Speaking of ventilators

Charge nurse, to me: K, I went and picked up your "Milk of Amnesia" for you (hands me Diprivan drip).

Hey, can we bum a vent?

So, what do you do if your hospital runs out of ventilators at 3 am, including the super double-triple back-up ventilator from the early 80s found in the basement which is being affixed to the vent tubing of your patient as the RT mutters "we burned the last vent" to his supervisor?

That's right, work out an emergency deal at 3:05 am with a hospital down the street that uses the same vents as you whereby you toss a couple vents in the back of a truck and haul 'em to your hospital and, in the meantime, pray no one codes nor comes in by ambulance needing a ventilator.

Another crisis averted.

Shout-out to stuff I tell my patients

So, I've had this viral syndrome thing for a few days now. Hacking cough, mild fever, body aches, poor appetite, etc. Yawn.

To have a little fun, I decided to do a variant of what I tell my patients to do, which is as follows:

• Push fluids
• Take ibuprofen 600mg 3 or 4 times daily
• Take Tylenol in between ibuprofen doses 3 or 4 times daily
  
• Rest more than usual
• Call in sick to work if necessary ( I did last night)
  
• Boil water in the house and/or increase the humidity of the house with a humidifier (I boiled water)

I must say that all this together adds up to a not-so-terrible viral syndrome experience. When I wake up in the morning, I feel like I got hit by a train, but after I get back on the ibuprofen/tylenol routine, it's not so bad. I've largely kept my temp under 99.0, my body aches are minimal, and I slept an obnoxious amount yesterday and called in sick as well.

I figured in a previous post that I was about to get Influenza A or something due to my repeated exposure to influenza, the recent strains of which are not entirely prevented with the flu vaccine (and I have fever, body aches without nasal congestion, so maybe I do, who knows). If I do have influenza, perhaps it's mild due to the flu shot I received.

All and all, I'd give this viral syndrome a 2-3/10 on the illness severity scale. It's sad that people would rather come to the ER for this stuff than do what I did.

Update (3/1/08 3:57am): Just kidding, still feel like ass, worse even. Grrrr.

Poll: Emergency cooter issues

Right about the time you want to hit me in the arm is when I know I'm in the right spot

Yesterday, I had the perfect game. Eight out of eight patients I swabbed for influenza came back positive.

Today, I have a cough and my eyes are starting to water.

The abusive boss

So, I bring a patient back who was trampled by a rather large farm animal, including being stomped on the head by said animal. Neck pain, head pain, transient loss of vision, you name it.

Her teenage daughter looked a little distraught, and I assumed that it was from being shaken up over mom's accident. It was that, sure, but there was also the fact that when she called her boss to let him know that she was bringing her mother to the emergency room, he told her over the phone that if she didn't show up to work that she would be fired.

Basically, the daughter said "too bad, my mom has been stomped about her skull and needs emergency care at Nurse K's awesome hospital". Mom lividly---despite her severe pain--- calls up the boss and tells him that, yes, she really was in the emergency room with a head trauma and didn't feel that driving would be a stellar plan born of wisdom and sagacity and, alas, enlisted the assistance of her daughter to drive.

I'm listening to this exchange one curtain over. Normal bosses would hear "emergency" and just say 'oh okay, sorry for trying to fire you over such a thing. Just kidding.' However, this boss was drilling mom, wanting details of what happened and was obviously being a dickweed.

So I finished my business one curtain over and stormed into the room and demanded the phone from my patient.

"This is THE NURSE. This woman has had an emergency and her daughter did what ANY DAUGHTER SHOULD DO in that situation and appropriately drove her to the hospital to be seen and treated. If you want a letter on HOSPITAL LETTERHEAD, I'll WRITE YOU A LETTER."

Trying to fire a teenager over helping her mom in an emergency is just plain abusive and pissed me off. Yeah, let's guilt-trip the poor girl over not calling other people to work for her when her mom was lying the barn floor with a head trauma and all she thought about was getting her help. That seems reasonable. Here's a letter on hospital letterhead, a**hole, and I want to personally deliver it where the sun don't shine.

When your hospital is threatening to turn into King-Harbor Lite

The other evening, we were 4 nurses short. We had the amount of staff needed to staff the ER at 3 am during the busiest time of the day.

So, Nurse K was rollin' solo at the triage desk. No other triage nurses to be found. It takes me about 5-12 minutes to triage your typical patient, 5 minutes being a healthy teenager with a cough and 12 minutes being a hard-of-hearing grandpa on 20 meds. All it takes to get screwed over is for like 5 people to sign in within 10 minutes of each other, and then by the time you finish those 5, there are 5 more to be seen and so on and so on.

When I ran back to take a leak, I kissed my nursing license and told it I loved it and didn't want it to go. Who can re-assess these people? I'm doing 2 peoples' jobs here trying to get the really sick ones back (when the back is 3 nurses --- equal to about 12-13 beds worth of appropriately-staffed nursing care --- short and don't want to take any more patients ever).

If someone lies on the floor, I have to run out there and see what the deal is and make a quick judgment about what to do. If the LOL in the corner starts to clench her abdomen and double over, I gotta (a) notice it in the chaos (2) run out there (c) re-assess in like 20 seconds and decide what to do and then (d) fight with the back about her getting a bed. People come up and hover over you so when you are done triaging someone, they can bitch about the wait time when you're done--if you're lucky. The ballsy ones will pitch a fit, talking over you talking to someone else.

