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Famous Last Words
60Gunner

Posted on 01/31/2007 3:42:31 PM PST by 60Gunner

He came in at 1 in the morning, and I triaged him. His chief complaint: "Well, my chest kind of hurts, and my girlfriend made me come in." His girlfriend sat next to him, appearing fretful and unhappy. The patient was a 37 year old who appeared to be in general good health.

I was tired. It had been a long shift so far, having been spent sticking IVs into dehydrated babies suffering from GI bugs that have been particularly vicious this year. I was shipping demented elderly people to the floor at a record pace, and the nurses in MedSurg were threatening to form a lynch mob. I was 9 hours into a 12-hour shift that I worked because my opposite has decided to break his leg skiing.

But medical emergencies don't care how tired or busy I am. My triage assessment had to be thorough, and that meant that I had to elicit as much information as possible in order to find out what was really going on. I've been doing this long enough to suspect when a patient was not giving me the whole story, and I could tell that this guy was not being very candid about what was going on. Generally speaking, when a patient evades the questions it is likely that either the patient was doing something he should not have been doing, or he is in denial of an emergent problem. So we went through the sparring ritual at triage, with me probing and he evading while his girlfriend fretted on.

The training that has been pounded into my brain took over as I attempted to classify the patient's chest pain. Is this a heart attack, a pulmonary embolism, a bad gall bladder, gastroesophageal reflux, an anxiety attack, or what? I'm trying to get as much information from the guy as I can, but he is not helping.

The patient's vital signs were stable. He was not sweaty, he was not clutching his chest, and he did not appear anxious. Finally, agitated with her boyriend's evasiveness, the girlfriend could stand nor more. She interrupted him and told me: "His brother had a heart attack when he was 35, and his dad had one when he was 36."

This guy was 37.

Uh-oh.

In that instant, the lesser possibilities were automatically disqualified and I began to operate on the assumption that this patient was having a heart attack.

Now let me acquaint the reader with a big fat truth. If you have a heart attack, it may not necessarily feel like your textbook heart attack. You know, the elephant on the chest, the sweating, the horrible left-sided chest pain that radiates down the left arm and up into the left jaw. People are all unique. While that's a beautiful altruism, the fact also makes my job a lot more challenging.

I had one patient whose only symptom was a severe case of the hiccups. He was having an acute myocardial infarction (MI). I had another MI patient who simply fainted. I had yet another who had pain in both elbows. Diabetic patients often feel no pain at all (called a "silent MI"). These seemingly innocuous manifestations and vague complaints are why thorough patient assessment will always be at the top of the Challenge-O-Meter.

This is also, of course, is why ER nurses tend to jump all over a patient and stick monitor leads and IV lines in them in a hurry any time someone verbalizes symptoms that trigger our alarms- which is exactly what I did to my patient within 0.5 seconds of his girlfriend's statement.

In the Museum of Famous Last Words, three words are at the center exhibit. Here they are:

"It's probably nothing."

(Hah. I bet you thought it was "Hey, watch this." Those actually run a close second.)

And guess what the patient snapped at his girlfriend when she interjected?

"Stop it! It's probably nothing."

But with his familial history, my suspicion index was going bonkers and I was not about to be caught flatfooted if it turned out to be something. So I unceremoniously took the patient back to a cardiac room (dragging a bewildered ER Tech with me) had the patient strip out of his shirt, and slapped the blood pressure cuff, pulse oximeter, and the cardiac monitor leads on him. The patient shot his girlfriend a "see what you did?" look, but cooperated.

Now, a note on the 5-lead cardiac monitor: In terms of monitoring heart rhythm, the 5-lead monitor is great. But for diagnostics, it's like taking a picture of the Grand Canyon using the camera on your cell phone. It's informative, but not precise. So I ordered the tech to do a 12-lead.

The plot thickened.

The patient had some suspicious aberrations in his inferior-septal EKG tracings. That means that the electrical impulses that travel through the part of his heart containing the SA node (the natural pacemaker) and the AV node (which regulates the ventricular contraction) were not traveling as they should. The artery that supplies these parts of the heart may be occluded, and if that part of the heart dies, the result is a "negative patient outcome" (i.e., death). Furthermore, if that region is affected, the patient may not show classic signs of cardiac injury. Isn't that encouraging?

