What's wrong with this patient?

Put on your thinking caps. It may or may not be obvious.

A 22-year-old is brought in by his significant other for an overdose of Vidodin. He'd had a fracture of his leg from mountain biking in the mountains that was repaired with surgery two months prior. The Vicodin was for his leg pain, but it hurt so much that he took 6 of them instead of the prescribed two. He claims over and over that he wasn't trying to hurt himself, just that he wanted the pain to go away so he could sleep. He looks to be anxious, is crying, and is coughing (not vomiting) up bright red blood. The chest pain, coughing up blood, and shortness of breath weren't there until 1 hour after taking the overdose of Vicodin. He has the following additional complaints/findings in triage:

• 10/10 chest pain
• Shortness of breath
• Epigastric pain
• Vitals Bp 152/104, HR 108, O2 sats 95% on RA, RR of 24
• Numb face, numb body
• Tingling in his hands
• Feeling like he needed to sleep
  

What is wrong with this patient? Would you get him a room right away despite there being no rooms in the department?

Patient education theme

A girl calls 911 twice in less than 24 hours. The first call was because her tooth (that she'd been to two other ERs for) was still sore. The second call was because she woke up a little itchy. No rash. No shortness of breath. Just itchy. Did she try benadryl? Nope. How about some lotion? Nope. How about sucking it up and getting over it? Hell no.

I mean...who thinks like that?

Her nurse charted her "patient education" regarding the concept of EMS abuse. Ballsy.

Later on, that same nurse had a young man who called 9-11 for what amounted to a cold. Fever, sniffly nose, body aches, etc. She made sure to run in there, and charted the same thing for that patient too after giving him a lecture on how ambulances were for emergencies and a fever of 100.1 isn't an emergency. Ballsy again.

Let's see how long it takes her to get fired.

I love my job!

Female security officer: Sir, you need to stay in your room.

Floridly psychotic patient: I want my door closed!

FSO: We can't close the door all the way, sir.

FPP (yelling for all to hear): Well I need to jerk off!

FSO: [After briefly trying to convince him that was inappropriate] Uh, go right ahead then. Door's staying open.

And, yes, he did "jerk off", or at least pretended to, but under the blanket.

Stuff I have to sign or else not work at my hospital

Okay, I'm still f'in confused on HIPAA. We had to sign some thing saying we would not access anyone's EMRs after they were out of the ER for reasons such as satisfying our curiosity as to the patient's status a couple of days later. Even if you helped to bring a guy back from THE DEAD, you are not allowed, according to this learning module, to see if the guy has brain function two days later because you are no longer part of the treatment team. However, you can access the chart in order to enter a late note or to create an [anonymous] case study for education purposes (like at a presentation for instance). It seems, however, you can't just use your former patient's chart to educate yourself which doesn't make a lick of sense. However, if my boss wants to educate me on some topic using the same chart, that's okay.

Riddle me this, mofos. Aren't I always a student? Should I be penalized because I want to see the outcome of a treatment or what a patient admitted with a mystery issue was ultimately diagnosed with? Gene Gandy said it best:

When we kill the curiosity of medical providers about patients, whether they be a Clooney or a homeless mope, we set medical care back.

Medical professionals who are more interested in whether or not an employee violated a technical rule than whether or not that employee can provide good patient care are the despicable examples of form over substance that infects medicine and makes us less than the best system in the world, when we clearly ought to be.

I guess all my patients I'm interested in following up on will be getting late notes two days later so I can educate myself. To reiterate: Late notes are okay, but learning is not.

When home therapy for anything at all fails, immediately go to the ER

Me: So you came to the EMERGENCY DEPARTMENT today for vaginal itching, is that correct?

Patient: Yeah, it itches real bad down there!

Me: Did you try Monistat or anything before you came?

Patient: Yeah, I put the thingy up there two hours ago, and it STILL ITCHES! I had to come in!

No, you had to just wait for your OTC treatment to work like a normal person.

Of course, guess how many times she was on the call light. Yeah. Lots. Wanting us to immediately cure her itchy downtown zone. I repeated gently that we didn't offer immediate relief of problems like that, but there was probably some external itching cream in the over-the-counter product she abandoned to come to the EMERGENCY department. I must have used the phrase "over-the-counter" ten times for emphasis.

Again people, the emergency department is for possible LIFE/ORGAN emergencies. It is not for scratchy snatchies nor yeasty boxes nor most types of mild discomfort.

For the unindoctrinated, here is a list of stuff you can buy over-the-counter (remember, this is not medical advice!):

• Monistat for itchy crotches and/or cottage cheese discharge
• Azo or Uristat for UTI symptoms (frequency, urgency, painful urination) until you can see your clinic doctor or urgent care doctor
  
• Plan B morning-after pills
  
• Pregnancy tests (yes, they're the same ones we use)
  
• Bonine/Meclizine/Antivert for dizziness, including vertigo. May also work on vomiting if there is a dizziness component to it.
  