People are vomiting (including not in the bucket on purpose so they can get back faster---luckily housekeeping was staffed) and screaming and being dramatic and threatening to call an ambulance from the lobby and saying I'm discriminating and HOLY HELL ON EARTH, SHUT THE HELL UP. Then the migraine patient comes up and tells me to stop the people from yelling so loud and the appropriate but obviously painful lady with a kidney stone sits quietly crying, and I run out to give her some Kleenex, which is all I can do.

Meanwhile, I get these little slips of paper with names, birth dates and complaints, and I have to shuffle-shuffle-shuffle to see which one looks promising for an emergency and call that person first. There's no one to help me if I get bogged down because they're trying to keep people from croaking in the back.

Oh, and I should say...was there a bolus of ill calls? Why were we four nurses short? Oh, we knew we were four nurses short for that shift for 6 weeks and no one in the staffing office did anything about it until that afternoon when they started trying to find extra help. Can we put up a sign-up sheet or something? A "critical shortage" sheet? Nope, we're going to wait until the last possible second to find staff for the shift.

I don't think I killed anyone, including the quiet guy with the "10/10" abdominal pain who had an ischemic bowel who got back right away thank-you-very-much.

Sounds like a good idea to me

Health Care BS has a good article today on the hilarious practice of emergency departments in Britain keeping people outside in ambulances for hours on end, only letting them in when it is possible for them to be seen in four hours to "meet" their government's emergency wait time goals.

Here's my comment on that practice:

Nurse K wrote:

Sounds like a good idea to me as long as I get to pick who stands outside. Stuffy nose, cough for a month, “fever” of 99.1 (it’s high for me!), and 10th visit this year for low abdomen pain can all wait outside. Posted 22 Feb 2008 at 10:05 am

I think I may be softening up to this idea of socialized medicine after all!

The ER: The place to send your patients when the crap at your clinic breaks

A nice young man is a patient of one of the clinics in town who accept self-pay patients. I quickly note on his demographics sheet that he is uninsured as I call him to be triaged. His triage slip reveals the reason he is here is to "get an EKG." No one signs in with that complaint, so I know there is going to be more to this story.

The young man produces a note from his clinic doctor which explains that he is being sent to the ER to obtain a routine pre-op EKG for a surgery he is to have next week because "the EKG machine at the clinic is broken." Chest pain? Nope. Shortness of breath? Nope. You're really just here for this EKG for your surgery? Yep. That's it. I feel great otherwise.

So, aside from the abuse of the ER, it is just sickening that they'd send this poor young man to the over-crowded ER (we were on ambulance divert at the time, on top of it, if I remember correctly) for a routine EKG, especially given that he is self-pay and will have to pay full price for the visit. Maybe the doctor thought we'd just take him back, hook him up to the machine, and then fax the EKG to him under-the-table-like.

Nope, the poor kid is going to be charged full price for the EKG, which is charged at the highest rate (the emergency rate), plus the fee to receive a medical screening exam. I'm sure he'll be happy to get that bill in the mail---he probably could have paid to fix the clinic's EKG machine for cheaper.

You think that's related?

Nurse K: So, you have low belly pain. When did that start?

Patient: Oh, about a month ago.

Nurse K: Has it been going on for the whole month?

Patient: Yeah, but it's worse today.

Nurse K: Ever been seen by a doctor for it?

Patient: No, not really.

Nurse: How does your pain feel?

Patient: [Calmly] Like someone is tearing my insides out.

Nurse K: Vaginal bleeding or discharge?

Patient: Well, I had vaginal bleeding after my c-section a month ago, but none now.

Nurse K: You had a c-section a month ago??

Patient: Yeah.

Nurse K: So the pain is RIGHT OVER YOUR C-SECTION INCISION?

Patient: I guess; you think it's related to that?

Jesus H. Christ.

"Sick"

God, I hate it when people sign in "don't feel well" or "I'm sick". Usually it's just some BS virus or --- heaven forbid --- a cold, but every once in awhile, people really just don't know how to describe their problem.

Recently, an elderly gentleman signed in "sick". This in and of itself is a rarity in the English-speaking population. Generally, elderly folks put down the exact reason why they want to be seen. So, I wheel him over and he explains how he's had this wicked case of the diarrhea for a few days and feels dehydrated. Okay. Another one of these, eh? Why couldn't you just have written "diarrhea"?

So, I go through everything, and "oh, by the way, I'm a little dizzy right now too" and "oh, by the way, my chest feels tight" and "oh, by the way, I think I could pass out."

Blood pressure is "indeterminate" on the monitor. Whatever. Pulse is "indeterminate" as well. Good God dammit already.

I wheel him back, slap him on the monitor, slap him on the BP cuff and --- gee, that's why you feel sick, Grandpa --- your heart's beating at 210 beats per minute (hm, looks a bit like a fast a-fib) with runs of v-tach and your blood pressure is 60/30.

Nothing brings a whole bunch of people in a room like that. My work here is done.

Poll: ER knitting projects

Terrifying chain of events

Put these in the order in which they happened. The patient is a healthy female with no meds, no medical history, with only a recent history of a mild URI. Urine drug screen, head CT, CBC, and blood alcohol level are negative/normal upon arrival to the hospital.

1) First responders shock patient
2) Patient has tonic-clonic seizure activity
3) Patient has coffee-ground emesis
4) Patient is noted to be gasping for air
5) Patient is noted to be pulseless and in v-fib
6) Patient is noted to be in a sinus tachycardia rhythm
7) Husband attempts CPR after receiving instructions from the operator
8) Patient intubated and brought to the hospital
9) Patient collapses

Something to do on night shift: Make something

Every once in awhile, usually between 3:30-6:00 am or so, it will slow down and you find yourself getting antsy. Certainly, sometimes you are suicidal and wishing to run screaming from the department from all the crayzees overtaking the joint during those hours, but, for the most part, business drops off.

