The countdown is on....

T-minus 2 days until my trip to Europe.

First stop is Germany where I'll be staying in the former Soviet stronghold of East Berlin. Luckily, I will not be denied my freedom, forced to inefficiently work at nearly slave wages in a factory to ship goods back to Russia, drive a shitey Russian car, nor be shot for crossing into West Berlin.

Apparently, there used to be some wall dividing the city where one part was as free and prosperous as could be expected and the other part was "equal" and poor. Wonder what that was about.

It will be cool to see what all was done to modernize the "equal" part of Berlin up to non-3rd-world standards since 1989. It will be a case study in what freedom can do for an economy and a populace in a relatively short period of time.

Oh, and there are supposed to be really bitchin' kebobs around where I'm going to stay.

Also, here is an article from 1990 which describes the exodus of nurses and physicians from East to West after the reunification of Germany. Physicians were happy to get their hands on the latest literature and nurses were using their days off to scope out positions in the west.

Even more than most other formerly Communist countries, East Germany made its citizens live in isolation from the West. Severe travel restrictions left all but the most favored of its professionals comparatively separated fom their colleagues and the advances in their fields.

Again, I hope some day we can be just as equal as they were in East Berlin. Prosperity is over-rated.

Ticking time bomb

Patient: The last few days, when I walk, I'm so short of breath that I can't do anything. I can't even really go from the couch to the dining room for dinner, so my sister has been giving me food on the couch. When I get up to take a leak even, I can barely breathe. Feels like there's a giant weight on my chest and I try to catch my breath, but I can't.

Nurse K: Okay. I see you have some nitro here. Did you try a nitro for that?

Patient: Oh, no, I didn't. My doctor told me not to take that unless I really need it.

Nurse K: You need it.

Abuse of the system

Nurse K: What is wrong with your knee?

Patient: Oh, nothing. Feels pretty good. Pain's gone actually.

Nurse K: It says "knee" on your sign-in sheet.

Patient: Yeah, I twisted it last week.

Nurse K: Okay....

Patient: I just need to be re-seen for a work note so I can return to work. They gave me restrictions last time I was here.

Nurse K: You didn't make an appointment to see your doctor for that?

Patient: I'm here, aren't I?

Nurse K: Touché.

Haunted ER

Twice, just twice today, no more, no less, my blood pressure machine's BP cuff in triage inflated on its own for no apparent reason. I checked to see if it was set to be timed to go off Q1 hour or something for some reason.

Nope.

It's weird to be reviewing your email between patients and to watch dumbfounded as the cuff starts to inflate all by itself then alarm beep-beep-beep, beep-beep-beep "pump timeout".

Alright, who croaked in this lobby and is messing with me? It's okay to come out and play, ghosts, just so it's not anyone I triaged today.

Fibromyalgia Gone Wild!

Recently, I triaged a teenage girl with complaints of depression, anxiety, and difficulty sleeping. Not much was different than the usual 16-year-old coming in with depression until I got to her medication list. In addition to a slurry of every category of psych med, she was on Vicodin daily and before bed and naproxen twice daily as well. What's up with that?

I'm sure you know where this is heading. Yes, the teenager with severe depression had "fibromyalgia" and chronic pain from that.

Now they're getting depressed teens hooked on narcs for this ill-defined syndrome that oh-by-the-way seems to pop up with depression and anxiety.

Happy St. Patty's Day!

At 10 am, we got word that county detox was already full and not to call for beds.

*Sigh*

Okay, we enjoy your interpreting services, but...

...for shitsakes, quit freestylin'.

If I ask 'where does it hurt?', the interpretation shouldn't take ten minutes with numerous questions independently asked by the interpreter followed by a heated discussion while I stand there surfing the web, checking emails, and playing (and sometimes finishing) Sudoku from both the NY Times and the local paper.

Just ask what I ask. I know you've listened to doctors and nurses ask LOTS of questions to patients, so you may be able to even anticipate what I'll ask next.

I don't care. You're not helping. I have 5 other patients that need me right now and I'm stuck here listening to Jumblese that wouldn't be relevant even if spoken in English. I'm asking my questions in a certain way on purpose, mainly because I don't care about answers to questions I'm not asking. If I cared, I'd ask it.

