It's Been Way Too Long. . .

It has been way too damned long since I've posted anything. . . about five months or so.  I think that part of the problem is that, when I get home from work, the last thing I want to do is think about work.  I just want to get it off of my mind and move on with my day.

For some reason, I got off work this morning, came home, and opened up the old blog.  Well, I got all nostalgic and decided to write something again.  To be honest, I don't know if I will keep it up or not.  But, I'm in the mood. . . time now.

Ok, I've Said It Before, And I'll Say It Again. . .

I've talked about people asking me about becoming a doctor before. . . sort of.  I actually linked to somebody else talking about it.  They said it as well as I could.

Last night, I had a patient who was fairly advanced in age.  Her daughters were with her.  When I came into the room I introduced myself as the triage nurse and explained what I would be doing.  As I finished my assessment, the patient asked me, "you're the doctor, right?"  I responded by telling her I was the triage nurse and what my job was.  The rest of the conversation went like this:

Annoying Lady: But you're going to be a doctor. . .

NurseHubba: No, ma'am.  I'm a nurse.  I don't want to be a doctor. 

Annoying Lady: Oh, I bet you don't.  That makes sense.

NurseHubba: *smiles*

Annoying Lady: They work way too hard.  I wouldn't want to do that either.

Suddenly, I found myself wanting to throat punch an old lady.  What the hell does she think nurses do?   Sit on our ass and do the NY Times crossword all shift?

Don't get me wrong, I appreciate the doctors and all that they do.  There is a lot of responsibility there.  But, who is it that is actually carrying out most of the treatments, assessment, and patient care?  The nurses!

Again, love the docs. . . but come on!

 

 

 

Great Advice For New Grads ***UPDATED***

I'm posting links to three articles that I read today from Shepherd Of The Gurneys, written by Aesop.  These are specifically for those of you who are students now, are about to graduate, or have just graduated.

Aesop gives some good advice in these, and I really recommend you take the time to read them.  And, even if you're an experienced nurse, they're fun to read and reminisce about your own "new nurse" experience.  Ok, here they are:

Part I: Commencement

Part II: NCLEX, and getting a job

Part III: Doing It 

Enjoy, and take the advice to heart!

This Sets The Tone For The Night

Ok, many of you know that I work night shift.  So, I come on around 7pm and work until 7am.

This particular night, I was working triage.  In our ER, we have a "pull 'til full" system where patients are brought to a room immediately until we are full up.  Then, we begin the normal triage system where people end up sitting in the waiting room.  If we aren't full, then the EMS patients coming in are triaged by the triage nurse when they come in.  If full, the primary nurse or the charge nurse nurse gets in there to do it.

This night, I came in to a very nice looking board with only a handful of patients on it.  This, in itself, is a miracle at 7 in the evening.  Right when I came on, the outgoing triage nurse told me that everything was caught up and that we just had one ambulance out.

Sweet.  This is an excellent situation to come in to.  I've had some seriously shitty shift changes leading up to this, so I'm excited to have a good one.

EMS arrives with the patient on a stretcher.  She's kind of just looking around, wide-eyed.  She's surrounded by six EMTs of various levels, including the shift leader.  Hmmmmm, that doesn't seem like a great sign.  I start to walk towards them and the shift leader says, "Hey, NurseHubba.  Whatcha got tonight?"  I reply that I'm triaging, and he kind of giggles.  Then he says, "Come here, bro.  I gotta talk to you about this one."  He pulls me off to a corner of the ER and gives me the run down:

"Dude, this chick is seriously jacked up.  42 year old female.  Found her in a hotel parking lot with no clothes on.  She's got no ID.  No nothing.  We don't know where she came from.  Asked around at the hotel lobby, restaurant next door, and the gas station across the street.  Nobody has any idea.  But, bro. . . she's batshit crazy.  She agreed to come in, but I don't know what the vital signs are because she wouldn't let me take them.  Won't let me assess or anything.  You're probably gonna need a sitter and maybe even some restraints.  Sometimes, she decides to 'go off' and you have to get her back down.  Sorry, man.  Good luck."

After hearing this report, I was sure glad that I was triaging and not having to take care of this patient all night.  Immediately, she tried to get up and get the hell out.  Remember, she's nude.  The sheet she was covered with dropped to the floor and she tried to bolt in all her glory.  I got an order for physical restraints from the doc, but not chemical (drugs).   Ok, this made it a little easier, but it was hard to get a good physical assessment done.  Ok, fine.  Vital signs, which I was able to get, were pretty normal, though.  The lady was a useless historian, unable to tell me anything.  I couldn't find any obvious injury or trauma.

Ok, so she's restrained.  She's screaming (sort of) in this weird, raspy, exorcist sounding voice, that she wants water.  Nurse Shaggy (who started at the hospital at the same time as me and has LOTS of hair) is a really nice dude.  He decides to let her out for a few, give her some water, then re-restrain her.

Of course, she tries to bolt.  We all get her back in bed and restrained again.  Two hours later, an hour and a half after an initial dose of Geodon and Ativan, we are completely full with too many ambulances out and too many people in the waiting room.  So, I'm in "the box."  This is what we call the triage area.

Suddenly, I hear multiple voices screaming, "SECURITY!!!  GET SECURITY!!!  SHE'S LOOSE!!!"  I look out the little window that faces into the waiting room and see a very large, very naked woman sprinting through the waiting room with three nurses and our security dude chasing her out the front door to the ER and into the night.

The patient that I am triaging at the moment is there just to have a ring cut off, which I was in the middle of when the commotion happened.  She looked up at me with the most horrified, scared look I have ever seen.

I looked at her, shrugged, and said, "Meh.  Just another night in the ER."

Really, Nursing Home?

*Received a call from a nurse at a nursing home around 5:30am.

Shouldn't Be A Nurse: Hi, just wanted to call and give you guys a report on a patient we are sending you.

NurseHubba: Oh, ok.  Go for it.

Shouldn't Be A Nurse: Ok, 92 year old male with moderate dementia.  No complaints, but we did his vital sign check at 4 and found his O2 Sats were down to 72.  We put him on oxygen at 1L, and got sats to 78.  Went up to 2L and got sats to 84.  Went up to 3L and got sats to 90.  EMS is about to leave with him, so they'll be there in a few minutes.

NurseHubba: So his sats are doing better now, then. . .

Shouldn't Be A Nurse: Well, no. . . after a few minutes, his sats went back down to 78 on the 3L.

NurseHubba: Alright, so you weren't really ever able to get his sats up.  Does he have any respiratory or cardiac issues?  Is he sick right now?  

Shouldn't Be A Nurse:  Nooooooo. . . but. . . He's a DNR *click*

SERIOUSLY, NURSING HOME?!?!

A Refreshing Moment

Had a gentleman come to us from home recently who was, basically, a vegetable.

There was no quality of life.  He could communicate a little and was breathing on his own, but couldn't feed himself (had a PEG tube), bathe himself, get out of bed, or even move (really bad contractures).  The family had a nurse that was at the house most of the time to take care of him.  The rest of the time, the family did it.

The family wasn't home when the man started having severe chest pain, so the nurse called EMS.  He got to us and turned out out to be having a STEMI.  The family had been called (including the daughter with medical power of attorney) and arrived at the same time as the ambulance.

As we started our STEMI procedures, the man sort of whispered to one of the nurses, "Please. . . no."  The nurse had me come over and we asked him to repeat what he said.  Again, "Please. . . no. . . stop." The daughter with POA was brought in and witnessed her father say, again, "No. . . please. . . just stop."

Tears began to roll down her face and she said, shakily, "Ok, Daddy.  We'll let you rest now.  I love you."

She left the room momentarily, giving us a chance to clean up the room and set up chairs bedside for the rest of the family.  She returned shortly with the other family members.  The dying gentleman continued to receive comfort measures for pain, nausea, etc.

It took some time, but the family was able to be there with their loved one, holding his hand, giving him their love.  How refreshing to see a family that didn't want to continue torture on a poor old man who had lived his life, had no quality of life now, and was ready to go.  How refreshing to see a family honor the wishes of a dying man rather than prolong his suffering in order to selfishly delay their own grief.

In my not-so-humble opinion, this family did it right.

This Should NEVER EVER Happen!!!

Ok, so this isn't my experience, but that of a co-worker.

I just want to say that nobody should EVER EVER EVER EVER EVER have to pick maggots out of parts of another living human being.