I know that alot of this is arcane to the reader who is not well-versed in heart attacks. Suffice it to say that I was not reassured in any way after looking at the EKG. Could it be that he was having a heart attack? Maybe. But then again, maybe not. But again the old adage applied: when in doubt, assume that the patient was having a heart attack. I was not reassured at all when I showed the MD the 12-lead, and he became immediately suspicious and got on the phone to the on-call cardiologist right now. Meanwhile, I stuck an IV into him and drew blood for more tests. I tossed 325mg of aspirin down his throat. I put him on 4 liters of oxygen.

With every minute that passed waiting for lab results, the patient became more and more impatient. And he was still not communicating his symptoms. We found out that the patient was again having chest pain only because his girlfriend came out and told us. When she did, the MD and I rushed in. I did another 12-lead EKG and as it spit out the results, the top of the page had this:

************************************* ACUTE MI **************************************

I was not reassured.

The cardiologist arrived and reviewed both EKG results with the MD, and then strode into the patient's room and informed him that he was going to be admitted to the CCU and would be going to the Cath Lab for angiography.

"Oh, no I'm not! I have to be at a meeting in the morning."

"Sir, you are having a heart attack."

"I feel fine. You don't understand- I have to be at this meeting. My business depends on it. It's not an option."

"No, sir, you don't understand." The MD countered. If we don't fix this problem right now, you will probably miss your meeting anyway because you will be dead.

The patient opened his mouth to say something to the MD, thought otherwise, and then turned on his girlfriend. "Thanks a lot! None of this would have happened if you'd have just SHUT UP!"

"I don't want you to die," she answered weakly.

"I'm not going to die! I'm FINE!" The patient turned on the ER MD. "You can't keep me here if I don't want to be here."

"That's true."

"I don't want to be here. Take this stuff off of me NOW. I'm leaving."

The girlfriend stood and declared, "If you leave you'll be walking home, because I won't drive you."

"FINE!" the patient roared. I caught the girlfriend's attention and motioned her out of the room and into the waiting area. She turned to me with tears in her eyes.

"I don't believe him! He's in total denial of this. How can he be so stupid?"

"I can't explain his attitude; but I can say that bringing him in was a wise choice on your part. Right now, the most important thing is to keep him calm. Getting angry is the worst thing he could do. How well do you know him?"

"I've been with him for a little over a year."

"Is he under any stress?"

The woman threw her arms up and said, "Oh, yeah! He works two jobs: He owns his own construction company but he's also the top loan officer for a mortgage company. He's their Golden Goose. He works constantly, and he never lets up." She paused, then added: "He has a lot riding on that meeting. Could he really die if he goes home?"

"Yes, he could."

"If he could possibly die, can't you keep him without his consent?"

"Not in this case, no."

"I have to talk him out of leaving," she concluded. I put both hands up.

"No, ma'am. Right now, we need to get him calm. Can I offer a suggestion?"

"Sure. I'm all out of ideas with him."

"Just have a seat in the waiting room for a little while. Let me get you something to drink. Getting away from the room will help both of you to calm down right now. Do you agree?"

"Yes."

I heard commotion in the treatment area, and a lot of feet. I excused myself and rushed to the patient's room to find him ashen, sweaty, and limp. His monitor showed a disorganized and slow rhythm. He was in full heart block, meaning that the connection between his SA node and AV node had been completely severed by the injury to his heart.

Oh, crap.

I joined the rest of the code team and slapped the pacer pads onto the patient, hooking it up to the defibrillator. The MD ordered sedation, which another nurse was in the process of giving. As the patient slipped out of consciousness, he slurred, "Stop it. I'm fine."

The MD looked at me and rolled his eyes. "Famous last words."

After the patient was unconscious, we managed to "capture" his heart and pace its rhythm. His vital signs began to stabilize, and we all started to breathe again. I prepared the patient for transfer to the Cath lab and gave report to the receiving nurse.

