Taking a stand long enough to sign off to another nurse

I have funny hours at my job compared to the other nurses, and, because of that, I often get moved around the department.  I may work 2 hours in the non-critical side, 4 hours in fast track, and 2 hours in triage in a single shift, for instance.

The other day, I had a situation where I had a teenaged female patient who had made a pretty serious suicidal gesture and was brought in by police. She'd been defiant, not wanting to talk to staff, but after awhile, I got her to tell me what was up and some of the stuff she'd been thinking.  

She'd spoken with the social worker, and was informed that she was going to be admitted to the hospital.  The patient responded by screaming, crying, and kicking the chairs in the room which she had to herself.  Security removed all the chairs and she decided to sit in the corner and sob loudly.  I sent one of the security guards in there and closed the door as to not disturb everyone else.

The doctor (Dr. Made-Me-Cry) went in there and ordered haldol 5 mg and ativan 1 mg IM.  

We all know what happens when I try to question one of his orders.   

Me: She was just told that she was being admitted and freaked out, let me give her a few minutes to simmer down.  She's not trying to hurt herself nor anyone else.  Her mom's in there now and she's starting to calm down.

Doctor: Well, she's going to do the same stuff on the floor when she's admitted, better that she be sedated now.

Me: I really don't think a depressed teenager crying loudly is an indication for Haldol nor ativan, sorry.  I'm going to wait.  I told the patient if she starts trying to hurt herself, anyone else, or run away that we'll have to give her stuff to calm her down.  She says she won't, so I'm going to give her a chance.

The doctor kind of mumbled some crap about whatever, enough to let me know that he was displeased with my decision, but decided not to attempt to make me cry again at that time.

By the time I signed off my patients to another nurse to go to another area of the ER, my patient was talking with her mom, crying softly.  Apparently, at some point soon after I'd left, the crying progressed to the loud temper-tantrummy crying again.  The doctor told the other nurse to give her the Haldol.

At least I didn't have to do it.   

I wonder if the depressed girl who'd just tried to kill herself and decided finally to talk to staff about it is going to hold back tears now so she doesn't get tied down and shot with Haldol.  

Do you have any heart problems?

"No, I don't."

After beating it out of her, it turns out she had 6 stents, 2 heart attacks, hypertension, high cholesterol, type II diabetes, and was a smoker for 40 years.  Of course her chief complaint was "chest pain" too.  

"But I thought the stents took care of everything!"   

Whatever, come back for an EKG like now.

Refusing admissions

House float nurse (working in the ER): "I was charge nurse on med/surg one evening and there were five nurses.  By the end of the shift, every single one of the nurses had refused to take an ER patient and some of those had to be reassigned to other units.  I ended up taking extra patients myself in addition to the other ones I was assigned and being charge.  I don't know how people think they can get away with that.  I begged and pleaded, but no one would budge."

In my hospital, it is policy that if a floor nurse "feels" that they can't handle a new patient"safely", then they can refuse to take them for the entire duration of their shift if necessary.  

If an ER nurse, however, "feels" that she can't handle another patient "safely", then she takes another patient anyway.

Ways to dispo a patient from my ER in under 7 hours

1) Assign them to Dr. Bloody Gloves when they have a serious illness.  They will be celestially discharged, but it's still a discharge.  Depending on how many times you do this in one day, the morgue may be full.  This will cause your plan to backfire.  Very dicey.  

2) Fake or actually have a patient with a STEMI.  Cath lab will arrive and take your patient away for you and no one can refuse report, you can't hold the patient for the hospitalist consult that never shows up nor another round of labs and imaging.  

3) Tell the floor: "I'm going to bring your admit upstairs and park them in their room.  When you want report, feel free to call down and get it."  This is the only way to give report on your patients in under 7 hours.   

4) Hire board-certified emergency physicians.

5) Flood the radiology suite with 12 feet of water or more.  Alternatively, take all your magnets off the fridge and those big honkers to turn off pacemakers and start launching them at the MRI scanner.  

6) Light the place on fire.  If your patients run for dear life, you can discharge them as 'eloped'.   Note that if you've already attempted #5 recently, #6 will not be as easy.  Best to either do #5 or #6 and switch it up next week.  

7) Trick patients into thinking they're giving away free narcotics and/or flat-screen TVs outside and have them all sign AMA forms.  

That about covers it, I think.  

Overheard

One thing I'm forced to endure every second of every aching, bone-crushing hour of every shift is listening to doctors dictate.  Some doctors are rather impressive with their dictation abilities, finishing off a chart in 17 seconds flat; others will drone on for like 20 minutes.  Obviously, the 17-second doctors all apparently interned as auctioneers at Bob's Estate Sale Palace in Pocatello, Idaho and the 20-minuteurs apparently interned like at the cerebral palsy speech therapy treatment center or something because it's like one word at a time.  If two of them are dictating at different speeds at the same time sitting right next to each other, my brain just explodes a little bit inside. It's hard to explain, but it's like listening to your yoga instructor super-imposed over trailer people screaming on The Price is Right.  You get the picture.  Maybe not.  

One of the 17-secondeurs was dictating a few neglected notes from previous shifts. There is some weasely-looking dood who comes around in pastel shirt-and-tie and deposits little "deficiency" sheets on the doctor's desk which tells them things to add to their documentation for billing purposes or whatever.  I didn't have shit to do, so I was just listening in because I'm fascinated by how good doctors can rattle off presentation, labs, imaging, family history, findings, differential diagnosis, and treatment plans in like four seconds.