"Do you have seizures?" is a yes/no question, not a verbal excursion across the space-time continuum and back. I want a yes/no answer, not you asking the patient to describe the types of seizures, the doctor who you see for seizures, the date of your last seizure, your last admission for seizures, and/or how your little nephew also has seizures. This ain't no neurology office visit meet-and-greet, nor am I nervous med student who does a 45-minute H&P on every ER patient.

So, interpreters of the world, please be advised: No freelancin'.

Overheard

Anxious patient: OH MY GOD OH MY GOD OH MY GOD! IT HURTS SO BAD!

Nurse: What's wrong?

Anxious patient: IT HURTS! OH MY GOD, IT HURTS SO BAD! MY STOMACH! IT HURTS SO BAD! IT'S A TEN!

Nurse:

Anxious patient: I GOT GAS PAINS! I. CAN'T. STOP. FARTINGGGGGGG!

The dinosaur

Doctor: Look at this dinosaur!

Nurse K: What IS that thing? It looks heavy, doc. Don't hurt yourself.

Doctor: This is a 'paper chart'. I got it from the museum in the basement that used to be called the "medical records department". Kids your age probably haven't seen these things, but that's how we used to document back in the good 'ol days.

Nurse K: Wowwww....How...primitive.

Disgruntled Nurses, a play starring everyone in your department who wants to party and smoke a butt after work

If you're interested in partying after work and don't want to be inconvenienced by having to go outside to smoke a butt at the local pub due to a smoking ban, consider keeping your scrubs and stethoscopes on and start play-acting scenes from "ER". Bring a defibrillator. Shock asystole. A drunk going out on his 21st birthday? Put a nasal airway down and give him an emesis basin. Someone throwing a temper tantrum? No problem! Locked 4-points and have one of your non-medical friends play the crisis team social worker. Have your non-medical friends go around with clipboards and ask patrons for their insurance cards and emergency contacts. Bar fight? Call a "code 87 in the ER" overhead at the DJ station and have some more of your non-medical friends be the security guards who spend 20 minutes applying gloves before attempting to use a soothing tone of voice to diffuse the situation.

You get the idea.

Dumb chief complaint

CC: Diarrhea, indigestion

History: Takes MOM 2 or 3 times a day to relieve indigestion. "But it doesn't work!"

I'm guessing she was intending to buy Maalox, but who knows what these people think.

Nail clippers

Patient's adult daughter: Can my mom get some nail clippers?

Nurse K: What for?

Patient's adult daughter: Well her nails be long and she need to stick her finger down her throat to make herself throw up and it scratch her throat if she do it with long nails!

Nurse K: Uh. We don't encourage people to make themselves vomit in the ER.

Patient's adult daughter: Well how she supposed to vomit then? That's how she do it!

ROWR

You haven't lived until a mentally retarded patient ceases to vomit long enough to wind up and slap you on the ass, laugh, and then spit up some of the nasty feculent emesis on your boob.

It was hot.

The damn computer

Okay, I read GuitarGirl's rant today about old, cranky nurses and I want to also express my irritation with nurses and doctors who do nothing but bitch about the computer all day and all night.

Yes, I get it. You don't like the computer.

There are some doctors that won't order certain things because they can't figure out how to enter it on the computer or order something Q6 hrs PRN instead of "one time" because they can't figure out how to switch the default order to "one time". If they forget to order something, it's the computer's fault. "Oh, I didn't order that because I can't find it on the computer."

Dude, I get it, but this happens every shift all shift. Maybe you should take notes or something. The computer ain't going away anytime soon, so you may as well take a bite of the big sh*t sandwich like everyone else, suck it up like a man, and learn the dang program. It's not that hard. I'd even go so far as to say it's intuitive.

Some nurses and doctors feel that the general skill of typing isn't a particularly useful thing to know. I frickin' learned to type in second grade on Mavis Beacon Teaches Typing on the Amiga 1000. Maybe you should pick up a $5 typing program at Wally World and practice a little bit. If a 2nd grader can learn to do it, you can too. Twenty minutes to triage someone because you can't type is too much. When you take 20 minutes per patient and I take 5-10, guess who triages a lot of patients?

Watching you type is worse than listening to the lazy charge nurse complain about having to get up off her butt and help settle an ambulance.