It's just wrong.  Maggots should not live off of living humans.  Want to know where these maggots were found?  Within the fat folds of a nearly SEVEN HUNDRED POUND person.  Ok, if you're a little overweight, I get it.  I, myself, am a little overweight.  And, when I notice myself weighing more than I want to weigh, start exercising more control over myself in order to stay within my personal weight requirements.

If you weigh NEARLY SEVEN HUNDRED POUNDS, it's time to rethink your lifestyle.  Ok, you came in for abdominal pain.  Unfortunately, we just can't diagnose it with the blood work, clinical exam, etc.  We're going to need a scan.

Guess what?  Normal CT machines can't fit somebody that big.  So, you know what we need to do?  Nope.  Not transfer to another hospital with a larger CT machine.  The answer is that we need to transfer you to a popular ANIMAL PARK in order to find a scanner large enough for you.  We need a scanner that can accomodate a person the size of a small whale.

WHAT. THE. HELL. IS. WRONG. WITH. PEOPLE???

Ok, I realize I may sound a little insensitive, but COME ON!!!

Make Your Choice. There Are Only Two.

Look, lady.  Your husband is not in good shape.  That's probably why you called EMS in the first place.  You recognized that something is really wrong.  He needs a nurse to take care of him that has no other patients, or, at the most, one other patient.  In other words, he needs to be in an ICU.

The nurses up there are very well trained in monitoring and taking care of critical patients.  You know who isn't?  The Med/Surg nurses.  Don't get me wrong, I appreciate everything the Med/Surg nurses do.  And some of them are very good nurses.  But they aren't trained or equipped to handle a patient as critical as your husband.

Guess what else?  He's definitely not staying in the ER.  We each have at least four patients.  And many of them need serious interventions and care.  Nobody in the ER has the time to sit on one or two critical patients for very long before kicking them up to the ICU.  That's what we're good at.  We stabilize.  Then we punt.  We're very good at that, especially in our ER (in my humble opinion), but we aren't an ICU.

So, remember when we said your husband needs to be in an ICU?  Well, all that is why.  Well, unfortunately, we've had some seriously shitty days recently.  That means we've had a lot of really critical patients coming in.  That means our ICU is completely full.  Sorry, can't help that one.

If you want him to live, he needs to be transferred to another hospital with an ICU bed available.

That means you have two choices:

1) Let your husband go (not that we wouldn't do our best to keep that from happening, but we don't have the manpower).

2) Let us transfer him down the road to another hospital so that he can receive the care he deserves. 

That's it. . . Now, choose. . .

Interesting Case

Ever seen an "incarcerated diaphragmatic hernia?"  I have.  Last night.

The guy who had it was in seriously rough shape.  In the CT, his entire stomach was sucked up north of his diaphragm and was sitting next to his heart.

You know who figured out that something way worse than the simple chief complaint was?  It wasn't the doctor.  It was the nurse.

Strong work, Nurse. . . Strong work.

Biting My Lip

Have you ever been triaging a patient that is just so utterly ridiculous that you want to laugh in his face?  Have you ever actually lost your shit right there and started cracking up?  Last night, I had one of my more favorite triage experiences.

A guy came in with the chief complaint of "High Blood Pressure."

When I took him into the triage room, I asked a simple question: "So, what brings you in here today?"

Oops.  Here's the answer I got (and I'm pretty sure the 55-ish guy didn't take one breath throughout the entire process:

"Well, my blood pressure felt like it was really high, so I checked it with my cousin's thingy that measures blood pressure.  It was REALLY REALLY HIGH!  It was 179/106! Oh, and can I tell you one more thing?  I had a kidney transplant about a year ago.  Well, and I drink a lot of water.  My pee is clear.  Is that ok?  I'm worried about having clear pee.  So, I want to get my kidney checked out too as long as I'm here.  Oh, and I have to tell you.  Can I tell you one more thing?  I'm pretty sure my blood pressure is up because of my girlfriend.  She stresses me out, man.  I'm really embarrassed to tell you this, but you're a nurse, so I guess you don't really care that much.  Anyway, she's a really big girl.  She's like, you know, really big.  I had to lift up the front of her stomach to get to her in order to have sex.  And you know what?  She's so big that I couldn't get close enough to her to get inside her.  Have you ever heard of that?  So, anyway, the other day, since I can't get inside her, she gave me a b***job.  She's got another boyfriend, though.  She says she's only been with this other dude and me.  So, as long as I'm here, I wanna get checked and make sure I don't have anything.  I don't want AIDS, man.  I really don't."

V/S were completely normal.  Ten minutes after going through all this, the guy signs an AMA form and walks out of the ER.

Well, ok, bro.  Have a good one, I guess?

New Doc Strikes Again

Ok, I know I've talked about New Doc before, but she seems to be getting worse.  Honestly, I think she just needs to get her confidence up and learn to trust her clinical skills.  She knows her shit.  She does.  But she doesn't trust that she does.

I promise you, New Doc, you don't need a full cardiac work up on every single patient with pleurisy.  Stop asking, "do you have chest pain?" to every single patient.  Given the patient populous that we see, you will have people claiming "chest pain," not actual chest pain, every single time you ask.  Try questions like, "does it hurt when you cough?"  Perhaps the answer to that question is less scary than an affirmative chest pain question.

We all know what happens when you get a positive on the chest pain question.  Nurses, techs, etc are suddenly flung into a whirlwind of activity in order to meet our Joint Commission  time guidelines.  So, stop it.  You stop that now!

Patients who could easily leave within a couple of hours end up staying five or six to get repeat EKGs and cardiac enzymes.  These people just want to go home.  And we want them to go home too!

Every now and then, a patient ends up worse off because he or she needs to go to the bathroom and trips on a molecule of thin air in our bathroom.  When that happens, do you know who gets screwed?  We do!!!  It's a measure of how good of medical providers we are, you know?  Sometimes that person who trips ends up with a broken arm and a broken hip, regardless of age.

I have three words for you, New Doc: DISPO, DISPO, DISPO!!!

Oh, and if someone comes in with no cardiac history, no family history, one risk factor, and COMPLETELY NEGATIVE chest x-ray, labs, cardiac enzymes, and EKG, please prepare yourself mentally, to meet up to the challenge and actually discharge a person home!

People don't need to be admitted just to see if they have an elevated Troponin later.

Ok, I think I'm done. . .

Day vs. Night

I feel like there has been more animosity between day shift and night shift lately in our ER.

From the night shift perspective, it seems like we have really been taking over some shit sandwiches.  My last few shifts, I have walked into codes, intubations, conscious sedations, strokes, and STEMIs.  What happens when I, as a night shift person, walk into one of these?

Well, the day shift people walk off because they are done for the day and leave us swimming in a sea of turds.  I feel like we, as the night shift, often stay late in order to make sure that everything difficult will be taken care of before the day walkers have to fully take over.  Maybe it's just me, though.  Maybe the day walkers feel the same way about us?

Dude, Stop Arguing With Me

You came in because you are in pain after having a cholecystectomy.  I get it.  We'll help you out, bro.

But, when the doc is wanting to check things out to make sure there isn't something else going on other than post surgical pain, please don't argue.  Or, if you do, don't get mad when you only get a pain shot.

Patient "Tough Guy" came in the other night with this pain.  He was wheezing, had course lung sounds, but his biggest complaint was RUQ pain.  Of course, Tough Guy just had his Chole, so I get that.  Incision site looked great.

Doc wanted to help him with his breathing, but Tough Guy refused.  Ok, fine.  We'll give you a pain shot and send you home.  The guy even got Dilaudid IM.  He wanted it IV.  Ummmm, no.  We wanted to give Zofran ODT.  He wanted Phenergan IV.  Ummmm, no. 

He continued to fight and argue, taking up way too much of my time.  Eventually, I walked out of the room.  On my way out, I told him, "If you want the shot, let me know.  Otherwise, I'm getting your discharge papers right now."

Suddenly, he was ok with the shot.  Still refused Zofran.  Reason?  He doesn't like the taste.  Reason he didn't want the Dilaudid IM?  It hurts.  But, dude is ok with an IV?  Nope, definitely fishy.

GOMER! (Get Outta My ER)

Been Awhile. . .

Ok, I haven't posted in quite a while, now.  There are multiple reasons for this.  They are mostly just average, run of the mill reasons.  It's been busy.  At work, yes, but mostly in my personal life.  Also, I had a bit of a problem: injury.