• Motrin! Tylenol! for fever and aches 'n pains! (You wouldn't believe how many people have reasonably mild pain who don't even try ibuprofen first before coming to the ER).
  
• Ice! Make your own ice packs and use 20 minutes at a time every 2 hours the first 2 days following a muscle injury, bruise, sprain. Combine with elevation, Tylenol and Ibuprofen!
  
• Wrist braces/ace wraps/gauze
• Allergy pills such as Claritin
• Nasal saline irrigations for sinus congestion, allergic congestion, and congestion in general (very effective!)
• Benadryl for rashes or itching
• 50,000 different pills or treatments for epigastric pain/GERD
  

There. I just saved our health care system billions of dollars of ER visits. If the FDA would approve any OTC anti-emetic tabs like phenergan (it's OTC in Canada, Britain, and Australia, for instance), we'd save millions more, plus, perhaps, gain millions of dollars in productivity from all those people calling in sick to work due to feeling nauseated.

Mystery

So, I have been having some major trouble with water in my basement. I would routinely use my Shop-Vac to suck up 40 or more gallons of water Qstorm. My house is old, and the basement is just concrete and used for storage (everything being stored is, of course, elevated off the ground). I hired a dude to inject bentonite clay into my soil around the area where all the water was leaking in because I figured there were big open areas underground where water was collecting. This clay expands when wet so, not only does it fill up unseen holes, it can hold water and keep it from leaking into my house.

Incidentally, it's also used as a "detoxifier" which is totally gross. If 60 gallons of clay can hold 300 gallons of water as the guy said, I don't want to know what it could do to someone's digestive system. "I keep drinking water! I always feel both bloated and cotton-mouthed all at the same time!"

Anyway, Dude starts injecting the clay and tells me he wants to look downstairs to see if it is leaking in. Nope. Not leaking in. Why do you ask? Oh, because I've dumped more clay into your soil than like anyone else's with no resistance.

So he re-loads and dumps another whole load of clay in there. Finally, he says he thinks he filled that area up. You had some giant open something-or-other down there, Nurse K, he says. Then he goes around the yard and is all "Dude, lemme show you something."

He stomps around on my soil like some Indian chief praying to the Sun God or something. What do we hear? Well, my DIRT sounded like tympanic abdomen sounds like when someone hasn't shat in 2 weeks and is full of gas. And the tympany was heard in a very distinct area, like a 6 foot by 5 foot area in my soil. Also, he said, he couldn't get his hose more than 3 feet down in that area and didn't think the clay was getting into that part.

So what does that mean? Yeah, I have an entranceless "secret room" underground...with a roof that was covered over with soil long ago. He said it may be an old cistern or a really big well, but my house was built in the 1920s, so it would be a little new and urban to have a cistern. He thinks the room started maybe a foot off the side of the house because he was able to fill in that giant void (with two loads of clay) which he suspects was the area between the house and the start of the "room".

"Hey, is this the most exciting thing that has happened since you started doing this clay job?"

"Yeah, pretty much." He then went on to tell me I should "dig up" the area to see what it was. Meaning, most likely, he was curious to find out what it was. So, what should I do?

911, what is your emergency?

EE responds to a 9-11 call to remember. You'll laugh. You'll cry. You'll be ashamed to be a homo sapien.

I need an expert opinion on how I should end this torture

The other day, I worked with the infamous Dr.Bloody Gloves, CEO of the Narcotics For Everyone and Anything No Matter What patient advocacy group at our hospital. While he didn't repair lacs and pick up the phone with blood-soaked gloves today nor spit in an incised boil by accident, he did this all day today, which drove me up the f'n' wall:

He called for the radiologist's opinion on 100.0000% of all Xrays.

I totally get that sometimes there is something questionable on an Xray and a 2nd opinion is needed. However, if every injury requires a phone call to radiology for a "second opinion", maybe you need to not be reading Xrays to begin with?

One lady had a fall with a finger so dislocated that I asked if she had rheumatoid arthritis, and he needed a second opinion to confirm that it was dislocated. Another guy had pain in one specific place after suffering a softball injury. The area of pain was like 1 inch by 1 inch on his ankle and he had a "crack" on the Xray in that exact location. Are we going to splint the patient and send him away? No. We're going to get a second opinion which takes about 30 minutes then refer him to an orthopedics office across town to be splinted. Uh. What the F? I told him he needed to splint the dude's foot, and I wasn't sending him to anyone's office until he did. It's not like the foot was mangled beyond recognition. Come on now. Is this a cocktail party or an ER? Quit talking, start splinting.