So, the other night, at exactly 0330 am in triage, I learned to knit. It took about 5-10 minutes to learn the basics. Most of the night shift nurses knit or do crafts of some sort, and even one of the Gen-X secretaries makes beautiful bags and accessories. Me? I'm a craftard. I was just the official craft admirer.

I expressed interest in learning how to knit so I had something to do on long-ass plane and train trips. A nurse offered to help me, even brought me knitting needles and a ball of yarn and donated it to the cause. Awww, how nice.

Let me tell you something, y'all. I find typing on the computer to be somewhat relaxing. I find the act of drinking coffee relaxing. I think knitting is not only relaxing, but hypnotic. You do the same thing over and over and over and OVER again. It's like meditation or some sh*t.

Crayzee Central weekend music selection

Stuff white people like: Natural medicine

The comedically insightful blog "Stuff White People Like" shares with us the real reason white people like natural medicine:

Since white people can’t really blame any race for their problems, they need to blame corporations. In this case, the reason that they are sick or fat or without energy is because the drug companies are in a conspiracy to keep them addicted to placebos. This helps them shed accountability, and it lets them feel like they are helping the environment by rejecting the polluting, greedy, awful drug companies and taking natural, organic medicine from the earth.

But perhaps it goes deeper. Hundreds of years ago, another group of people believed firmly in natural medicine and it’s ability to cure disease. Then white people gave them blankets with small pox and they all died. So perhaps turning to natural medicine also helps white people feel better about killing natives.

H/T to steve_in_hb who also is feeling "dissed" because this post accurately describes his mix CDs

Mental illness or genius?

A fourteen-year-old polite and charming honor student with his highly functional and equally as kind and respectful parents is brought to the ER for new-onset auditory and visual hallucinations in the context of worsening depression:

Nurse, I'm not sure if I'm actually hearing and seeing things that are not there or if it's more of a way of my brain handling how fast it works.

Secondary gain

I thought I'd seen every possible reason for one to go to the ER that didn't involve an actual emergency, but this one was new:

A lady comes in for her 6th visit in the previous month or so at an odd time of the night with complaints of 10/10 vague back pain with tenderness sometimes-here and sometimes-there with some vague history of some car accident back where she used to live. She is a resident of one of the local homeless shelters, and I'm not sure how it works, but in the morning they basically kick everyone out and they "go to the streets" until they let you back in around dinnertime. Apparently, this is a common practice for homeless shelters.

Oh, and she was morbidly obese. I still haven't figured out how so many of these people who are homeless and walk around all day long are morbidly obese.

She does the usual homeless shelter patient speech: Can I have a blanket? Can I have something to eat, and, quite ballsily, can I make a long-distance phone call at your nurses' station? Uh, no. Even before my assessment, she explains to me that she would like a note from the doctor giving her permission to "not go to the streets" that day so she could rest. Apparently, only people who have evidence of recent hospital admission get to stay during the day, but sometimes they make exceptions if there is a doctor's note. Alternatively, she'd like to be admitted for at least 24 hours because they don't allow you to sleep during the day if the admission is less than 24 hours.

"We haven't even assessed you nor given you anything ma'am."

Then, after her complimentary narcotics, she'd like me to explain to the staff what drugs I gave her and that they were sedating, that they should "come pick her up" (the staff at the shelter use their own cars to pick people up!), and she surely could not be walking around outside and that she should rest all day.

*Sigh*

Drug seekers' lawyers: Do you really answer the phone at 0430?

So, the lament of the drug seeker after they are denied narcotics is "I'm calling my lawyer!" Nothing makes us all yawn faster than hearing those words. I mean, you just yawned right now didn't you?

"Okay, dial 9 to get out."

"Oh, really? That's interesting. I was about to call out for Chinese myself."

One of our doctors gives the patient the Yellow Pages, graciously turning to the "attorney" section, and offers to speak directly with whomever is on the other end of the phone. Always good for a laugh.

Of course, professional drug seekers don't work only 9-5, so sometimes lawyers need to be called at 0430. Last night, a patient claimed to be talking to her lawyer on the phone at that very time. I wondered...are there really lawyers on the other end of the phone or are they just talking to the dial tone or their boyfriend-masquerading-as-their-lawyer?

I mean, criminal defense attorneys are often available at that hour, but are other lawyers awake? Do they really care if some guy with chronic back pain is being denied a 3rd dose of dilaudid at 0430? Do they "advise" the patient to throw a temper tantrum and get hauled out by security or do the patients come up with that idea on their own?

The retarded baby

Other Nurse: Oh, you have a baby in the NICU right now and you're coming down to the ER at 0400 for another pregnancy test, eh?

Upstanding citizen, 19 years old: I think I pregnant again, but if I is, that no big deal cuz I's giving up that NICU baby cause she retarded from coming out too early and my mama take care of the other ones. Maybe I keep this one, I dawn-o.

This would be her 5th pregnancy (at least). Yes, she was pregnant. Fifth friggin pregnancy at 19, with a "retarded one" still in the NICU that she planned on giving up...

All we could do was say, "Well, let's hurry everything up so she can get out on time to make it to work in the morning." And we laughed, and laughed, and laughed. WORK. Yeah right.

