What do you do when you start to feel like a drug dealer at work?

Girlvet asks for input on how to deal with situations where she feels narcotics are being prescribed inappropriately:

It makes me uncomfortable and I would like to bring it up. No doubt I would be shut down immediately with an answer saying its up to the doctor what is prescribed, you got nothing to say about it. It feels unethical to me though. So what do you do? Grin and bear it? Keep your mouth shut and realize its part of being in ER

Here are some of my thoughts on the subject:

1) Most of the time I get the inappropriate narcotic prescriptions vibe, it's for a frequent flyer with a chronic "problem" or for someone who comes in for variable somatic complaints on a regular basis relative to the severity of the complain.

It's a doctor's AS WELL AS a nurse's job to educate patients about chronic pain. Chronic pain management may include: NSAIDS, physical therapy and strengthening, preventive medications (for migraine, for example), abortive medications (migraine), anti-neuropathics (for neuropathy pain), ice during acute stages, treatment for depression or other psychiatric issues which may be manifesting themselves as "physical pain", treatment for other underlying conditions which may make the pain worse (back pain and morbidly obese? neuropathy + out-of-control diabetes?), help with sleep disurbances which may exacerbate the pain, lifting/activity restrictions, surgeries (eg. laproscopy for endometriosis) and, for some people, intermittent opioids and, if all else fails, carefully managed daily opioids.

Notice how "frequent trips to the ER for narcotics" isn't on there.

If a patient routinely comes to the ER with the same complaint over and over and expects narcotics each time or says conventional treatments don't work (or they're allergic to conventional treatments) or is rude or abusive to the staff when it comes to their preferred pain medications, this is a red flag and should not be ignored or disregarded. It's the nurse's job to voice their concerns to the physician and to document any relevant patient behavior or statements "I lost my last percocet prescription" or "only dilaudid works" or "Patient chatting with friends on cell phone about weekend plans, rates pain 10/10" etc.

I sometimes will print a list of visits and attach it the patient's chart to get my point across at the very least.

2) No doctor should suffer ridicule from management for refusing to treat chronic pain with narcotics, especially when the patient is a frequent flyer. Sure, they do, but you as a nurse should pre-emptively back them up in your charting, especially since they're probably going to complain about you too.

3) If you go to work every day feeling like a drug dealer, it probably means doctors really are prescribing narcotics inappropriately. For migraines, I always ask for non-narcotics first if the first treatment ordered is dilaudid or whatever then I document that I asked. I'll also occasionally ask for different routes of meds that reduce the euphoria. Pelvic pain in females? How about a pill with a little sip of water? If a doctor blows you off every time, it may warrant a complaint to your boss.

4) If a doctor gives a questionably appropriate or inappropriate outpatient narcotic prescription, it's the nurse's job to instruct the patient that it is only to be used for severe pain unrelieved by _____ (ice, ibuprofen, tylenol, change in positions, etc). If you know a patient has "lost" a recent prescription or "ran out" soon after getting a prescription elsewhere or something to that effect, it is your job to question the need for a replacement due to the patient's admitted irresponsibility with a controlled substance. Those who come often and lack appropriate follow-up for whatever reason despite referrals being given should probably not be given a controlled substance either.

5) If a doctor seems to give everyone narcotics without much thought, a complaint is probably appropriate.

Why does it hurt when I pee?

Good luck trying to not sing this while you're at work.

Based on the presenting complaint, it seems the song composer had a kidney stone. I think the toilet seat theory is just a red herring. I don't know if anything else could make one's "balls feel like a pair of maracas" AND make it hurt when you pee.

He even does a little mini kidney stone dance in there. Watch for it!

Vertigo: Enough with the frickin MRIs

Vertigo is one of those things that doctors can either be a minimalist or a maximalist on. Most of the younger doctors will just order medications (meclizine/benzos) for a patient who has the classic symptoms of BPPV and tell the patient to follow up with their clinic later that week. Maybe an occasional CT for patients with high risk factors for stroke even in the absence of other neuro deficits. Sure, why not?

Some doctors just do some oddball things though.

Recently, one doctor (Dr. Napoleon) wanted to rule out a vertebral artery nerve compression with an MRI prior to even ordering meclizine. The patient had never had a C-Spine operation or injury or anything like that. He was in his late 70s and dizzy only upon change in positions, including sitting up from a lying position and turning his head side-to-side with intermittent nausea. He'd had a previous episode of vertigo effectively treated with physical therapy and meds. The fact that he ordered this none-too-cheap test without even attempting conventional therapy made me want to puke. Of course, the patient used to work with metal many moons ago, so we had to do the expensive screening CTs for metal fragments in the face too.

So, yes, 10/10, I think doctors like this are weenies.

DR. NAPOLEON, I UNDERSTAND THAT YOU ARE AWARE OF EXTREMELY RARE ALTERNATE CAUSES OF VERTIGO. AREN'T YOU SPECIAL? DO YOU WANT A FRICKIN' COOKIE?

Even if the patient didn't have a problem with his vertebral arteries, he'd be at risk for stroke from the blood clot that was probably forming in his calves from sitting in the department for hours waiting for the MRI scanner, making the head MRI indicated as well by the time the department was ready for the C-Spine MRI/MRA. May as well get that too.

Overheard

"Hey Dr. M! Can you see the new psych patient the medics just brought in? She's nude from the waist down*, restrained, and singing 'Beat It' by Michael Jackson."

*=Yes, she was covered with a blanket, but that's how the medics found her

What broke the doctor?

One of our newer doctors, we'll call him Dr. M, a year or so out of residency, used to be active duty military before going to med school a little later in life. He is very orderly and seems to be able to calmly handle any situation. If there are septic people, people coding, people with decapitated heads just rolling in one after the other by ambulance, not so much as a dribble of sweat graces his forehead. If one part of the ER is busy and his part isn't, he'll go over and help without anyone having to ask for it. Never has an ill word been uttered about another doctor, staff member, family, patient, or anything else. He doesn't gossip, and heaven forbid he should utter so much as a cuss word.