Now, this was ALL DAY. All f'n' day. Chest xrays, ankle xrays, hip xrays, nose xrays. You name it, he needed an "expert" opinion on it. How about this? You're an ER doctor. You should be the expert, sort of like how I'm an expert on catching and fixing all your orders you put on the wrong charts.

I was so anxious from all this needless waiting that I had to walk around aimlessly throughout the department x 3 to burn off some anger and hide from the patients.

Overheard in triage

I wasn't in the Treehouse of Terror today, but one of my favorite nurses Nancy was. She is the the epitome of ER nursing, and is, for the most part, my ER idol. Efficient, not lazy, knows her stuff, helps others as needed, and calls people---patients, doctors, other staff members---out on their bullshit (without whining about everything, it's hard to explain) without any fear.

Nancy: So what brings you in today?

Patient: I don't want to tell you about it.

Nancy: Why not?

Patient: I just don't.

Nancy [goes into her 'no bullshit' mother-voice]: Well look, I got 10 other people waiting to be triaged and I didn't drag you from your house to be seen here today, so if you don't want to talk to me about it, you can go back to the lobby, and I'll call you again later when you feel like telling me about your emergency!

And, I shit you not, the patient stared at her for a couple of seconds in shock and proceeded to tell her what was wrong. It was something stupid like vaginal itching and discharge or something. I stood up at the charts for an extra few seconds just to hear how this all played out. Nancy is my f'in' IDOL, dood.

Poor bastards

Someone freaked out over at ERStories because I referred to Ted Kennedy as a "poor bastard".

If he has GBM [Gliobastoma Mulitforme], hopefully they won’t torture the poor bastard by keeping him alive for very long with maximum interventions.

Nurse K on May 21st, 2008

Here's part of the freak-out comment:

my Prayers to the Kennendy’s and I don’t think anyone should be referring to him as a “Poor Bastard”…There are still a few people in this world who know how to talk without being so outright disrespectful. It is scary that she is a nurse.

mca on May 21st, 2008

First of all, at least I know how to spell Kennedy correctly, put capital letters in the correct places, and omit any extraneous apostrophes when referring to the guy. That aside, I thought I'd explain to you the phenomenon of nurses referring to patients as a "poor bastard."

In the ER, the term "poor bastard" is deployed sparingly, but in very specific circumstances. First of all, I must say there is no female equivalent of which I'm aware, so being a poor bastard, first and foremost, means you're a male. You most certainly are not investigated for true "bastard" status in its literal sense. I don't ask you if your parents were married at the time of your birth, etc. It's idiomatic, you see. Primarily, it's a term of empathy. Like "here is a fella who has met a terrible fate".

The term is also used due to the frequent need and tendency to summarize cases to physicians and other nurses in the ER. When I go on break, the patients I have are not the same patients I had an hour ago, nor will they be the same ones I have an hour after that. A patient who arrives is usually unknown to the physician as well. You just get sick of saying "that guy" or saying the patient's name. Sometimes you need just a little something extra to get your point across when talking about your patient's situation.

Like 10,005 times per shift, a doctor will say "who's in room 1?" I give a 3-sentence or so summary of the case, complete with what I think it is. If the patient meets criteria for poor bastard status, you may refer to him as a poor bastard.

So, who's in Room 1?

"Oh, that poor bastard has a history of bladder cancer with TURP and bladder resection, and is on chemo right now. He's been having dizziness, syncope, and near-syncope for the last few days. Blood pressure was 71/45 in triage, and I found no evidence of infection. Probably volume depletion based on history, so I'm giving him fluids."

The doctor will react with some sort of confirmatory statement such as "oh, that sucks" or make some other expression of empathy.

That's one example of appropriate use of the term "poor bastard." I used it in that case because he is in the midst of his struggle with cancer. While he is not facing imminent death, he has faced a bladder resection, TURP, and is going through chemo. He is unable to drink enough liquids due to chemo side-effects to keep his blood pressure up. Struggles with cancer involving surgeries, complications, and chemo make you a good candidate for "poor bastard" status, especially if you're an otherwise agreeable individual and/or have an agreeable family. Notably, if you lost your bladder to cancer several years ago or something, you are not a poor bastard unless you meet one of the other criteria. If you're a total asshole for some non-medical reason (rare in the cancer population, I've noticed), you probably won't win yourself a "poor bastard" designation. If you have a less-aggressive cancer which was cured with only a single surgery or is responding well to chemo/radiation with only relatively minor inconvenience or set-backs, you probably won't meet poor bastard status.