Let's just lay it all on the line: Computers are important for almost every job out there, including medicine. Learn to type. Learn to click on stuff. Learn that shutting down the EMR after every use so someone has to re-load the entire program is a pain in the ass.

Being old is not an excuse anymore.

Non-allergies can kill you

WhiteCoat's post on antibiotic resistance reminded me of a patient I had who had quite a few allergies.

The short version is that she was allergic to vanco, the 'cillins, erythromycin, etc, etc, until it became clear that the only family of antibiotics she wasn't "allergic" to were the quinolones (Avelox, cipro, etc).

We did everything to try to find documentation of the actual allergies to these things because few people are really truly allergic to that many antibiotics. Remember kids: Loose stools and nausea are not allergies!!!

The patient couldn't remember what caused what and between her clinic and the old charts and the patient's memory, no one had documented reactions to the drugs.

There were like 15 of them total.

So, for her pneumonia, we hung the Avelox, and the patient promptly declared herself to be having a reaction to the medication. She was ITCHING! Notably, the itching occurred even before the piggyback made its way down the tubing. She demanded that the drip be stopped. I documented her utter lack of rash and shortness of breath or throat closing. She wanted the generic and brand names of the drug so she could add it to her list of allergies.

I told her not to add it to her list because there was no rash and she was not having trouble breathing. I got an order for benadryl (placebo would have probably been just as good) and re-started the drug, and she declared that I was giving her something she was allergic to.

Look, there is no way in Hell I'm marking that down as an allergy, and if you tell people you're allergic to it, you could die because you will not be able to take any commonly-used antibiotics. This is not an allergy. Telling people you're allergic to this drug may kill you.

So, in short, nurses and doctors of the world: Putting something down as an allergy when there is no allergy just because the patient is a little inconvenienced by some side effect is a big problem, especially given antibiotic resistance. Don't do it. If you must write down a side effect or other non-allergy in the "allergies" section of the chart, write down the reaction and make sure the patient knows that nausea, vomiting and itching with no rash are not allergies for the most part.

Backed into a corner

A patient comes in with pleuritic chest pain. It hurts when I breathe!

Yawn. Okay. So she gets her pain medications and compulsory chest XR and screening labs, including a d-dimer, all of which were normal. Yawn. Vitals stable. Yawn again. No fever. YAWWWWNNNN again. No cough.

You just yawned, didn't you? Yeah. Now you know how I felt about the case. Just like that.

The patient's chart is in the discharge slot, and it said she was being discharged with "bronchitis" as a diagnosis, complete with antibiotics and an expectorant.

"Uh, the patient's been here two hours and has never coughed nor complained of a cough. I'm going to look like an idiot when I go in there and give them the bronchitis spiel."

The doctor had taken the patient as a sign-out, and told me that Other Doctor said she was a bronchitis and to give antibiotics, and blah blah blah.

I told him I thought that wasn't correct and why. He didn't seem to care about my opinion, so I backed him into a corner in the chart.

"Discussed discharge diagnosis of bronchitis with Dr. Such-and-such who took over for Other Doctor. MD informed that, throughout stay, patient was never observed to have a cough and denied cough to me (see initial assessment)."

Take that.

He huffed and puffed and re-evaluated the patient and changed the discharge diagnosis to "pleurisy". Good. Much better. Not that it makes much of a difference, but at least I don't look like a moron who didn't listen to a word the patient said the 15 times I was in the room.

Juice: Enough to turn a grown man into a total spazz

It all started with a blood sugar.

A diabetic patient there for something not related to diabetes complains of feeling a little hypoglycemic. Her blood sugar is 63, so I give her a little apple juice. Yawn. No big deal. I have the aide go in to re-check her blood sugar and she tells me it's 76, and I tell her to give one more little hospital juice to the patient.

"Why is that patient getting blood sugars checked?" so says Dr. Controlfreak.

"She said she thought her blood sugar might be a little low and low and behold, her blood sugar was low, so I gave her some juice and wanted it re-checked to make sure it came up."

Duh.

Now, the doctor had checked a metabolic panel and the glucose was low on the labs, too. He even put a little red mark next to the glucose to indicate that he recognized that it was low, but didn't order any interventions. No need. By the time the labs had come back, her repeat blood sugar was already nearly normal.