The magical chemical

Most drug seekers are like yawny-yawny back pain or yawny-yawny fake injury or yawny-yawny exaggerate a real condition. Of course, the cure-all for all of these conditions is the need to go outside for a smoke, but I digress. The complaints are...

BORING! The acting is EXAGGERATED and the screen-writing lacks nuance and sophistication. Two thumbs down.

Luckily, there is still some creativity left in the drug seeker community.

Awhile back, a guy signs in with a follow-up on a chemical burn he'd received earlier that week. He was, of course, wanting to be seen for stronger pain medications, but he also told the nurse the name of the other ER he'd been to and on what day, so, I dunno, maybe it was legit.

I get dude back and I'm all....

.....

I'm looking at your arm, but I don't see any burns. Could you point out the burn to me, please?

Here's the kicker.

"Oh, you can't see the burn, nurse, this is a special chemical. Oh, what's it called....hydoph--chlori something-something. They use it at the place I work to clean the inside of disk drives, but it's weird because if it spills on you, it goes right through your skin to the bones where it causes damage to your bones and nerves. It's like a 7/10 now! They gave me this stuff...Vico-something, but I need something stronger."

Um, you're expecting me to believe that you have a massive chemical burn bad enough to cause bone and nerve damage under your skin from a chemical splash which people use for routine cleaning? Okay, the doctor will waste his time seeing and discharging you shortly, sir.

Six quirks/fun facts about yours truly

Discovery Channel star Whitecoat and Johnny Weissmuller's pet did it, and Diet Coke Addict tagged me for a similar dealio, so I suppose I will enlighten thee, eh?

1. I have a hard time reading fiction (although I don't mind writing brief fiction). I find non-fiction books to be far more fascinating. It's like I can't get past the fact that what I'm reading is made up. Currently, I'm reading the book version of this. It's bitchin'. This quirk is probably why things like blogs are also quite fascinating to me.

2. While I don't claim to be 100% error-free in my writing or anything, I get really uptight with blatant spelling and/or punctuation errors, especially in things like "chief complaints" as listed on the computer or in posted notices in the break room. If a chief complaint is spelled incorrectly, even on a patient to whom I'm not assigned, I'll change it. If apostrophes are used incorrectly (especially in lieu of a plural), I'll anonymously X them out as I'm reading the notice (I won't do it if other people are in the room). Like:

Make sure all your patient's are charted on every hour.

That crap drives me bonkers, man.

3. Despite the fact that I have a kid and I've been on a greater-than-average number of plane trips/vacations in the last couple of years, I don't own a camera. I do, however, have a Kodak disposable at my...disposal.

4. I've been continuously employed > 20 hours per week since age 14. I've never not had a job since then, even for a week.

5. When I was 10 or 11 years old, I learned this and wrote a couple of text adventures. It was really hard in retrospect. In one of them, a dragon was in the attic of a kid's house, and the point of the game was to make your way up to the attic doing/collecting various things so that you could properly slay the dragon when the time came.

6. I used to have sleep paralysis. I still get it sometimes, but not like once a month as I did in college probably because I'm not as stressed out now as I was then. Before I knew what it was, I used to tell befuddled people that before I went to bed, I'd feel like I was being choked to death in a cafeteria (the "auditory hallucination" portion of it often sounded like very loud background noise you'd hear in a busy cafeteria or, less often, like a devil). One time, a couple of years ago, I woke up on my couch at 2 am, and I heard my gigantic clawfoot bathtub overflowing with water. I ran to the bathtub and the faucet was not running. I ran down to my water heater to see if it was flooding the basement. Nope. I checked the other faucets/pipes, etc until SNAP! the sound went away. Hm. A little mobile hypnopompic auditory hallucination action.

So, in summary, I'm a hard-working, world-traveling dork, and I hear things sometimes.

No tags, but play if you so desire.

Nurse K: As funny as Michael Richards

A quote about me, care of my new favorite Crayzee Central mascot "The Dawn", deserves its own post:

On a comedy scale of 1 to 10 with Lucille Ball a 10, I consider you a 5 in line with Michael Richards.

I, in turn, gave her a "12/10" on the ER Comedy Scale with a 10/10 being when an idealistic resident maintains a straight face as a coked-up drug seeker tells him to "lay down next to his bowl" after being denied narcotics. She's funnier than that.

Update: Be sure to read "Dawn"'s final comment in my comments.

I hope you're kidding

An otherwise healthy 12-week pregnant patient sits down rather uncomfortably at my desk.

What brings you in today, young lady?

"I was sent here by my OB/GYN to get an enema for my constipation. Since I'm pregnant, she said the enema should be 'medically supervised' in the emergency department."

I hope this OB/GYN doctor has figured out by now out of which hole these babies come. The holes are really close together, so I can see how confusion would arise.

The canaries are dead; could someone up there toss me a frickin' rope or something?

ER quotable quote of the millenium

Here.

Heaven forbid, eh? That about sums up every ER nurse's frustrations with the state of the emergency department.

If you can stomach it...

HotMedicalNews has an historic lobotomy video narrated by the guy who narrated all 1950s educational videos. While many neurosurgical procedures from this era would probably look similar, I just want to give you double-fair warning that you're watching something that caused mentally ill (or, frightingly, not mentally ill) people to become permanently disabled in many cases during a time when few effective treatments were available for mentally-ill people.

The most famous recipient of the lobotomy, Rosemary Kennedy, was made incontinent and severely mentally retarded from the procedure...

