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. . .