Another use is referring to the ultra-old crowd who are coming to the end of life from something like complications from Alzheimer's and the family is insisting on maximum interventions like intubation. Bonus points if the patient is emaciated, non-communicative, has multiple other medical issues, and is total care in general. Grandpa gets a pneumonia and the family decides he needs to be intubated. He has reached "poor bastard" status, although, most total-care Alzheimer's patients could reasonably be called "poor bastard" during any trip to the ER and not violate any of the ER usage rules for the term; however, the more common usage is as described above (old+emaciated+demented+inappropriate medical interventions). Any comatose, intubated ultra-old person is also a poor bastard even if they were high-functioning prior to the incident which landed them in that situation.

Notably, young people (such as the severely brain-injured) with similar issues are rarely called poor bastard, especially if the medical issues have been chronic for a long time. Most people we refer to as poor bastards are upper middle-age or older, and that's totally arbitrary.

The final common reason to deploy "poor bastard" when referring to a patient is the situation in which Ted Kennedy has found himself. That would be an unexpected, new, possibly life-ending diagnosis regardless of current patient status. In the early stages of a glioblastoma multiforme, you may be walking, talking, and chewing gum at the same time; however, everyone in the department knows you will rapidly decompensate over the next few months and turn into a total-care patient no matter what medical care is available to you. Like, we can see the future and the future doesn't look good. Bonus points if the patient was powerful or very healthy (such as a marathon runner, business owner, active elderly volunteer, or something else that totally contrasts with the diagnosis) at the time of diagnosis such that the diagnosis would turn them into a totally differently-functioning person and rip anyone's heart out who hears of the story. This situation is a judgment call though since you have to die some way, and usually requires a baseline high-level of functioning.

An already-decompensated elderly patient who is in the nursing home may not be a poor bastard with a new diagnosis of an aggressive brain tumor or metastasis to the brain, but would become a poor bastard if the family opted for intubation and/or craniotomy as described above.

So basically, as someone who has taken care of dozens of glioma/glioblastoma multiforme patients in my career (moreso in my former job on the neuro and neurosurgery unit), I know what he will likely go through. For the sake of discussion, I'll assume he has a GBM, a common and highly aggressive primary brain tumor in the older population.

GBM patients have "tumor debulking" craniotomies to extend life for a little bit of time. The tumor grows back, and they may have a couple of repeat surgeries for "palliative" reasons. The term "tumor debulking" is used because there is no hope of the surgery being curative. Despite these multiple debulkings, the patient goes downhill in a matter of months, usually to include headaches, tube feedings, paralysis, lethargy, and incontinence progressing to coma and then death. It's a shitty way to go, and the term "poor bastard" can properly used as an expression of empathy at any time from initial diagnosis to end-of-life by our rigorous standards.

Customer service in the ER

Platy, the most under-appreciated ER blogger out there (maybe because he or she doesn't really comment on other blogs), demonstrates good customer service in the ER:

I went to get a bag of IV fluid for one of my patients and found a woman in the supply area with a grocery bag. Being all about customer service, I asked her if she was finding everything okay and she answered something about rubber gloves before walking away and disappearing behind a curtain. I wonder if she really thought it was end of it. I got on the phone and paged security to her location, told them they needed to find out what was in the bag, and they went in and found three unopened boxes of rubber gloves and a package of medicine cups.

Notably, security didn't throw her out of the ER nor call police for theft. Same thing happens in our ER. Steal endless amounts of stuff, get caught, and the punishment is being asked to return to whatever room you came from and to give back your plunder.

A couple shifts ago, I caught someone ripping off the blue chux pads of all things because "they make good puppy pads." Okay, that's true, but that supply area isn't your personal Petco.

Pet peeve

PET PEEVE

People who ask for a free cab voucher because they
"don't want to wake someone up to give them a ride home."

Well, seeing as you had an emergency, I'm sure there are tons of your friends, family, and confidants awake anyway nervously waiting for any word from you on the status of your life/organ emergency or traumatic accident or injury. Or throat pain. Or chronic pelvic pain. Or chronic migraines. Whatever. They'll not only be happy to give you a ride home, they'll be relieved to hear from you. There's the lobby. There are the phones.

Notably, before the Great Cab Voucher Crack-Down of 2007, our hospital gave out $56,000 per year on average in free cab rides just from the emergency department alone. Oddly, there haven't been people camped out in the lobby since 2007, so these people always seem to find a ride home.

That's a new one, Part 2

A chick comes in for her usual complaint of "something, but not sure what" which usually means anxiety. The complaint is ever-changing, and is never statically focused on one thing or another. Showing up asking for lasix, a sleeping pill, a breathing treatment, a prescription refill, a head CT, and something for chest pain all in one sentence is not abnormal. She may sign in as leg swelling and then ask for a head CT because she thinks she has a brain tumor or sign in as a cough and want something for leg pain. It's very nonsensical without the saving-face benefit of known psychological pathology.