I discovered, during the course of my injury and treatment, that I am one of those pain in the ass patients.  Not because I'm a jerk.  Not because I tell the docs and nurses what to do.

I'm a pain in the ass patient because I refuse to help myself.  Maybe because of my experience as an ER nurse, I don't know.  I started having lower back pain.  It felt like muscle soreness, and I work out, so I ignored it.  Then, it got worse.  I still ignored it and continued to go to work.  It got worse again.  I still went to work.  Of course, I'm not as effective when I have limited ability to lift, run around, etc.

I went out of town and the pain got to the point where I couldn't get up off my back.  I barely made it to the bathroom.  Finally, I acquiesced to my wife and family's urgings and went to the urgent care center down the street.  X-rays were done.  Pain medicine was given with instructions to take it easy until the pain got better.

I took my Vicodin and took it easy.  I felt bad about taking Vicodin.  I felt really bad about calling in sick to work.  But, honestly, it had to be done.  There's no way I would have been able to function efficiently.

I'm still hurting now, but I'm continuing to get a little better every day.  I'm at least functional now.  I've been going to work again for a few days.  And I'm glad to be back.

4/20

Worked 4/20.

Waaaaaaay more OD patients than average were brought in.

Coincidence?

Sure, I'm Not Busy At All (sarcasm)

*This story comes from one of the docs I work with*

One of the hospitals he used to work at had a big ER bay with nothing but curtains separating the beds.

Well, it just so happened that three patients who were right next to each other all coded at the same time.  The doc is standing in the middle of the three running all the codes.  Obviously, there are nurses surrounding all three beds performing CPR, pushing meds, etc.

An older lady from somewhere else in the ER pulls back the curtain and sticks her face in, staring right at the doc running the code and says, "Excuse me!  Can't somebody get me a pillow?!?!"

The doc just pulled the curtain back over her face without so much as taking his eyes of his coding patients.

Well done, doc.  Well done.

Go Home Now. . .

*Lady comes in via EMS.  EMS guys have a look of sheer irritation on their faces.  The paramedic pulls me aside and tells me that they don't know what the hell her problem is.  She called EMS out for one thing, told the guys another story when they got there and kept changing her story during the ride.  No pain, stable vitals, no injury, patient is perfectly calm, alert and oriented, and doesn't seem like a psych patient to them. . . just a pain in the ass.

NurseHubba: Ok, Ma'am.  What brings you in tonight?

Not Sure What To Name Her: My legs!  Look at them!

NurseHubba: Ma'am, I don't see anything with your legs.  Did you fall?  Hurt yourself in any way?  What's going on?

Not Sure What To Name Her: MY. LEGS.

NurseHubba: You're going to have to tell me exactly what the problem is.  I don't see anything wrong with your legs.

*She sits up and points to three tiiiiiiiny, tiny, tiny little bumps.  Two on one leg and one on the other.

Not Sure What To Name Her: Can't you see those?!?!

NurseHubba: Ma'am, those look like mosquito bites.

Not Sure What To Name Her: Well, they're not! 

NurseHubba: Ok, tell me about them.

Not Sure What To Name Her: I was sitting outside on my porch since the weather's been getting nice.  I was wearing these same shorts.  Suddenly, I noticed that my legs were a little itchy.  I went to scratch and found that there were these little bumps in the same spots my legs were itching!

NurseHubba: You know mosquito season is starting, right?  Those really seem like mosquito bites to me.

Not Sure What To Name Her: Nothing bit me!  I didn't feel anything bite me!

NurseHubba: Do you normally feel mosquitos bite you?

Not Sure What To Name Her: Of course not!  Don't be ridiculous!

NurseHubba: Ok.  The doctor will be in to see you shortly.

Not Sure What To Name Her: Oh, something else too!  I felt like I might, possibly go into A.fib later.  

NurseHubba: Do you have a history of A.fib?

Not Sure What To Name Her: No.

*Facepalm!!!*

Triage That Rash A Level ONE Next Time!!!

Or don't.  Probably don't.  Definitely don't.

At our hospital, we use the ESI triage system, where a 1 is the most critical patient (CPR currently in progress) and a 5 is the least critical (somebody sneezed earlier).

Well, there was a young lady there with her six year old son who had a small, seven inch by 3 inch red area on his left forearm.  It was itchy, and red.  The kid had been playing outside at a friend's house, out in the monstrous expanse of property that people tend to have out here.  The kid has had poison oak before, and it looked just like this and felt just like this.  This rash had been progressively getting worse over the last week or so with continuous scratching.   No, the kid had not been to a dermatologist or his primary doc.

The night this mom decided to bring her son in for the poison oak spot was a particularly rough one.  Rooms were all full.  The on-call nurse had been called.  We had CNAs sent down from the floor to help vitalize, transport, and take care of other CNA-y tasks in order to free up the nurses to do meds, assessments, and work codes.

Out of the 8 nurses there (including the charge nurse and triage nurse), three were in a trauma room with a traumatic arrest, two were in another room (on the opposite side of the ER) working a cardiac arrest, and one (me) was in yet another room working a damn STEMI.  The triage nurse was up front, triaging patients in the waiting room.  With two doctors, we had one in each of the arrests, while one occasionally popped his head into the STEMI since he was close.  This left one nurse to attempt to take care of the other seventeen rooms by himself while the rest of us were in critical situations.

Well, this night happened to be one where the majority of people in the ER were using it for something that they actually needed to be in the ER for.  That meant that most of the other seventeen rooms were needing monitoring, meds, etc.

Ok, so here comes the lady with the poison oak kid.  She marches out of her room (I can see out of the glass doors of the room I'm in) and asks in a quiet and respectful tone screams her lungs out at the poor nurse trying to keep an eye on seventeen rooms.

The Not-So-Patient Patient: This is fucking bullshit!  I've been here for three damn hours!  When is the doctor going to see my son!?!?

Nurse BusyAsHell (in a calm, but stern voice): Ma'am, there are multiple patients in this ER that are dying on the table as we speak.  The doctors and other nurses are in the middle of saving them and bringing them back to life.  You guys are going to have to wait a while.

The Not-So-Patient Patient:  But we've been here three hours!!!

Nurse BusyAsHell: Ma'am, we don't see patients based on how long they've been here, but on how critically ill they are.  That means your son is going to have to wait a long time.  The good news is that he's not the sickest person here.

The Not-So-Patient Patient: Well, if there isn't a doctor in my room in the next thirty minutes, I'm walking right out of here!

Nurse BusyAsHell: Well, that's just not gonna happen, so have a nice night.

*Lady grabs son by the arm and stomps out of ER cussing and yelling.

Buckle Up For Safety. . .

. . . buckle up for fun!  Oh, and, you know. . . your life.

Over the past several weeks, our ER has seen an influx of MVC (motor vehicle collision) folks coming in.

First of all, people do some seriously stupid shit.  So, I guess my first piece of advice is don't do stupid shit. . . you know, like driving 90 on a 30mph winding road.

My second piece of advice is don't be the asshole who tailgates.  I see a lot of people who get rear ended by somebody because they didn't have enough stopping distance when something happened suddenly up ahead.  You know who comes to the ER with injuries from that?  It isn't the guy who was following too close.  It was the person who was being tailgated.  So, don't be an asshole.

My final piece of advice for this little post is WEAR YOUR DAMN SEATBELT!!!  With this influx of MVC folks, I've noticed something.  I'm sure it's different everywhere, but thus far, I have seen this:

100% of the people coming in who were wearing a seatbelt have survived whatever crash they were in.

Also:

100% of the people coming in who were not wearing a seatbelt have died in one of our trauma rooms.

Now, I recognize that there are more variables out there than whether or not somebody is wearing his or her seatbelt, but I've gotta tell you, this is an important one.

So, to recap:

#1: Don't be stupid

#2: Don't be an asshole

#3: Wear your seatbelt 

Thank you.  That is all.

You Don't Have That Right

When you come to the ER, you have a right to be seen.  For better or worse, it's the law.

That doesn't mean that the ER is free health care.  It isn't Burger King.  It's not your way, right away.

Also, coming to the ER does not give you the right to be an asshole.

