Stock up on oral and nasal airways and party it up!
I'll be ringing in the New Year by filing a police report against the ex for refusing to return my son today as ordered by the divorce decree. Apparently, he thinks he has the magical power to just decide whether he wishes to follow a court order or not and, on top of that, decide that he'll take him to a different state whenever he feels like it too, whether or not it's his day to visit him.
I gave the bastard four chances to come back with my son. That's all the chances he's getting this time.
I wonder if they sing Auld Lang Syne in jail.
Monday, December 31, 2007
Sunday, December 30, 2007
Saturday, December 29, 2007
How to die from cancer expensively
One day, you're fine---well, you know, not fine-fine, you're not eating very much, your liver and bones are riddled with metastic lesions, but you're not on death's door-fine. The next day, your family comes by with the Trivial Pursuit board to give you something to pass the time, find you unable to speak, covered in excrement and urine, and breathing about a breath every 1 1/2 seconds.
Your platelet count is curiously low even though it wasn't too bad last week, your d-dimer is the highest number the machine will read. You have DIC. Brain, lungs, legs, you name it, it has a blood clot in it. Oh, and did I mention that you're bleeding internally as well?
Your family decides you need to be intubated and everything should be done.
The last thing you remember in your life is not your family telling you they love you, but some blonde-haired girl-of-a-nurse talking about a shot of something to "relax" you and "paralyze" you while a doctor stands over you in a blue gown, wearing a face mask muttering "I hope this tube going down doesn't cause a hemorrhage into his airway. Respiratory, please stand-by with suction." Then: The lines, the drips, the platelets, the suctioning, the alarming ventilator, the ABGs, and that white lipid emulsion to keep you unconscious.
This is how to die from cancer expensively.
Dr. Worm
Here's something that will (1) entertain and (2) cause MonkeyGirl to email me and say, "Where the Hell do you find this stuff?"
I'm not a real doctor, but I am a real worm.
Also, I'd like to announce a new ER website that I have linked written by a "real doctor" (who may or may not be a real worm; he never said one way or the other). Please stop by ERStories and check it out!
I'm not a real doctor, but I am a real worm.
Also, I'd like to announce a new ER website that I have linked written by a "real doctor" (who may or may not be a real worm; he never said one way or the other). Please stop by ERStories and check it out!
Wednesday, December 26, 2007
The team
Oh no, not the team. Anything but the team.
Dr. Overkill always finds it necessary to call in "the team" for any and all cases beyond a simple sniffle. This may sound like a good thing, but, I assure you, it's the equivalent of standing in your front yard running around in circles for five hours with the goal of eventually ending up next door. Most people would simply stroll next door, a mindless 1-minute stroll, but not Dr. Overkill.
A memorable "team" case involves that of a bed-bound LOL on coumadin with 60,000 co-morbid conditions who was found unresponsive. Her stat head CT showed impending death from a "massive" head bleed. The radiologist's first question as he read the results over the phone was "is this person still alive?"
The family says that they would like grandma intubated until all the in-town relatives showed up, which might be an hour or two, then she could be on comfort cares only. Let's call the team! Remember, when you call the team, you must present the entire case from beginning-to-end, waiting up to 1 hour for a call back.
1) Neurosurgeon to consult on possible surgery
2) Patient's personal neurologist to see if decadron was appropriate.
3) Intensivist for ET tube and related critical care issues. Doctor, the plan is extubation, why are we consulting an intensivist? Doesn't matter.
4) Oh, the patient is seizing. Let's call back the neurologist to ask about anti-epileptic medications.
5) Ok, time to page the patient's internist. Better discuss all the co-morbid conditions that need management and admission to the hospital.
Okay, the family is all here. Time to extubate grandma. Round II of team management:
1) Call intensivist to ask how long we should turn off propofol before extubating.
2) Call respiratory and anesthesia to extubate. Um. Just deflate the tube and pull it out, doctor, we don't need anesthesia for that, no we will not page them overhead. Can we please order a bed? No one is extubating this patient until there is a bed ordered. Oh, you're too busy to order a bed? No, we will not page anesthesia overhead to deflate a tube for you.
3) Take patient off ventilator for 30 minutes, have her breathe through ET tube. Yep, she's breathing...okay, let's keep waiting....okay, no, seriously, we're not paging anesthesia. Okay, the patient is extubated now.
4) Order bed for admission to hospital for comfort cares.
Dr. Overkill even micro-manages death. I was almost too embarrassed to be in the same space as the guy. Seven hours of emergency micro-management, in fact.
Dr. Overkill always finds it necessary to call in "the team" for any and all cases beyond a simple sniffle. This may sound like a good thing, but, I assure you, it's the equivalent of standing in your front yard running around in circles for five hours with the goal of eventually ending up next door. Most people would simply stroll next door, a mindless 1-minute stroll, but not Dr. Overkill.
A memorable "team" case involves that of a bed-bound LOL on coumadin with 60,000 co-morbid conditions who was found unresponsive. Her stat head CT showed impending death from a "massive" head bleed. The radiologist's first question as he read the results over the phone was "is this person still alive?"
The family says that they would like grandma intubated until all the in-town relatives showed up, which might be an hour or two, then she could be on comfort cares only. Let's call the team! Remember, when you call the team, you must present the entire case from beginning-to-end, waiting up to 1 hour for a call back.
1) Neurosurgeon to consult on possible surgery
2) Patient's personal neurologist to see if decadron was appropriate.
3) Intensivist for ET tube and related critical care issues. Doctor, the plan is extubation, why are we consulting an intensivist? Doesn't matter.
4) Oh, the patient is seizing. Let's call back the neurologist to ask about anti-epileptic medications.
5) Ok, time to page the patient's internist. Better discuss all the co-morbid conditions that need management and admission to the hospital.
Okay, the family is all here. Time to extubate grandma. Round II of team management:
1) Call intensivist to ask how long we should turn off propofol before extubating.
2) Call respiratory and anesthesia to extubate. Um. Just deflate the tube and pull it out, doctor, we don't need anesthesia for that, no we will not page them overhead. Can we please order a bed? No one is extubating this patient until there is a bed ordered. Oh, you're too busy to order a bed? No, we will not page anesthesia overhead to deflate a tube for you.
3) Take patient off ventilator for 30 minutes, have her breathe through ET tube. Yep, she's breathing...okay, let's keep waiting....okay, no, seriously, we're not paging anesthesia. Okay, the patient is extubated now.
4) Order bed for admission to hospital for comfort cares.
Dr. Overkill even micro-manages death. I was almost too embarrassed to be in the same space as the guy. Seven hours of emergency micro-management, in fact.
That's interesting
You can't make this up:
Patient: Yes, doctor, my tooth has been hurting for a week.
Doctor: Which tooth is it?
Patient: Up here (points to affected tooth). You know about Pompeii, doctor?
Doctor: Um. Yeah, the city that was buried by a volcano....
Patient: Well, that's what everyone thinks happened. You see, "Egyptian" pyramids were built by aliens and powered entire cities with nuclear energy. There was a alien pyramid near Pompeii full of nuclear energy and it exploded, causing the city to be buried. That's something that the government doesn't want anyone to hear about because it would prove the existence of aliens.
Doctor: That's interesting. I will get you some antibiotics and motrin for your toothache.
Patient: Yes, doctor, my tooth has been hurting for a week.
Doctor: Which tooth is it?
Patient: Up here (points to affected tooth). You know about Pompeii, doctor?
Doctor: Um. Yeah, the city that was buried by a volcano....
Patient: Well, that's what everyone thinks happened. You see, "Egyptian" pyramids were built by aliens and powered entire cities with nuclear energy. There was a alien pyramid near Pompeii full of nuclear energy and it exploded, causing the city to be buried. That's something that the government doesn't want anyone to hear about because it would prove the existence of aliens.
Doctor: That's interesting. I will get you some antibiotics and motrin for your toothache.
The curtain
An elderly man was brought in by EMS after telling his family he didn't feel right and collapsing on the floor during Christmas dinner. He respiratory arrested en route and was intubated by the paramedics. The family members arrived and streamed in and out of the room, including little children in their Christmas dresses, seemingly mis-matched with their clunky winter boots. It was pretty sad to watch the family emerge from the curtains, including the little kids who were crying for their grandpa.
My patient, a big, burly middle-aged laborer-type fellow who had pneumonia, was across the hall from the dying guy. His curtain was left open just enough so he could apparently see the family members exiting in tears from the room across the hall.
I went in to talk to my patient about his admission and antibiotics, and I noticed a tear or two streaming down his face. What's wrong?
"Are those little kids losing their grandpa on Christmas?"
Of course, I explained that I couldn't say one way or the other due to HIPAA. I think the guy would have jumped off of his cot and hugged those little kids if he could have.
I went on to explain what was going to happen with him and closed his curtain fully on my way out.
My patient, a big, burly middle-aged laborer-type fellow who had pneumonia, was across the hall from the dying guy. His curtain was left open just enough so he could apparently see the family members exiting in tears from the room across the hall.
I went in to talk to my patient about his admission and antibiotics, and I noticed a tear or two streaming down his face. What's wrong?
"Are those little kids losing their grandpa on Christmas?"
Of course, I explained that I couldn't say one way or the other due to HIPAA. I think the guy would have jumped off of his cot and hugged those little kids if he could have.
I went on to explain what was going to happen with him and closed his curtain fully on my way out.
Sunday, December 23, 2007
Saturday, December 22, 2007
The most expensive schedule in the hospital
ERNursey's post reminded me of this: I learned the other night that one of the ER physicians, all of whom are employed by the hospital and get paid hourly, gets paid a 0.4 just to do the ER physician schedule. That means he gets paid for 32 hours every 2 weeks for the schedule at the usual ER physician hourly rate.
Another doctor opined: "I could do the physician schedule for the whole year in 32 seconds. Make a template which never changes. Want a day off? Get someone to switch with you. Take your vacation time off a year in advance. That's how it works everywhere else."
My knowledge of this budgetary anomaly comes at the same time as we cut:
$4,000 per pay period to be exact, if you assume $125/hour, and it's probably more since the doc doing it has >20 years experience. The highly conservative cost to do the schedule estimate is $104,000/year. At $160/hour, it would be $133,120, the equivalent of 3 or 4 full-time secretaries, and you only need one half-time secretary to do the job.
Another doctor opined: "I could do the physician schedule for the whole year in 32 seconds. Make a template which never changes. Want a day off? Get someone to switch with you. Take your vacation time off a year in advance. That's how it works everywhere else."
My knowledge of this budgetary anomaly comes at the same time as we cut:
- Front desk staff, a complete cut (all positions, all hours)
- Patient transport hours
- Nurse scheduling secretary (another quizzical decision since now the assistant nurse manager will do the schedule at the ANM hourly pay rate---how that saves money, I'm not sure) for ER nurses
- Physician support secretary for ER physicians
- Nursing managers throughout the hospital
- Ward secretary/health unit coordinator hours in the ER
$4,000 per pay period to be exact, if you assume $125/hour, and it's probably more since the doc doing it has >20 years experience. The highly conservative cost to do the schedule estimate is $104,000/year. At $160/hour, it would be $133,120, the equivalent of 3 or 4 full-time secretaries, and you only need one half-time secretary to do the job.