For some reason, she had an IV, and at the end of his visit, the nurse d/c'd it and gave her the gauze, told her to push on it, etc.

She closed the curtain and the IV bled a few drops of blood on the sheets, probably because, like many, she didn't hold pressure on the site. She stood over the bed, letting it drip-drip-drip onto the sheets and a couple drops on the floor. She starts freaking out, and the nurse goes in to give her another gauze and remind her to hold pressure. She responds by getting out a digital camera (why are you bringing a digital camera to the hospital?) and starting to take pictures of the "carnage", telling us that she's going to sue for malpractice or something. Again, it didn't make any sense.

Okay, Sugar Pops. Go right ahead. Oh, and stop taking photos and hold pressure on that IV site.

Watching the nurse hold pressure on the offending IV site while the patient was threatening to sue and taking photos of the CARNAGE (a few drops of blood) was good physical comedy.

Here's a new one

A patient threatened to sue us for discrimination for putting his white girlfriend in a smaller room that we sometimes use on nights as a de-facto Fast Track room because there is not much else you can do in the room besides examine the patient. Very little stabilization can occur there for any length of time. Of course, she had a complaint that didn't really even need an exam by a doctor let alone stabilization, just effective individual coping skills, but whatever. EMTALA.

Notably, she was triaged, registered, assessed by me and the doctor and dispositioned in under one hour. It's not like all the other rooms were open either. The only other open room on the critical care side was the stabilization room. Sorry, sweetcheeks, you ain't getting the 'stab room.

TOTAL RACISM AT ITS WORST.

Racism is telling white people that we don't give out Percocets for 5-day old vague injuries that may or may not have occurred. Racism is putting white people in small rooms for immediate treatment and disposition without having to wait in the lobby. Martin Luther King is turning over in his grave, and I'm sorry I had to be a part of this awful institutional racism which involves skilled care, rapid assessment, and disposition in small rooms without mints on the pillow.

Racism like this needs to be stopped, and we stop it most every day by making people wait 4-6 hours and then 4-6 hours after getting back to a room, but sometimes people slip through the cracks and we return to our good-ol-boy selves and offer an immediate physician's exam and disposition.

Sadly, I was kind of hoping a post-arrest or major trauma would arrive for the stab room while they were still there, but no such luck.

The first EKG was normal, but the 2nd EKG I got was ****ACUTE MI****

"Nurse, that last nitro you gave me made my chest pain worse."

I saved someone's heart muscle today by getting a second EKG.

So, what I'm saying is....who wants to f'in touch me?

Drug-seeking for the black box drugs

A patient with every somatic complaint all rolled into a medical egg roll with anxiety, "post-traumatic stress" and "myalgia and myositis" (ie fibromyalgia) asks me for 'the only thing that works': Dilaudid and Ativan for her pain. Blah blah blah, another seeker. Just as I was about to d/c her with acute on chronic nothingitis, she asks for the following:

I need more dilaudid.

I'm sorry, you have been discharged and the doctor already said no, so I will not ask him again.

Okay, can you ask him for droperidol? That really works on my pain too.

Yes, I will definitely ask for droperidol, and I can see why it would work so well in your case.

Public Health Announcement

If you're going to put out a bowl of public jellybeans for the staff under the guise of preserving satiety and health at the same time, make sure you post some sort of skull-and-crossbones warning sign that your innocuous-appearing, SUGAR-FREE, purtily-colored snack contains a fuckload of sorbitol.

If you're like me, you just grab a hand-full of jellybeans and munch away like all is dandy in the world not thinking of any possibility of poor outcomes from your snacking.

Then it hits you and you think your intestines are going to escape your body cavity and be plastered about the wall. This goes on for several hours.

You see your co-workers looking bloated and running to the restroom. You run in and one-up them by wreaking up not only the bathroom but the entire world, or so it seems. Methane is everywhere in your department, and you wonder in your head if you should stay away from the patient on high-flow O2 and/or carry a fire extinguisher with you.

One unintended benefit: Sugar-free jellybeans eaten by several people keep the patrons from sticking around too long, asking for more narcs, work notes, and cab vouchers. I can't even say anyone stuck around long enough for their discharge papers, to tell you the truth.

Various specialty ER rushes

The ER is packed full from approximately noon to three in the morning, but there are some specialty rushes that deserve mention:

2301-?: "I forgot to check in and reserve my spot in the homeless shelter before they locked the door" malingering psychiatric rush. AKA the "Blanket and Crackers" rush AKA "I want to jump off the bridge" rush. Call ahead and ask if there are any male beds, and if "no", come in because you'll be guaranteed to not get kicked out. Bonus jackpot: 72-hour-hold.