He does, however, giggle quietly at my stupid jokes and say some hilarious stuff every once in awhile.

So, today, from the doctors' corner of the nurses' station I hear an "ARRRRRRRRRGH!"

Holy crap. It was Dr. M. expressing....frustration? WTF?

Nurse K: That's the most anger I've seen outta you since you started here.

Dr. C: That's the most anger he's expressed in his whole life.

So what broke the doctor, you ask? Why did an eek of frustration cross his lips?

Dr. M: I'm sick of people asking for work notes! Can't anyone suck it up anymore?

Yep. Work notes. After that 30 seconds of frustration, he was back in the zone. No more ill was spoken of anyone or anything, birds were singing and a rainbow traveled across the sky over the ER.

Okay, the rest of the day was Hell, but you get the picture. Poor guy was probably building up steam over work notes for months.

Weekend poll: The deaf phone

In our department, we have a TTY phone for the deaf, and it's essentially just a thing that sits there taking up space that we use to receive wrong-number and telemarketing calls. From the deaf phone alone, I've won a free trip to Disneyland, a free flat-screen TV, and have been alerted that my car's warranty was expired.

Never have I ever heard of nor seen a legitimate call from a deaf person who was trying to speak with someone in the ER.

Alas, here is our weekend poll:

Completely random totally awesome video link

Online shopping, webcams, e-bill pay, and e-mail as envisioned in 1967 here.

This blog totally and completely rules, by the way.

*Hat tip to Cosmic Watercooler*

Work note?

A patient pharmacologically treated for mild situational anxiety asked me for a work note saying he didn't want to go to work the following day because he might get anxious about having to work with all this anxiety.

Um. No. Come on, people.

Politics at work? STFU, please

Even though you people can probably figure out my political bent pretty easily on the blog, I pretty much never utter a word about politics at work. I just don't think it's particularly appropriate, unless it's about internal politics, as in, hospital politics, and you're talking about it at some hospital politics meeting. Even then, I try to avoid politically-charged meetings and things because I'd rather just do my thing and let other people yelp at each other.

Overheard at the nurses' station:

Dr. S: [Reading USA Today] George W. Bush has murdered more people than Saddam Hussein. He's responsible for more deaths than Saddam is! George Bush is a mass murderer.

My boss: Damn right!

Me: [In my head] Don't say anything, don't say anything, don't say anything, don't say anything...Don't point out marked lapse in logic, don't attempt to explain Constitutional duties to protect citizens, don't say anything, don't say anything....

I wonder who they'd blame if al-Qaida blew up a bunch of people and they all showed up in our ER. Hm...lemme guess....oh yeah....probably George Bush for pissing off the terrorists and making them blow up Americans instead of sending them gift baskets and chocolates.

Plus, it would be a little disconcerting to overhear that, from your direct boss especially, if you or one of your close relatives served or were currently serving in Iraq or Afghanistan. Like, "Hey boss, my son's in Iraq. You think he's helping to commit mass murder, hm?" I'll assume that no patients nor patients' family members heard the conversation, but....who knows. Those people have nothing to do in those rooms but sit and listen to us talk.

Luckily, the ER was pretty empty, but still. Sheesh. Have a little respect.

I wonder if hooking an ER nurse to it during ambulance divert would break the thing?

Hmmmm....

Circuit boards smokin', flames shooting, spontaneous explosions, software crashing, cords breaking, monitors flickering, fatal errors, gas leaks, sirens blaring....

Rare boredom

I was so bored at work today that I was actually HOPING more patients would sign in. That's pathetic. Shhh. Don't tell anyone I work with; otherwise, I'm sure to get hazed.

Even so, our patient crop was remarkably boring, including but not limited to: STD checks, crotch problems for years, work notes, psych problems for decades, abdomen pain for a millenia, ear pain since last Spring, med refills (including one that wanted a med refill that had a doctor's appointment in 1 hour from the time, um, her ambulance dropped her off) and work notes. Notably, the med refill patient had no ride to the clinic for her appointment, so she decided she better call 9-11 so she could get the med refill at the hospital, the only place ambulances drop off patients. Jesus, can't anyone suck it up and take the bus anymore? We're in a frickin' city, people.

I went out front to talk to the security guard about something and after much contemplation, I signed myself in with the little slip of paper. My chief complaint I had listed as:

Sick of working today. Needs work note to be excused from work.

The elderly receptionist lady asked me if I really needed to be seen. Yes, yes I do.

ER fantasy draft, round 3

Third round draft picks! Here are some 3 am ambulances for you.

The following two ambulance calls were received at the same time. Which one will you take (assuming, again, bed placement is not an issue)?

1) Frequent flyer with mental health problems who is coming in for his third ER eval for "panic attack" of the evening. Yes, evening. Patient called ambulance from gas station across the street after being discharged from your ER 10 minutes prior. Patient will be screaming that he's having a heart attack and begging for ativan as per usual. You're out of paper bags because he'd already breathed into all of them on the previous shift. Patient is likely to make himself pass out due to rapid respiratory rate.

2) Frequent flyer former/current? prostitute and current crack addict with blood alcohol level of 0.56 and crack on board. Will be walking in with the medics and cops for eval. In handcuffs.

Fantasy ER Draft, Round 2

Who would you rather put a Foley cath in? The other patient gets delegated to the aide. You're the nurse, so you get first dibs.

1) Moderately mobile 200 lb lady with history of Munchausen's who has the worst PID the doctor has seen. Patient is putting out copious amounts of stanky pus from her crotchocological region. By "copious" I mean approximately 400-500 cc's thus far. Yeah, that much.

2) 600 lb lady whose thighs are so thick that it would be a blind cath. Patient is not draining anything particularly foul from any particular orifice, but patient doesn't practice optimal hygiene due to weight. You must squeeze your little arms through her thighs in order to reach the area no matter how far she can spread 'em. There are no elbow-high gloves available. Having an assistant to help spread the labia and/or thighs will do you little good.