Friday, December 21, 2007
Attention-seeking behavior 101
Scene: The lobby. Time: 1 hr 15 minutes into whining fit about the wait
[Name called by chaplain, lady gets up and follows her into ER]
Attention-seeking patient: I was here WAAAY before that lady. Why does she get back before me? She doesn't even look sick! Why doesn't anyone care about me here? Can't anyone here see how much pain I'm in?
Nurse K: Okay. That lady wasn't even a patient. She was a family member of a very sick patient. This is getting out of hand. We have a little room with a couch in it over there. I think it is open.
I wheel the patient into the claustrophobic waiting room normally reserved for psych patients, and let her lie down on the couch. Complaining about the chaplain calling to speak with the somnolent family member of a cardiac arrest patient was just too much.
Attention-seeking patient: Oh great, now that I'm in here, I won't get to see who is going ahead of me!
Nurse K: Yes, that's true, ma'am. [Exits the room, turns out the lights AND closes the door]
Later:
Patient's nurse: Okay, there's a room ready. Let's get into the wheelchair.
Attention-seeking patient: Are you kidding? I'm curled up in the fetal position on this couch and you're expecting me to get into the wheelchair? I'm in a lot of pain here, lady!
Patient's nurse: Okay, that's fine. I'll get a different patient, and when you're ready to sit up and go to a room, you can let the triage nurse know. I'm not going to carry you to your room.
[Patient immediately gets up under her own power and sits in wheelchair].
Other notable things shouted less than 10 feet from my triage desk in a whiny voice:
I'll let you guys guess what she was there for. Hint: She wasn't a regular, and the problem wasn't "chronic".
[Name called by chaplain, lady gets up and follows her into ER]
Attention-seeking patient: I was here WAAAY before that lady. Why does she get back before me? She doesn't even look sick! Why doesn't anyone care about me here? Can't anyone here see how much pain I'm in?
Nurse K: Okay. That lady wasn't even a patient. She was a family member of a very sick patient. This is getting out of hand. We have a little room with a couch in it over there. I think it is open.
I wheel the patient into the claustrophobic waiting room normally reserved for psych patients, and let her lie down on the couch. Complaining about the chaplain calling to speak with the somnolent family member of a cardiac arrest patient was just too much.
Attention-seeking patient: Oh great, now that I'm in here, I won't get to see who is going ahead of me!
Nurse K: Yes, that's true, ma'am. [Exits the room, turns out the lights AND closes the door]
Later:
Patient's nurse: Okay, there's a room ready. Let's get into the wheelchair.
Attention-seeking patient: Are you kidding? I'm curled up in the fetal position on this couch and you're expecting me to get into the wheelchair? I'm in a lot of pain here, lady!
Patient's nurse: Okay, that's fine. I'll get a different patient, and when you're ready to sit up and go to a room, you can let the triage nurse know. I'm not going to carry you to your room.
[Patient immediately gets up under her own power and sits in wheelchair].
Other notable things shouted less than 10 feet from my triage desk in a whiny voice:
- [After explaining that she had stable vital signs and was awake and yelling so she was in no imminent risk of dying by waiting in the lobby]: Patient: I have stable vital signs because I take medication for my blood pressure! Maybe I'll just not take it next time. Nurse K: You can do whatever you want, ma'am. Tonight, you're not getting back any faster.
- Patient: [Wailing in attention-seeking voice] I've been here for 3 hours! How can you make people in pain wait three hours! Nurse K: No, actually, our computer starts clocking time from the time you walked in the door and you've been here 1 hour and 10 minutes. Patient: Well, I left the house earlier than that, so you should take that into account then we had to look for a parking spot! I've been in pain a long time!
I'll let you guys guess what she was there for. Hint: She wasn't a regular, and the problem wasn't "chronic".
Dread
I made the mistake the other day of looking ahead on the physician schedule to see who would be working the next shift.
Then, the dread. I had a 50% chance of getting Slow Doctor and a 50% of getting an acceptable one (I ended up working with Slow Doctor). I knew I wouldn't be getting my usual amount of sleep on that shift, so working with a slow doctor was highly unacceptable. I figured it was my duty to attempt to remedy this potentially annoying situation that was brewing for the next night shift.
Nurse K: I see Slow Doctor is on tonight. I think he needs a night off. I think you should pick up his shift, Favorite Doctor.
Favorite Doctor: I'd rather set my hair on fire.
Nurse K: Okay then.
Then, the dread. I had a 50% chance of getting Slow Doctor and a 50% of getting an acceptable one (I ended up working with Slow Doctor). I knew I wouldn't be getting my usual amount of sleep on that shift, so working with a slow doctor was highly unacceptable. I figured it was my duty to attempt to remedy this potentially annoying situation that was brewing for the next night shift.
Nurse K: I see Slow Doctor is on tonight. I think he needs a night off. I think you should pick up his shift, Favorite Doctor.
Favorite Doctor: I'd rather set my hair on fire.
Nurse K: Okay then.
Thursday, December 20, 2007
Triage Nanny
Every time I'm in triage on a certain shift with a certain individual in the department, I must brace myself, for she is....
***THE TRIAGE NANNY***
If I triage someone as a "3" and they are of the opinion that they should have been a "4", this person will "review" with me what a "3" is and that they didn't meet the criteria. Pretty much no number I have ever or will ever assign to a patient is correct when the Triage Nanny is on.
A "3" is someone who may need complicated testing or more monitoring. This patient clearly doesn't meet that criteria. You should have made him a "4".
Um. The patient is drunk off his ass and his wrist is at a right angle to his forearm. Yeah, most wrist fractures are "4"s, but this one is very bad, might need surgery, and the patient is stumbly-wumbly.
Well, you should review your triage criteria, Nurse K. That patient is a "4".
Sure, whatever you say, Triage Nanny. You know best. Not me, the one who triaged the patient.
Nevermind that Triage Nanny isn't the charge or my boss or the boss of anyone or anything. I'm a young thing, and I have a couple thousand more hours of nursing under my belt, too, if you really are making me point that out.
Don't be reviewing numbers with me. If I make a major mistake or miss something obvious, sure, let me know, but why oratorically flay me with your condescention? Hell, the difference between a "3" and a "4" is often subjective anyway. I triaged the patient, not you, and I arrived at my number based on my interaction with the patient.
Triage Nanny, let me do my job. You're not helping. Now go see your patient.
A "3" is someone who may need complicated testing or more monitoring. This patient clearly doesn't meet that criteria. You should have made him a "4".
Um. The patient is drunk off his ass and his wrist is at a right angle to his forearm. Yeah, most wrist fractures are "4"s, but this one is very bad, might need surgery, and the patient is stumbly-wumbly.
Well, you should review your triage criteria, Nurse K. That patient is a "4".
Sure, whatever you say, Triage Nanny. You know best. Not me, the one who triaged the patient.
Nevermind that Triage Nanny isn't the charge or my boss or the boss of anyone or anything. I'm a young thing, and I have a couple thousand more hours of nursing under my belt, too, if you really are making me point that out.
Don't be reviewing numbers with me. If I make a major mistake or miss something obvious, sure, let me know, but why oratorically flay me with your condescention? Hell, the difference between a "3" and a "4" is often subjective anyway. I triaged the patient, not you, and I arrived at my number based on my interaction with the patient.
Triage Nanny, let me do my job. You're not helping. Now go see your patient.
Extended release
Nurse K: Guess who's back, doctor?
Doctor: Oh great. What's he here with this time.
Nurse K: The same. Everything and nothing.
Doctor: I'll write him a prescription for Placibinex. That should do the trick.
Nurse K: Good idea, but he was just here 2 days ago, so I'd go with Placibinex ER.
Doctor: Oh great. What's he here with this time.
Nurse K: The same. Everything and nothing.
Doctor: I'll write him a prescription for Placibinex. That should do the trick.
Nurse K: Good idea, but he was just here 2 days ago, so I'd go with Placibinex ER.
Wednesday, December 19, 2007
Self-righteousness 101
It's not hard to find self-righteous comments like this in the blogosphere.
Everyone is entitled to their opinion. JimII can say "eh, I don't like the tone of most ER blogs, with the exception of Movin' Meat" and that would be an opinion. However, he goes far beyond being opinionated, far into the territory of self-righteousness, with this comment.
Of course, remember, that not all opinions are created equal. For example, if I were to get tax advice, I would not give the same weight to my computer programmer brother's advice as I would a competent, professional tax advisor's advice. Likewise, if I had melanoma, I would value the treatment opinion of a Mayo Clinic physician specializing in skin cancer more than a family practice doctor's. It would be intellectual laziness to declare all opinions on medicine equal or all possible opinions on taxes equal.
So, JimII is working from a starting state of opinion disadvantage if he is commenting on physicians' treatment or opinion of patients. He is not a physician nor does he work closely with them. He reads blogs written by physicians and watches TV shows with physicians on them.
When people wish to comment on something they can't personally relate to or can only peripherally related to (by virtue of reading blogs or watching fictionalized TV programs on the subject), they often fall into the trap of self-righteousness. Maybe they live and conduct most of their business in a suburb with little crime and virtually no violent crime and have known no one who is has been a victim of crime. They might sound self-righteous when they suggest no one, even trained, law-abiding citizens, under any circumstance should carry weapons to defend him or herself because owning of guns is bad and carrying them in public is worse. He may have little personal stake in whether people should carry guns or not because the chances he will be a victim of a home invasion or rapist are slim. A victim of domestic abuse whose husband repeatedly breaks into her house and threatens to kill her may have a different opinion on the subject and, as I see it, a more valid one because she is the person who is more likely to need the gun to defend herself, not the suburbanite with no enemies.
So, a warning sign for self-righteousness is exerting a strong, rather all-encompassing opinion on a subject where you have little stake. If you have no children, it would be self-righteous to proclaim that children in impoverished neighborhoods with bad schools should have no choice but to go to the bad school because all public schools should be excellent and we should fund them until they are, and, thus, school choice is not necessary. Yeah, easy for you to say that. You don't have the kid who will be missing out on a quality education.
Let's take one part of the statement:
By using the word "hatred", he is trying to elevate his marginally-informed, self-righteous opinion of blogging physicians (and/or physicians in general) since few people would be able to argue in favor of hating patients. The overall opinion he's trying to exert is that no distinction should be made between Medicaid patients and insured patients, despite there being well-documented differences. He's trying to be a defender of the poor by cutting down the physicians who help them every day, oftentimes with little personal gain or reimbursement and a full risk of being sued, as haters. Strange that someone would do that, but he is actually attempting to defend the poor by condemning those who help them as "haters."