0200-0400: Drunks, drunken injuries (lac, head injuries), Sumdood victims, drug-seeking, and vaginal discharge rush. Lacs, screaming drunks in 4-points, 20-year-old Medicaid girls with foul vaginal odors toting three screaming kids with foul odors in general, scary-eyed people limping in the building and walking fine when going outside to smoke, etc.

0500-0600: Elderly people awakening-with-chest-pain rush or falling on their way to the bathroom rush.

0701-0900: It's-cold/rainy-outside-take-to-the-streets homeless-shelter-malingering rush (when they close the homeless shelter for the day and evening). This is when people shows up with 8 or 9 "cousins" or "sisters and brothers" for a "twisted ankle" that happened sometime somewhere for some reason and they all camp out in the lobby or cafeteria.

Sundays 0930-1100: Octogenarian syncope-in-church rush.

Every holiday where family comes to visit(Christmas, Easter, Thanksgiving): Grandma-doesn't-look-so-good-since-I-saw-her-last-year chronic illness rush where you haul grandma into the ER because "something must be wrong". Bring at least 4 or 5 other family members with you. Notably, grandma never offers any complaint, just the family members.

Overheard at the party last night

[Mid-conversation, after about 3 "deluxe" Southern Comforts]

Hefty girl: ...fibromyalgia, I have that!

Me: Oh really. That's a cuss word to me.

Hefty girl: What? Fibromyalgia is a cuss word?

Me: Yeah. Nevermind.

Where does your unsafe staffing form go?

So, historically, we'd fill out those unsafe staffing forms that supposedly serve some purpose after working X number of nurses short on a shift or X number of aides short or whatever. They go to some internal mailbox and....where do they go? It wasn't like anyone ever came back with any sort of plan to address staffing shortages or anything.

On nights, we'd been filling out a form Qshift for nearly the entire Winter. Having only two nurses scheduled plus a float on overtime when we need six wasn't a rarity. Finally, one of the nurses decided she'd take a stand and write a letter to senior administration (not nursing administration, like the president of the hospital) expressing concern about the chronic under-staffing in the department.

This caused a meeting between staff and senior management. People talked about the staffing and the Veep was like 'oh really? I wasn't aware, but that sucks ass and I want to help.' Magically, we got approved to hire 60 bajillion new people, and in the span of 2 1/2 months, all of our slots were being consistently filled. In addition, he said he'd make the ER a priority for staffing with respect to floats and have more floats trained to ER, all of which was done.

He said up until our nurse wrote the letter that he didn't even know what an unsafe staffing form was or that they even existed. He demanded to see these forms, and noted that they were neatly filed away in folders divided by unit, with the ER's stack being about "two inches thick".

He said that he wouldn't let these forms get lost in cabinets anymore and hired someone to do some sort of mathematical regression to determine the actual number of nurses needed to fill shifts on all floors with the appropriate number of straight (ie not overtime) people.

Woo-hoo. Someone who cares and gets stuff done. Take home lesson: If your staffing needs are not being met, try writing a letter to the top dogs (not the nursing top dogs) and see what happens. Or, if you have balls the size of a bull's, try attaching your two-inch-thick folder of unsafe staffing forms to your letter.

Different kind of frequent flyer

I'm just going to throw this out there.

If anyone was thinking about a frequent flyer credit card, you can help me leave the, um, frequent flyers behind by applying for the Northwest Airlines WorldPerks Visa card. If you are approved for a card, I get 5000 bonus miles per referral. Basically, if I get 8 of you to get a card, I can go to Europe for free. Keep in mind that the WorldPerks miles will be merged with Delta SkyMiles at some point after their merger is complete.

Here's what to do:

• Click the link above
• Figure out what card you want
• ***Enter Nurse K's WorldPerks Number in the 'Referring WorldPerks Number' field on the application*** My WorldPerks Number is 100207222323.
• Enjoy your card. A doctor at my work, for instance, says just using the WorldPerks card for everyday purchases and bills has given him a total of eight free roundtrip tickets.
  Flippin' Sweet!

If you like me but don't want a card, feel free to link my post or whatevah. Send me to Europe for free [I'll probably go next year, but I have to amass my miles now]!!!

Wellness check

Chief complaint of a 20-year-old male coming in at 11pm: I just want to see if I'm okay.

Me: Okay, what's been bothering you?

Well-person with no emergent complaint: Nothing. I just want a physical.

Me: Um. That's not something we do here. This is an emergency department. You'll have to see a clinic for that, but if you want to see our doctor, you can.*

Well-person with no emergent complaint: Yeah, but I don't have insurance, so I need to do my physical here.