Who would you take?

Dilemmas, dilemmas. You can only take one patient and your colleagues across the ER will take the other. Which will you take? Assume each patient would be appropriate for each persons' available room.

1) Middle-aged female with history of prescription narcotic dependence and numerous iterations of "chronic pain" syndromes, including but not limited to those pain syndromes that start with "M" and "F", who is belligerent following narcan

2) Wheelchair-bound old guy (unable to bear any weight) with history of neurogenic bladder (self caths at home) who is pissing blood, looks pale, with stable vitals, and history of multiple blood transfusions for the same

I'm pretty sure Monkeygirl would take patient #2.

Huh?

If the environment, or, specfically, medical waste is one of your top considerations when it comes to your personal health, I'm sorry, but you're crayzee or, at the very least, lonely.

Potential patient [lacking sarcasm]: "I'm going to start going to the gym so area hospitals won't have to chop down trees to generate paperwork for me or contaminate the Earth with the unused sterile gauze in a central line kit."

Potential patient's wife: "Don't you care about how dying would affect me? It's all about Mother Earth with you. How about me and the children? Don't you care about us?"

Potential patient's child: "How about not getting sick so you can see me graduate college and attend my wedding, dad? Wouldn't that be nice? Or is it just landfills and paper with you?"

The passive-aggressive doctor

When you get into medicine because you want to drive a nice car, be the "big man on campus", attend galas in nice suits, and purchase expensive racing horses, everyone will dislike working with you because it becomes readily apparent after a few, well, minutes that you hate being there and every ounce of your energy is, instead of treating patients, focused on keeping up the facade of your power. Treating patients is a concern, of course, but only insofar as it advances one's agenda of being the big man on campus for whom the sorority sisters will want to go all Girls Gone Wild.

Don't get me wrong, money should be a primary concern when picking one's career, but there's a difference between enjoying your money and waking up every day just to make a paycheck and not giving a flying frog's ass about anything else.

Our Dr. Napoleon, three inches or so shorter than I, totally hates his job. Of this I am certain although he has never said it as such.

Napoleon likes me, I think; he says hi to me every day and whatever else. However, even with me, he is passive-aggressive as Hell.

So, you ask, how is an ER doctor passive-aggressive?

His main weapon against nurses who try to infringe on his all-powerful territory is the Strategic Ego-Based Denial of Request. Nurses in the ER are used to approaching the doctors and asking for orders for stuff that patients need. Most doctors will order whatever it is we ask for because, as a general rule, what we're asking for is reasonable and it benefits the patient, otherwise we wouldn't bother to ask for it.

However, Dr. Napoleon can't stand that a nurse would suggest something to He Who is All-Knowing, so he deliberately will order something related to what you ask but specifically NOT what you ask for. This is so he can claim full responsibility for it.

For example:
"Can the patient in bed 2 get some Ativan for her severe anxiety? She's really freaking out in there."

"Sure, you can give her 5 mg of IV Valium."

Of course, he also orders as many monitored transports to long, drawn-out tests as possible, even on patients who are not already on a heart monitor, have belly pain and stable vital signs or whatever. This causes long delays in treatment (since we sometimes have to wait 30 minutes or more for the transport nurse to be available) so he has time to go to the doctor's lounge for the 5th time during the shift and watch television and make some phone calls. If he can think of any peripheral reason for a monitored transport, he'll use it. Maybe they're old and have a cough. It might be a PE, better get a monitor. Maybe they're 30 and diabetic with belly pain and stable vitals. It might be atypical chest pain, better get a nurse transport just to be safe. Maybe they're 80 and have shoulder pain with movement and a known rotator cuff problem; better get a monitor to the unnecessary MRI because that shoulder pain just might be cardiac. Who is he to judge afterall?

Of course, in addition to buying him time to make his phone calls, he gets to piss the nurses off and remind us yet-again that no matter what logic and efficiency would dictate, he is still top dog in the department and our protests mean absolutely nothing. I can order something completely ridiculous and you have to obey it, nurse.

Don't even get me started on how he deals with patients. If he spends more than 30 seconds in a room or a total of 1 minute with a patient, you feel the need to ask him if he's feeling alright. There's no explanation of the plan; there's no attempt to differentiate between non-cardiac and cardiac chest pain or whatever. There's plenty of interrupting, there's no time for questions; there's no nothing other than what Dr. Napoleon wants there to be.

So, how do I deal with Dr. Napoleon?

1. Ignore him.

2. Deadpan egocentric sarcasm.

"No, I'm not going to order a neb."

"Well doctor, if you order the neb, you'll be ordering what I think you should order which will show the world that you too have a keen understanding of proper treatment of patients."

I've had him giggle and order what I wanted a couple of times with that. Backfire potential is high on this, and it requires that the doctor already "like" you.

3. If all else fails, tell him in private that he's being a jerk and that I feel it's affecting patient care or that it's pissing me off or whatever. It's amazing what a little heart-to-heart in the Xray room will do to keep someone from being an ass. It also has the big overtone of "if I have the balls to tell this to your face, I'll have no problem telling your boss too", which, to someone who you know has been talked to about the same thing on numerous occasions, may calm the ego and get you what you want for your patient.

4. Tell him to go into the patient's room and explain to him or her why they can't have X or why they need an IV and a chest CT when they're 22 and have a cough. If you can't defend it, you shouldn't order it, doctor. If a patient, for example, expresses concerns about the necessity of a test that YOU as a nurse also think is unnecessary, it's the doctor's job to go in there and explain it to the patient. I'm sure-as-Hell not his PR representative for unnecessary tests.

More on this subject here.

How many female abdominal pain patients under the age of 30 can we get in one lobby?

It's 3 am, and we had 8 patients in the lobby still. All are females under the age of 30, none being of the pediatric variety.

It drains on you.

Retrieve patient. Walk patient to bathroom. Obtain urine. Room patient. Listen to long, drawn-out story of everything wrong with passing mention at the end of oh-by-the-way I've not had a period for 6 weeks. Dip urine, get pregnancy test.