Thus, he is, overall, attempting to make himself sound better than a physician in a busy ER who is taking care of the poor even though he does no such thing himself! I'm assuming as a lawyer that he does not blindly defend all who see him without asking about money nor seeking retainers. Hell no. There is no law saying that if a potential client is within 250 feet of his office and wants legal services of any kind, that he must at least determine if legal services are necessary and, if they are, render said service without even so much as asking about ability to pay.
How dare he say physicians (and presumably nurses), especially emergency staff, should not be "glorified" in popular culture. If there is anyone that should be glorified, it should be emergency physicians and nurses, dammit.
Collect your retainers and sign your contracts, JimII. When you're not in the trenches, you'll never know what it's like. I can only hope that when you need our services, I mean need our services, that you have access to a well-appointed hospital in your area without a lot of patients who don't need to be there tying up the triage nurse, the staff nurses, the physicians and the rooms we could put you in to save your life.
JimII said...Every once in awhile, something I read chaps my ass and, in order to restore peace to, um, my proverbial ass, I have to comment on it in a long-winded and essay-like manner. Brace yourselves.So, here's my question, do all doctors hate their patients? Or is it just ER doctors, or is it ER doctors who blog?
It is funny because it is clear that Movin' Meat is an Oasis in the blogosphere desert of hate that is ER blogging, but it has nonetheless opened my eyes to the people being glorified every night on the TeeVee and lauded by popular culture.
The hatred of the poor is particularly obnoxious. The constant snark about people with publicly funded insurance really bothers me.
I'm still voting for Obama, but these blogs make me like Edwards more all the time.
Everyone is entitled to their opinion. JimII can say "eh, I don't like the tone of most ER blogs, with the exception of Movin' Meat" and that would be an opinion. However, he goes far beyond being opinionated, far into the territory of self-righteousness, with this comment.
Of course, remember, that not all opinions are created equal. For example, if I were to get tax advice, I would not give the same weight to my computer programmer brother's advice as I would a competent, professional tax advisor's advice. Likewise, if I had melanoma, I would value the treatment opinion of a Mayo Clinic physician specializing in skin cancer more than a family practice doctor's. It would be intellectual laziness to declare all opinions on medicine equal or all possible opinions on taxes equal.
So, JimII is working from a starting state of opinion disadvantage if he is commenting on physicians' treatment or opinion of patients. He is not a physician nor does he work closely with them. He reads blogs written by physicians and watches TV shows with physicians on them.
When people wish to comment on something they can't personally relate to or can only peripherally related to (by virtue of reading blogs or watching fictionalized TV programs on the subject), they often fall into the trap of self-righteousness. Maybe they live and conduct most of their business in a suburb with little crime and virtually no violent crime and have known no one who is has been a victim of crime. They might sound self-righteous when they suggest no one, even trained, law-abiding citizens, under any circumstance should carry weapons to defend him or herself because owning of guns is bad and carrying them in public is worse. He may have little personal stake in whether people should carry guns or not because the chances he will be a victim of a home invasion or rapist are slim. A victim of domestic abuse whose husband repeatedly breaks into her house and threatens to kill her may have a different opinion on the subject and, as I see it, a more valid one because she is the person who is more likely to need the gun to defend herself, not the suburbanite with no enemies.
So, a warning sign for self-righteousness is exerting a strong, rather all-encompassing opinion on a subject where you have little stake. If you have no children, it would be self-righteous to proclaim that children in impoverished neighborhoods with bad schools should have no choice but to go to the bad school because all public schools should be excellent and we should fund them until they are, and, thus, school choice is not necessary. Yeah, easy for you to say that. You don't have the kid who will be missing out on a quality education.
Let's take one part of the statement:
The hatred of the poor is particularly obnoxious. The constant snark about people with publicly funded insurance really bothers me.First of all, he uses "hatred" when no one has said "I hate Medicaid patients" anywhere that I've seen. He is overstating blogging physicians' opinions on things like inappropriate use of the ER by those who have no cost to them to use it. This is called a Straw Man argument. He is lumping all opinions of the users of the Medicaid or other similar welfare programs (which aren't "insurance" by the way) under the umbrella of "hate". If you point out a pattern of abuse in the health care system or specific abusers of the system, you are a hater, not someone illustrating a point.
By using the word "hatred", he is trying to elevate his marginally-informed, self-righteous opinion of blogging physicians (and/or physicians in general) since few people would be able to argue in favor of hating patients. The overall opinion he's trying to exert is that no distinction should be made between Medicaid patients and insured patients, despite there being well-documented differences. He's trying to be a defender of the poor by cutting down the physicians who help them every day, oftentimes with little personal gain or reimbursement and a full risk of being sued, as haters. Strange that someone would do that, but he is actually attempting to defend the poor by condemning those who help them as "haters."
Thus, he is, overall, attempting to make himself sound better than a physician in a busy ER who is taking care of the poor even though he does no such thing himself! I'm assuming as a lawyer that he does not blindly defend all who see him without asking about money nor seeking retainers. Hell no. There is no law saying that if a potential client is within 250 feet of his office and wants legal services of any kind, that he must at least determine if legal services are necessary and, if they are, render said service without even so much as asking about ability to pay.
It is funny because it is clear that Movin' Meat is an Oasis in the blogosphere desert of hate that is ER blogging, but it has nonetheless opened my eyes to the people being glorified every night on the TeeVee and lauded by popular culture.In addition to the obvious butt-kissing, now he's saying that, again, in general, those in medicine should not be praiseworthy because they don't fit his opinion litmus test. He has never been given the task of weeding through the 6 BS complaints of convenience care or drug-seeking patients to find the quiet little old man who is infarcting. He's never had to place a central line in a kid hopped up on ecstasy found down on the street on the verge of cardiovascular system collapse and saved his life while his mom cried outside the curtain. He's never told someone their father will probably not make it until morning while holding back tears himself. He's never re-located a dislocated shoulder, nor earned the respect of a hoodlum with a broken hand, nor taken a miniscule piece of metal out of a factory worker's eye without causing a corneal abrasion. His narrow-minded and uninformed Straw Man opinion of [especially] ER physicians trumps anything and everything they will ever do so much so that portraying ER staff in a positive manner on television is inappropriate.
How dare he say physicians (and presumably nurses), especially emergency staff, should not be "glorified" in popular culture. If there is anyone that should be glorified, it should be emergency physicians and nurses, dammit.
Collect your retainers and sign your contracts, JimII. When you're not in the trenches, you'll never know what it's like. I can only hope that when you need our services, I mean need our services, that you have access to a well-appointed hospital in your area without a lot of patients who don't need to be there tying up the triage nurse, the staff nurses, the physicians and the rooms we could put you in to save your life.
Nursing home nurse stupidity explained
EMS picked up a pretty young female, maybe 25, at the Wal-Mart following a first-time seizure witnessed by the poor, huddled masses yearning to breathe free. She was in her scrubs; her nametag was still attached, and proclaimed her to be a nurse at a local nursing home. Maybe they'd have to limit her license now because she's epileptic. Maybe she's got a brain tumor. Maybe she popped an aneurysm.
Nope. No tumors, no bleeds. Labs are all okay except for the urine drug screen.
POSITIVE Cocaine, POSITIVE Amphetamines
Has the secret to nursing home nurse stupidity been revealed? It's possible they're all simply strung out like Amy Winehouse at a rave.
Nope. No tumors, no bleeds. Labs are all okay except for the urine drug screen.
POSITIVE Cocaine, POSITIVE Amphetamines
Has the secret to nursing home nurse stupidity been revealed? It's possible they're all simply strung out like Amy Winehouse at a rave.
Tuesday, December 18, 2007
Sick grandpas and grandmas
Drunk Kid with Boxer's Fracture (on the way back to a room from the waiting room): Yo man, my shit done got fucked up. Look at my hand. It's fucked up! I can't believe how fucked up my shit is!
Nurse K: [Whispers] Shhh. Watch your language. There are sick grandpas and grandmas here.
Drunk Kid with Boxer's Fracture: [Whispers] Oh, I'm sorry. I shouldn't have said that. [To drunk friend, still whispering] Yo man. Don't be saying no cuss words. The nurse juss said there was sick grandpas and grandmas in some of these rooms. We shouldn't be cussing like that. That ain't right. I'm sorry nurse. I won't do that again.
Nurse K: [Whispers] Shhh. Watch your language. There are sick grandpas and grandmas here.
Drunk Kid with Boxer's Fracture: [Whispers] Oh, I'm sorry. I shouldn't have said that. [To drunk friend, still whispering] Yo man. Don't be saying no cuss words. The nurse juss said there was sick grandpas and grandmas in some of these rooms. We shouldn't be cussing like that. That ain't right. I'm sorry nurse. I won't do that again.
No clue
Usually when I triage you, I have a pretty decent idea, at least in general, of what might possibly be wrong with you. Recently, a young one with no health issues signed in with a bizarre tale that I believed. Usually fanciful tales turn out to be some sort of cover story for some indiscretion or a psych problem or whatever. I got the story, got a complete set of normal vitals, except for a little tachycardia. I felt that funny feeling, and brought him back to a room.
I don't know what's wrong with him exactly, but I don't like how I'm feeling. The story is too weird. The way he looks is just not right. If a patient's complaint and my little 2-minute triage interaction makes me nervous and shaky, you win a room.
Registration told me I was nuts for bringing him back. Him? He's full of it. He probably just wants drugs. The nurses in back gave me a funny look for bringing him back as well.
No. There's something wrong with this one.
An hour later, the walking, talking, near-normal vitaled, strange-behaving young man with a fanciful story was almost dead. Not just a little hypotensive or something. Almost dead.
As I walked to my car, I started to cry. I don't like having you be (1) young (2) formerly in my lobby talking to me then (3) almost dead a little while later.
I don't know what's wrong with him exactly, but I don't like how I'm feeling. The story is too weird. The way he looks is just not right. If a patient's complaint and my little 2-minute triage interaction makes me nervous and shaky, you win a room.
Registration told me I was nuts for bringing him back. Him? He's full of it. He probably just wants drugs. The nurses in back gave me a funny look for bringing him back as well.
No. There's something wrong with this one.
An hour later, the walking, talking, near-normal vitaled, strange-behaving young man with a fanciful story was almost dead. Not just a little hypotensive or something. Almost dead.
As I walked to my car, I started to cry. I don't like having you be (1) young (2) formerly in my lobby talking to me then (3) almost dead a little while later.
That's my dawg
[Doctor enters patient's room, preparing to splint]
Drunk kid with Boxer's Fracture (to his drunk friend): Yo, dis my doctor, he a real good doctor.
Drunk friend: Fo real?
Drunk kid with Boxer's Fracture: Yeah, that doctor be my dawg, yo. I know I be stupid for fuckin' that guy up, but he good. He's treatin' me right.
Drunk kid with Boxer's Fracture (to his drunk friend): Yo, dis my doctor, he a real good doctor.
Drunk friend: Fo real?