I know you don't feel good and that you aren't exactly in the best mood.  But, please, don't start bitching at me every time I come into the room to do something.  Don't tell me how unhappy you are or how this is bullshit or how you haven't eaten in 10 hours (you've only been here 3 hours, so what were you doing the rest of the day?) or how the ER stretchers are uncomfortable or how much you hate the doctors, nurses, techs, etc.  If you do want to vent, that's fine.  Get it out of your system once, then let's move on with our time together. But, if you are going to bitch and moan every time I come into the room, I am not going to want to come into the room anymore.  I am going to avoid you like the plague.  I will delay coming to see you for as looooong as I possibly can.

So, if you think being a dickhead will make us really step up our game and provide you that exceptional care you're craving, then you're wrong. . . It makes us hate you.  It makes our sympathy level plummet.

It makes me want to punch you in your throat.  That was specifically covered in nursing school under the "what not to do" column, but keep it up douche-nozzle. . .  Just keep it up. . .

I Should Stop Answering The Phone

*Call from a 30 year old woman. . . yes, an adult*

NurseHubba: Emergency room, this is NurseHubba.

Mothra (high-pitched wail): Aaaaaaaaaah, it went in!  It went in!

NurseHubba: Ma'am, what is going on?  What's wrong?

Mothra: It went in my ear!  It's gonna eat my braaaaaaaain!

NurseHubba (sighing): What did, ma'am?

Mothra: The buuuuuuuuuuuuuuuug!

NurseHubba: . . . .

Mothra: Wait.  I think it flew out. . . . Yeah, it's gone.

NurseHubba: Good.  So, you're all set, then?  

Mothra: Do I need to come to the ER?

*I gave the whole speech about medical advice over the phone, etc while trying to dissuade her from coming.

Fifteen minutes later, I see on the tracker that, in the waiting room, there is a 30 year old female who might have a bug in her ear. . .

Damn.

Another WHY Moment. . .

*Triaging a patient who was brought in by EMS, who gave me a good report.  But, I like to hear things from the patient's perspective*

NurseHubba: So, what brought you in today?

Not Humpty Dumpty: I fell.

NurseHubba: Ok.  What kind of surface did you fall on?  From ground level? What part of your body did you land on? (All these asked as separate questions, of course)

Not Humpty Dumpty: Carpet. Ground Level.  I landed on my butt.

NurseHubba: Any pain?

Not Humpty Dumpty: No

NurseHubba: Weakness or dizziness before you fell? 

Not Humpty Dumpty: No.  I'm just old.  My legs went out from me.  I'm supposed to use my walker, but I wasn't

NurseHubba: Ok, so what made you call EMS?

Not Humpty Dumpty: I fell

NurseHubba: But you're not hurt, right?

Not Humpty Dumpty: No, it happens sometimes.

NurseHubba: Do you usually call EMS?

Not Humpty Dumpty: No

NurseHubba: So, Why'd you call EMS?

Not Humpty Dumpty: I fell

NurseHubba: But you're not having any problems at all? 

Not Humpty Dumpty: Nope

NurseHubba: So, if you're not having any problems, why'd you call EMS?

Not Humpty Dumpty: I fell

*Facepalm*

*Neither the doctor or I ever found out just exactly why he called EMS and came in.  The guy got up and walked around, then got released.*

And Theeeeeeeennnnn?

*Walks in to patient room who came in EMS after hearing ludicrous tale from triage nurse about patient's chief complaint*

NurseHubba: So, what brings you in today?

Energizer Rabbit Of Complaints: My blood sugar's really high.

NurseHubba: Okay, what was your blo --

Energizer Rabbit: And my stomach hurts

   . . . And I'm nauseous

   . . . And I have a headache

   . . . And I'm having chest pain

   . . . And I'm short of breath

   . . . And my shoulder hurts

   . . . And I'm experiencing symptoms of appendicitis

   . . . And I think I have a kidney stone

   . . . And I think I have a urinary tract infection

   . . . And a yeast infection

   . . . And I'm having some rectal bleeding

   . . . And my back hurts

   . . . And I'm pretty sure I'm dehydrated 

So, I guess the better question to ask her is, "what doesn't bring you in?"

Am I Really?

Sorry you and your child had to wait three hours to be seen

Sorry your child vomited once at 8am this morning and was sent home from school (It's now 11pm)

Sorry your child had a 99.2 "fever"

Sorry there were people lined up in the hallway and stacked in the waiting room with silly little things like chest pain, GI bleeds, respiratory failure, and appendicitis

Sorry the docs and nurses had to make sure those people were going to live

Sorry your child was placed behind them in the priority list

Sorry we needed to stop people from bleeding out

Sorry we couldn't place you on top of the "to be seen" pile


Wait. . . No. . . I'm not sorry about any of those things

Wait. . . So, WHY Are You Here?

From my co-worker, Nurse FunnyBone (this is around 11pm):

*Chief Complaint: Left Shoulder Injury*

*Oh, and New Doc ordered a complete cardiac workup on this one*

Nurse FunnyBone: Ok, ma'am.  I have some Toradol for your pain.

Evolving Complaint Lady (without looking away from television, and with perfectly flat affect):  Toradol?  *Grrrooooooaaaaaaan*. . . . Oh, my mouth hurts sooooooo baaaaaad.  It's unbearable.

Nurse FunnyBone: Mouth pain?  What kind of pain?  Teeth?  Gums?  

Evolving Complaint Lady (still staring at TV): I don't know, but it's easily 10+ out of 10 pain.

Nurse FunnyBone: Ok. . . Well, I'll let the doc know. . .

*New Doc finds nothing wrong with her mouth, but FunnyBone and I were both surprised she didn't order a CTA and maybe even a central line.

Nurse FunnyBone: Ma'am, I have some Tylenol for your mouth pain.

No sandwich!  You STOP that!

Evolving Complaint Lady (again, without looking away from TV): Tylenol?  Well, can I at least have a sandwich?  I haven't eaten since noon.

Nurse FunnyBone: No, ma'am.  We don't have food down here.  Besides, wouldn't chewing aggravate your mouth pain?

Evolving Complaint Lady: Meh.

*To her credit, New Doc didn't cave and give any narcotic prescriptions either.  She's really good about that.  Lady was definitely not happy about that, though!

Every Day With This Crap

*Phone rings during a stupid crazy day*

NurseHubba: ER, this is NurseHubba.

Not The Sharpest Knife In The Drawer Dude:  Ummm. . . hi.

NurseHubba: How can I help you, sir?

Not The Sharpest: Yeah, my friend is sick.

NurseHubba: Okaaaay. . .

Not The Sharpest: Well, I don't know what to do.

NurseHubba: Okay, what's going on?

Not The Sharpest: He's sick.  I don't know what to do.

NurseHubba: Okay, sir.  I don't know what you mean by that.  How is he sick, exactly?

Not The Sharpest: He's, ummm, like,  throwing up and stuff. . .

NurseHubba: And stuff?

Not The Sharpest: Yeah. . . like, ummm. . . you know. . . like, diarrhea. . .

NurseHubba: Ok, look. . . I can't give medical advice over the phone, but if he feels like he needs to come to the EMERGENCY room, then he's welcome to come on by. 

Not The Sharpest: Oh, ok.  Cool.  It's free, right?

NurseHubba: Wait. . . what?!?! 

Not The Sharpest: It's free, right?  We don't have to pay for the ER.

NurseHubba (ugh): No, sir.  It's not free.

Not The Sharpest: Oh. . . Well, is it expensive?

*FACEPALM*

Why Bother?

Why do people bother to go to see the doctor?

It's not like most of them actually listen to what the docs and nurses tell them.  Some do.  That's great.  But this post isn't about them.

So many people come in to the ER or to their primary care provider (PCP) for problems, but don't seem to give a crap enough to do what we tell them to.

Case in point:
18 year old female with abdominal pain, nausea, vomiting in the ER.  Turns out the girl has a UTI.  We give her discharge instructions, along with a prescription for some antibiotics and set her up with our low cost clinic for follow up care by the PCP.

One month later, same girl shows back up with the exact same symptoms.  I happen to be her nurse again.

NurseHubba: Oh, no!  Sorry to see you back again (sympathetic tone, not irritated).  

Repeat Offender: Yeah, I didn't get better after last time you people (you people was said in a derogatory tone) saw me.

NurseHubba: The antibiotics didn't help?

Repeat Offender: Nope.

NurseHubba: Well, did you follow up with the clinic to get something else?

Repeat Offender: No.

NurseHubba: Did you take the whole bottle of antibiotics like we talked about?

Repeat Offender: No.  I didn't get them.  I can't afford to buy antibiotics! 