Retrieve patient. Patient refuses to walk. Read complaint as "low abdomen pain and discharge." Tell patient to walk. Walk patient to bathroom. Obtain urine. Room patient. Listen to long, drawn out story of everything related to crotch with passing mention at the end of oh-by-the-way my boyfriend just got diagnosed with chlamydia and can I get an STD check and a pregnancy test? Note that abdominal pain started same evening as patient learning of probable STD status. Dip urine, get pregnancy test.

Retrieve patient. Walk patient to bathroom. Obtain urine. Listen to tale of woe which includes heavy lifting and back discomfort and oh-by-the-way my urine smells funny and I've had 8 kidney infections in the past. Dip stinky urine. Obtain pregnancy test.

And on, and on and on with IVs and IVs and IVs and contrast and contrast and pelvics and cultures and urine and urine and URINE and whiny and whiny and dilaudid and morphine and tenderness in all 4 quadrants and frothy foul-smelling neisseria discharge and crying and IVs and IVs and contrast and dilaudid and contrast and cultures and menses and endometriosis and percocet and ovarian cysts and Vicodin "allergies" and fibroids and IVs and IVs and IVs and contrast and negative workup negative workup and negative workup and trichomonas and pyelonephritis and whining and whining and WHINING. Stop hitting the damn call light already.

I give up

A chick who'd been having "kidney pain" for 3 months calls 9-11 to be brought to the hospital because the cab or bus makes you pay up front and you can ignore an ambulance bill. The UA and bloods are negative, but Dr. Bloody Gloves writes her a prescription for an antibiotic anyway (asking him why I'm giving her an antibiotic prescription for a completely negative work-up didn't really yield any sort of cogent answer). The patient complains she doesn't have $4 to pay for the prescription (after telling her it's one of the $4 Wal-Mart antibiotics).

So, basically, our uninsured patient will pay $1000 for an ambulance ride and $700 or $1000 for the ER bill to look at her 3-month-old problem because $2 for a bus was too expensive and, after all that, she didn't have the money to pay for the outpatient prescription anyway.

*Sigh* I give up.

Holiday tradition addendum

[Background]

Nurse K: Dr. Dad, ya know how yesterday it was cold and the air was crisp, seasons changing and whatnot? You know what that made me think of?

Dr. Dad: What?

Nurse K: Sarah Smith.

Dr. Dad: WHEN I SAW YOU THIS MORNING, I THOUGHT OF HER TOO! You know she'll be back this year. Right about the same time everyone else is carving their turkey, she'll be getting IV dilaudid and making one of the nurses cry.

So, yes, dear readers, both I and Dr. Dad immediately think of this patient when the seasons begin to change. Waiting for her to either arrive or not, starting now until the end of the Christmas season, is like waiting for your AIDS or tumor biopsy or NCLEX test results to come back, or, most accurately, waiting for all of those to come back at the same time. The anticipation/dread/suicidal ideations are too much to handle.

The air is crisp, the countdown is on

Since everyone is talking about migraine/headache patients (the term "migraineur" is irritating and should never be uttered by another human being again), I'll tell you about our little holiday tradition.

It all started when I worked up on neuro as a floor nurse. The night before Thanksgiving, an overnight "headache" admit came, and I knew I was in for the usual drug-seeking/whiny behavior that I'd come to expect from such an admit. However, nothing could have prepared me for the wafting stench of manipulation and verbal abuse from the patient I'll call Sarah.

Sarah was a patient with a grandiose tale. She'd come from a state two states over to be with her family for the holiday when her TERRIBLE headache came on. She added on a story of woe that included a busted ventricular-lumbar shunt that needed repairing and oh, there's only one surgeon that she trusts to look at the shunt and she'd not allow anyone to investigate the shunt in my state. The sub-par performance of the shunt caused "severe" headaches that were frequent. Or something. She also added on that the shunt was working so poorly that she was nearly blind. Or something. However, she'd just prefer to wait for the one surgeon two states over to repair it, and in the meantime, it was "standard" for her to receive high-dose narcotics for her headaches as well as spinal taps to remove fluid, which the ER doctor did, finding normal pressures in her spinal fluid and no other abnormalities.

She had a neurologist there, but refused to be treated by any neurologists in my hospital because only that one "understood" her problem. She, of course, declared that IV dilaudid chased by Benadryl was the only thing that worked.

At first, I figured maybe her tale could be true, but after the hours and hours and HOURS of her following me around (remember, this is like 3 in the morning), yelling, cussing me out, following me into other patients rooms to demand narcotics or threaten to leave AMA (go ahead, I'm not stopping you), I knew her to just be a plain 'ol narcotics addict with a tall tale. I tried to reason with her that "if she was going blind, it would probably be a good idea to have someone look at the shunt" and, nope, she didn't trust anyone in my state to do so, she'd rather go blind and oh-by-the-way can I have some more dilaudid, you nasty cunt.

At 5 am, I called the hospitalist on call, and pretty much demanded that she come up there and pat the patient on the head and tell her to leave me the F-itty F-F alone or authorize a 1:1 security guard because she was disrupting everyone.

And on and on and ON it went over the entire Thanksgiving holiday until she finally left AMA.

So, next Christmas, a year later, she came back. A holiday tradition. Same thing. I remembered her tricky little story (the shunt STILL hadn't been repaired, heavens me, even after a year) and the CSF was STILL normal and she STILL required high-dose narcotics for her pain and she was STILL going blind. This time, it took 3 ER visits before the doctor admitted her. I proceeded to put a pagan voodoo curse on the ER because she'd ruined my holidays 2 years in a row. Same deal, verbally abusive, following me around, refusing to stay in her room, screaming at me, etc. She even tried to convince me that she hadn't been there last year and it was her first time in our facility.

So, the year after, I was working in the ER and I heard the doctors and staff talking about her impending arrival, since she'd made quite an impact on them as well. In 3 weeks, it's Thankgiving, Sarah will be back! Last year it was Christmas, this year it will be Thanksgiving!