As the Cath lab team pushed the stretcher down the hall, I turned and found the girlfriend beside me.

"I'm sorry I couldn't come get you sooner," I said. "Are you going to be okay?"

She sighed. "Yeah. I'm glad it happened this way. Is that wrong?"

"Well, for what it's worth, I would rather he did it here than at home."

The woman paused and then asked: "Is it my fault that he got upset and his heart attack got worse?" She lowered her head and looked at the floor.

I turned to face her and told her, "Look at me." When she met my gaze, I continued: "Consider the possibilities. What if you had not brought him here? Upset or not, it's likely that if he was not here, he might be dead right now. So you tell me: was bringing him in worth making him upset?" "Yes," She replied. She began to cry. "He's never snapped at me before like that."

"I can't give you an answer for why he did," I said, handing her a box of Kleenex. "You know him better than I do. But I've seen alot of people who come in with heart attacks who refuse to believe it even when they can hardly breathe and the staff is swarming them. It is a frightening thing to face, and people respond to the prospect of mortality in their own ways."

I then asked, "Would you like to go to the Catheter Lab waiting room and wait for him there?"

"I'll go there. How long will it take?"

"Maybe a half hour to an hour. I'll call over so the team will be expecting you, and I'll have one of our Techs walk you over there. I have to finish charting, so I'll say goodnight now."

She extended her hand. "Thank you. You all were very good with him."

"It's our pleasure. Try to get some rest, Okay?"

"Okay."

I found an available Tech to escort the woman to the Cath Lab and turned to the arduous business of documentation so that I could run the chart over to Cath Lab quickly. As I sat down, I looked up at my watch: two hours more, and I would be off. I stretched, yawned a long and obnoxious yawn, and set to work.


TOPICS: Your Opinion/Questions
KEYWORDS: 3words; 60gunner; emergencynursing; er; ernursing; famouslastwords; heartattack; itsprobablynothing; probablynothing; threewords
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1 posted on 01/31/2007 3:42:33 PM PST by 60Gunner
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To: MaryFromMichigan; SunnyUsa; bad company; RobFromGa; doodlelady; Slings and Arrows; NonValueAdded; ..

Emergency Nursing Stories Ping.


2 posted on 01/31/2007 3:43:35 PM PST by 60Gunner (ER Nursing: Saving humanity... one life at a time.)
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To: 60Gunner

Thanks for your posts, which are always well-written and informative.


3 posted on 01/31/2007 3:47:12 PM PST by dighton
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To: 60Gunner

I really appreciate your stories and your dedication.

You convinced me to call my cardiologist tomorrow.


4 posted on 01/31/2007 3:49:00 PM PST by arjay (I would rather be right than consistent.)
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To: 60Gunner

Will you please start pinging me to these? Fascinating read.


5 posted on 01/31/2007 3:50:01 PM PST by patton (Sanctimony frequently reaps its own reward.)
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To: 60Gunner

good story.....been there { I was an EMT for 16 years}. Saw many people who denied having the big one, right up to the time I was kneeling besides them doing compressions.
Doctors save lives....Nurses Save Doctors....


6 posted on 01/31/2007 3:54:58 PM PST by Yorlik803 ( When are we going to draw a line a say"this far and no farther")
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To: 60Gunner

Great story. I hope that young man is okay now. Could you add me to your ping list, please?


7 posted on 01/31/2007 3:56:44 PM PST by CaliGirlGodHelpMe
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To: 60Gunner

Twenty months ago I was having chest pains and left work and drove myself to the ER. I will never forget the look I got from the nurse when she heard I drove in. I was stupid and lucky. I had 6 bypasses the next day.


8 posted on 01/31/2007 3:59:53 PM PST by chesty_puller (USMC 70-73 3MAF VN 70-71 US Army 75-79 3d Inf Old Guard)
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To: 60Gunner

Fine work... and fine work. Keep 'em coming.