Let me make sure this is clear for everyone.  It was a $4 prescription.  She smokes.  She reeks of it.  She's playing with an iPhone.  Foregoing one pack of cigarettes for her prescription would have been relatively easy.  Hell, she could have panhandled outside the pharmacy to get enough for the script.  She can afford an iPhone and cigarettes, but not her prescription.  Then she bitches at us for not taking care of her properly.

People always want a magic pill for their problems.  In this case, we were able to get her one, but she still didn't take it.

I FEEL LIKE I'M TAKING CRAZY PILLS!!!!!!!!

Discharge Instruction Of The Day

Young lady came in today because she had a pretty violent seizure at the local grocery store.  

She has no history of seizures or any other medical problems, but she does like smoking pot.  

She bought some synthetic marijuana from "some guy," smoked it, went to the store, and had a seizure.

She was ok and was discharged with the had-written instructions from Dr. Discharge:

"Stop smoking synthetic marijuana."

That was a fun discharge to do. . .

Can You Please Hurry?

*4:30am:  Thirty minutes after arrival for chest pain.  EKG unremarkable.  Initial Troponin slightly elevated.  Still waiting on other cardiac enzymes and blood tests.*

Impatient Wife: Ummm. . . excuse me?!?! 

Nurse V: Yes, ma'am?  How can I help you? 

Impatient Wife: I'm not impatient, but when are we going to get to go home?

*Nurse V explains [again] what the plan is, including the meaning of additional tests we are waiting for.

NOT Impatient Wife: Oh. . . well, we both have to be at work at 7am.  Do you think you could hurry it up?

Seriously, lady?  You brought your husband, who has multiple risk factors for ACS, in for chest pain and you just can't wait to get him out of there?  You came in screaming about him having a heart attack and crying.

How about if you just leave and let us take care of your husband, since you don't really seem to care now that the dramatic entrance is over?

Why Can't You Fix Her?

*Family of a 99 year old woman with slightly more altered mental status than usual is bedside*

Dr. Discharge: Well, all her labs look good.  Urine is clean.  She has a history of Alzheimer's that's been getting worse over the years.  I can't find anything acute going on.  We're going to go ahead and send her back to the nursing home now.

*The nursing home, for once, didn't think she needed to come in but the family insisted*

Family: What about her confusion? 

Dr. Discharge: She's been confused for years and, I hate to break it to you, but she's only going to continue to get worse. 

Family: What about her shaky hands? 

Dr. Discharge: She's had Parkinson's for years. . . 

Family: What about her high blood pressure? 

Dr. Discharge: She's had that for years too and is on medication. 

Family: But it's too high!

Dr. Discharge: It's 140/90.  It's a little elevated, but the doc at the home can take care of a med adjustment.

Family: What about --

Dr. Discharge (giving me the look that he's about to lose patience): Look, there isn't anything going on that hasn't been going on for years.  There's no emergency.  There's no acute illness.  This is an EMERGENCY room.  We can't fix or test for every little thing that is going on.  Unfortunately, there's no magic pill or procedure that's going to fix everything she's got going on.  She's ninety-nine.  She's got to see her primary doc at the home.

*Dr. Discharge walks out*

Family (Great, now their attention is on me): Well, where did he go to medical school?!?!  He's the worst doctor I've ever seen!

Some people have no idea. . .

Thank You, Dr. WhiteCoat

I read this post on Dr. WhiteCoat's blog.

He links to a couple of videos that he and his colleagues were watching a lot at the time.  Well, one of those videos stood out to me.  The first time I watched it, I thought, "What the hell?"

But, for some reason, I had to watch it again. . . and again. . . and again.

I then shared it with my colleagues.  On slow nights, goofy videos help pass the time.  

WARNING:  Strong and offensive language.  Watch it and suck it up.  Or don't and don't bitch at me.

Here is the video

Soon, I hope, you'll be quoting along as we are.  The lines from the video have become a staple of our night shift conversations.

Whether The Weather Is Nice

It's interesting to me how much the weather impacts people's "emergencies."

You'd think that an emergency is an emergency, and that, no matter what the weather is, it needs to be treated.  I'm not talking about snow storms, tornadoes, or hurricanes here.  I'm talking about temperature.  People will actually stay home if it is "too cold."

I say "too cold" rather than too cold because I live in a part of the country where it doesn't really get that cold.  If it's below fifty or sixty out, people don't want to come.  Well, ok, fine.  I'm not complaining because that usually means we get patients in who actually need emergency services.

But it's funny that the same person who won't come in because it's cold out will come in on a nice day with the sniffles and tell me how they just had to come because it's an emergency to them.

I've got news for those folks.  If the temperature influences whether or not you come in to the emergency room, it isn't an emergency!

Bond. . . James Bond

*With a dude complaining of chest pain (in English accent) who is definitely schizophrenic and possibly manic*

This was not my patient

NurseHubba: Sir, your name is not James Bond.  Please tell me your real name.

Not James Bond: Bond. . . James Bond.

NurseHubba: Sir, stop that.  Remember that conversation with the cops you had just now?  This is real life.  What's your name?

Not James Bond: Eric Jones (pt gave real name, but obviously, this isn't it)

NurseHubba: Thank you.  Mr. Jones, what brings you in today?

Not James Bond: I'm 91 years old and I'm having chest pains.

*Dammit.  I need to get him back on track!*

NurseHubba: Ok, you're having chest pains.  But you are not 91 years old.

Not James Bond: No. . . no, I'm not.

Finally got him triaged, settled in, and evaluated.  Not sure if he ever really was having chest pains, but he was in his 50s. . . not 90s.  Ended up discharged by the awesome Dr. Discharge.  Also, we had to continuously corral him back into his room.  Every time we had to go help another patient and we'd disappear from his view, he'd start yelling, "NurseHubba!  NurseHubba!  I can't see you, NurseHubba!"

It took about a 20 minute stand off with police in the lobby to get this guy calmed down enough to come to the back.  The guy originally came in with an empty bottle of wine and a hand held work light that he was waving at people like a metal detector wand.  Also, he tried to pull the fire alarm and steal an O2 tank and a fire extinguisher.

Did I mention that the only thing he was wearing was a knee length skirt?

I love my job.  Never know what the hell is gonna walk through that door. . .

Another Day, Another Carnie

We've had a string of carnies (you know, as in folks traveling with the carnival) coming into our ER because there's a fair in town.  Wow.

None of them are your average patient.  One was totally wasted with track marks everywhere (ok, that's normal).  But, he was there because his best friend stabbed him in the back.  His plan was to go stab his buddy to get even.  He said it was "carnie code."  

Last night was a dude whose feet were so swollen, dry, and cracked he could barely walk on them.  And, nine days before coming in, he had fallen down some steel stairs and "scraped" his shin.  

Yeah, that was some scrape.  I pulled up his pants leg to find a four inch diameter hole in his shin.  Yep, the bone was just sittin' there.  All out for God and the world to see.  He said it had been like this for nine days!  Didn't want to go to the hospital because he makes commission off of what his carnie booth (known as a "joint" in the carnie world) brings in.

The best part is, I learned a hell of a lot more than I'd ever want to know about the ins and outs of the carnie world.  Interesting stuff!

Never Again. . .

. . . will I take a sore throat for granted.  That's what she came in for today.

Four days ago, this chick in her early 20's comes in for sore throat, worried it's Strep.  We check.  It's not.  But her tonsils are swollen pretty good.  Script for antibiotics with instructions to follow up with primary doc.

Never follows up with primary doc.  Never fills prescription.  Why?  Can't afford it.  It's four dollars!  Yet, she certainly has no problem indulging her pack-a-day smoking habit.

Comes back yesterday because of continuing concern for swelling.  Yep, everything's ok.  Follow up with doc.  Take antibiotics.  Again, never follows up.  Never fills script.  Still smoking.

Comes back last night.  Same thing.  Same thing.  Same thing.

Comes back again later the same night.  Says her throat is really sore.  After a little while, the girl states that she "feels like she's drowning."  Her throat is swelling up.  Can't talk to us.  You can hear the voice changes when she does try to talk.  Everything else is hand written communication.  Sats are 95% on arrival.  Soon, they're 93.  Then 90.  Shit.