I immediately knew what they were talking about. She did not come that year.

Wonder if she OD'd.

Although, it's still an inside joke between me and the ER doctor who saw her 2 years in a row. One time, back when we had more control over the input of names into the computer, the little sh*t doctor "registered" her and had triage in on it, getting me all worked up. Ha ha, very funny.

Today, the air was crisp and, officially, the Sarah countdown will be on.

A visit from a friend whilst on vacation

I dreamed about you while on vacation. I was in San Antonio working in the ER even though I've never been there, and you came in by ambulance. You walked funny from, presumably, your stroke and couldn't talk very well, but, in between my tears, you managed to tell me that your second child had just died. You had no second child. You said his name was "Billy, Jr".

You looked good, though, Connie, considering you've been dead for over 6 years now. See ya again in a few months.

I don't care what you say, I'm going!

Flame on without me for a few days. I'm getting the Hell outta Dodge 'til Tuesday night.

Anyone want to hazard a guess as to what that white thing is on his neck?

When armageddon is upon us, what will YOU do?

After reading Ambulance Driver's chilling tale of a battle between Sumdood's evil army of meth-mouthed drug seekers and the staff of a small, podunk ER, I thought:

If we are next, we're screwed.

I mean, we have no battle plan. It will be chaos. So I have worked feverishly to come up with a tentative rough battle plan should Sumdood's Evil Army invade our ER. Find your job and rehearse your role until it is second nature.

Big, hot-bodied fire medics: Pull the fire medics out of the room where they keep the free Lorna Doones and Oreos. Hot-bodied fire medics shall remove their shirts (no particular reason other than to give me something to look at) and post themselves in front of the door to the locked med room where the Pyxis machine is stored. The Evil Army is going for the Vicodin, phenergan, demerol, and Percocets and you need some muscle guarding the booty (and I only want yummy hot-bodied fire medics guarding and protecting MY booty). Their weapon-of-choice is their brute force as well as the nitro spray they give to everyone who complains of pain anywhere in the torso or upper extremities, regardless of age, risk factors or symptoms, making them pass out.

Nursing thugz: After the ememy's BPs drop to 80/60, the nursing thugs shall GRIP THY BANDAGE SCISSORS 'O DEF and pull up the right flank near the door from the ambulance garage. The door to the ambulance garage is in plain view of the street corner where all these regulars hang out, so you know they'll use this "staff only" entrance to gain access to the ER. If the meth-heads aren't intimidated by the BANDAGE SCISSORZ, you can always at least make the males ages 20-55 run away screaming if you threaten to Foley cath 'em. Note that even light tapping on long bones and vertebrae of meth-heads with bandage scissors will cause their bones to spontaneously shatter. Overhead page for an EKG stat near the med room.

ER techs/aides: Respond to page per protocol. Grab portable EKG machine and ram the remainder of the Evil Army as they approach med room with EKG machine as fast as they can saying, "Who needs an EKG?"

Security: Stand there, spend 10 minutes applying gloves, watch staff members get their asses kicked in hand-to-hand combat, wait for back-up, smile as they purposefully make keys jingle as they go in the break room and take food from yesterday's potluck.

House nursing supervisor: Come down with code clipboard and record the battle's play-by-play. Use no inflection in voice under any circumstance. Ask charge nurse about staffing needs for the battle. Tell charge nurse they'll have to work 2 soldiers short for next shift.

Nursing students: Calculate drip rate of blood dripping from the wounded. Say things to Evil Army like, "It must be hard being addicted to prescription pain medications."

ER resident: Stab the soldiers in the chest wall with scalpel so he can put in a chest tube. Make sure to let them bleed a little too, so he can place central lines for rapid blood infusion. Call blood bank for uncrossed blood in the wrong blood type. Go to doctor's lounge and get arm-full of Pepsis and egg salad sandwiches for other ER doctors. Listen to and ignore requests from nurses and other staff members to pilfer egg salad sandwiches for them too. Hey, we need someone to feed the troops. May as well be the ER resident.

Housekeeping: Wait for busiest, bloodiest part of battle and fire up loud wax machine, running it through the battle zone saying, "Move out of way! Need to wax floor! It Thursday!" Make soldiers on both sides slip and fall. Put up excessive number of yellow "Wet Floor" signs, causing mass chaos as people trip over them.

Charge Nurse: Frantically re-arrange ER carts so that they block entrance to the med room. In other words, make it look like a typical Monday afternoon bed configuration.

Unit Secretary: Unplug computer and phone equipment and throw at Evil Army, making sure to break all the outdated stuff. Call Help Desk, report that computers are all broken, dangit, and we'll need new ones.

Transport aides: Evac wounded to CT, making double sure not to hook the bad guys back to the heart monitor when they return from the test; in other words, do what they usually do. Do not tell anyone when they take a wounded soldier and CERTAINLY don't tell anyone when they come back.

ER physician: Run to area where prescription pads are located, writing out hundreds of prescriptions of 150 Vicodin each, saying, "Just get them out of here. Refer them to the charity family practice or dental clinic for follow up." Write down a-hole doctor's DEA number so he gets hundreds of calls from pharmacists questioning need for 150 Vicodin.

Triage nurse: When the Evil Army is defeated and killed or discharged to street after acknowledging understanding of wound care, medications and needed follow-up care as explained on discharge paperwork, wait 1 hour and start to sign them all in again as they come back a second time that shift saying they lost their first prescriptions. Audibly mumble, "F*ck EMTALA, man. F*ck JCAHO. F*ck Press-Ganey. F*ck 'em all."

Change of Shift is about protective barriers

Change of Shift is at Someday Nurse and the theme is those little protective barriers known collectively as student nurses.