We went through the top of the head, I think she was awake. She had a mild tranquilizer. I made a surgical incision in the brain through the skull. It was near the front. It was on both sides. We just made a small incision, no more than an inch." The instrument Dr. Watts used looked like a butter knife. He swung it up and down to cut brain tissue. "We put an instrument inside," he said. As Dr. Watts cut, Dr. Freeman put questions to Rosemary. For example, he asked her to recite the Lord's Prayer or sing "God Bless America" or count backwards. ... "We made an estimate on how far to cut based on how she responded." ... When she began to become incoherent, they stopped.

—James W. Watts ^[3]

Poll: Blog-stalkers

This is anonymous, so feel free to answer honestly, dear blog-stalkers. Don't bother answering if you're like my mom or ex-boyfriend whatever.

Update: Poll is closed, thanks for answering.

I must admit it's creepy that four of you know where I work. By "where", I obviously don't mean "the ER, duh."

If you are a blog-fan, but happen to know where I work (and are not MG, AD, Scalpel, 911, nor Christine---I could care less if you guys know where I work), feel free to be a champ and email me (crasspollination@yahoo.com) with how you know/figured it out.

Psychotic trap patient

A "trap patient" is one who is, for whatever reason, not clearly demonstrating their illness for all to see. He might usually be a drug seeker, an addict, a drunk, or some other problem that is sufficient to mask their underlying, possibly serious medical problem. Sure, they may complain of some symptoms, but they've done the same thing a dozen other times this year, so yawny-yawny.

So, county was on psych divert the other day, and so we were getting all these county psych patients by ambulance. County, of course, has numerous holding rooms, staff, and numerous crisis social workers to our 3 measely rooms, sleepy security guard, and perpetually web-surfing crisis social worker. So, the short version of the initial trap set-up is that this patient normally went to county (thus, having no records at our facility) and was undeniably psychotic in the context of county being on psych divert. Alas, he was sent to the waiting room to wait in the holding room with all the other county psych patients waiting to come back. Lucky for him, though, there wasn't a lot else going on, so, instead of waiting in the lobby for 6 hours like most other psych patients, he got back relatively quickly.

He arrives completely out of his mind: Delusional, hearing things, off his meds for some unspecified amount of time because he "keeps puking them up, dammit". He says he is suicidal oh, and, by the way, he's yelling in the lobby that he wants morphine. It's hard to get any story from this guy.

*Sigh*

Eventually he comes back, and he starts complaining of everything under the sun: Back pain, belly pain, pain all over, and he wants morphine still. Oh, and he's crayzeeier than a mercury-drinking, jungle-dwelling Johnny Weissmuller* and meaner than Margaret Hamilton.

So, the doctor comes in and assesses the patient to clear him medically for psych evaluation. Hm. Rigid abdomen. Vomiting. Unable to take PO for a couple of days.

The county psych divert patient had a high-grade small bowel obstruction and was admitted to medicine after being given some happy drugs. And narcotics, of course.

Triage: Fevers

Patient presents to triage ambulatory. Pertinent symptoms include subjective complaints of fever. Pt did not check temperature at home. Patient has not tried any OTC anti-pyretics, denies drinking cold fluids prior to arrival in triage. Temp in triage=97.8. Pt states that is high for her.

---

We are not allowed to tell her she needs to go home. It's against the law.

Unions: Everything is based on seniority, and since I'm not that senior, this system can bite me

I've been a nurse for a little over 4 years working full time, and this year is the first year I get a week of vacation off during the summer.

One crapside of unions is that everything is based on seniority. It's not a free-for-all for vacation time; you have to attempt to take your week off after everyone with more seniority has taken their time off. ER is a high-seniority area. Some nurses have 70,000 seniority hours or something like that. If you're a senior nurse and you want to take a month off during the summer, go right ahead, even if it means that 4 or 5 peons like me can't have any summer vacation. Ain't no one gonna stop ya, you're a senior nurse.

Last year, I had 2 days of paid summer vacation time! Yeah! That's worth it. There is one secretary with 25 years seniority who takes every single one of her weekends off during the summer, so no other secretary on her weekend gets the chance to have any weekends off for the whole summer. Seniority rules, you know. Even a secretary who works the same weekend and has 20 years seniority can't take a weekend off.

So, basically, unions favor nurses based on seniority only. Pay is based on seniority, vacations are based on seniority, who gets to pick up a double shift is seniority-based, who gets a job is based on seniority (if two nurses meet minimum qualifications for a job, the one with the most seniority HAS to get the job even if the other nurse would probably be a better fit---why even interview?), who gets to leave early from a shift is seniority-based (not "who just worked 10 shifts in a row?"). Even who gets what parking spots is laid out in the contract and, yep, senior nurses even get better parking spots.

This crap has to be limited somehow, but it never will be because all the union reps are the senior nurses. Yeah!

Hypothermia protocol works again

Awhile ago, we had a patient with no medical history/no history of drug use arrest at home, an arrest witnessed by her husband who didn't know how to do CPR. I could go into the details, but the important part was that she was down for around 8 minutes with no CPR. She was shocked once, restoring a perfusing heart rhythm, tubed and comatose/posturing upon arrival to the ER. I argued, in lets-just-say a very assertive manner, with the doctor for about 20 minutes as to the necessity of the hypothermia protocol (there was some other stuff going on with her), and after consultation with the neurologist, we starting cooling this chick. Sweet. Let's preserve some brain function.

If you read this linked article, she was exactly what the study was looking for: Witnessed cardiac arrest, down for less than 15 minutes, perfusing rhythm restored in under 15 minutes, didn't regain consciousness immediately, blood pressure ok.