Drunk kid with Boxer's Fracture: Yeah, that doctor be my dawg, yo. I know I be stupid for fuckin' that guy up, but he good. He's treatin' me right.
Monday, December 17, 2007
Doodads
When you're in triage, you get paper after paper in a little pile with chief complaints and basic demographics written. Each time you pick up a paper, it's a little surprise. Wrist pain, back pain, arm pain, nose pain, lac on my right hand, lac on my left hand, fall, heart palpitations, etc, etc. Most papers contain straightforward and routine complaints, so when you get a funny one, it's way more funny than it should be.
ER chief complaint as written by the patient: MY DOODADS ARE BIG AND RED
(An actual medical problem, scrotal cellulitis, but it was still funny)
ER chief complaint as written by the patient: MY DOODADS ARE BIG AND RED
(An actual medical problem, scrotal cellulitis, but it was still funny)
Sick people or "Why calling 9-11 doesn't always get you a room"
Reminder to my readers: Sometimes I take care of sick people too.
Lobby: 79F "My belly just starting hurting out of nowhere, and I'm so bloated. I don't normally come to the hospital, but this pain I just can't stand any longer. Do you something to vomit in?" On no meds, no chronic medical problems, on calcium supplements only. Hm. Looks like coffee grounds. Cha-ching, grandma, you get a room! Diagnosis: Small perforated stomach ulcer [Don't be fooled by "small". Small still=baddddd].
Lobby: Wheelchair-bound 55F "I feel weak all over." Diagnosis: Hypotension, raging UTI, pneumonia, sepsis. Central lines, pressors, fluids, lactate of 3.9, ionized calcium of 0.75, sure why not?
Lobby: 87M "I have had really bad heartburn for the last 2 1/2 hours. It's right there in the middle of my chest, and it's really hard to breathe. I finally called my daughter to bring me in. Maybe you have something stronger than TUMS. I didn't want to wake her up, and I feel so stupid." Heartburn? Like Hell you do, you pale, sweaty, tachypneic little old man, you. Diagnosis: Heart attack.
Lobby: 58M "I woke up an my thongue and faceth were thwollen." Diagnosis: Impending loss of airway from ACE inhibitor. Holy shit. Carts, carts. I need carts! Which ones? ALL OF THEM. Oh, and a doctor. A DOCTOR AND ALL THE CARTS.
By Ambulance: 23F "My nose is really stuffy! I think I need an antibiotic." Diagnosis: Go home and take your Afrin. You're not sick. In fact, you're in the wrong blog post altogether. This is the sick people blog post.
Lobby: 79F "My belly just starting hurting out of nowhere, and I'm so bloated. I don't normally come to the hospital, but this pain I just can't stand any longer. Do you something to vomit in?" On no meds, no chronic medical problems, on calcium supplements only. Hm. Looks like coffee grounds. Cha-ching, grandma, you get a room! Diagnosis: Small perforated stomach ulcer [Don't be fooled by "small". Small still=baddddd].
Lobby: Wheelchair-bound 55F "I feel weak all over." Diagnosis: Hypotension, raging UTI, pneumonia, sepsis. Central lines, pressors, fluids, lactate of 3.9, ionized calcium of 0.75, sure why not?
Lobby: 87M "I have had really bad heartburn for the last 2 1/2 hours. It's right there in the middle of my chest, and it's really hard to breathe. I finally called my daughter to bring me in. Maybe you have something stronger than TUMS. I didn't want to wake her up, and I feel so stupid." Heartburn? Like Hell you do, you pale, sweaty, tachypneic little old man, you. Diagnosis: Heart attack.
Lobby: 58M "I woke up an my thongue and faceth were thwollen." Diagnosis: Impending loss of airway from ACE inhibitor. Holy shit. Carts, carts. I need carts! Which ones? ALL OF THEM. Oh, and a doctor. A DOCTOR AND ALL THE CARTS.
By Ambulance: 23F "My nose is really stuffy! I think I need an antibiotic." Diagnosis: Go home and take your Afrin. You're not sick. In fact, you're in the wrong blog post altogether. This is the sick people blog post.
Sunday, December 16, 2007
B-team floor nurse
Here's something that happens to me all shift every shift.
Nurse K: Hi, I'd like to give report on Mr. So-and-So.
B-team nurse: Oh. I can't take report right now.
Nurse K: Why is that?
B-team nurse: Oh, I have to chart on my patients. I can't take a new one until I'm done charting on the ones I've got.
Nurse K: Can't you chart after you're done admitting the patient? It'll take 10 or 15 minutes for him to get there anyway.
B-team nurse: No, I won't take report. I need to chart. It will take awhile.
Alas, I pussied out and held on to the patient 2 additional hours (a couple extra calls to the floor yielded similar excuses of being too busy). God, I suck. At least the patient got to hang out with me for 2 hours rather than the B-squad floor RN.
The A-squad floor nurses will do things like have the charge take report and settle the patient if they're super busy. The A-squad nurses will hear my tale of woe of ambulance divert or patients stacked up in the hall and say, "Oh, in that case, send him up. I'll figure something out." The A-squad is a team player. The B-squad can't prioritize worth a damn. Remember: We're ER Nurses (TM). The Emergency Department is an outpatient area, which is exactly the opposite of an inpatient area. That's why we want inpatients to be on your floor.
We can do floor nursing, but that's not our specialty. There are no I&O sheets to be found in our department, the beds are uncomfortable, taking the patient to the potty is a long trip down the hall, our monitors are attached to the wall which impairs mobility/ambulation, it's noisy so the patient gets no rest, the computers give us no access to inpatient screens, and, due to an annoying feature of our EMR, looking at inpatient orders in the ER goofs everyone and everything up. Once they're stabilized and ready to go, they're all you.
Take the patients, oh floor nurses of the world. Please. I beg you. Or I'm calling the nursing supervisor on your ass. Just be aware.
Nurse K: Hi, I'd like to give report on Mr. So-and-So.
B-team nurse: Oh. I can't take report right now.
Nurse K: Why is that?
B-team nurse: Oh, I have to chart on my patients. I can't take a new one until I'm done charting on the ones I've got.
Nurse K: Can't you chart after you're done admitting the patient? It'll take 10 or 15 minutes for him to get there anyway.
B-team nurse: No, I won't take report. I need to chart. It will take awhile.
Alas, I pussied out and held on to the patient 2 additional hours (a couple extra calls to the floor yielded similar excuses of being too busy). God, I suck. At least the patient got to hang out with me for 2 hours rather than the B-squad floor RN.
The A-squad floor nurses will do things like have the charge take report and settle the patient if they're super busy. The A-squad nurses will hear my tale of woe of ambulance divert or patients stacked up in the hall and say, "Oh, in that case, send him up. I'll figure something out." The A-squad is a team player. The B-squad can't prioritize worth a damn. Remember: We're ER Nurses (TM). The Emergency Department is an outpatient area, which is exactly the opposite of an inpatient area. That's why we want inpatients to be on your floor.
We can do floor nursing, but that's not our specialty. There are no I&O sheets to be found in our department, the beds are uncomfortable, taking the patient to the potty is a long trip down the hall, our monitors are attached to the wall which impairs mobility/ambulation, it's noisy so the patient gets no rest, the computers give us no access to inpatient screens, and, due to an annoying feature of our EMR, looking at inpatient orders in the ER goofs everyone and everything up. Once they're stabilized and ready to go, they're all you.
Take the patients, oh floor nurses of the world. Please. I beg you. Or I'm calling the nursing supervisor on your ass. Just be aware.
Saturday, December 15, 2007
The pen
This one nurse (we'll call her Nurse C) will do ANYTHING to embarrass/tease other co-workers. Usually there is a special "victim" or two each shift.
We were all standing by the time clock in the back, away from the patients, dear managers. Waiting. Waiting. Waiting for the shift to be over. Enter The Doctor [male].
Nurse C: Hey Nurse P, where did I leave my pen? I can't find it.
Nurse P: It's in your....breast pocket.
Nurse C: Oh! REEALLLLY? Can you....get it for me?
The Doctor: You're sick (turns away to get stuff from his mailbox, not looking at the nurses).
Nurse C: Lower....lower....lower.... Oh! Right there! Oh! You found it!
Nurse K: YOU PUT THAT BACK WHERE YOU FOUND IT. AND LET ME WATCH.
The Doctor: [Runs red-faced into the locker room]
You probably had to be there, but Nurse C exhibited good comedic timing as always. We ancillary characters were on the ball with improv. Made for a good laugh.
We were all standing by the time clock in the back, away from the patients, dear managers. Waiting. Waiting. Waiting for the shift to be over. Enter The Doctor [male].
Nurse C: Hey Nurse P, where did I leave my pen? I can't find it.
Nurse P: It's in your....breast pocket.
Nurse C: Oh! REEALLLLY? Can you....get it for me?
The Doctor: You're sick (turns away to get stuff from his mailbox, not looking at the nurses).
Nurse C: Lower....lower....lower.... Oh! Right there! Oh! You found it!
Nurse K: YOU PUT THAT BACK WHERE YOU FOUND IT. AND LET ME WATCH.
The Doctor: [Runs red-faced into the locker room]
You probably had to be there, but Nurse C exhibited good comedic timing as always. We ancillary characters were on the ball with improv. Made for a good laugh.
Healthy young man ER 2-fer: A little help here
A teen with no prior medical/surgical history comes in with a day-long history of generalized belly pain and intermittent vomiting of partially undigested food with no fever/blood in stool etc. He looks to be in legitimate severe pain and is a little hypertensive even. This young man turns out to have:
1) New-onset type 1 diabetes with ketones in the blood (blood sugar low 400s despite nothing to eat for 15 hours or whatever, normal blood CO2, not tachypneic)
2) Partial small bowel obstruction diagnosed by CT
What the Hell? Are these two related somehow? I've been perplexed.
1) New-onset type 1 diabetes with ketones in the blood (blood sugar low 400s despite nothing to eat for 15 hours or whatever, normal blood CO2, not tachypneic)
2) Partial small bowel obstruction diagnosed by CT
What the Hell? Are these two related somehow? I've been perplexed.
Friday, December 14, 2007
Classic Nurse K: The pre-natal class
Um. Mom. You're embarrassing me:
This was a rather eye-opening experience, a glimpse into, among other things, the cycle of poverty, if you will. There was exactly one couple there, a Somali couple, with the woman in the full-on hijab, but most were pregnant teenagers there with their mothers. I think, if I remember correctly, there was an older teen there with her boyfriend. The class was intended generically for first-time parents, but, given the nature of the population using the facility, it just turned out that the people who were pregnant for the first time were all teenagers except for the married Somalis.
There was one thing that was burned into my mind forever. A 14-year-old girl who was pregnant was there with her loud, outspoken mother who interrupted everything with her own personal stories. The 14-year-old was quiet, withdrawn, and, if she expressed any emotion at all, looked frightened the whole time she was there.