Steroids and anti-inflammatories given.  Doc says, "time to intubate and transfer."  Pt says no.  Can't afford transfer.  Husband (who I'm pretty sure is in his fifties) says too bad.  Do it.  Pt says no.  I want to go home now.  I feel better.  Doc says, "Ok.  Go home.  You're going to die.  See ya on the other side."  Pt says, via pen and paper, "ok, let's do it."

Pt intubated.  Husband is drama.  Pt saved.  Pt transferred.  Everything went great.  The doc, who is my favorite doc we have, says it was a pretty difficult intubation, even though he got it fast and on the first try.

Another life saved.  Strong work, team.

Yep, I've Heard That Before. . .

. . . and it drives me crazy.

Check out this post to see what I'm talking about:

My *favorite* thing to hear

Please Just Go Away. . .

. . . other people need this bed.  Sick people.  People who aren't perfectly fine!

I understand you came in because you were scared.  You started taking a new medication and started breaking out in a rash.  I get it.  Then you called your primary doc and he told you to come in.  I get that too.

But the ER doctor has examined you.  I've assessed you.  The triage nurse has assessed you.  You have a few red spots on your belly.  Yes, they are really itchy. . . but they aren't life threatening.  No swelling of tongue, lips, or throat.  You, yourself, are telling me that you feel fine. . . just itchy.  And you're already on hydroxizine because your doc thought you might get a rash.

So, when I discharge you with instructions from the doc to stop taking your new medication and to continue the hydroxizine, please don't argue with me.  Have peace of mind that you have been looked at by three trained professionals and nobody thinks you are in any danger.

Please don't go out to the lobby, call your primary doc, and have him call to interrogate us for sending you home. . . especially when he hasn't even seen what you look like to assess you!

Does Day Shift Have Any Idea?

I often wonder if the day shift folks have any idea what goes on at night.  Personally, I believe that they think it's slow.  That nobody comes in at night.  That we all just sit around catching up on our continuing education, shooting the shit, and messing around.

Nothing could be further from the truth.  I feel like, more often than not, we clear everything out by discharging patients and transferring people upstairs about fifteen to thirty minutes before they get here.

Then, they show up and see four people on the board.  I'm pretty sure they have no idea and wouldn't believe me if I explained it to them. . .

I Don't Know What It Was

I don't know what it was about last night, but it sucked the soul out of every nurse, doctor, tech, and clerk who worked last night.

To be honest, it wasn't even that busy.  We didn't have anybody that was super sick.  We didn't have drug seekers or drama queens.  No ETOHers.  No psych patients.  It was a fairly reasonable night.  For some reason, it sapped everything out of me and all the other staff tonight.

I actually feel kinda bad.  I usually try to leave the day shift folks with the best situation possible.  I will even stay to make sure stuff is done that they don't have to do.  But, this was not the day for that.  I left my relief in sort of a mess.  I felt bad, but obviously not bad enough to stay any later. . .

Tonight's Winner

Chief complaint of the night.  17 year old male.

"Possible rock in nose"

Man, I love my job.

ANOTHER Stubbed Toe

It is truly ridiculous how many people go to an ER for stubbing their toe.  We had one who was a teenage girl, which always adds drama to the mix.

NurseHubba: So, what happened to your toe?

*Great toe looks relatively uninjured with the exception of the nail having been bent back a bit.

Teen With 'tude: I got attacked!

*Mom facepalms and shakes her head, giving 'Tude a dirty look.

NurseHubba: You got attacked?  What happened? 

 'Tude: A stupid chair decided to attack me!

*Now I'm facepalming. . . internally, of course.

NurseHubba: So, what really happened?

'Tude: That's what really happened!

NurseHubba (getting frustrated after a long night): So, what really happened?

'Tude: It attacked me!

NurseHubba (wondering if I'd get in trouble for slapping her): Just tell me what happened.

Embarrassed Mom:  Just tell him!

'Tude: Fiiiiiiine!  I stubbed my toe on a chair in my room and it bent my nail back. . .

People drive me nuts, sometimes.

 

 

 

 

 

 

 

 

Here Comes Santa Clause

The night started off great.  We only had about eight or nine patients on the board.  Everything had been done.  We had only to wait on some results before decided whether to admit or discharge.  Nobody was in pain.  Nobody was short of breath.  Nobody was puking.  

Then, one of the registrars did it.  She said the dreaded Q-word.  I don't even want to say what the Q-word is on this blog for fear the ER gods will take their revenge tonight at work.  I don't know what the hell the registrar was thinking.  She's not new.  I know she knows better!

Within an hour, we were full with three ambulances on their way in with two chest pains and one shortness of breath.  No discharges were in our near future.  We had New Doc, who moves painfully slow and over-does work ups.  Even when somebody is admitted with orders and report called, New Doc usually still hasn't finished her T-sheet yet, so we have to wait to send them up.  Grrrrrr.  Time to move people into the halls.

As this was happening, the unit clerk came around a corner looking pale.  "I need help!  This guy outside is huge and looks really sick!"  I grabbed the only empty stretcher and another nurse grabbed an ambu-bag.  We headed outside to find the tech and another nurse already trying with futility to lift this man out of the back seat of the van and into a wheelchair.  Once the other two of us showed up, we were able to get him onto the stretcher.  

This guy was huge!  He was taller than the stretcher had room for and was very stout and very wide.  

Yep, that's him.  Only he was taller

I'd estimate weight around 350 pounds.  Once we got him on the stretcher and started checking signs of life (ABCs), we found he was breathing and had a pulse, but was rather gurgly.  He'd have to wait for suction, though, until he got outside.  Anyway, I noticed his face.  It was Santa Clause.  Same beard, same jolly, red face.  It looked just who I imagined he looked like as a kid.  

He could respond to commands, but couldn't really talk at us well.  I checked bilateral hand grip, foot strength, etc while we were wheeling him back to a room.  Yep, left sided weakness.  Droopy face.  Shit.  Santa was having a stroke.  

We flew into the room, got in three IVs at once, got an EKG, doc came in and evaluated, and he went to CT.  Shortly, we had the scan in our hands, and he was definitely having an ischemic stroke.  New Doc did an awesome job.  The nurses did an awesome job.  The tech did an awesome job.  The unit clerk did an awesome job.  We had this guy with tPA running and the helicopter picking him up in record time.  By the time he left, he was already having some improvement.  Found out the guy is doing great.  Santa will be on his toy run once again this year.

These moments. . . these truly life-saving moments, are what I got into emergency nursing for.  I love being able to be a part of saving a life.  

Unfortunately, the fact that we dared take time to save somebody's life really pissed off some of our toothaches, abdominal pains, back pains, and ETOHers.  Even after explaining to them what the wait was all about, they just don't care.  What the hell is wrong with people?

The New Doc

We have this new doc in the ER.  I've posted about her briefly before.

The other week, she was ordering a full cardiac workup on just about everyone.  As I was starting an IV on a 5 year old kid with severe nausea and vomiting for a while to give him some fluids and get blood, the lab tech came up behind me to collect the tubes, and said:

"I'll just go ahead and start the I-Stat Troponin now."

I Just Had To Walk Away. . .

A while ago, I got into a little bit of a Facebook argument (I know, real mature, right?) with some lady. A friend was in a bad place with some back pain he was having and wan't sure what to do.  Not having insurance, he wanted to try to find something other than the ER, since he intended on paying his bill, and didn't want to pay so much money.

He was on Facebook asking for recommendations on what to do.  I gave him some recommendations on places he could go get checked out for relatively low cost in our community.

Well, some other lady told him just to go to the ER.  She said it would be expensive, but not to worry about it because she just walked away from her bill and it never showed up on her credit report, so he should just go for it.

Weeeellllll, as you can imagine, that just really pissed me off, and I wasn't able to go on without responding to her idiocy.  I mentioned how people walking away from their bill means less money for the hospital, which means freeze on raises, freeze on 401k match, freeze on hiring to help reduce other nurses' work loads, freeze on tuition assistance, and suspension of other benefits.  I explained to her that the ones who suffer are the ones who provide her the care, not some big money grubbing corporation (not that it would be ok then either).

Her response?

"It was a LIFE or DEATH situation where I was having an ALLERGIC REACTION!!!  I had to go!  Besides, it took an hour for them to see me and all they did for me was give me Benadryl, so the bill was outrageous anyway!"

At this point, I "walked" away from the conversation.  I wanted to give her a lesson on financial responsibility, but I didn't.