Great. Whatever. There's the vending machine and the TV. Make yourself comfortable.

After the 4-hour wait (not bad considering he didn't have a chief complaint), the doctor went through the medical screening exam which consisted of checking lots of boxes "no", didn't draw any bloods, and sent him on his way. A waste of time for all involved. For his 4 hour wait, he received a card for a clinic that takes uninsured patients to do his real physical (which he doesn't need anyway---he's 20 for shitsakes), which he proclaimed he wasn't going to use because a sliding-scale fee (of $20 since he doesn't think he needs to work at a real job for whatever reason) isn't free. Instead of waiting four hours for us to tell him to go to a clinic, he could have begged on the street corner and probably made the $20. *Sigh*

Nurses need to be able to refer to a clinic when a complaint is clearly not emergent.

*=Don't hate, if I didn't say that, I'd be violating EMTALA!

Suggestibility

Every once in awhile, I'm thinking about nothing in particular and something that may or may not be brilliant pops into my head.

I was wondering if, in this culture of a-pill-for-everything and pharmaceutical ads which run through symptoms that "you should seek medical attention" for that we are to some extent just triggering all the suggestibility of people. I think suggestibility is an under-appreciated concept in the world of medicine.

How many of you have gone through a bunch of questions with a patient to try to narrow down your diagnosis only to have the patient start to complain of something of which they weren't previously complaining?

Maybe they deny dizziness, but then the next time you enter the room, they insist they are dizzy. You ask about burning on urination, and they say no, but then after they pee the next time, all-of-a-sudden they have burning on urination despite having a stated chief complaint of headache.

Or, of course, there are the patients who just answer "yes" to everything you ask, which, to me, is less evidence of suggestibility than some sort of secondary gain issue.

Similarly, how many people watching Lyrica ads have subconsciously or consciously associated their aches and pains with "fibromyalgia"? How many people who hate their jobs and are feeling annoyed with the world have become "depressed"? How many have the anxious runs and have convinced themselves they have irritable bowel? A little heartburn every once in awhile? It's GERD! How many of these people have exaggerated symptoms or come up with additional symptoms to fit the "mold" of the disease they are convinced they have?

People in a state of emotional distress are more suggestible. Those with low self-esteem are suggestible. Those who are more passive/less-assertive are more suggestible too. Oddly, these people seem to be the people who have some of these soft diagnoses like chronic fatigue and irritable bowel.

Our culture has triggered the suggestibility of people into seeking medical care for things that they have unconsciously come up with on their own, that's for sure. Could this concept apply to entire disease states? Are there entire diseases that are nothing more than the manifestation of mass suggestibility?

One time, I was bored and one of my readers and I visited a fibromyalgia chat-room. My reader was chatting, and I was feeding her information to say to the group to test their suggestibility and see their reaction. It happened to be cold that day, and I told her to say "the changing temperatures have made my irritable bowel flare up again." I simply made that up. If it was hot, I would have said the heat made it flare up. Of course, the fibro-chatters chime in with "I know, sweetie" and "Yeah, me too."

With the ten or so people in the chat-room, at least one person agreed with my ever-increasing asinine correlations ("am I the only one who THIS happens to?") between things like Raynaud's Disease and left-shoulder pain and pollen content leading to full-blown fibro flare-ups. Suggestibility.

NOOOOOOOOOOOOOOOOOOOOOOOO!!!!!!

An extremely frail, thin patient with end-stage Alzheimer's and various other conditions commonly found in elderly patients comes in with her family for a rip-roaring UTI. Scanned into her chart is the living will with the DNR/DNI order.

Now, lemme describe to you what "end-stage Alzheimer's" means:

• Unable to speak, even without added insult of a UTI
• Unable to engage in any sort of meaningful activities other than attempting to kick our asses
  
• Incontinent of bowel and bladder
• Contracted extremities
• Unable to walk
• Unable to feed herself
• Unable to drink water, except in very small amounts (leading to dehydration)
• Pressure ulcer(s)
• Emaciated appearance
  
• Unable to cooperate with basic cares, leading to struggles with even the most basic of daily tasks

And it never gets better, it only gets worse, if there is such a thing.

So anyway, after a really fun time trying to do a straight cath, bloods, and an IV with two other people as my spotters, I went and hung the antibiotic. Soon thereafter, AFTER having watched the hour-long struggle to obtain these basic lab studies and IV, the patient's daughter says the following to me:

"I was thinking that I'd like to maybe make it so she gets resuscitated if she needs it."

My Inner Voice screamed, got into the fetal position, and crawled under the nurse's desk to suck its thumb.

I convinced her to wait until the primary came to see her later that day. On the way home, I heard the sound of her sternum and ribcage cracking. Gahhhhhh.