Her mother latched on to me and said she was happy she was going to have a grandbaby (um, okay) and her only wish was that her daughter would have "a premature baby" because "my 2-pound baby was so much easier to deliver than my 5-pound baby and my 6-pound baby."
Yep, folks, she showed up at a pregnancy and parenting class with her 14-year-old and had a vision of her having a premature baby because those were "easier" to deliver. This didn't strike her as insane or at least ironic at all.
I almost started crying right there.
Then came the 15 year old pregnant female whose mother brought her in for an evaluation of mild spotting earlier in the day. To get an idea whether the blood is coming from the bladder or from the uterus we usually get a catheterized urine sample.Yeah. I'd sh*t my pants if my mom said that to me even if I was 35 and pregnant (although mother wouldn't be downstream of a pelvic exam nor a catheterization either). Anyway, I had a flashback to nursing school where it was my task to observe and teach a portion of a pre-natal education class at the Big County Hospital which typically serves the disadvantaged members of society.
Since the patient was only 15, she didn’t know what a catheter was. The nurse showed her a catheter, and then she became concerned that the catheter may hurt. She looked to her mother for support and her mother seemed very understanding. Her response: “Just lay down and flop your legs over like you’re having sex. It will be over before you know it.”
This was a rather eye-opening experience, a glimpse into, among other things, the cycle of poverty, if you will. There was exactly one couple there, a Somali couple, with the woman in the full-on hijab, but most were pregnant teenagers there with their mothers. I think, if I remember correctly, there was an older teen there with her boyfriend. The class was intended generically for first-time parents, but, given the nature of the population using the facility, it just turned out that the people who were pregnant for the first time were all teenagers except for the married Somalis.
There was one thing that was burned into my mind forever. A 14-year-old girl who was pregnant was there with her loud, outspoken mother who interrupted everything with her own personal stories. The 14-year-old was quiet, withdrawn, and, if she expressed any emotion at all, looked frightened the whole time she was there.
Her mother latched on to me and said she was happy she was going to have a grandbaby (um, okay) and her only wish was that her daughter would have "a premature baby" because "my 2-pound baby was so much easier to deliver than my 5-pound baby and my 6-pound baby."
Yep, folks, she showed up at a pregnancy and parenting class with her 14-year-old and had a vision of her having a premature baby because those were "easier" to deliver. This didn't strike her as insane or at least ironic at all.
I almost started crying right there.
The Ultimate Guide to Frequent Flyers
The Happy Hospitalist, in his amazingly comprehensive way, runs down the types of frequent flyers, a post that I'm required by the credo of the blog to link.
At the end, he writes this, almost as a challenge to find something he didn't cover:
He pretty much covered every type of FF that I could think of...except one, which is continually perplexing to me as someone who used to throw some monstrous temper tantrums as a child:
At the end, he writes this, almost as a challenge to find something he didn't cover:
What are your frequent flyers?
He pretty much covered every type of FF that I could think of...except one, which is continually perplexing to me as someone who used to throw some monstrous temper tantrums as a child:
The teen or tween with "behavior" or "anger" issues
This is the child who, despite only being 12 years old, is diagnosed bipolar, ADHD and oppositional defiant disorder whose parents proudly talk about all the "services" they've gone through with the child: The case worker, the youth shelter system, the school social worker, the psychologist, the psychiatrist, the hospital-based psychiatrist who admitted him last time and so on and so forth until I need to leave the room because I'm feeling lightheaded and strangely nauseated thinking about it.
So what happened tonight that brought you into the emergency department?
Well, junior yelled at his father and slammed the door. I think he's manic and needs a med adjustment. I know my son and he's manic. Meanwhile, the kid is sitting calmly on the bed, not saying a word.
Of course, I think of all the yelling/screaming/kicking/punching fits I had with my mom and the walls in my house, and go "okay, we'll sort it out" while handing the chart to the social worker to deal with. Maybe I'm not getting it, but since when do parents bring children in to the emergency room with outbursts that sound well within the bounds of normal demanding med adjustments and admissions or shelter placement...and get it? Let's tweak the adderall and the clonidine and depakote and everything else this kid is on. He's MANIC. He's been bipolar since he was FIVE YEARS OLD.
And, the next week, the next time the kid mouths off to a teacher, he gets hauled in again for another mental health intervention rather than a trip to the principal's office.
Can't kids be little shits anymore without being medicated and "treated" for it? I really don't get this "naughty kids" ER visit phenomenon.
So what happened tonight that brought you into the emergency department?
Well, junior yelled at his father and slammed the door. I think he's manic and needs a med adjustment. I know my son and he's manic. Meanwhile, the kid is sitting calmly on the bed, not saying a word.
Of course, I think of all the yelling/screaming/kicking/punching fits I had with my mom and the walls in my house, and go "okay, we'll sort it out" while handing the chart to the social worker to deal with. Maybe I'm not getting it, but since when do parents bring children in to the emergency room with outbursts that sound well within the bounds of normal demanding med adjustments and admissions or shelter placement...and get it? Let's tweak the adderall and the clonidine and depakote and everything else this kid is on. He's MANIC. He's been bipolar since he was FIVE YEARS OLD.
And, the next week, the next time the kid mouths off to a teacher, he gets hauled in again for another mental health intervention rather than a trip to the principal's office.
Can't kids be little shits anymore without being medicated and "treated" for it? I really don't get this "naughty kids" ER visit phenomenon.
100,000
Despite my leaving for a month and a half, there have been 100,000 visitors to this site since its inception. I don't normally post these "so what"-type blog milestones, but, hilariously enough, here's the 100,000th visitor:
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Yep, someone searching for how to get pain meds from the ER. How appropriate.
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Yep, someone searching for how to get pain meds from the ER. How appropriate.
Thursday, December 13, 2007
Mangoes
"Nurse, I haven't been feeling well lately. I'm sick to my stomach all the time, and I feel so dry that my eyes and tongue feel like sandpaper. I can't even sleep because I have to keep going to the bathroom. I've been eating a lot of mangoes and drinking a lot of fruit juice to try to feel better."
---New-onset diabetic, blood sugar 983 by lab
---New-onset diabetic, blood sugar 983 by lab
This just might be the worst thing I'll ever tell you
An elderly gentleman with a history of end-stage cancer calls 9-11 from his assisted living(?) care center because he couldn't find his nurse to give him his painkiller prescribed by his hospice physician. Just a confused little old man calling 9-11 because he's demented, right? WRONG.
Get this.
The facility's aide informed the police and paramedics that there was no nurse available to give his hospice medications. After numerous unsuccessful attempts by paramedics and police to find the elusive "on-call nurse" to give the patient his medication, the patient was transported to the ER to receive his PRN painkiller for cancer pain. There was no paperwork nor anything else sent per shitty care center protocol, so it was unclear what he was supposed to get, if anything, and when. Phone calls to the facility from everyone involved in the case yielded no more information. He had no other complaints other than wanting a dose of a routine pain medication for inoperable, end-stage cancer.
Again, it was like a bad dream.
*Note: This is a very brief semi-truthful adaptation of a complicated and confusing story. The real episode this was based on was reported to the state by the patient's physician. Please read my disclaimer!
Get this.
The facility's aide informed the police and paramedics that there was no nurse available to give his hospice medications. After numerous unsuccessful attempts by paramedics and police to find the elusive "on-call nurse" to give the patient his medication, the patient was transported to the ER to receive his PRN painkiller for cancer pain. There was no paperwork nor anything else sent per shitty care center protocol, so it was unclear what he was supposed to get, if anything, and when. Phone calls to the facility from everyone involved in the case yielded no more information. He had no other complaints other than wanting a dose of a routine pain medication for inoperable, end-stage cancer.
Again, it was like a bad dream.
*Note: This is a very brief semi-truthful adaptation of a complicated and confusing story. The real episode this was based on was reported to the state by the patient's physician. Please read my disclaimer!
Wednesday, December 12, 2007
Trypanosomiasis
A patient who was rather uniformly described as the human embodiment of anxiety came with with a chief complaint of "I think I have [everything] wrong with me" with "everything" being 1 or 2 things from every branch of medicine from lung cancer to pancreatitis to influenza to diarrhea and headaches and heartburn and foot pain and on and on....
Our physicians on that night responded by having an ongoing battle of wits regarding the proposed work-up based on the perplexingly comprehensive collection of symptoms. Just to be dorks, they went on like this ALL NIGHT LONG, long after the patient discharged, but here's is one round. Creativity was the key, but deadpan delivery was worth double points.
Doc #1: Your patient mentioned difficulty sleeping at night and fatigue during the day. Did you ask about tsetse fly exposure? Maybe he has trypanosomiasis.
Doc #2: Oh, I'll certainly work him up for that. Come to think of it, the patient has a rather distended abdomen; I am wondering if he is also stricken with kwashiorkor.
Nurse K: If you put in a nursing order, I'll grill him a steak and mix up a protein shake.
Doc #1: Maybe he has acute kwashiorkor from an acute lack of steaks in his diet. Did you ask if his wife recently left him?
Nurse K: That would make sense. He was probably sleeping all day from the African Sleeping Sickness and that started to piss her off, calling him lazy when, little did she know, his "laziness" was the Sleeping Sickness ravaging his central nervous system. She didn't give a shit, however, and left for greener pastures. Then, between his fatigue and lack of spouse to prepare his steak, he developed kwashiorkor from lack of consistent protein intake...
Our physicians on that night responded by having an ongoing battle of wits regarding the proposed work-up based on the perplexingly comprehensive collection of symptoms. Just to be dorks, they went on like this ALL NIGHT LONG, long after the patient discharged, but here's is one round. Creativity was the key, but deadpan delivery was worth double points.
Doc #1: Your patient mentioned difficulty sleeping at night and fatigue during the day. Did you ask about tsetse fly exposure? Maybe he has trypanosomiasis.
Doc #2: Oh, I'll certainly work him up for that. Come to think of it, the patient has a rather distended abdomen; I am wondering if he is also stricken with kwashiorkor.
Nurse K: If you put in a nursing order, I'll grill him a steak and mix up a protein shake.
Doc #1: Maybe he has acute kwashiorkor from an acute lack of steaks in his diet. Did you ask if his wife recently left him?
Nurse K: That would make sense. He was probably sleeping all day from the African Sleeping Sickness and that started to piss her off, calling him lazy when, little did she know, his "laziness" was the Sleeping Sickness ravaging his central nervous system. She didn't give a shit, however, and left for greener pastures. Then, between his fatigue and lack of spouse to prepare his steak, he developed kwashiorkor from lack of consistent protein intake...
A "cornucopia of crayzee"
No fair, Scalpel (AKA "Scapel")! MYYYY blog is supposed to be CRAYZEE CENTRAL. Back off my territory.
Tuesday, December 11, 2007
A new low in emergency chief complaints
CC: Wants to be weighed.
Now, it's not like there was a history of CHF, an eating disorder, nor something that could obviously indicate a wasting syndrome from cancer. Dude, at a God-awful time of the night, was just interested in finding out how much he weighed. Why the Hell not think of the EMERGENCY department as your first choice? I asked why he didn't just use a friend's scale if he didn't have one, and he said something to the effect of "they're not accurate."
