrast, the clinical pharmacy staff responsible for these areas has increased from 1 to 5 with a 6th position already in the budget. Recently, the opening of 24/7 oncology center has added approximately 8-10 oncology patients to the daily chemotherapy count. The nature of an out-patient infusion center dictates these infusions are prepared on a STAT basis. Compass chemotherapy entry and verification has placed additional constraints on total preparation time. Also, not to be discounted in importance, is the loss of 1 of the 2 day shift IVRM technicians to the 13 CAM pharmacy.

Staffing of the area was one of the main highlighted issues during the Risk Management root cause analysis of the chemotherapy preparation sentinel event of about four years ago. As noted above we are currently working with 1/3 -1/2 of the staff we had at that time. Another outcome of those meetings was a follow up with other similar institutions to compare policies on staffing. To my knowledge, nothing ever came of these contacts because none of these institutions was doing anything comparable to the 5900 sat IVRM, with its combination of chemotherapy floors, ICU's, surgery and out-patient areas at the volume and staffing that we have.

The RIE of last year left the satellite with a totally inadequate filling/checking area. The current procedure of checking bins full of different patients’ chemotherapy amid the myriad of distractions in the satellite is increasing unworkable and potentially dangerous with regard to patient safety. In my opinion, this is the major flaw of the original workflow design and a contributing factor, if not the main reason for the most recent and probably most chemotherapy errors. If underlying causes of errors are in fact system breakdowns and not errors of individuals, then what we are experiencing fits that definition exactly. A system, suspect from the beginning, no longer workable.

All chemotherapy and IV admixtures should be checked by an IVRM pharmacist BEFORE IT LEAVES THE IVRM. The staffing of the IVRM by a single unsupervised technician has always been less than ideal. Our current staff of technicians are of varying experience and competency, the former not necessarily indicative of the latter.

Any chemotherapy safety RIE could address these core problems only marginally. For example the recent directive to assign responsibility by designating chemotherapy checking to a specific pharmacist at a specific time is unrealistic in the context of a staff of only 1 or 2 pharmacists. Any additional guidelines to assign responsibility without control only serve to sidestep the real issues and make the current process more cumbersome with negligible positive effect.

The addition of 1 pharmacist FTE would be a major first step. I would suggest a Mon-Fri 8-hour evening 1500-2300 shift. This would allow the shift time of the 1000-2000 7on/7off pharmacist to be changed to a start time of 0830. This position becomes the IVRM pharmacist, working and checking in the IVRM until 1900. This obviously adds morning help to the 0600 pharmacist, who currently works alone until 1000. The 1900 shift end time is late enough to have the majority of the evening scheduled chemotherapy completed. I would also foresee this position to do the majority of the chemotherapy verification in addition to helping the clinical staff enter orders when necessary. The new 1500 8hr position coincides with the end of the 0600 day shift, as well as help later into the evening/night shift when home medication sheet entry/checking has become an increasing problem in addition to the usual late chemotherapy new order starts.

I realize adding additional FTE's can be problematic. At this point I don't believe any procedural changes can make enough of a difference to solve our current problems. Steps need to be taken to prevent further chemotherapy errors. I hope that this can be accomplished in lieu of discussing a problem I've outlined here at a post error root cause analysis meeting.

Respectfully,

I'm doin' nothing and it's everything I hoped it could be

A lot a new shit has come to light, man. A lot of ins and outs. I'm gonna try to keep it separate but it's all interrelated. I'll start with the job. I quit. Bunch a assholes. I've previously mentioned that I question the integrity and wisdom of the current pharmacy managers. After the shift/personal switch things pretty much continued down the toilet with respect to workflow and my attitude. I investigated a couple other jobs but nothing came out it. One of them I didn't even apply for and I withdrew myself from consideration for the other. Early on in my displeasure in the direction the job was taking I spoke to a friend of mine who services some nursing homes, pretty much told him if something opens give me a call, I was ready to jump. Be careful what you wish for. More on that later.