I wanted to tell her that, if it was a life or death situation, then the ER staff obviously saved her life since she is still thieving oxygen alive today.  I wanted to tell her that if, indeed, the ER staff saved her life, then isn't forking over a little bit of dough so that they can have a cost of living raise at the end of the year a small price to pay for her life?  Is there really such a thing as a ridiculous bill for saving one's life?

Also, I truly don't think it could have been that much of a life or death situation if they felt comfortable letting you wait for an hour while they saw to people who were probably coding and bleeding out.  An hour really isn't a very long wait anyway.

I understanding that she was probably scared, which is why she went to the ER, but does that really excuse her behavior of just walking away from her bill?  Then recommending somebody else do the same thing?

What do you think?

Wait. . . Wouldn't You KNOW That?!?!

Chief complaint of the day:

"I think I may have shot myself"

You don't know?!?!

Turns out the guy was cleaning up his house for family to arrive and was putting his rifle in the closet where it was out of view.  The guy needs work on his firearm safety practices.  Well, his thumb hit the trigger and the rifle fired.  The muzzle was pointing completely away from him and he had no body parts anywhere near the muzzle.  He just wanted somebody else to make sure for him.

A Question For You All. . .

Ok, all you experienced docs (ok, fellow nurses too) out there, I have a question for you.

Patient stats:

Male, 45 years old.
DM II
Pacemaker
Hx of MI and "other cardiac issues" as it was put to me by the doc

Pt presents to ER c/o cough, congestion, body aches, mild nausea, "a little bit of lethargy" x1 week.  Pt states that his chest hurts only when he coughs.

New ER doc orders complete cardiac workup.

EKG normal sinus rhythm, not paced.
All labs come back normal.
Chest x-ray unremarkable.

Question for you guy is:

Was that workup reasonable?  Too much?  Given the information presented, what would you do with this patient?  Admit?  Discharge to follow up with primary doc?  Discharge to follow up with cardiologist?

Please answer in the comments.  I'll tell you what happened with the patient in the comments section after I get some answers. . .

Just Another Gastroenteritis

This last fall and winter, we had a huge influx of patients with gastroenteritis, aka "stomach flu."  It seemed like three quarters of our peeps came in with nausea, vomiting, and abdominal pain.  It became pretty routine: Zofran, fluids, maybe something for pain, discharge with Zofran ODT script.

One lady came in who was maybe in her 50s with the same ol' symptoms.  So, what did we do?  Well, the plan was to do the same ol' thing we do for all of them.  However, this one was a really difficult stick.  I couldn't get it and neither could the charge nurse.

So, we gave her some IM meds and held out on the fluids, but the doc really wanted us to have IV access because he was pretty sure she was gonna need fluids.  Luckily, she felt better after the IM stuff and Dr. Discharge was getting ready to let her go.  When I went to do the discharge, though, her pain came back in the worst way and she started retching again.

I let the doc know.  Nothing was super out of whack on her labs and her xray showed a little bit of constipation, but the doc didn't think it was necessary to do a CT.  He ordered a repeat of the same IM meds we gave earlier.  Success!  Until I took her discharge papers in.  Same thing happened again.  Ordinarily, we'd say, "ok, lady, come on."  But she had no history of being in there or any other hospital that we could find.  So, doc gave her the benefit of the doubt.

This cycle of meds, then retching/pain went on one more time.  Finally, the doc said, and I quote, "Fuck it.  Let's just order the damn CT."

He wanted contrast, so we needed the IV.  But, like I said, she was a tough stick.  We had five different nurses try.  The doc tried with an ultrasound machine.  Nobody could stick this lady.  We don't have the benefit of a PICC team on night shift.  This poor lady kept getting stuck over and over and over.  Finally, one of the nurses asked for another shot, and she got it!  Away she went to CT.

In a little while, we got the results back. . . Ischemic Colitis. . . Oops!  Time for surgery!

Sooo. . . Which Is It, Then?

Frequent Flyer, a dude in his 50s, comes up to the ER registration desk and signs in, giving the chief complaint of "left shoulder injury."

Now, just like any other day, it's really busy, so people with a musculoskeletal injury tend to get put on the back-burner while we see the more ill patients.  Mr. Flyer must be noticing that a bunch of people who got there after him are getting to go back before him.

Finally, Triage Nurse Gigantor calls back Mr. Flyer:

Gigantor: What brings you in today?

Mr. Flyer (clutching stomach with both hands): Oooooooh, my stomach huuuuurts soooo baaaaad!!!

Gigantor: Sir, it says you signed in with a left shoulder injury.

Mr. Flyer: Noooo, I don't know why it saaaaaays thaaaaat.  My stooooomaaaaach!!!

Gigantor: Fine, sir. . . (continues triage process) 

Mr. Flyer moves up a little bit to get ahead of some of the other folks and ends up in one of my rooms.  Being as busy as we were, I wasn't able to get in to see him right away, as I was trying to get a critical patients squared away to go to ICU.  I come out of Mrs. Critical's room and see one of my favorite docs, who is notorious for taking no shit come out of Mr. Flyer's room.

Doctor Takes No Shit makes eye contact with me and rolls her eyes.  She comes up and asks me what the hell is wrong with this guy since the triage note says one thing and he's now complaining to the doc about back pain.  I told her I didn't know, but would investigate.   She sits down at her desk and says, "oh, I see.  NurseHubba, look at this."  I look over her shoulder and see that this guy has been given "the mark."  This tells us that the guy is on the narcotics watch list, is not allowed to receive narcs, and has gotten both a letter from the medical director of our ER and a visit from the case manager.

Hmmmm.  Curious, I go in to see Mr. Flyer.

NurseHubba: So, what brings you in today?

Mr. Flyer: My left shoulder is killing me!

No drugs for you!

NurseHubba: Sir, please help explain something to me.  You came in with shoulder pain, told the triage nurse abdominal pain, told the doc back pain, now you're telling me shoulder pain.  Which is it?!?! 

Mr. Flyer: Well. . . ummmm. . . It's all of it.

NurseHubba: Which one is the worst?

Mr. Flyer (without the slightest grimace): Oh, definitely the shoulder.  It's 10/10 pain!

NurseHubba: Uh-huh.  

Since I was helping out to cover shifts, this was during the day, which meant we had a case manager there.  She was the next person to go see Mr. Flyer to explain that he wasn't getting narcotic pain meds. Next thing I know, I hear him yell, "This is bullshit!  This is the worse hospital I've ever been to!"

He takes off his gown and throws it with his "injured" left shoulder and stomps out of the ER.

Gotcha!

 

 

Nurses Who Happen To Be Dudes

I'm no expert, but I've done a little bit of research into the history of men in nursing.  Here's a summary of a few articles I've been looking at this morning on the subject:

Did you know that around the turn of the last millenium, women weren't allowed into nursing?  That's according to this post on allnurses.com, anyway.  In fact, that post has a pretty interesting timeline of the history of men in nursing.

The first nursing school, according to the article/post, was founded around 250 B.C. and was exclusively for men because women were considered to be not pure enough.

It wasn't until just after the turn into the 20th century that men went nearly extinct from the profession.  In fact, according to this Medscape article, nursing schools for men were relatively common in America around 1900.  In just 30 years, the percentage of nurses who happen to be dudes dropped down to less than 1%.

So, what's the reason for this?  Well, there are a few theories.  One, talked about in this article, posits that men found "other, more lucrative occupations" and, slowly, left the field.  I'm not sold on this, however.

Personally, I'm more apt to believe the theory set forth in the previously mentioned Medscape article.  The hero of nursing, Florence Nightingale, lobbied women to take up the call to care for the sick and injured.  Also, she lobbied governments to make it more difficult for men to become nurses, saying that men were "not suited to nursing."  She is actually pretty well known as one of the reasons for the downfall of men in nursing.  Lots of nurses don't know about this, though, because "Flo" is always so strongly doted on as a hero for the profession.  I suppose she is, but she sure made it difficult for dudes.

Graduating class of 1899 from Victoria General Hospital, Halifax, Nova Scotia
(from this Medscape article)

In 1972, it became illegal for education programs to discriminate based on gender (again, from previous Medscape article).  After this, the numbers of men in nursing began climbing again. . . slowly. . . oh, so slowly.  By 1980, we made up 2.7%.  By 2008, 6.6%.

It's a long, slow climb, but we're getting there.  Nursing went from being the doman of men only to becoming known as "women's work."  It's taking a while, but we're working on swinging that pendulum back towards the middle of the spectrum.