9 posted on 01/31/2007 4:02:02 PM PST by Interesting Times (ABCNNBCBS -- yesterday's news.)
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To: 60Gunner

Was the girl cute? I have a feeling she is going to be available pretty soon, and she seems like a keeper.


10 posted on 01/31/2007 4:02:03 PM PST by krb (If you're not outraged, people probably like having you around.)
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To: 60Gunner

ping


11 posted on 01/31/2007 4:02:51 PM PST by ROLF of the HILL COUNTRY ( ISLAMA DELENDA EST!)
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To: 60Gunner

Fascinating story about how you not only have to deal with the patient, who definitely can be very uncooperative, but also the loved ones. Appreciate your posts, 60Gunner!


12 posted on 01/31/2007 4:05:43 PM PST by Theresawithanh (Growing old isn't so bad, especially when you consider the alternative!)
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To: 60Gunner
You write a good story. Your explanations of the med terms and phenomema are very helpful as well.

This story is especially good since it deals with the mystifying symptoms of the MI.

Keep up the good work!

13 posted on 01/31/2007 4:06:38 PM PST by doberville
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To: 60Gunner

pretty please could I be on your ping list?


14 posted on 01/31/2007 4:10:24 PM PST by verum ago (The Iranian Space Agency: set phasers to jihad!)
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To: 60Gunner

I married one of these gals, met her in the ER working triage at Parkland.

Checked your page. I'll keep mine. LOL.

Put me on your ping list.


15 posted on 01/31/2007 4:11:09 PM PST by GopherIt
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To: 60Gunner

Please add me to your ping list - I still have a copy of your kindergarten teacher's BAC report. Great stuff.


16 posted on 01/31/2007 4:16:20 PM PST by RabidBartender
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To: 60Gunner

Thank you SO much for another great story and for the ping! I'll say it again, you have a very readable style - entertaining and informative.

And thanks for the job you do saving folks, sometimes in spite of themselves.

Question for when you have the time: What's your experience in the differences, if any, between MI symptoms manifested in women vs. men? I've heard women's symptoms can be more subtle. As a female whose paternal bloodline tends to heart disease, I have more than passing interest in the subject.


17 posted on 01/31/2007 4:16:47 PM PST by Titan Magroyne ("Y'know, I've always thought of politics as show business for ugly people." Jay Leno:Al Gore 11/29)
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To: 60Gunner

That was amazing.

Do you have a "ping" list? Please add me to it, if so.

FReep mail coming.

-Radix


18 posted on 01/31/2007 4:17:44 PM PST by Radix (It is useless to attempt to reason a man out of what he was never reasoned into)
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To: chesty_puller
Twenty months ago I was having chest pains and left work and drove myself to the ER. I will never forget the look I got from the nurse when she heard I drove in. I was stupid and lucky. I had 6 bypasses the next day.

Driving yourself to the ER is always a bad idea, which is why I probably won't do it again... The last time, I did it, I was told that I was going to need back surgury in the next few days, after having given me some demerol. I had a disc rupture into my spinal canal, and I was losing control of my right leg, as the injury got worse. Of course I was in incredible pain. When they released me, they asked where my ride was, and I just told the nurse that they had gone out to get the car. When nobody was looking, I drove myself back to work, and once there, asked for some time off for my surgery.

Mark

19 posted on 01/31/2007 4:18:12 PM PST by MarkL (When Kaylee says "No power in the `verse can stop me," it's cute. When River says it, it's scary!)
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To: 60Gunner

I've heard of people being that ridiculously stubborn before, but it always amazes me. It's especially bad when someone who cares about them is worried sick and they still are defiant.


20 posted on 01/31/2007 4:18:24 PM PST by SIDENET (Everybody was kung-fu fighting)
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To: 60Gunner

Could you add me to your pinglist?


21 posted on 01/31/2007 4:26:08 PM PST by Knitting A Conundrum (Act Justly, Love Mercy, and Walk Humbly With God Micah 6:8)
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To: 60Gunner

Please add me to your ping list.

Thanks!