Need scrubs?

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Save your gas money. Don't go to the store. Go to Scrubsgallery.com!

ER FAQ: Is it anything like TV?

Ten out of Ten answers that question. The title alone kills me.

When family history makes a difference

A young lady in her 20s comes to my department with onset of left-sided chest pain radiating down her left arm while helping her mother around the house. I tried to get her to say it was musculoskeletal or pleuritic to no avail. It was a pressure; it didn't go away, wasn't worse with movement, palpation, nor deep breathing. She didn't look anxious nor have any other obvious cause for her chest pain identified.

She had the following family history:

Mother had an MI at age 35, father died of MI at age 30, and her only sibling had what sounded like a NSTEMI at age 21 (chest pain and a heart attack found only on the labs).

Holy shit.

In addition, this girl had type II diabetes, hypertension (controlled with meds times THREE), and high cholesterol (on meds), and was morbidly obese. Due to her family history and having every additional major risk factor for heart disease by her mid-20s, she saw a cardiologist to get stress tests which had all been normal.

The girl was angling to go on a nitro drip, but I finally got her pain down to a zero, and she was admitted.

That's gotta be the worst family history of early cardiac disease that is even possible.

The most expensive sore throat ever

I got a patient with the classic "heart history" who awoke with throat pain. He told me he thought he might be having a heart problem because his brother had a heart attack that featured only throat pain. Of course, the medics maxed the guy out on nitros, started the line, monitor, aspirin, etc.

Dr. Controlfreak goes in and starts "assessing" the patient (scare quotes intended), gets the story about the patient getting nitros that "improved" the pain, the heart history, and listens to the lungs, declaring that he will need to be admitted.

So, Dr. Controlfreak leaves the room.

So, guess what I do? Yep, I look in the patient's throat. You know, the area of the patient's chief complaint 'n stuff. Oh, gee, look at that ginormous tonsil (it looked like the photo only on one side only).

Me: "Does your throat hurt right now?"

Patient: "No, but it hurts a lot when I swallow."

Me: "Does it ONLY hurt when you swallow?"

Patient: "Well, it hurts a little, but it's much worse with swallowing." He even did that little wince-thing sore throat patients do when they anticipate having to swallow.

Then I go on to get the story of how the patient was feeling generally ill with body aches and malaise and went to bed early that day. Uh. Doesn't sound cardiac to me. I couldn't find anything that made it sound cardiac. Not worse with activity, no shortness of breath/nausea/sweating/chest pain then nor recently, etc.

So, here we go. If you've ever worked with a total ass of a doctor, you know that some peon like me (everyone but him is a peon) telling him essentially that I think he's missed something obvious isn't going to turn out pretty. Our working relationship is not good for many reasons, including the major disciplinary meeting I caused by writing him up, and his general need to be in control of everything including basic ER nursing care. I've had to remind him on 6 or 7 million occasions that we are not only taskmasters that just prance about the department in our brightly-colored, flowery scrubs getting ordered around by the physician.

Me: "Hey, Dr. Controlfreak, you may want to check the patient's throat. He's got a huge tonsil on the left side and he tells me now* it only hurts when he swallows."

Doctor: "He's admitted already."

Me: "Uh. Looks and sounds pretty clearly like your run-of-the-mill throat problem."

So he storms in there, comes out, and still refuses to change the patient's admission because that would mean he missed a Medicine 101 diagnosis. Asking him what I thought of the patient's throat yielded no response other than an angry "he's admitted" which I took to mean "he's admitted because delaying the admission or not admitting the patient would have meant you were right and I missed something". Can't people with heart histories just have a sore throat? Apparently not, especially when a physician's pride is involved.

*="Tells me now" used to help doctor to save face vs. "If you'd have asked anything about the characteristics of the throat pain, you'd have learned..."

The underlying cause for obesity

I was going through the triage flowsheet on a cute old guy and got to the questions to determine whether the patient would need a nutrition consult if admitted (why can't they do this when they're admitted if it's only applicable if the patient is admitted?!):

Me: "Have you had any unplanned weight loss in the last three months?"

Cute Old Guy: "No, but I've had some weight gain. I think that's from sitting too close to the table at dinnertime."

So what would you like us to do for you tonight?

A patient with a psychiatric history comes in with a chief complaint of "anxiety" and "can't sleep." So, he gets back to a room and promptly falls asleep. The social worker, the doctor, and I all woke him up for our assessments. He complains that we are bothering him and should leave him alone.

Me: "So what would you like us to do for you tonight?"

Patient: "I don't know. What did I say I was here for?"

Of course, after being discharged, he promptly asks for a cab voucher back to his 3rd ring suburb so he doesn't have to wake anyone up to bring him home. Nope. Sorry.