Another Nurse: "We have a scale?"
Nurse K: "Yup, it's in the dirty utility room next to the hopper and dirty commodes, and it's about 45 years old."
Of course, you can't just show up and be weighed. You need to be triaged, including a full medication reconciliation, screening questions for communicable diseases, vitals, etc, get registered, receiving all the government-required HIPAA disclosures, name, insurance, emergency contacts, a full nursing assessment and a medical assessment to satisfy EMTALA. Then you need to be dispositioned, have your discharge instructions reviewed ("come back if any emergencies exist in your lifetime"), and signature. So your asinine request to be weighed on an emergent basis in the department that exists to diagnose and treat life-threatening illnesses takes up a good hour total of staff time.
I think this might be the career-low in chief complaints.
Now, it's not like there was a history of CHF, an eating disorder, nor something that could obviously indicate a wasting syndrome from cancer. Dude, at a God-awful time of the night, was just interested in finding out how much he weighed. Why the Hell not think of the EMERGENCY department as your first choice? I asked why he didn't just use a friend's scale if he didn't have one, and he said something to the effect of "they're not accurate."
Another Nurse: "We have a scale?"
Nurse K: "Yup, it's in the dirty utility room next to the hopper and dirty commodes, and it's about 45 years old."
Of course, you can't just show up and be weighed. You need to be triaged, including a full medication reconciliation, screening questions for communicable diseases, vitals, etc, get registered, receiving all the government-required HIPAA disclosures, name, insurance, emergency contacts, a full nursing assessment and a medical assessment to satisfy EMTALA. Then you need to be dispositioned, have your discharge instructions reviewed ("come back if any emergencies exist in your lifetime"), and signature. So your asinine request to be weighed on an emergent basis in the department that exists to diagnose and treat life-threatening illnesses takes up a good hour total of staff time.
I think this might be the career-low in chief complaints.
Monday, December 10, 2007
Fear of The Man and not blogging the unique
Hi, I'm a scared-shitless medical blogger who only seeks to inform and entertain. Good to meet you.
I have a confession to make, and you are the only ones who will understand. I am scared to death to talk about unique cases. I talk about funny little quirky things that are unique and oftentimes make them more unique just because I can, but I almost never talk about very interesting, possibly highly-informative things that don't happen very often medically.
For instance, I found out my Lucky Bastard went asystole for a very unique reason, a reason I'd never heard of before (however, I knew the reason before I wrote the post---the case was rather ancient at the time I wrote it). I wrestled with whether I should add the reason why the patient went asystole. I even scoured (read "Googled") the medical literature to see how unique that thing was. According to one article's abstract (I'll be damned if websites will let you read the whole thing), there were only 30-some known cases of that thing ever happening.
I decided that I would make the post more about the importance of coming to the emergency department despite not having insurance, but I think I did you all a disservice by leaving out the educational portion of the post because it probably happens more than the 30-odd times it was reported, and you will maybe see it sometime in your practice and not be able to relate the asystole to the thing that caused it.
I'm sorry.
Oh, I'm still too scared to tell you. I'm still not sure if mentioning something like this is too rare to be considered the "unspeakable" as far as HIPAA goes, despite it being potentially educational. *Sigh*
The Man=1, Nurse K=0
I have a confession to make, and you are the only ones who will understand. I am scared to death to talk about unique cases. I talk about funny little quirky things that are unique and oftentimes make them more unique just because I can, but I almost never talk about very interesting, possibly highly-informative things that don't happen very often medically.
For instance, I found out my Lucky Bastard went asystole for a very unique reason, a reason I'd never heard of before (however, I knew the reason before I wrote the post---the case was rather ancient at the time I wrote it). I wrestled with whether I should add the reason why the patient went asystole. I even scoured (read "Googled") the medical literature to see how unique that thing was. According to one article's abstract (I'll be damned if websites will let you read the whole thing), there were only 30-some known cases of that thing ever happening.
I decided that I would make the post more about the importance of coming to the emergency department despite not having insurance, but I think I did you all a disservice by leaving out the educational portion of the post because it probably happens more than the 30-odd times it was reported, and you will maybe see it sometime in your practice and not be able to relate the asystole to the thing that caused it.
I'm sorry.
Oh, I'm still too scared to tell you. I'm still not sure if mentioning something like this is too rare to be considered the "unspeakable" as far as HIPAA goes, despite it being potentially educational. *Sigh*
The Man=1, Nurse K=0
Chantix
"Nurse, let me be honest here. I want to stop smoking cigarettes. I even got a prescription for Chantix, but I'm worried I'm not going to be able to smoke weed if I take it. Will I have to quit weed too if I start Chantix?"
---Young man with bronchitis and asthma
---Young man with bronchitis and asthma
For your visual enjoyment
The world's first insulin pump, 1963
Link from here. No seriously, that's an insulin pump; dude's not trying to fly away nor blow himself up. If the man wants to wear a jet pack to regulate his diabetes, let him! Don't poke fun at compliance. DKA is deadly, jet packs with insulin affixed to them are just strange-looking. Which is worse, hm? Death or funny-looking jet pack with porcine insulin? I thought so. Now go to your room and think about how fortunate you are that you don't have to wear the jet-pack to stay alive.
Sunday, December 9, 2007
Any other day but today
Once upon a time, an otherwise healthy gentleman develops rather difficult-to-ignore abdominal pain, presenting classically as appendicitis. But he doesn't want to go to the ER. Any other day, he says, not today. It gets worse and worse and worse until he reluctantly sauntered into the ER, getting pain medications and the CT scan where, yes, he has appendicitis and will need emergent surgery.
Can I just take some pain medications and come back? Can the surgery wait? No, it cannot...which will mean he will miss his mother's funeral which was scheduled later that day.
Can I just take some pain medications and come back? Can the surgery wait? No, it cannot...which will mean he will miss his mother's funeral which was scheduled later that day.
Nurse K: Diagnostic genius
Christine-Megan and I chat on the IM frequently, and she excerpted a couple examples of my uncanny ability to diagnose people with stuff via the Intertubes. Feel free to bask in the glory of IM-based diagnostic GENIUS.
Note to government officials: The disclaimer still applies. I'm not acting as someone's health care provider. Quit looking at me that way. She's a smart girl. We're just chatting, K? K. We're diabetic buddies. Don't haul me down to the Big Office Building and question me again.
Note to government officials: The disclaimer still applies. I'm not acting as someone's health care provider. Quit looking at me that way. She's a smart girl. We're just chatting, K? K. We're diabetic buddies. Don't haul me down to the Big Office Building and question me again.
Saturday, December 8, 2007
Hanging on for dear life
Scene: At the nurse's station. Dr. Bloody Gloves is frantically trying to order something on the computer, cussing intermittently. Enter OB/GYN resident in full surgical scrubs, stage right.
OB/GYN about to take patient for surgery [appears pissed]: Dr. Bloody Gloves, did you really tell the lady with the ectopic that her embryo was "alive and hanging on for dear life onto a little ligament thingy outside of her fallopian tube?"
OB/GYN about to take patient for surgery [appears pissed]: Dr. Bloody Gloves, did you really tell the lady with the ectopic that her embryo was "alive and hanging on for dear life onto a little ligament thingy outside of her fallopian tube?"
Polypharmacy gone crayzee!
A patient makes a bounceback visit for decreased level of consciousness. The first visit, I had her as sort of a secondary nurse and it was felt she was septic. I was hanging pressors, liters upon liter of fluid, and watching her blood pressure slowly normalize. She was barely responsive, but breathing okay. Her eyes were pinpoint, and I informed the physician that I thought we should try narcan first due to her many prescribed opiates, but he said that she was clearly septic and had been septic before, so that's what it was and narcan would just make her painful and septic. Of course, no source was ever found for the sepsis prior to admission, but as I saw her sign-in for visit #2 for decreased LOC, I read the discharge summary of her "sepsis" admit, only to find that later on narcan cleared up her decreased LOC. Of course, I was pissed.
Don't listen to the nurse, she may be right, and we're already ass-high in pressors and fluids.
Anyway, I give her nurse the run-down on the opiates and the unnecessary pressors. I offered to do the medication reconciliation on her and, after about the 20th minute of this, I counted the number of home meds she had prescribed.
Fifty-four.
You heard it.
Fifty-four. Gee, I wonder why she keeps coming back for mental status changes.
Don't listen to the nurse, she may be right, and we're already ass-high in pressors and fluids.
Anyway, I give her nurse the run-down on the opiates and the unnecessary pressors. I offered to do the medication reconciliation on her and, after about the 20th minute of this, I counted the number of home meds she had prescribed.
Fifty-four.
You heard it.
Fifty-four. Gee, I wonder why she keeps coming back for mental status changes.
Ambulance report on the nursing home patient
Since Monkeygirl is doing it, I'll do it too.
Driver 'o Ambuli: This is an 86-year-old brought in after nursing home staff called for shortness of breath. She has her paperwork with her. Vitals are [blah blah blah] and blood glucose is [blah] and lung sounds are [blah blah]...
Nurse K: Well, what exactly happened?
Driver 'o Ambuli: Well, no staff there spoke good English. I really can't tell you what happened. I apologize, I tried.
Nurse K: Great. The patient doesn't look too bad---you sure you got the right one?
Driver 'o Ambuli: This is an 86-year-old brought in after nursing home staff called for shortness of breath. She has her paperwork with her. Vitals are [blah blah blah] and blood glucose is [blah] and lung sounds are [blah blah]...
Nurse K: Well, what exactly happened?
Driver 'o Ambuli: Well, no staff there spoke good English. I really can't tell you what happened. I apologize, I tried.
Nurse K: Great. The patient doesn't look too bad---you sure you got the right one?
Insight into what I want in a man
Hey there single men with careers who don't live with their mothers and aren't alcoholics! Yes, I'm talking to you. How ya doing? Yes, I'm the only single nurse on Earth; good to meet you.
Click this video to see a brief exploration into what I want in a man. Awww, how sweet...they did The Sprinkler.
Friday, December 7, 2007
The More You Know: The difference between coughing up blood and vomiting blood
To clear up a chronic societal confusion on this subject, if you "spit up blood", that is not vomiting blood. If you have a blood-tinged loogie generated via a wicked, funky-sounding deep cough, you are spitting up blood, not vomiting it. Likewise if you vomit up blood, that is not "spitting" nor "coughing" up blood. Vomiting is the thing you do when you're hungover, pregnant or feeling the effects of bad Chinese food. Most of you can relate to some or all of those options, so there's no excuses to be going on and on about how you are spitting.
If you tell me and the doctor the tale of how you keep vomiting blood and have been for months that is a way different deal than if you have been spitting up blood for months.