Her body temp was brought down to around 33C/91F in the ICU with their fancy cooling equipment (we use the chilled fluid bags and ice under the armpits to start the process in the ER).

She was re-warmed per the ICU protocols, and, soon thereafter, started to follow some commands, move all her extremities, and nod yes/no to questions soon thereafter.

She was down for 8 minutes with NO BLOOD NOR OXYGEN FLOW TO ANY BODY ORGAN INCLUDING HER BRAIN and was nodding yes/no to questions 2 days later. It's just frickin' amazing.

Wonder how she's doing now.

Clots!

We have a new frequent-flyer! She, like a quarter of all pregnant people, is having first-trimester bleeding in small amounts, and she comes in with every "clot" (she had a big one the other day---pea-sized) and waits for 5-7 hours to be seen. Each time we explain that if she's going to miscarry, she's going to miscarry and only to return with massive clots, severe abdominal cramping and/or fetal tissue along with dizziness, and within a couple of days she signs back in with a "clot 6 hours ago". Any continued bleeding? No. Cramping? Well, a little then, but none now. Oddly enough, no one has ever seen any vaginal bleeding from her, so she's probably one of these.

Just tell 'em you passed a clot and you'll get another sonogram!

She's 6 or 7 weeks pregnant now and has made 4 visits or something since onset of pregnancy (and 4 or 5 more looking for pregnancy tests prior to actually getting pregnant).

Primary care? Not until the 8th week for pregnancy.

I wonder if getting a job might prevent some of this nonsense.

Happy Birthday Mom!

Today is my mom's birthday. For her birthday, she has thus far, since about 0700: Received a (1) cardiac echo (2) repeat sets of troponins (3) complimentary remote cardiac monitoring (4) and a preliminarily positive stress test. Or, as she put it, "the doctor said these little things on the EKG that are supposed to be going up go down when I'm walking."

Seems having a near-syncopal episode while climbing the stairs preceded by right-sided neck pain, tachycardia, and shortness of breath isn't a good collection of symptoms to have. Notably, she went home to email me to ask me what to do while I was sleeping yesterday.

Good morning, mom. What's going on? You okay?

"Yeah, what's ischemia? I guess that's what they keep saying I have."

*Sigh*

Also, notably, she doesn't want me to come down there, but, if she is discharged today, I should bring her makeup "in case anyone from work [she works across the street] sees me."

*Sigh*

My mom is in her 50s, has low blood pressure, low cholesterol, doesn't smoke, weighs less than 110 lbs, and works out.

*Sigh*

Update: Mom is home, and she tells me her cardiologist wasn't as "impressed" with her EKGs as her internist, but that he thinks she has an enlarged heart. (One atrium and one ventricle, not sure which). She made it out of there fine without her make-up.

Night shift housekeeping

Nurse K: Dude, come on already, this bed for my patient has been listed as dirty for an hour. Why isn't anyone cleaning it?

Bed placement chick: Oh, well, there is only one housekeeper on duty on nights now, so he has to singlehandedly clean all the beds plus the other stuff he has to do. Budget cuts, you know.

How many beds is he responsible for? 626. One housekeeper. There we sat with 6 admissions and 6 dirty beds listed while he went around the entire facility cleaning them one by one.

Random non-medical thing that annoys me

Okay, so today I'm volunteering to stuff envelopes at my kid's school, and just now an email came through to all the people who volunteered which illustrates this pet peeve very well:

What the Hell is up with people who have "family" email addresses?

These email addresses, with the exception of mine and one other, are stuff like "Billandcathy" or "JessieandSteve" or "SallyJoeandKatie" @ something dot something.

Dude, get your own email addresses. There's no need to share email addresses, especially with your kids. Does your husband have to double-check all your emails to make sure the spelling is correct or that you're not sleeping around? Do your kids really log in to this email address and read too? Do you gather around the computer to read email and sip tea like your grandparents did with the radio during FDR's Fireside Chats?

Family email addresses are weird. Get your own.

British door-to-balloon time: However long it takes to get to day shift

If you're on bended knee this election season hoping for a state-run medical system, consider this comment left by Dr. Shroom at MDOD (a post you should read no matter what):

DrShroom said...

Nice post. Nothing sums up, for me, the difference between the UK and the US better than the phrase "door to balloon at 3a.m 40 minutes... not excellent". Where Shroom works, a large University teaching hospital, a regional centre for interventional cardiology, there is NO balloon out of hours. None. Ever.
Go figure

4:56 AM, February 08, 2008

I remember him somewhere else saying his ER had 120,000 patient visits each year for 20 beds. No cath lab after-hours. We're a third of that size and our cath lab probably gets used at least once 3 or 4 night shifts per week (and God knows how often on evening shift, the busiest shift of the day) for an acute MI patient, whether they're being transferred in from a rural hospital or one of our own. This doesn't count the admitted patients who infarct while on the floors. There are also a few other hospitals in our area who offer the same all-night cath lab services. It's the standard of care, after all.

At night, if there is a STEMI, we call a 1-800 number which sends a page out to all the pagers of the people on the cath team. The cath team (including an on-call cardiologist) is supposed to be there, dressed, and ready in 30 minutes, so, usually the door-to-balloon time is around 40 minutes as well. If they are coming in from a rural hospital, they call in our cath team. Paramedics in certain companies can activate the cath team as well after seeing ST-elevation on their 12-leads and, if the cath team is fast enough (more applicable to day shift), they can skip the ER altogether. We routinely have door-to-balloon times of less than 60 minutes on patients coming in from towns an hour or more away by non-ambulance drive (their door, not ours).