I decided I needed to put every bullshit problem down on paper and send it to the director of the department. Cleaned up of course. A well thought out, concise, white paper with a list of concerns. My Treatise. I composed it over about 4-5 days total, first drafts, re-writes, etc, until I was happy with the finished product. I must say here by way of full disclosure that my wife was instrumental in proofreading and with toning down my rant to keep with general business decorum. She's corporate. I sent it off in an e-mail to the director, as well as cc's to the daily operations manager and the safety officer. The responses were positive and tempered by corporate logic, pretty much what I expected. The director forwarded a copy to his boss, one of the vice-presidents. He's a lot a things, stupid isn't one of them. If in the interim anything I warned about came to pass and he's sitting on my memo it probably wouldn't have been good for him.

The next significant event came in the form of a rapid improvement event (RIE) for our area. This is an offshoot of Kaizen and Lean Six Sigma. If you're unfamiliar with these management absurdities consider yourself lucky. Among other things, this is the thinking that you need to designate exactly where everything is to be placed in your physical work environment. No shit, these people are putting fucking blue tape outlines where everything is on your desk. Around staplers, tape dispensers, marks on the floors where the chair sits, it's FUCKING crazy. I am not making this up. One of the other parts of this is the RIE. This is where you throw shit against a wall and see if any of sticks. You look briefly at a process or workflow over the course of a few days or so, make a bunch of changes, then see what happens. It's really a ridiculous exercise, people following others around with stopwatches and counting steps. Where it all falls down is if you don't go back and revisit the process to see what helped (if anything), otherwise the people who work in the area are just stuck with a bunch of nonsensical procedures that only make things more cumbersome. People do whatever they can to avoid being part of one of these shit storms. I volunteered.

Here was my thinking. I had already laid out an outline of what would help in My Treatise. Nothing short of additional staff was really going to cut the mustard. If more staff was not an option on the table, and it usually wasn't, this would be yet another avenue to gets my thoughts on the record. I would just have to suffer through the week of nitpicking little shit like it was going to make any fucking difference at all. As it turns out changes in staffing were not being ruled out and I was able to manipulate things to get my plan the official recommendation of the committee. WTF! Things might actually change?

No. They wouldn't. Another made up budget/FTE crunch squashed me like the bug I am. Here's what happened. In a seemingly unrelated event a few months prior the hospital changed time accounting systems. Clocking in/clocking out that type of thing. With this change the administration had access to all kinds of new numbers, just the type of stuff that gives bean counters a hardon. They figured out that the pharmacy was averaging ten FTE's (full-time equivalents, basically an 8hr shift) per day over budget. Concerning-yes, but hardly a crisis if you consider this has been going on in perpetuity. Instead of trying to find out reasons why, there's a typical knee-jerk reaction. No new positions, no coverage for anyone who calls in sick, no extra pays shifts, did I mention knee-jerk? Pretty deflating. A few weeks later my friend who services the nursing homes calls. He has a job. I'm out.

Here we are a few months later. Dust has settled. In retrospect I have no regrets about leaving the hospital. It was the best move for me then, still is. I figure I did all I could there. You can bitch and moan about a job, which I did. You can try to affect a change, I did and almost fucking pulled it off. After that all you're left with is continuing to complain, sucking it up and doing the job, or moving on. I was prepared to suck it up, but an opportunity came along.

In a final note, 6 months later, the pharmacy department is in the process of implementing the changes. You're all welcome.

isn't it beautiful

Concert reviews

What a great 2 month run of concerts. I'm not much of a big venue guy anymore but I did venture out into the crowds on occasion recently. Started on Sept. 29 with Australian Pink Floyd @ Scottrade. Solid show, pretty much delivered what it promised, an enjoyable evening. Not Gilmore and Waters, but really what is? As close as you can get at this point.

Oct. 3rd was the Outlaws at great outdoor site that I'd never seen a show at before, Jefferson Barracks Park. My regret here is that I didn't spend the money for a spot closer to the stage. They killed it. The Florida Guitar Army Lives. Even without Hughie, a great, great show. Place was packed for what I thought was an under-promoted show. CDB was the headliner, but I didn't stick around for them. Guy in the row in front me summed it best--Outlaws finished their set with with SCREAMIN' guitars and this guy, who I got the impression didn't know what to expect, turns around to his friends and says "THAT WAS HUGE".