If you've been coughing and spitting up blood for months, you might have a really advanced lung cancer or tuberculosis, so for shitsakes put a mask on. If you've been barfing blood for months, your stomach probably looks like one giant abrasion and your hemoglobin is like 3.5 and you'll need a blood transfusion.
Now, here's where things get muddy. If you are coughing so hard that you vomit, are you coughing and thus "spitting" or vomiting? You are vomiting. Pay attention to where your offending bodily fluid is coming from.
Here's another tricky one. If you are dry heaving, nothing comes up and then you, out of frustration or show, expel some clear, frothy-looking mouth contents into an emesis basin, is that spit or vomit? That's spit.
See, if it's in a barf bucket, that doesn't automatically make it barf either.
An example of someone whose confusion muddied the work-up waters was an ill-appearing gentleman who was a big alcoholic and a big smoker. He went on and on about how he had two rather violent sounding-episodes of vomiting blood. Of course, we are thinking "oh, an alcoholic vomiting blood" and put a couple of big IVs in and get the fluids going. Protonix bolus and drip coming riiiight up!
Turns out, after much poking and prodding, he was actually coughing up the blood after violent fits of continued coughing and had been for some time, but tonight it was really bad with giant chunks of blood.
Poor bastard had lung cancer, not gastritis or whatever.
Let's work together to distinguish between the words "spit" and "vomit". The first step is understanding. Your life may depend on it.
Image from here.
Thursday, December 6, 2007
Night shift in triage: The anti-paycheck
Night shift in triage can be horrifically boring. Most people have some sort of activity they do while in triage at 3 am, whether it be knitting, sewing, reading a book, balancing the checkbook, paying bills, catching up on backlogged education packets, playing online games, studying for the CEN exam, chatting with registration, or reading MSN News (or some combination thereof).
One nurse loves to online shop while in triage, much to her detriment. Actual quote:
"Thank God you're in triage tonight, K. I need to save money. Last time I was there, I spent $800! The time before, I spent $200."
One nurse loves to online shop while in triage, much to her detriment. Actual quote:
"Thank God you're in triage tonight, K. I need to save money. Last time I was there, I spent $800! The time before, I spent $200."
More on the prospective medication review
Hey JCAHO or the Joint Commission or TJC or whatever:
We saw 20 patients, 8 of whom needed something approved for pain or nausea. It took approximately 30 minutes to get the medication orders approved by the pharmacist due to your new regulation that says I can't give anything without a pharmacist review. So that means that just tonight, a relatively slow night, JCAHO has caused 240 minutes of needless suffering just in our patients alone.
When you, oh benevolent regulators, have the unavoidable need to rush into the ER at some odd hour of the night in sub-zero temperatures with a 7 mm obstructing kidney stone and hydronephrosis, I'll see if you think the 30 minutes of wait time to get your pain and nausea medications approved is a good thing or not. I'll be more than willing to give you an emesis basin whilst you ponder that very topic, emptying your stomach contents as I stare at you, helpless to do anything about it.
We saw 20 patients, 8 of whom needed something approved for pain or nausea. It took approximately 30 minutes to get the medication orders approved by the pharmacist due to your new regulation that says I can't give anything without a pharmacist review. So that means that just tonight, a relatively slow night, JCAHO has caused 240 minutes of needless suffering just in our patients alone.
When you, oh benevolent regulators, have the unavoidable need to rush into the ER at some odd hour of the night in sub-zero temperatures with a 7 mm obstructing kidney stone and hydronephrosis, I'll see if you think the 30 minutes of wait time to get your pain and nausea medications approved is a good thing or not. I'll be more than willing to give you an emesis basin whilst you ponder that very topic, emptying your stomach contents as I stare at you, helpless to do anything about it.
Wednesday, December 5, 2007
Do you know you're drug seeking?
Scalpel receives and responds to a letter from a chronic pain patient wondering how she can bypass arguing with an ER physician in order to get the drugs she wants for her undefined condition. I'll assume that her condition is just a worsening of the pain associated with a non-life-threatening pain syndrome.
Again, coming to the ER to obtain a specific drug, namely a controlled substance, is drug-seeking, especially if one writes blogging physicians in advance wondering what the best way is to get your preferred drug, whether it be demerol, dilaudid, or whatever else, without much hassle despite already having Actiq pops, a drug only approved for breakthrough cancer pain. If you have "legitimate" chronic pain, it's still drug-seeking. Finally, if your doctor's pain care plan includes scripted trips to the ER, he is an a**hole.
Remember kids! Pain doesn't kill. Narcotic overdoses do.
Doc,This is one of those subsets of drug-seeking that is probably the hardest to deal with. When a patient comes in with a collage of this-that-and-the-other thing all kept neatly in a 3-ring binder and demands a certain type of, likely, narcotic pain relief to be delivered in shot or IV form because that's what her personal physician recommends, it's simply drug-seeking.
During a flare where my pain is intolerable, how can I present myself at my local ER/ED to where I don't have to go through an hour of verbal jousting with the doc, even when I bring my pain contract and a personal letter from my neurologist explaining the situation and giving directions for treatment? I take along all meds with me, including the Actiq suckers so the doc can see when it was prescribed, when it was filled and how many suckers I have left.
Again, coming to the ER to obtain a specific drug, namely a controlled substance, is drug-seeking, especially if one writes blogging physicians in advance wondering what the best way is to get your preferred drug, whether it be demerol, dilaudid, or whatever else, without much hassle despite already having Actiq pops, a drug only approved for breakthrough cancer pain. If you have "legitimate" chronic pain, it's still drug-seeking. Finally, if your doctor's pain care plan includes scripted trips to the ER, he is an a**hole.
Remember kids! Pain doesn't kill. Narcotic overdoses do.
Tuesday, December 4, 2007
The Joint Commission jacks with our Pyxis again
The Pyxis machine, home of blank medication profiles. For the unindoctrinated, in all those drawers are single medications that open after we select them from the computer menu under the patient's name.
Maybe there's a way to pry them open.
So, a nurse asks me to get a neb out of the Pyxis machine and give it to her patient, something I do in some capacity many times a day. I select the patient and --- huh?--- all I see is a blank screen. Normally, there are many commonly used emergency medications on the screen and I just select the ones I want to give. When I started in the ER a couple of years ago, we could get those ADDvantage antibiotics and pill forms of antibiotics out of there too, but JCAHO said no antibiotics were allowed in Pyxis any longer, which served to make us and the patients wait 30-40 minutes for a cipro tablet until pharmacy could send it to us.
So, apparently, after frantically trying to figure out why the patient's profile was empty and giving up, I learned that --- OH --- sorry, you can't take ANY medications out of the Pyxis any longer without the medications being individually approved by a pharmacist sitting in some basement office or something in some undisclosed location somewhere that may or may not be in our hospital. Sure, there are a few "emergency" medications on there, but nothing useful like anti-emetics nor atrovent (you can get albuterol, but we almost always give a albuterol/atrovent combo for at least the first neb, so having albuterol in the Pyxis does us little good). I guess according to JCAHO, all initial stabilization of breathing problems should not include atrovent. Hell, in 15 minutes, I can give 2 of those nebs.
So, thanks to JCAHO, we get our orders and then we wait for 15 minutes minimum before we can take our basic anti-emetics and dilaudid or whatever out of the Pyxis to give to our patients. The trade-off is that some of our antibiotics are back in there.
I'm not sure what they're approving exactly. The computer already cross-checks the medication against the patient's allergies. Oh, I'm sorry. They're reviewing it for "appropriateness". Whatever that means. Last time I checked, physicians were sort of the experts on appropriateness since they're the ones prescribing it.
Since this started, we've had the guy with a a-fib and a heart rate of 195 wait a long-ass time after some mix-up for a diltiazem drip (previously available immediately) to be "approved" by the pharmacist because that is not an emergency medication available on the override function. You tell me how that improves his safety?
We also had the pasty man who probably had a heart-related syncopal episode where he lost consciousness and aspirated his vomit continue to vomit as I stood at the Pyxis machine logging in and out waiting for the anti-emetic to be approved by the pharmacist right before the family rightfully said, "Aren't you going to get him the medication for nausea that the doctor ordered?" I'm sorry, the Joint Commission regulations say he must continue to vomit until a pharmacist somewhere approves the medication for appropriateness. Obviously, between the doctor and me, we have no ability to independently determine the appropriateness of an anti-emetic for vomiting. We need a third person to get involved in this decision. THANK GOD the Joint Commission stepped in.
Guess what, sometimes vomiting is an emergency.
I can't even give IBUPROFEN any longer without approval, and that's on our triage protocol for nurses to give without a physician's order. I guess everyone's getting Tylenol from now on.
Then there's the constant inconvenience of knowing what I need, but not being able to take care of starting an IV and administering medications all in one trip. I have to either wait the full 15-30 minutes to do everything all at once or start the IV and fluids, wait 10-20 more minutes and then, probably after doing something else for another patient in between, go back to the Pyxis and retrieve my medications, which completely throws off my groove. When I'm constantly running around like a madwoman having to essentially make two trips to do something that should take one trip really is irritating.
Of course, besides irritating the Hell out of me, it delays treatment for these and other patients who are waiting in the waiting room longer. While I know little about the day-in-day-out toils of the pharmacist, I do know that, like nurses, there's a shortage of pharmacists, especially PharmDs, and this prospective review of medications for the ER crap taxes them more.
Also, there was one time where a doctor ordered 2 mg of Morphine and 4 mg syringe popped up on the profile for some reason, so someone not paying attention could have given the patient twice as much. Apparently, the system to prevent medication errors allows for the pharmacists to "accidentally" switch the dosages on the patient's Pyxis medication profile.
Finally, this rule put our staff in danger because an acutely manic patient who was yelling, screaming, and thrashing around could not receive IM haldol from the Pyxis for 25 minutes. The patient also probably had to wear restraints for 25 additional minutes than he otherwise would have had to since we often remove all or some of the restraints after the meds kick in. I wonder how many patients will have marks on their wrists or ankles from fighting the restraints for an extra half hour?
In short, this new system sucks. I'm not the only one that thinks this either. This is a must-read letter with more detailed information from ACEP, AAEM, and ENA, the who's-who of emergency medicine groups. Anyone else actually implementing this?
Update: ERNursey tells me we're doing this for no reason, that's it's not actually a requirement anymore. WTF?
Monday, December 3, 2007
Free trip to New Zealand and back!
One of our first-name-basis frequent flyers came in by EMS of course with one of her usual chief complaints. An agency nurse was assigned to her, and I wanted to give her the rundown on the patient since she was asking what her deal was and why everyone from housekeepers to aides to visitors of other patients knew her. I was specifically looking for information from a previous visit maybe 3 or so months ago (but it all blends together after awhile, so who knows what month it really was) which describes an event simply known as "the nastiest thing ever", a medical issue so nasty that it (1) became ER legend and (2) actually induced a dry heave in the physician in my presence. I thought it would be required reading for a nurse new to this frequent flyer.