The cath team always looks fresh, cheery, clean, and ready for action, too. I've never figured that out.

Opening blocked arteries as fast as possible is the standard of care for acute heart attacks and often is the only thing that relieves a patient's chest pain during such an event. In this hospital with 120,000 visits/year, there are no after-hours cath lab services. This would be unacceptable in the United States, even scandalous.

I hope someday we can have a system like that one. It's free afterall. Oh, and they spend less per patient per year than we do. I mean, they put people in never-ending queues for things like total knees and total hips, but can Her Majesty not cough up a few bucks to save her citizens who are in-frickin'-farcting in London of all places?

In London, at this major hospital, everyone has equal access to cath lab services after-hours. If you can't provide reasonably equal access to an actual service due to cost or lack of qualified staff or whatever, the only fair thing is to deny the service to everyone, right?

The dirty old dishrags

She was 46, looked 65, and had the usual disease processes found in a former alcoholic with liver disease and diabetes. She weighed, perhaps, 100 pounds, her hair was all over the place, and I could have picked her up in my arms like a child. "I don't have any appetite." She was a dirty old dishrag.

Another was 41, looked 41, had hair stuck up in the air, no makeup, a T-shirt and boxer shorts on despite it being 8 degrees out, didn't speak, but shook all over. Her family didn't know what was wrong with her. Her husband spoke for her despite me asking her the questions and asking her again after he answered. He followed her to CT to speak for her. She didn't make eye contact but cried silently as I helped her to the bathroom. Her children texted their friends in the corner despite me telling them to shut off their cell phones. She was a dirty old dishrag.

Another was 68, looked 80, who was found down by her family after a fall sometimes the previous night with no visible injuries but for a bruise or two. She was covered in stool and urine, but strangely 100% oriented. Around her neck was a LifeAlert button which was never pushed; the medics found empty bottles of medications from December that needed to be refilled. Her husband had died the month before. She was a dirty old dishrag.

Consultants

How can a hospital maintain its credibility by simultaneously cutting the hours/positions of the $10/hour transport aides and housekeepers (causing a marked increase in the time it takes to get patients to the floor and to tests, with waits of 30 minutes per transport commonplace*) and hiring expensive "consultants" to work on the problem of patient flow? I don't want consultants, I want the cheery, friendly transport aides back; I want someone to clean the room my patient is going to, not have it sit dirty for two hours because "the housekeeping staff hours were cut and there's only one for the entire floor".

I mean, what a way to piss people off.

Some of our staff are protesting by refusing to talk to the consultants. If you can hire expensive consultants, you can have a couple extra housekeepers on staff to turn rooms over faster.

*=If we don't just simply give up and do the transports ourselves to keep things moving

The bad version of the Midas Touch

There was one day where everything I touched turned to clots. Here is a summary of a recent shift:

• 32-year-old female with persistent pleuritic chest pain and normal vitals, waited in lobby for 4 hours. Dx: PEs x 4.
  
• 61-year-old uninsured male who had severe chest pain. Tells a story of how he hasn't been walking for 1 week because "every time I get up to walk somewhere, even to the mailbox, I can't breathe, my chest hurts, and I nearly pass out". Dx: Acute MI. Worried about who was going to take care of his 95-year-old mother while he was in the hospital.
  
• 83-year-old female who hasn't been to the hospital since the birth of her children, wants to go home and not waste our time (reminding me of my grandma), presenting with sudden-onset chest pain. Dx: PEs x 2, "new"-onset a-fib. Pills include...calcium supplements and "occasional" ibuprofen.
  
• 48-year-old male with history of hypertension from the lobby, put in a hallway bed for an EKG, complaining of chest pain. Dx: Acute MI. Went to cath lab. Who said you can't work magic in hallway beds?
• 94-year-old with syncope and generalized weakness. Dx: Elevated troponins, normal EKG.
• 56-year-old thin, athletic female (she probably looked 38) with transient numbness and garbled speech for 30 seconds. Dx: Normal head CT, small acute rt frontal CVA
• 81-year-old female with no speech, no movement on left side of her body, and eyes deviating towards the left, dx: Normal head CT, MRI shows gigantic CVA

I mean, seriously, what the HELL? No sepsis, no pneumonia...just clots, and lots of 'em.

I was kind of hoping that my ex-husband would sign in that day.

We don't go by stage names in the ER

To all the cross-dressers out there:

If your name is "Robert", you are Robert when you're in my department, not CRYSTALLE.

If your name is "Steven", you are Steven in my department and not BRANDEE.

Calling you made-up girl name while in a health care setting is just strange, and I'm sorry that I'm not down for it. I'm totally up for it if I'm at a drag show, however. That's different.

Oh, and to clear this up in advance, if you have a penis, whether you want it or not, you are anatomically MALE and I will not have registration switch your gender on your chart because you "feel" female. Also, you do have to wear the gown, even though it makes you look more like a dude with lipstick on because it doesn't accentuate your--gack--curves. Sorry, your water bra is coming off too, and it will make you look flat-chested. I look flat-chested in a hospital gown too, so that's accurate at least.

We don't go by stage names in the ER nor do we assign you a gender based on your pathological perception thereof. Please be aware. Maybe we should make up a sign.

Problem solving 101: My doctor doesn't have an appointment this month!!!