22 posted on 01/31/2007 4:27:45 PM PST by JZelle
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To: 60Gunner
I can relate. I only went to the Dr. today because my rales were loud enough to keep me awake last night...
23 posted on 01/31/2007 4:28:10 PM PST by null and void (<----- Shocked and odd...)
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To: 60Gunner
I don't know what the stats are these days, but 30 years ago when I involved prehospital emergency care their sudden-death episode was the first sign of trouble for 50 percent, yes half, of those who died from heart problems! No chest pain, no sweating, no fear of impending doom, just suddenly dizzy, then unconscious and then usually dead.

A few of them would be resuscitated but for the most part they were simply alive one minute and dead the next.

Interestingly in a study we did it was found that smokers had a better chance of surviving an out of hospital cardiac arrest. We figured it was because their body was already accustomed to less oxygen.
24 posted on 01/31/2007 4:31:09 PM PST by jwparkerjr
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To: 60Gunner

I enjoy reading your nursing stories. Please add me to your ping list. Thanks.


25 posted on 01/31/2007 4:39:59 PM PST by niteowl77
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To: 60Gunner

I would like to be on your ping list.....I enjoy your stories.


26 posted on 01/31/2007 4:40:42 PM PST by Guenevere (Duncan Hunter for President....2008!)
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To: 60Gunner
"I can't give you an answer for why he did," I said, handing her a box of Kleenex. "You know him better than I do. But I've seen alot of people who come in with heart attacks who refuse to believe it even when they can hardly breathe and the staff is swarming them. It is a frightening thing to face, and people respond to the prospect of mortality in their own ways."

You are so great - what a wonderful way to help her out when she was feeling guilt - for doing the right thing! We so often have our patients, and then our patient's loved ones too to care for!

I would think he was very out of character/anxious considering how his heart was trying hard to say alive despite it's severe injury.

Do you find that codes happen often at change of shift? We had a successful code the other day - one of two - both happened at change of shift - what's up w/that?

27 posted on 01/31/2007 4:46:50 PM PST by SunnyUsa (No man really becomes a fool until he stops asking questions.)
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To: 60Gunner
Please add me to your ping list.

What a great story and what a sad guy.

28 posted on 01/31/2007 4:53:46 PM PST by Volunteer (Just so you know, I am ashamed the Dixie Chicks make records in Nashville.)
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To: 60Gunner

Please add me to your ping list.

Funny how your last story (at least the last one that I saw) was about a patient who was obviously quite dead, but whose heart insisted on continuing to beat anyway.


29 posted on 01/31/2007 4:55:29 PM PST by GovernmentShrinker
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To: 60Gunner
"I bet you thought it was "Hey, watch this." Those actually run a close second.)"

That was my choice for first.

30 posted on 01/31/2007 4:56:35 PM PST by ex-snook ("But above all things, truth beareth away the victory.")
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To: 60Gunner

Very good writing. I was interested in each and every word.


31 posted on 01/31/2007 4:57:11 PM PST by ItisaReligionofPeace
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To: 60Gunner

Dude, you've got to write a book if only using your FR threads. They're highly informative and helpful in so many ways.


32 posted on 01/31/2007 5:02:23 PM PST by xJones
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To: 60Gunner

This is an excellent piece and may, very likely, save someone's life. God bless you. With all the modern technology today, I'm afraid people really believe they are more invincible than in times past.


33 posted on 01/31/2007 5:02:56 PM PST by Paved Paradise
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To: 60Gunner; aculeus; Billthedrill; Senator Bedfellow; AnAmericanMother; All
The noted English surgeon, Joseph Henry Green, passed away in 1863. Just before the end he looked at his doctor, pointed to his heart, said “Congestion,” then counted his own pulse, remarked “Stopped,” and died.

— Clifton Fadiman, Some Passing Remarks on Some Passing Remarks.


34 posted on 01/31/2007 5:09:19 PM PST by dighton
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To: 60Gunner

Add me to your ping list, please.

Thanks!


35 posted on 01/31/2007 5:10:28 PM PST by beaureguard
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To: 60Gunner

Very riveting. Thanks.