Dr. Controlfreak gets all dickweedish when--gasp!!!--the nurse discovers a problem before he does, so the fact that I discovered AND treated a problem, even one as simple as borderline hypoglycemia in a diabetic, without his unnecessary help really put him into status hissicus.

"WELL, THAT NEEDS TO GO THROUGH A PHYSICIAN. NURSES SHOULDN'T BE DOING THAT!"

"Uh, it's in our protocol; I can check a blood sugar and treat hypoglycemia with juice without a doctor's order."

"I DIDN'T ORDER ANY BLOOD SUGARS ON THAT PATIENT!"

"Like I said, it's in the protocol. If you have a problem with the protocol, talk to the person who designed the protocol."

Meanwhile, the aide is all buggy-eyed because of our little tiff.

"Um. So, should I give the juice or not?"

"Don't give her any juice!" grumbles Dr. Controlfreak.

"Ask the patient if she wants juice, and if she does, give the juice. She hasn't had anything to eat all day and is a competent human being. I'm not going to deny her a juice. Sorry."

"Well. Who am I supposed to listen to? You or the doctor?"

"Nobody, I'll do it."

You wanna step over JUICE, control freak? Homey don't play that. Watch me walk all the way to the room with it with a big shit-eating grin on my face.

Huh?

Today is apparently the "Spring ahead" daylight savings time.

I had no clue.

Don't worry, I'm not late for work yet.

The only reason I found out is because I fell asleep next to my cell phone and one of my drunk-ass friends who actually gets to go out on the weekend texted me at 4 am to ask me a medical question that could have waited until, oh, some other time, and I noted the time on the phone as I cussed at it for waking me up to be different than the time on my clock.

So, yeah. It's daylight savings time. Be advised.

Blog design!

I called Gunilla and asked her to make my website as rip-roaring awesome as the Stewart University website. How do you like my new website design?

Crayzee Central required reading

A cache of crayzee! First read here then here.

More highlights of the Stewart University Medical School include the following:

• No need to currently be living to be in administration.
• Nepotism
  
• R. Aubree Guancione! I'm totally a fan already.
  
• They support the Scottish-American Military Society
• While the MCAT isn't required for admission, if you feel like taking the MCAT anyway, well, lucky you, you can take a prep course at Stewart as well!
• They're negotiating to get access to a library!
• Website designed using Tripod, complete with cool tartan sidebar
• Education may or may not be recognized in up to 80% of states!
• Student body president Saul Amezcua thinks Caribbean Medical Schools are out to get him!
  
• They have bitchin' shirts!
• Marketing person Lance LOVES to party and RAWWWWWK! (Click his name to read all about it!)
  

CRAYYYYYYYYYYYYYZEEEEEEEEEEEEEE!

Oh, and by the way....since they are looking for pretty much anyone with a doctoral degree to teach pretty much every subject, I can recommend someone-who-shall-remain-nameless that I know with no job and a doctoral degree. She would go along perfectly with this school.

Rip-off!!

Here's a random reminder for people of the world:

A cheap price on something a lot of people want may be a scam.

So far, I've ordered a Canon digital camera with two different online retailers that I wasn't familiar with because they offered the cheapest prices.

The first one's email said "call to confirm your order". I called to confirm and they tried to sell me accessories. I figured, sure, no biggie, I'll just decline. This is probably how they make profit on the camera. When I said no, they said "if you want the American version of the camera, it's $50 more. The version you ordered has no accessories, no warranty, and is the German version." Of course, on the website, the camera was listed as neither German nor lacking accessories. Um. No. Cancel.

I then ordered the same camera with a different retailer and, once again, had to call and confirm my order. They tried to sell me accessories available everywhere else for $20 for $170 and then when I said no, they said okay, the order was confirmed and the camera would be shipped. So, today, I call back and, low and behold, the camera is on back-order for a long time. Since I'm retarded, I didn't check the reviews of this place, and it turns out that they are a bait-and-switch company who will say your cheap camera is on "backorder" if you don't buy the over-priced accessories. The backorder will last so long that you must cancel the order. So. Again. Cancel.

I'm buying from Amazon. Screw this bullshit. They're still cheaper than Best Buy, which is sold out at every store in my area, by the way. Amazon has never done me wrong.