Bum vacation, Day 6

Things to do tomorrow (8 am-4pm):

1) Send my son to school
2) Check blogs, email, maybe write something
3) Take nap
4) Watch "Antiques Roadshow" on Tivo
5) Drink coffee
6) Look at pile of clutter near front door, ignore it for 6th day in a row
7) Check blogs
8) Text taunting cell phone messages to friends about how it must suck to be at work
9) Look at weeds in front yard, ignore them
10) Remove laundry from dryer that I did 2 days ago, bring laundry into bedroom, leave in laundry basket
11) Look at bed in bedroom, think about making it and, instead, settle down for 2nd nap of the afternoon
12) Grab a spoon for a microphone, stand on my computer chair and rock out to Heart
13) At around 3pm, laugh because I just got paid for 8 hours of work

No fretching this time

Dr. Whitecoat at White Coat Rants today talks about a couple of his most "jaw-dropping moments" while working in the ED.

A drug-seeker spits in the face of an attending, and what goes on after is...excellent.

I must admit that after reading this piece, I'm questioning if said jaw-dropping moment isn't just an ER legend. ER legends are those stories that happened "ten [or more] years ago" that are so goofy as to provide some sort of comic relief but where you suspect the facts have been altered to some extent in order to make the story more interesting. I'll give the doctor the benefit of the doubt though.

Be sure to also click the link which describes the term "fretching" too. I'm definitely using that. I usually call that "dramatic spitting" or "bullsh*t", but I like "fretching" better.

The student nurse

Kim at Emergiblog is talking about student nurses today, and so I thought I'd tell you a little tale.

First of all, YO, more student nurses in the ER please. Student nurses, for some reason, give the ER some sort of protective barrier whereby no patients can pass through the gate. Seriously, whenever there's a nursing student, no one is critically ill and there seem to be fewer overall patients.

I'm sure 95% of the nursing students in my state think all we do in the ER is swab throats for strep and that myth of critically ill patients is something we make up for TV shows. So, YO, nursing students fight the good fight. FIGHT for more observation days in the ER. We'll take ya, you little angels of mercy, you.

So, I had a nursing student with me one day (we don't seem to assign our students to anyone so much as pass them around whenever something "cool" is going on, if something cool is going on, which is rare), and we got an ambulance call saying an elderly guy from the nursing home who was recently admitted and discharged after having urosepsis was coming back with a low blood pressure in the 70s.

First, I cursed her for not turning the protective shield on when she came to clinicals. After the cursing, we had a brief discussion on sepsis, how low blood pressure can be a sign of severe sepsis, and what we normally do for that. I said the action plan would be to check vitals, attach the patient to the monitor, and if the blood pressure was still low to hang fluids as fast as we could. I explained, not entirely unseriously, that in the ER we had four speeds of fluid for new patient arrivals: (1) TKO, (2) almost but not quite wide open, (3) wide open, and (4) pressure-bagged since nursing students always want to calculate drip rates. While we did our full assessment, we'd look for other causes of low blood pressure such as GI bleeding, a heart problem, dehydration, or C-Diff diarrhea from all those IV antibiotics and all that.

At the end of the day, the nursing student extensively thanked me (like listed off all the reasons why she enjoyed working with me etc), and went on her merry way.

Weeks later, the nursing student signed in as a patient in the middle of the night and complained of persistent body aches and fever. I didn't recognize her at first, but she said she was glad that I was her nurse. Not remembering who she was, I asked her why that was, and she explained who she was and said, "I was awake again tonight in pain and just remembered that you knew so much about that sepsis patient, and I thought that I should come back here so you could figure out what was wrong with me." She'd apparently drove from a different city just to come be with us because "we knew a lot about nursing care". She'd also apparently asked the triage nurse if I was on.

Awwww....

Chocolate Fever

My 7-year-old and I have been reading the book Chocolate Fever at the rate of about a chapter a night. The basic idea is that a little boy named Henry who eats too much chocolate suddenly develops a febrile illness, complete with spots all over his body which look and smell like chocolate. He has a bumbling physician named Dr. Fargo who doesn't seem to know a pimple from a hole in the wall. After being admitted to the hospital, the boy becomes scared, goes AMA, gets picked up as a hitchhiker by a random older black male (with whom he has a lunch and a discussion about what it's like to be different, as what normally happens when children get picked up by strangers), gets teased for his spots by other schoolchildren, and so on and so forth.

In one place, Amazon says this book is for ages 4-8. If your 4-year-old can read and understand this book without constant help, your kid's a genius and will likely work right along with the physician in the early part of the story, saying things like: "Mommy, why don't they send some of the spots to the pathology lab for analysis?" or "The boy needs a derm consult!" or "Mommy, why don't they start the sepsis protocol?" or "Maybe that Dr. Fargo should check UptoDate if he's not sure what it is!" or "They should make some slides of the exudate and present it at conference!" or "Mommy, I'll bet the hospital will be held liable if anything bad happens to Henry after he escaped. I hope they have a world-class risk management and PR department." or "If the sores are known to be exuding 'chocolate', a known manufactured substance, and he senses a popping with each sore coming up, a psychiatric explanation would make sense, sort of a one-off variation of Morgellons Disease."

You know, the usual stuff 4-year-old geniuses reading a book about a mystery medical condition would say.

In response to these tough questions, I recommend saying to your 4-year-old genius: I don't know, dear, this was written in the 70s. The only things they had then were leeches, penicillin, digoxin, aspirin, and the precordial thump...now do you want to wear your Spiderman or Spongebob pajamas?

There was a street fair this summer in my 'hood and the used book store had 10-25 cent books for children in a tent, so I grabbed an assortment. This was one of them. Best 25 cent purchase I ever made, especially because I get to say "Chocolate Fever" every night while giggling at its alternate meaning.

Delegation

So, speaking of techs, we have really good techs in our ER. On the floor, I was accustomed to spending a great deal of time convincing the aides to wake up just long enough to take someone to the bathroom or change a diaper. In the ER, there is no getting around working. There's no homework, Yahoo Games, nor "let's disappear and take a nap in the visitors' lounge for an hour and a half". If you're in the ER, you're working and you're usually the best. I can't say that any of our techs are lazy or whatever else.