36 posted on 01/31/2007 5:12:08 PM PST by MoochPooch (I'm a compassionate cynic.)
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To: chesty_puller

I drove myself when I had my first heart attack. The doctor wasn't happy with it but he told me if I'd waited for an ambulance I might not have made it at all.


37 posted on 01/31/2007 5:14:24 PM PST by CaptRon (Pedecaris alive or Raisuli dead)
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To: 60Gunner

Fascinating. Instructive. Great writing.

(please add me to your ping list)


38 posted on 01/31/2007 5:28:53 PM PST by wideminded
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To: dighton
Well, THAT was a classy exit.

There'll always be an England . . .

39 posted on 01/31/2007 5:35:33 PM PST by AnAmericanMother ((Ministrix of Ye Chase, TTGC Ladies' Auxiliary (recess appointment)))
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To: 60Gunner

Ping me Gunner...remember we had that little chat about the Nursing unions crap......we could exchange stories.


40 posted on 01/31/2007 5:36:08 PM PST by JohnD9207 (Lead...follow...or get the HELL out of the way!)
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To: 60Gunner


41 posted on 01/31/2007 5:38:37 PM PST by SwatTeam
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To: 60Gunner
A few months ago I came down with atherial filbriation of my heart.. The only symptoms I could see was lack of ability to breath well.. which got worse.. Eventually driving me to the emergence room because I could barely breath or sleep..

Thats after 2 weeks of barely sleeping because I couldn't breath.. My heart was the last thing I thought.. I thought I had the flu.. or a cold..

After one week in ICU the nurses learned me a lot about my situation.. Duuuugh.. They said I could have easily have died driving to the hospital.. As they said "Men can be Soooo dumb about health".. I would have to agree..

42 posted on 01/31/2007 5:39:39 PM PST by hosepipe (CAUTION: This propaganda is laced with hyperbole....)
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To: 60Gunner
So.....What happened to the guy!?!!?!?!
43 posted on 01/31/2007 5:40:53 PM PST by sam_paine (X .................................)
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To: 60Gunner

later


44 posted on 01/31/2007 5:41:08 PM PST by I_be_tc
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To: 60Gunner

Thanks again 60!

By the way; your "Little Misbehavior" is required reading for my twenty-something year old Airmen. Especially the young ladies!

http://www.freerepublic.com/focus/f-news/1733043/posts


45 posted on 01/31/2007 5:42:40 PM PST by Grizzled Bear ("Does not play well with others.")
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To: 60Gunner

Add me tyo your ping list as well.

I am married to an ol' ICU nurse.


46 posted on 01/31/2007 6:05:56 PM PST by amigatec (Carriers make wonderful diplomatic statements. Subs are for when diplomacy is over.)
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To: 60Gunner

60...well done.


Thanks.


47 posted on 01/31/2007 6:09:21 PM PST by Tainan (Talk is cheap. Silence is golden. All I got is brass...lotsa brass.)
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To: 60Gunner; pax_et_bonum
Here's the last words I always heard my ex-wife say each night at bedtime...

Dear Lord,
I pray for:
Wisdom, To understand my man.
Love, To forgive him and;
Patience, For his moods...
Because, Lord, if I pray for Strength
I'll just beat him to death!
48 posted on 01/31/2007 6:14:08 PM PST by Bender2 (Gad, Millee! 1st Lindsy goes into rehab, then you bust a gut to get my attention...)
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To: Bender2

:-)


49 posted on 01/31/2007 6:23:25 PM PST by pax_et_bonum (I will always love you, Flyer.)
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To: dighton
Personally I've always preferred General John Sedgwick's last words "They couldn't hit an elephant at this dist-".

But sometimes the patient really IS fine - I was bundled off in an ambulance from an annual physical one time because I'd neglected to tell a new doctor about a heart abnormality that turned up on an ECG. Had a stress test and an angioscope over the next couple of weeks. Clean bill of health. It was nice to learn and an interesting experience but I could have done without the drama. Best thing you can do under the circumstances is whatever the Docs say. That's always good advice unless the fellow's name is Kevorkian.

50 posted on 01/31/2007 6:28:47 PM PST by Billthedrill
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