Z-packs for every man, woman, child, dog, cat, and mouse

Rob at Musings of a Distractible Mind has must-read information on appropriate use for antibiotics.

I can't say it has ever occurred to me to take a Z-pack for a cough or whatever, but everyone and their mama comes to visit us in the ER for said Z-packs. I still have my hacking cough from my virus of last week, and I can't tell you how many people have suggested I have a doctor write for a Z-pack. Employees in my department routinely ask for Z-packs for every little ailment.

Me? Um. No.

There is one aide in our department who brags about having lots of leftover antibiotics at home that her friends call her for. She will give them "a couple penicillin" for their earaches, coughs, and "sinus pressure".

I asked her if the people that come in with community-acquired MRSA are her friends. She had no clue to what I was ever referring. A discussion of why doling out a couple penicillin or clindas here and there to friends was a bad idea was met with "oh, well, they call me back and tell me it made them better!"

Well, maybe it was a virus and they would have felt better anyway?

Oh, shut up, Nurse K. I've always taken antibiotics for coughs and colds and they work!

Fine. Whatever. You can have your yeast infection, diarrhea, community-acquired MRSA, and C-diff; I'll have my mildly obnoxious cough for another couple days.

*Hi, government! I have no prescriptive privileges and appropriateness of antibiotics should be discussed with your doctor/PA/NP, but nurses have a role in helping patients to understand these things.

Idle minds

What happens when there is a "dull" moment in the ER?

We’re used to being busy, so when we aren’t busy, we either get into weird discussions, or we instigate fights like little kids.

Now, we don't do syringe fights like at Whitecoat's hospital, but we fancy taping people in rooms. When the socially awkward aide goes in to use the toilet or dump something in the utility room...whapppp, whapppp, whappp with the duct tape and he comes out and gets tape all over himself. It's like crossing the duct-tape finish line, man. Extra visual interest is achieved if you tape someone in the room with like every possible kind of tape in the department at the same time.

How does it feel to win the race, Bill?

Watching 50-something women frantically throw down their knitting and whisper "let's tape him!" is a sight to see.

Another good trick is to make fake poop, put it all nice in a bedpan in an empty room, and just turn on the call light and then mock whoever answers it as they come out looking confused.

There's shit in room 3, but there hasn't been a patient in that room for 2 hours! Did someone just wander in and pinch a loaf in a bedpan on this clean bed? What the Hell?

Of course, the fake poop has tons of mileage. It can go on the break room table, the fridge, the front desk, etc etc. You can sneak into the ambulance bay and put it on the front seat of the ambulance that just gave you a patient.

One girl makes action figures out of Coban. Action figures have included "Arnold, the Bloody Teddy Bear", "Bo-bo, the Ax-Murdering Fox" and other such things. The action figures have really sick minds sometimes. If it's a really slow night, you can make little houses for the action figures too [idea stolen from here].

The unhelpful triage note

So we have this nurse who is the queen of unhelpful triage notes. The triage note is supposed to be like a sales pitch for the case. Like yo, yo, yo...this patient is totally faking it vs. holy shi-zat, get them back before everyone else vs. "meh, not concerned" etc. After triaging, she doesn't usually find occasion to elaborate on the patient's chief complaint.

The patient signs in with "arm pain".

Note is as follows (spelling/typing errors left in for full effect):

25 year old patient arrives ambulatory. Significant symptoms per patient include: rtarm pain fell

Patient signs in with "abdominal pain".

40 year old male patient arrives ambulatory. Significant symptoms per patient include: adominalpain hurts a lot

Um. Hello? Tell me more, tell me more, like does he have a car?

Dschubapbap, dschubapbap, dschubapbap, dschubapbap,

Patient signs in with "Ankle pain"

66 year old male patient arrives ambulatory. Significant symptoms per patient include: ankle/footpain since thism ornpng

Tell me more, tell me more, but you don't gotta brag!

Tell me more, tell me more, 'cause he sounds like a drag.

Dschubapbap, dschubapbap, dschubapbap, dschubapbap...

Burn the pain scales

Stupid pain scale, stupid frickin' pain scale. I'm going to go all Nazi Germany and have a pain scale burning in the garden. Bring your pain scales! The Wong-Baker Pain Faces Rating Scale , the 1-10 scale, the visual analog scale, the Spanish version, the Somali version and every other last possible pain scale you can find. If it's in a text book, for godsakes, rip it out. If they're in a patient's room, just quietly remove them. Pain scale, you're dead to me.