One Badass Granny

This was one hell of a night.  Tons of patients.  Full waiting room.  One ambulance after another.  And it wasn't your every day, run of the mill, group of complaints.  Every single patient was sick as shit.

I was triaging that night in our pull 'til full (a system of immediate bedding for patients with triage at bedside) ER.  A lady was brought in by EMS from a nursing home with altered mental status.

One of the first things we do for that here is get a urine sample for a UA.  Also, we will usually get an IV going so that meds like Ativan can be administered easily via IV.  Awesome plan.

Well, this 93 year old lady, who probably weighed less than her age, seemed to have super human strength, as it took about six of us to hold her down for the IV and the Foley that we were putting in.  The whole time, she's screaming at us.  She's dropping f-bombs, cussing us out, and telling us to go to hell.

Then, she suddenly looks at her primary nurse (the one putting in the catheter) and says, "I hope your mother dies, goes to hell, and Satan eats out her p**sy!!!" in one of the most satanic voices I've ever heard.

Add This To Your Bucket List

You just haven't lived until you've seen an extremely combative drunk guy/gal hog tied and carried out of the ER by police.

The Follow Up

One of the frustrating things about working in emergency nursing/medicine is the difficulty in following up with patient outcomes.

We get people in sometimes who get stabilizing treatment, then air lifted or driven to another hospital with services that we don't have, like neurology or level 1 trauma.

Unfortunately, we don't always get to find out what happens to those folks.  One of the amazing things about being in the medical field is being able to make a difference in life or death situations.  The really critical trauma patients that we transfer disappear sometimes into the vast space that is the hospital system and we never know anything about them again.

I often wonder about some of these patients.  In my mind, they've recovered thanks to the excellent care they've received and are living their lives to the fullest.

These Phone Calls. . .

*Phone rings and I'm the only one at the nurse's station*

NurseHubba: Emergency Room, this is NurseHubba.

Ladies Man: Hi, I uh, well. . .

NurseHubba: Yes?

Ladies Man: Well, how do I, ummm, you know. . .

NurseHubba: Sir, how can I help you?

Ladies Man: How do I put on a condom?

NurseHubba: Say again?

Ladies Man: How do I use a condom?

*I'm definitely not going to explain this to a dude over the phone*

NurseHubba: I can't give advice over the phone, sir.  Google it.

Ladies Man: Oh, that's a good idea!  Thanks!

*Click*

A Friendly Tip. . .

If you check your blood pressure once and it's too high:

Give it a few minutes.  Sit down and relax.  Do you have a headache, dizziness, etc?  No?  Good.  Now, after about 15 minutes, re-check your blood pressure.  It's normal?  Good.  Have a wonderful day.

Don't call EMS if your blood pressure is 175/95 after you've been running around your house all day cleaning up for guests coming in from out of town.  Most likely, your pressure will drop a little bit after you've been sitting for awhile.  Sometimes (last night), your pressure will be down to 150s over 80s by the time EMS arrives.  Also, sometimes (last night), your pressure will be down to 130s over 70s by the time you arrive in the ER.

If you do that, and Dr. Discharge doesn't see anything wrong with you (no, you're not getting a full cardiac work-up with labs, etc), he's going to discharge you very quickly and you will have spent more time in the ambulance than in the ER. . . especially if you live an hour away.

That's Definitely NOT An Emergency

Ok, people, it is not ok to call EMS for "weakness," then tell ER staff that your chief complaint is:

"I just want somebody to hold me."

That's going to get you out the door pretty much just as fast as you came in here.

Figure Of Speech

Most of the time, it's a merely a figure of speech to say,

"My best friend stabbed me in the back!"

Sometimes, it's quite literal.

Oh, No. . . Please Stop. . .

. . . talking, that is.

I really don't need to hear all about your day in order for you to tell me what is wrong right now.  Please, for the love of all that is Holy, please just get to the point.

Usually, when triaging, patients are fairly cooperative.  They answer questions.  If I need more information, then I ask them further questions.  It's a simple system, really.  I ask.  You answer.  I walk out of room (we use a "pull 'til full" system).  Simple.

Usually, when I go in to a room to triage, I introduce myself, explain what I'm doing (triage process), then start with the question, "So, what brings you in today?"

The answer is usually, "I'm seeking drugs."  Ok, that's not usually the answer they say, but it is usually short and sweet like that.  "My leg hurts."  Or, "I've been throwing up."  You get the point.

Sometimes, though, the patient starts with what they ate for breakfast, what route they took to work today, why they were fifteen minutes late, who they had messages from on their desk phone, etc.  Finally, they get to the point.  It's an art as an emergency nurse or doc to get past all this crap and get the person to get to the point without threatening our beloved Press-Ganey scores.  Most, I think, are pretty decent at doing this.  However, every now and then, there is that one guy.

The one that no matter how much you hold up your hand and say, "Sir, so please tell me what brought you in today," they continue down their rabbit hole.  On and on and on.  The guy that causes the doc, lab tech, or x-ray tech to give you a pleading look as you walk by, hoping that you can please just bail them out from this conversation.  The guy who causes you to, prior to starting an IV or other procedure, ask the unit clerk to page you over the intercom a few minutes into you entering the room.

The point of all this?  Please, please, please just answer the questions.  I have others to triage. . .

You Can't NOT Give Them To Him

Look, corrections officer dude, I get that your facility is tough on the inmates.  I get that patients don't get certain luxuries.  I get that jail is supposed to be painful.

But, that doesn't mean you can not give a guy his Dilantin for seizures.  Your little trip to bring this inmate down to my ER could have been totally preventable if you had just, you know, given the guy his damn seizure medication! 

I know you know he has seizures.  You have the medication with the jail nurse.  In fact, how is the jail nurse allowing the corrections officers to tell her the inmate/patient can't come get his meds?!?!

It took two phone calls today (one from me and one from the doc) to speak to both the jail nurse and some other jail administrator in order to get this dude the ability to take his three a day Dilantin medications to prevent seizures.

Wanna bet I know who is paying for this little jailbird visit?

Dude. . . Really?

A dude comes in with scrotal pain.  Triage Nurse Gigantor tells him we're going to need a urine sample.  So, he gives him a cup along with the wipes to provide the sample, walks him to the bathroom, and gives him instructions for how to provide a mid-stream, clean-catch specimen.  Dude says okay and returns to the triage nurse a few minutes later, handing him this:

This is actually a duplicate I made to compare
to the actual sample.  They were identical.

Not sure if you can tell, exactly, but what you see is this:  Some clear liquid that is a little bit cloudy with a film of bubbles on top.  Now, I know what urine looks like.  I deal with it just about every day I work.  So does our gigantic triage nurse.

Triage nurse comes back to the ER from the triage area holding up this cup in the little biohazard bag and starts asking every other nurse he finds, just to confirm, "Does this look like urine to you?"  Everyone pretty much laughs and confirms his suspicions that it is not, in fact urine.  Even the doctor (one of my favorites because she doesn't take shit from anybody) chimes in.  One nurse says that it actually looks like soapy water.  Everybody looks at the "sample" again and decides that it probably is exactly that.

This pisses off our awesome doc who takes no shit.  She says that whoever ends up taking care of this guy is going to be giving him an in & out catheter (which is a horrific experience, by the way) in order to obtain a proper sample.

Once the guy finally gets back to a room and gets his cath, of course, the urine looks like. . . well, urine.  Not soapy water.

When doc confronts the guy about the first ridiculous sample:

Dude: What, that's just what I pissed out. (with defensive attitude, posturing and tone) 

Doc: Come on.  You're talking to a doctor and a bunch of experienced nurses here.  We deal with actual urine every single day.  Did you really think we wouldn't notice? 

Dude (sticking to story): No, really, that's just what I pissed out. 

Doc: *shakes head and walks out of room*

What a moron.  Why would he give us soap and water as a urine sample?  Was he afraid we'd drug test him?  For those of you who don't know this, we don't give a shit (legally speaking) if you're using drugs.  We're not gonna call the cops on you.  And, in a case like this, we most likely aren't even going to do a tox screen.  We're just trying to figure out what's going on with you.  And, frankly, if you're ever going to want to provide a real sample to figure out what's wrong, it's probably going to be when you're having scrotal pain.  Wouldn't you want to get accurate answers for that?  I know I would!

Gotta give the guy some credit, though, for sticking to his story until the bitter end. . .