To me, a nurse who insists on doing everything herself and not delegating is doing herself and her patients a disservice. So, good 'ol Nurse K and the boss expect the techs to hook the patients up to the EKG machine when they show up for chest pain. An overhead departmental page for an EKG is supposed to result in an aide running towards the room with the machine while I'm starting lines, giving nitro and aspirin and all that stuff that I can't delegate. This set-up is played out numerous times per day in order to quickly diagnose a heart attack so those that need to go to the cath lab get there as soon as possible. Teamwork is essential to save that precious ancef-pumper.

So, at some point recently, it occurred to me that I hadn't done an EKG myself in a long time. So, when one was paged for overhead and I saw no aide running with the machine, I responded to the page and commenced hooking the patient up. I had all my leads in the right spot and was getting ready to switch the machine on when I realized....I can't find the on/off button. All the buttons had been pressed so many times that some of their labels had been worn away. I just started pushing all the anonymous buttons as my heart raced. One of these suckers must turn the machine on. Not a single one turned the machine on. Can I start a line, give some nitro? Something else? Where is the damn aide?

Yes folks, I had to ask HOW TO TURN THE DAMN MACHINE ON.

Then I shunk to 1.5 inches tall and crawled away on my hands and knees.

The obligatory doctor name post

Geena and Girlvet have commented on this recently, and it's a common point of discussion for new ER nurses.

What do you call your doctors? First names, or Dr. Lastname?

I was aghast when the people I worked with referred to doctors by "Andy" or "Bill" or whatever. I'd never ever seen a doctor referred to as their first name. I was not ballsy enough to start on that myself. Who am I to be calling a doctor by their first name, I thought.

Even if a doctor told me to call them by their first name or introduced themselves with their first name, I just said to him or her that I couldn't call them by their first name. They'd just laugh and say it was okay, and I'd still basically refuse for whatever reason.

One day, I overheard the following:

Nurse P: Dr. Lastname, could I get an order for some pain meds for the patient in room 5?

Dr. Lastname [whispers]: Don't do that.

Nurse P: Don't do what?

Dr. Lastname: Don't call me Dr. Lastname. It makes me feel weird. Just call me Andy.

After that, probably 6 or 7 months into my ER career, I started calling Dr. Lastname by his first name. Generally, the new doctors who'd just finished residency would tell you straight-up to use their first names, but the older ones didn't seem to mind one way or another.

Even doctor Lastname introduces himself to patients as "Andy, one of the doctors." He doesn't like the whole last name thing. He, in essence, introduces himself to patients the same way I do ('K, your nurse' or 'K, one of the nurses here').

So, now, basically, nearly all doctors get referred to by their first names by me because I've been there long enough, and they seem to like it. However:

1) If there is an attending or consultant there, they're still Dr. Lastname, sometimes because, Hell, I don't know their first name anyway.
2) If there is a new doctor there, even young, strapping-buck residents, I call them Dr. Lastname until they tell me otherwise. Most do immediately. I would consider anything else to be rude. Even though I'm not old-school, I still call anyone with a doctorate in anything "doctor", even the Doctors of Nursing when I was in college, which was kind of weird.
3) If I were to work on the floor again, everyone would immediately become Dr. Lastname because there isn't the same camaraderie between nurses and doctors when working the floor. In some of the specialty departments, like surgery, interventional radiology or endoscopy where the doctors are usually the same few, I may revert back to the first name thing.
4) It's more polite to do what the doctor (or anyone else) wants with respect to name. When Dr. Lastname said it made him uncomfortable to be referred to as Dr. Lastname, that sealed that deal. It takes awhile for a floor nurse used to working with six thousand attendings to get used to this though.
5) In front of patients, even with Dr. Lastname who calls himself "Andy" to the patients, I call the doctor Dr. Lastname.
6) Here, I call myself Nurse K so people know what it is that I do, but I don't put the Nurse in front of my name in real life, except to be sarcastic at times. A couple of the older nurses do call me Nurse K**** though for whatever reason. I don't mind it, nor do I really think about it.
7) It should be noted that ER doctors even call consultants by their last names sometimes. This is kind of funny. One male ER doctor even calls all consultants "sir" or "madam" while communicating over the phone.

So, in short, I recommend calling all doctors Dr. Lastname until they invite you to do otherwise or the culture of your department is overwhelmingly to call the doctors by their first names. If you're new to the department, I'd still resist the first name thing a little bit until you've been there a few months and are more familiar with the doctors' personalities and they know you better.

The online long-distance relationship

If you haven't noticed, I'm on vacation from work and, mostly, from writing about work. If you want to only read funny or interesting tales from the ER, come back sometime after September 12th. I'll be en belle forme again at that time.

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When Babs and Ambulance Driver announced that they were "in love" a little bit ago, I immediately assumed they've been chatting online, emailing, and, occasionally, making the trek to see each other and that this has been going on for a long time.

While it's not particularly obvious, it seems that they have, in fact, never met and they're being totally serious about this love thing. Like, ya know, sometimes bloggers will say they have a "blog crush" on so-and-so because they enjoy their writing or they're hot or whatever. But these two are carrying on like wedding announcements are imminent.

And, to reiterate, they've [based on my inferences] never met.

This situation is perplexing to me, enough to occupy my overactive mind that needed something to think about while painting my office and doing the dishes this weekend.

This topic is of particular interest to me because back in April, I ended my long-distance relationship. Even though I found Mr. Darling via my [defunct] blog, I never uttered a public word on my blog about the relationship. Now, our relationship was a little more extensive than the usual long-distance relationship. We chatted and emailed for a long time first, just for fun. It seemed our senses of humor and general views on the world were pretty similar. We decided to meet, and for 8 months or so, he alternated between flying me to his state and flying himself to my state, usually one time a month for 4-5 days or so at a time.

While together, we did normal boyfriend and girlfriend things, including traveling to other cities, going to a wedding, going to friends' parties and houses, going shopping, making dinner, seeing movies, long walks on the beach (literally), walking the dog, etc. The whole time, save when he was snoring ;-), I was at perfect ease and felt perfectly comfortable and content. Leaving was sad, but I always knew I'd get to see him again in a month.