Let's burn 'em, girls! I'll get the flint, you get the steel.

A girl came in with "10/10" eye irritation (pink eye!) and wouldn't change her rating after I explained a 10/10 would be if I was drilling through her eye with a drill. She said it was a 10 because not only was it painful, they were "watery" and "itchy sometimes".

I'm burning the pain scales. You get the gasoline, I'll the lighter.

Following 10/10 eye irritation girl was 10/10 chest pain with cough guy.

"You realize 10/10 chest pain would be a Volkwagen parked on the top of your chest?"

"Yes, it hurts more like a Toyota Highlander when I cough."

Yeah right pal. Everyone quietly, yet efficiently, gather the pain scales and BURN EM. BURN THE PAIN SCALES!

Light up the night sky with pain scale-powered flames.

Burn the pain scale.

Not all experience is created equal

Attention everyone everywhere:

Not everyone is cut out to be an ER nurse.

Don't get me wrong. When I started, I was hardly Johnny-on-the-spot when it came to a lot of things. I'd only been on telemetry for like 8 shifts in school and had a critical care internship, but hadn't thought much about hearts nor unstable people in three years. ER also includes things like clinic nursing, OB/GYN nursing, oncology, and every other possible thing that is or is not wrong with someone and I had to learn that stuff from scratch much like everyone else who starts in ER. I'd not taken ACLS, and only had telemetry training in school, but no formal certifications, so I had to go through those classes.

Ask new Nurse K how to set up a pelvic exam and, hm, I dunno. Ask me to swab a patient for flu. Beats me. Ask me where to put an IV in someone with no veins? Oh, that's easy, call the IV nurse. Oh, the patient is dying and can't wait for the IV nurse? Okay, um, uh....

However, all that stuff can be learned pretty quickly by any reasonably competent nurse with some sort of medical/surgical background, even considering the highly specialized unit I worked on with a distinct patient population. The main thing, to me, is willingness to take chances and try new stuff, which I'm totally down for. Suction pus-like sputum from an ET tube? SURE! Try an IV on the patient that no one can get a line on? Sure! Put the line in the pinky finger? Why not? Stabilize an asthma patient? Oh! I want to! Someone with CHF in flash pulmonary edema? Me! I want to play!

I've mentioned before that the union has its elbows in everything in the hospital, even down to who gets to go home if it's overstaffed (the answer is always "the most senior nurse who works 2 shifts per week", not the young nurse who is on her 3rd double shift in a row). Seniority is a major factor in hiring of internal candidates for jobs, and many internal candidates apply to the ER, which is great. As a general rule, all things being equal, the nurse with the most seniority hours get the job.

As I understand it, there are exceptions to this. If the job requisition was submitted to HR with special qualifiers such as "ACLS and telemetry certifications preferred", a person who has these can go to the front of the line, even ahead of senior nurses who don't have those certifications.

We are seeing the effects of the seniority rule lately in the ER, where candidates are being hired who have literally no applicable patient care experience anytime recently because, barring any serious reason not to, the applicant must be hired if they are "senior". One poor girl came from a longstanding career on psych and is essentially learning basic nursing and assessment skills along with ER nursing in her training. Watching her train is frightening. There is no knowledge there of where organs are nor any insight as to what certain findings in an assessment could mean.

Again, don't get me wrong, as a neuro nurse, I didn't see any diverticulitis nor gallbladder attacks, but I could pick out that fever and abdominal pain could mean an infection or possible surgical issue near where the pain was and that, for instance, the patient shouldn't be given a large meal if they asked. The psych nurse may even completely ignore these finding and, instead, focus on the "fast" heart rate of 106, something that really wouldn't even enter my mind. The ability to prioritize symptoms isn't there. It's almost like watching a lay person try to differentiate the seriousness of his or her symptoms.

Here's a simple solution: Let the managers choose who gets hired, not some cookbook formula from a union contract which favors seniority above all else.

Was the bundle branch block seen on previous hairstyles or is it new this hairstyle?

Someone's hair EKG is whack at the Wally-World.

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