So a guy came in for what amounts to a follow up visit for chronic low back pain. Yawn. He, like many people, said the reason he was in the ER for his back was (1) I'm out of medications and (2) my doctor can't get me in for an appointment. When was the last time you saw a doctor? Oh, at The Other Hospital ER a couple of weeks ago.

So, he gets his complimentary high-dose IM narcotic. His discharge paperwork, of course, said to follow up with the person (who was with a different hospital system and had no privileges in our facility of course) he said can't get him in for months.

So, I gave him his handout on back pain and six, count 'em, six cards for large internal medicine and/or family medicine clinics all clipped to the corner. He had about 60 doctors to choose from right there.

While I think this visit was 99% bullshit, if your doctor can't get you in for "months" for an acute exacerbation of your problem, you need a new doctor. Plain 'n simple.

Hey doctor!

Okay, so your favorite nurse-blogger (um, me, duhhh) has to sometimes ask doctors for stuff or tell doctors stuff. Like, "Yo, the labs are all back on room #15..." or "Yo, yo, yo Doctor, the patient in room #12 is blowing chunks, can I get a little sumfin-sumfin ordered?"

Most doctors just say "thanks" or "oh, sure, give him a little Zofran". However, we have one doctor who thinks the best way to communicate with me is to not even flinch nor acknowledge anything I say ever. Certainly, as I am someone who is used to more normal methods of communication, I generally speak a little louder, starting again with EXCUSE ME DOCTOR, the patient in ROOM 14 is BLOWING CHUNKS, can I PLEASE get an ORDER? assuming, of course, that he did not hear me in the chaos.

He continues to ignore me and walks away or does anything else besides acknowledge me. This happens numerous times per day.

Of course, he sneaks away and puts the Zofran order in, or re-explains the patient's diagnosis or does what I need generally but without so much as flinching nor acknowledging my presence.

What a dick.

To the paramedics out there...

Look, if your patient isn't being ventilated, in severe respiratory distress, and/or isn't on the verge of cardiac arrest, a temporary spot in the hallway is just fine. I spent like 3 straight minutes arguing with some paramedic who refused to put a mentally disabled patient in the hallway when there were no beds because...he was mentally disabled. I even specifically chose the hallway bed literally 3 feet from the nurses' desk so he could be watched more closely. In fact, the hallway bed was probably more appropriate than almost all of the regular rooms for that reason.

So, please, if the patient is stable, don't argue about hallway beds. Our damn ER is full. Note how I said "OUR" ER as in "offer your input, but don't sit there and argue incessantly because you have no clue what's going on outside of your one patient".

Oh, and no more putting IVs in chronic pain patients en route because we can't send them to triage. That's another no-no that will surely piss everyone off.

Vending machine

We have ice cream machines, machines with chips, cookies, and soda, but...

Where's the machine with the pregnancy tests? I'll betcha a machine offering $1 pregnancy tests (same that your find in the dollar store) would be quite popular and save our taxpayers a few thousand bucks a year just in our ER alone. Each pregnancy test could have a Planned Parenthood brochure attached to it (where you can get free or subsidized birth control/pelvic exams).

I'm not kidding. We need the pregnancy test vending machines.

Time to link something totally awesome

I've been reading this for awhile, so you should too. In fact, you should do just about everything I tell you to do because you'd be better off---less full of yourself and your lofty communist ideals, a better nurse, and totally frickin' fun to hang around at parties, etc.

If you're all "oh, you're linking an entire website, just link one post so I can sample it, K?" then try this one that sort of keeps in the theme of this website. ERDoc85 and etotheipi-style language warning.

The Nurse K politics post

If you want to tax me more, you're not getting my vote. If you want to tax "rich" people more so you don't have to tax me more, you're still not getting my vote.

All I want is a paycheck and a nice life for my son, not somebody telling me my money would be better spent on other people. I want my son to have violin lessons and to come with me to France in 2010 like I promised. I want to have a bathroom that both looks nice and has a toilet that is not sinking into the rotten floorboards. I want a dishwasher in my kitchen. I want a new couch. I want someone to fix the hole in my foundation and get rid of the mold in my basement. I want to do something other than put my son in front of the TV when I come home from work exhausted after my 8th or 9th shift in a row. I want presents under my tree at Christmas (amazingly, my son is 8 and this is the first year I met that goal to any extent). I want to fix the damaged side-mirror in my car so I can see when I drive.

I do not want to pay any more taxes.

Please consider all the people like me who could have but don't due to the already high taxes we pay when making your voting decision this year. Consider all the children who are shuffled around to various relatives and friends while we work doubles to meet the bills and put some extra money away. Consider the places we will never go and the things we will never see because an ever-higher percentage of our incomes was taken by the government. Consider the people we will never meet and the opportunities lost (eg a graduate degree) because we are at work paying for others who have no desire to do for themselves. Consider the relatives we don't see at Christmas or Thanksgiving because we can't afford to not work those shifts, even if we are not scheduled to do so.

America should go back to its roots where people who were lazy or uneducated didn't succeed and had to suffer a little bit. If you didn't till your fields, you didn't grow any food, and didn't make any money. If you didn't get to the factory because it was too long of a walk, you didn't get a paycheck. If you had numerous children without fathers, you either had to work, let relatives raise the kids or live with your relatives, or live in the charity-funded poorhouse (of course, few people had numerous out-of-wedlock children back in the day because there were...consequences).

I'm Nurse K, and I paid $12, 743 in taxes this year, including property taxes, but not including sales or gas taxes. I hope you people enjoy it, wherever you are.