However, I'm not an idiot. There is a reason why people usually marry people who are in close proximity to them. At a certain point, not having relatively close contact with your partner is unacceptable. All your friends have a boyfriend or husband to take to a wedding, you don't. Everyone you know goes to the bonfire I talked about in the previous post, but you are always alone, unless it just so happens he's there that weekend visiting. It's Saturday night and you want to stay in and catch a movie. You sit there by yourself and watch the movie or spend it with your friends and their boyfriends and girlfriends....And, at some point, being on a plane for 4 hours ceases to be fun and exciting. In addition to that, traveling took away from time with my son, and I needed that too.

So, when I first started referring to myself as Mr. Darling's "girlfriend", I flat out put an expiration date on the relationship. I said that if he was unwilling to move to be with me after 1 year, the relationship would be over, no matter how much we liked or loved each other. Sure, there was some flexibility in that, but not too damn much.

I'm young. I'm not terrible looking. I didn't want to wait indefinitely. Sure, he said that he wasn't tied to his location and, since he worked from home and could do his job from any location in the world, he wouldn't have a problem moving should the relationship continue to be good. On about the 8th month, I essentially forced him to give me an update on what the overall plans for the relationship were. He told me that he wasn't willing to move ever, not because he didn't like me, but just because he liked where he lived and didn't want to move. And, thus, I kissed him goodbye. With a smile masking my disappointment, told him I would never be seeing him again, and walked into LAX.

So, why am I spilling my guts? This Babs-Ambulance Driver thing makes me sad. They say how much they love each other, but have never met. They're having that realization that I had back in July 2006 that 'I may have found someone that is just what I'd been looking for'. That excitement. Why does it make me sad? Because that distance thing is pesky and difficult to overcome and will eventually end the happiness should one of them not decide somewhat quickly to move.

Moving for an adult, of course, isn't what it used to be in college where you just borrow your dad's van and load all your shit in there at 3 am after treating your friends to beer, leaving everything that won't fit for your landlord to dispose of. There are children who would lose their school and who would be stripped of, presumably, other parents, grandparents, and their friends, not to mention your friends and family as well. When someone wants to move away from a non-custodial parent, usually the custodial parent has to go to court and testify as to the justification of taking the child away from the other parent. At least in my state, it's nearly impossible for the judge to "release" you from the state.

Now, I'm practical and never said "I love you" before meeting Mr. Darling, and, as far as I can remember, not even after I met him. To me, saying you love a man is the highest level of a relationship, right before he asks you to marry him or something like that. Sure, being treated like a piece of shit for 6 years doesn't help my cause when it comes to telling someone else you love them, but, really, it's not a phrase to be taken lightly, and, surely, not one you should say to someone of the opposite sex whom you've never met. Sorry. My blog, my opinion. Don't take it too harshly.

Here's the other weird thing that's been bugging me lately. It's really not fun to be broken up only due to distance, knowing full well that, absent the distance, it probably would have worked. That thought sort of creeps into any further attempts at relationships, let's just say. It nags at you, it says, "This just isn't as good."

If only he'd cheated on me, or punched me between the eyes, or called my mom a bitch drunk in public, it would have been much easier.

So, Babs and Ambulance Driver, good luck, but give yourselves an out, so you're not waiting around indefinitely for one or the other to decide to move. Trust me, at some point, not being together on a regular basis will become intolerable; if it doesn't become intolerable, you were never truly in love to begin with.

Overhead at the party I went to last night

First of all, this party's pretense was a little funny in an of itself. There have been some major wind and rainstorms around here lately, causing damage to homes and basements to flood, etc. The pretense of this party, held in a 1st-ring suburb, was that "a lot of my tree fell down and I have a fire pit". Alas, BIG FRICKIN HUGE BONFIRE. I'm pretty sure a 2-story tall "bonfire" in quiet suburb would violate some city ordinance somewhere, but, eh, if the cops come, the cops come.

Here are some of the good quotes from the party last night:

1) "Yeah, that last storm was bad. When I got home from work, I found my wooden fence blown over and nine Mexicans in my backyard." [Apparently, there's a pond in his backyard and the Mexicans were mostly children feeding the ducks.]

2) "Who the Hell dresses up like a ninja for no reason and brings nunchucks to a party?" [Later, this guy 'Nunchucks', who was literally dressed as a ninja for no reason, started ralphing behind a pickup truck. It was sublime.]

3) "Are we burning all the lawnchairs or just that one?" [After a lawnchair broke, guess where it went?]

4) "Yes, I'm the younger twin. I was 6 minutes behind my sister on the vaginal waterslide."

Drug seekers and children

ERNursey goes beyond the call of duty to keep a "mother", who wasn't even a patient, from driving off with a child while being seriously impaired from a Fentanyl pop.

I had one patient who, I believe, had "real" pain from a herniated disk in her neck ask me, after I gave her a prescription for Percocet and explained the side effects, if I thought she should find someone to watch her children while taking it. She had an infant and a 2-year old or something, and I said yes, definitely. She thanked me for my advice and started to call some people on her cell phone, explaining the situation.

It occurred to me that nobody in the entire year and a half or so that I've worked there ever asked me that. Hopefully, all these people (e.g. 100% of the patients seen on any given shift by Dr. Bloody Gloves) who are taking Percocet realize that they're tired and a little whacked out and find someone to watch their children.

I suspect that doesn't happen though.

I'm catching the bug

Real estate investment.

The house right behind me is a a foreclosure that I could sell for at least 70K more than they're asking for it right now in its semi-crappy but cosmetically rehabbable state. A good 20K or less into it and I make 50K minus taxes.

I may just do it.

Watch me.

I was going to wait until next Spring to start my investment career, but it's like the money is taunting me every time I drive by that house.

Could I do it? Yes. Am I ballsy enough? To be determined.