Lucinda Williams (sigh) 10/17 @ the Pageant. I don't know...I developed a real Love/Hate relationship here. Some background--I first discovered her when I started getting satellite radio thru the TV about 10 or so years ago. Went out and bought a bunch of her stuff--loved pretty much all of it. So by now I've seen her in concert about a half dozen times--every show worse the the previous one. For me it's a combination of poor song choice and concert pacing. She has all these songs that rock and some kick-ass musicians behind her but the shows just drag. Best show I saw of hers was the first one at the Pageant, she was really on that night. A good show in Memphis a couple years back, but the venue @ the university sucked. Now I'm not much of a hero/celebrity worshipper but that night as I was leaving the building I saw her tour bus with a handful of fans gathered waiting for her close to where I was parked. I thought what a great chance to get my copy of "Car Wheels" signed, so I hustle over to my car, rummage thru my CD's and get back over to the bus where maybe 6-8 people are waiting and I'm told she hasn't shown yet. So we wait...her band comes out, Pettybone stops and signs and chats, Carrie Rodriguez (opening act) comes out signs, chats, etc.--more time passes, finally somebody figures out Lucinda has been on the bus the ENTIRE FUCKING TIME. I think of her talking on stage about how it's all about the fans and we make the whole thing possible, you know as the usual bullshit, and this diva hypocrite bitch can't even get off the fuckin' bus for 5 min. It was a negative experience for me if you can't tell.

Bruce 10/25 @ Scottrade. What is there to say that hasn't been written better by any number of others. The guy fucking delivers a great show night in/night out. 60yrs old and he puts it all out there every single time. My only rant here is with the guy who does the reviews for "Backstreets"--what an asshole. I'm not sure what show this guy was watching, I'm sorry Bruce didn't pull out a song he hasn't played in concert in 30yrs to make the show worthwhile for you. Most people just get to see Springsteen once or twice per tour if they're lucky and some jaded, spoiled cocksucker critic who's seen however many shows over the past couple years, says (sniff) "this was an off night". As compared to what you prick? Great Show period.

Lastly, Leonard Cohen @ the Fox on Nov 7th. What a lucky decision to go to this show. I been a fan of his songs if not his singing for a while. This show brought it all together for me. Ten people on stage, all great musicians, I don't know how many instruments were played, 30? Bought the ticket 2 days before the show, didn't know it at the time, but I ended up center stage about 10 rows back. Maybe I've had a better seat at a show but I sure don't remember it (coulda been stoned). Here's a show I had no expectations for that turned out great, that makes it all the more sweet. My hopes were coming in that he would make it more of a story telling type show... after all he's an interesting guy who has seen a lot (so maybe I did have some expectations) but it was all music (and a few poems) and it was probably to concert of the year. Along the way during this concert glut I missed a few that I had earmarked, among them--Son Volt, Neko Case, James McMurtry, Bottle Rockets, Kings of Leon to name a few. Well, that's enough on that, except to say El Monstero 12/25 and Mark Knopler 4/22. Check back.

did ya think I was dead?

S0, 1 post every 2+ years. I don't know how I can keep up with this torrid pace I've set for myself. What's changed you ask? Well now I'm just on the other side of 50, no big deal there it happens to everyone. Another dog, bringing the total to two. And I now despise my job. First, the job--large midwestern hospital pharmacy with possibly the worst most inept departmental management ever. Here's how they deal with a problem, myself and another guy worked together on evenings 10hr shifts 7 days on/7 days off. So it stands to reason that another pair of pharmacists worked the opposite week, therein lies the problem. On our week things for the most part ran ok and were done in a timely manner. The other week was a cluster fuck, or so I was told by everyone who witnessed what was happening. (techs, students, RN's etc.) Instead of dealing with the problem, our managements' solution is to rearrange the shifts so myself or my co-worker is there every Mon-Thur and not even acknowledge to the other pair that there's a problem. They tell them this is being done to provide "continuity of service", whatever the fuck that means. Now every week I'm saddled with dead weight for 4 days a week. He's not really a bad guy, just has trouble staying focused and discerning what's important vs. what's not. This is my reward for being able to do my job. That place is just wrong in so many ways. See, I told you over 2yrs ago I had a lot of rants and beefs. I wasn't fuckin' lyin'.