My search for the visit information was complicated by the fact that her mileage was so great even in the last three months that said visit was impossible to find amongst the electronic charting. That month, for instance, she was under the care of a physician either at a clinic, in the hospital, or in the ER nearly constantly. In essence, there were notes and visits nearly every day, including a couple dozen ER visits in three months and hundreds total.
Incidentally, I also found a note from her healthcare insurers. It appeared at some point Medicaid allowed her to cash in her frequent flyer miles and awarded her a free 4-night, 5-day trip to the beautiful beaches of Cuba and back. Medicare awarded her a 6-night, 7-day stay in New Zealand in a luxury hotel in order to "save the American taxpayers money".
My search for the visit information was complicated by the fact that her mileage was so great even in the last three months that said visit was impossible to find amongst the electronic charting. That month, for instance, she was under the care of a physician either at a clinic, in the hospital, or in the ER nearly constantly. In essence, there were notes and visits nearly every day, including a couple dozen ER visits in three months and hundreds total.
Incidentally, I also found a note from her healthcare insurers. It appeared at some point Medicaid allowed her to cash in her frequent flyer miles and awarded her a free 4-night, 5-day trip to the beautiful beaches of Cuba and back. Medicare awarded her a 6-night, 7-day stay in New Zealand in a luxury hotel in order to "save the American taxpayers money".
The quiet gentleman
An elderly gentleman with a money address on his demographics sheet came in with some sort of vague but understated belly pain. After a circuitous workup that yielded a positive CT, we knew what was wrong. He waiting in the department for 3 additional hours for a bed, never really asking for anything other than occasional pain medications and a blanket.
I sent him up to his room at the ass-crack of dawn, and the nursing supervisor calls down to whine that we didn't tell him that So-and-So was the one waiting for a bed. I'm all, "Yeah?" Apparently, he knew who this person was.
He was one of the biggest donors to the hospital and was "eligible" for special treatment, ie a private room or whatever it is we do for special treatment.
He never asked to cash in though. He just lay there for 6 hours and settled down in his double room just like anyone else.
On the other hand, we had another patient recently drop the names of at least 7 physicians that she knew JUST while in triage. Yeah, yeah, yeah. You go skiing with who? Oh, that's interesting. You've been to parties and Dr.So-and-So's house eh? Fascinating. You donate money, eh? Thanks. Hm. The lobby's looking full, but there's a free chair next to the smelly paranoid schizophrenic and the guy with meth mouth and a tooth infection. Have at 'er.
I sent him up to his room at the ass-crack of dawn, and the nursing supervisor calls down to whine that we didn't tell him that So-and-So was the one waiting for a bed. I'm all, "Yeah?" Apparently, he knew who this person was.
He was one of the biggest donors to the hospital and was "eligible" for special treatment, ie a private room or whatever it is we do for special treatment.
He never asked to cash in though. He just lay there for 6 hours and settled down in his double room just like anyone else.
On the other hand, we had another patient recently drop the names of at least 7 physicians that she knew JUST while in triage. Yeah, yeah, yeah. You go skiing with who? Oh, that's interesting. You've been to parties and Dr.So-and-So's house eh? Fascinating. You donate money, eh? Thanks. Hm. The lobby's looking full, but there's a free chair next to the smelly paranoid schizophrenic and the guy with meth mouth and a tooth infection. Have at 'er.
An announcement for all medical and PA students
Dear students of medicine,
This is not an internal medicine rotation. Hurry the #$%@ up with your assessments. Speed is a skill you must learn sometime, might as well be here.
Love alwayz and BFF,
*The Nurse*
This is not an internal medicine rotation. Hurry the #$%@ up with your assessments. Speed is a skill you must learn sometime, might as well be here.
Love alwayz and BFF,
*The Nurse*
Sunday, December 2, 2007
The tale of Lucky Bastard
A long time ago, there was once a man named Lucky Bastard.
Lucky Bastard had been having moderately severe unstable-type angina at home for a good long while. Lucky Bastard, however, didn't have insurance and despite his heart history, including a heart attack some time ago, he decided to see if it would go away. It got better, but never really went all the way away.
I don't really want to be here because I don't have insurance, Nurse K.
The patient's wife told him she could deal with a bill, but not a dead husband. Good point, wife. It was obvious Lucky Bastard had been dragged in by the ball and chain even though he knew he had to be in our department.
After the initial ACLS stuff I do to everyone with chest pain, as I was filling in Lucky Bastard's JCAHO-required screening pages #1, #2, #2a, #2b, #2c with addendums #4, #5, and #6 along with the medication lists and all numerous other inane crap, another nurse appeared from Heaven and put in the IV. Thanks Another Nurse. I appreciate it.
Lucky Bastard was relieved to hear that he was not having a heart attack according to the EKG. Whew! Maybe the hospital bill wouldn't be too bad after all.
Then, within a few minutes of arriving in our department, longabouts the time I was typing away on Screening Section 16b Sub-Section 4, Lucky Bastard started looking like Death on a Stick and the heart rate started to go down a little bit. Hm.
You okay, Lucky Bastard? Oh, just a little dizzy is all.
Then, Lucky Bastard went to...oh...a modified asystole. Maybe a beat here and a beat there.
ATROPINE, PRAYER, AND.....WE'RE back.
This is why married people live longer.
Lucky Bastard had been having moderately severe unstable-type angina at home for a good long while. Lucky Bastard, however, didn't have insurance and despite his heart history, including a heart attack some time ago, he decided to see if it would go away. It got better, but never really went all the way away.
I don't really want to be here because I don't have insurance, Nurse K.
The patient's wife told him she could deal with a bill, but not a dead husband. Good point, wife. It was obvious Lucky Bastard had been dragged in by the ball and chain even though he knew he had to be in our department.
After the initial ACLS stuff I do to everyone with chest pain, as I was filling in Lucky Bastard's JCAHO-required screening pages #1, #2, #2a, #2b, #2c with addendums #4, #5, and #6 along with the medication lists and all numerous other inane crap, another nurse appeared from Heaven and put in the IV. Thanks Another Nurse. I appreciate it.
Lucky Bastard was relieved to hear that he was not having a heart attack according to the EKG. Whew! Maybe the hospital bill wouldn't be too bad after all.
Then, within a few minutes of arriving in our department, longabouts the time I was typing away on Screening Section 16b Sub-Section 4, Lucky Bastard started looking like Death on a Stick and the heart rate started to go down a little bit. Hm.
You okay, Lucky Bastard? Oh, just a little dizzy is all.
Then, Lucky Bastard went to...oh...a modified asystole. Maybe a beat here and a beat there.
ATROPINE, PRAYER, AND.....WE'RE back.
This is why married people live longer.
Saturday, December 1, 2007
The traditional treatment for ringworm
Are you a kid in high school wrestling or someone in contact with a small child? Notice a little redness and itching suspicious for the feared ringworm fungal infection? Short on cash? Medically illiterate? No worries, y'all. You have a "traditional treatment" for ringworm right inside of you right now.
Traditional healing methods are all the rage these days, and nursing schools teach about these various methods to rectify illness and suffering using all-natural ingredients, but I hadn't heard of this particular remedy.
Oh, how I was lacking in knowledge and didn't even know it!
According to one of my patients afflicted with a rather extensive ringworm, there is a folk treatment in her culture that is free and easily accessible. She wanted advice on whether she should be using it herself in addition to her prescribed anti-fungal creams and pill. She learned of it through her sage Gramma who had been liberally applying the treatment to the patient's infant nephew's affected skin, from whom she contracted her case.
Since it is traditional, let's discuss it in faux-Shakespearese, shall we?
Patient: O Nursemaid! Please at your earliest moment of respite from your toils come behind my curtain and advise me. My dear nephew, from whom I contracted my illness, is no better with his tineous lesions, and seems to be getting worse. Gramma, a wise woman who hath bore many children, sayeth it works as well as a hot iron to a wrinkle! I seek your apothecarial opinion on Gramma's remedy of the ages.
Nursemaid K: I am not gifted in mind-reading , but, as you say, I know of concoctions used in healing of the diseased. First, to properly advise thou, young maiden, I must know the secret treatment of which you speak. For each treatment from thine grand-parents, there is a formula born of much trial! 'Tis important thou doth impart thine knowledge completely and without omission.
Patient: O, Nursemaid, grateful am I for your time for I am not well-versed in the treatment of maladies of the outermost dermal layers. Perhaps I have misled. The formula is not complicated for we, as I have said, have no knowledge of health but for that we usually have it. People in my family rub the baby's own excrement all over his skin, into the areas of redness. Even though Gramma doth insist it will work, the baby hath been screaming and itching like he was the brunt of the anger of a thousand bees! Tell me, dear Nursemaid, if the dregs of my nephew will heal him or he shall continue to suffer?
Nursemaid K: O! For you shall not do that ever again and taketh thine baby to the doctor trained in London after cleansing his skin with soap of lye and water! Do not lay thine stool-stricken hands on this baby, for you do nothing but make him smell of fæcal matter!
Traditional healing methods are all the rage these days, and nursing schools teach about these various methods to rectify illness and suffering using all-natural ingredients, but I hadn't heard of this particular remedy.
Oh, how I was lacking in knowledge and didn't even know it!
According to one of my patients afflicted with a rather extensive ringworm, there is a folk treatment in her culture that is free and easily accessible. She wanted advice on whether she should be using it herself in addition to her prescribed anti-fungal creams and pill. She learned of it through her sage Gramma who had been liberally applying the treatment to the patient's infant nephew's affected skin, from whom she contracted her case.
Since it is traditional, let's discuss it in faux-Shakespearese, shall we?
----
Patient: O Nursemaid! Please at your earliest moment of respite from your toils come behind my curtain and advise me. My dear nephew, from whom I contracted my illness, is no better with his tineous lesions, and seems to be getting worse. Gramma, a wise woman who hath bore many children, sayeth it works as well as a hot iron to a wrinkle! I seek your apothecarial opinion on Gramma's remedy of the ages.
Nursemaid K: I am not gifted in mind-reading , but, as you say, I know of concoctions used in healing of the diseased. First, to properly advise thou, young maiden, I must know the secret treatment of which you speak. For each treatment from thine grand-parents, there is a formula born of much trial! 'Tis important thou doth impart thine knowledge completely and without omission.
Patient: O, Nursemaid, grateful am I for your time for I am not well-versed in the treatment of maladies of the outermost dermal layers. Perhaps I have misled. The formula is not complicated for we, as I have said, have no knowledge of health but for that we usually have it. People in my family rub the baby's own excrement all over his skin, into the areas of redness. Even though Gramma doth insist it will work, the baby hath been screaming and itching like he was the brunt of the anger of a thousand bees! Tell me, dear Nursemaid, if the dregs of my nephew will heal him or he shall continue to suffer?
Nursemaid K: O! For you shall not do that ever again and taketh thine baby to the doctor trained in London after cleansing his skin with soap of lye and water! Do not lay thine stool-stricken hands on this baby, for you do nothing but make him smell of fæcal matter!
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