Mary Johnsonisa39-year-old femalewhopresentstotheemergencydepartmentwithcomplaintsof dyspneaoccurringatrestworseningwithexertionforthelast2daysassociated with productivecough, fever, and tachycardiawhichsheattributestorepeatedalbuterolinhalerusage  PERIOD.  Shewasseenand foundtohaveexpiratorywheezing bilaterallyinmoderatedistresswith....

Blah blah blah for 13 more seconds then a deep breath, a little line through the name on the deficiency chart, and on to the next one.

Dr.Fast dictatingalatenoteon patient Ralph Washington PERIOD Criticalcaretimewas 30 minutesexclusiveofprocedures PERIOD.  SignedFastEndofdictation.

Cross-off, deep breath...

Secretary:  Hey, Dr. Fast, your wife is on line two!

Hey honeyhowareyoudoing and howarethekidstoday PERIOD?  Um.  Heheh.  Sorry.  YeahI'dliketohavesloppyjoesfordinner PERIOD.  Oh shit, okay, honey, sorry. Wow, lots of dictations today, just got the deficiency thing dropped in front of me.  Love you dear!

That was hilarious, Dr. Fast PERIOD. SignedNurseKEndofpost.

Ambulance Driver on Nurse K

RAWR.  No, he wasn't on me like that you pervs.  Here's an excerpt from a chat that we had:

Ambulance Driver: Your attitude is no nonsense and crusty. In other words, the *real* world of ER nursing, not that Pollyanna shit the media portrays.

I must say that I like being referred to as "crusty"*.  

He sent me his new book, and I'll have a review posted whenever my ADHD allows, hopefully next week.  

*=Anywhere but an OB/GYN appointment.

Sassy

There's one of the older docs who orders so much shit that the running gag is that 'all the radiologists have boats named after him.'  The secretary calls CT every morning he's there to 'warn' them when she shows up.  People send apology letters to the radiologists and lab staff signed by the whole department with chocolate and tears.

However, at least, unlike the other huge work-up docs, he is laid-back and reasonably pleasant to be around so we can tease him incessantly about everything.

Deadpan and dry-as-a-bone, almost like Ben Stein dressed up in scrubs, he was telling me about going to Catholic school in the early 60s this one time.  

"I must admit that I never really mis-behaved.  Always colored inside the lines.  Never spoke out of turn.  This one time, however, the nun slapped me across my face for being 'sassy'.  I, to this day, have no idea why that woman hit me.  I was not being 'sassy'."

"Oh, and by the way, if I had to do it all over again, I'd color outside the lines."  Said like Ben Stein, that comment struck me as hilarious, by the way.  

So, now and again, when I'm grumpy about a stupid chest CT to rule out PE on an 18-year-old with cough and no risk factors or some other abomination of an order, I'll just say something like, "Chest CT to rule out PE?!  I just called up a nun and told her you're being sassy down here."  

Answer: A rotten doctor

What kind of doctor puts in a whole ton of orders in on a patient based on reading a triage note alone?  No assessment, no review of previous visits, not even a discussion with the assessing nurse. 

How can he do this on every patient, regardless of whether it's busy or slow, and get away with it?  

Nice d-dimer on the dialysis patient, nebs on the patient in acute heart failure, blood cultures on the afebrile asthmatic, and gallbladder work-up on the patient with the bowel obstruction.  

Assess your damn patients.

Dictation WTF

Found in a chart:

Patient presents to [Nurse K's Hospital's] emergency department with complaints of tickly with teeth.  

No clue what that was ever supposed to be.

Kinda funny...to me

Dr. Controlfreak likes to order imaging on chronic pain patients, and not just one study, but like three.  Usually an XR, if negative, a CT, if negative, then an MRI.  I crap you naught.  This is all-day everyday, and moreso when I'm the nurse because he knows it pisses me off in particular.  

Today, a chronic paineur with back pain for 4 years and multiple visits for the same fall-down-go boom (FDGB) with new "tingling" in one hand and one foot and no weakness.  So....

XR C-spine, Lumbar, thoracic spine (neg)

CT of head, CT of entire spine (4 separate studies) (unchanged from previous)

MR of the c-spine, and lumbar spine (unchanged from previous)

Finally, after an epic ER adventure of glowing radiationopathy or radiculopathy or whatever, the patient stood up to stretch and sign his discharge paperwork.   He'd been in the department for so long (8+ hours) that he'd missed breakfast and lunch and nearly passed out.  Pasty white, sweaty, the whole bit.  "I think I'm just really hungry," he said.  

After a full meal, he was good to go.  

So, if your patients get a room immediately and are being irradiated for so long that they miss TWO MEALS and are passing out on yah, you are ordering too much sh*t and need to be like one of those guys that sits in an office reviewing charts for the insurance company or something because you're too slow to make it doing anything else.  NINE imaging studies.

Entitlement issues to the max with a side of defensive medicine

"I'm here because I didn't get prescribed Percocet yesterday and this stuff (naproxen) ain't workin for my chest pain!  I don't want to feel any pain!  It's getting better but it still hurts when I move to the side like this!  I rushed right back when it still hurt this morning.  I need some percocet for MY pain!"  

I couldn't open my mouth fast enough to let the yawn out, lemme tell yah.  

By the way, how is it everyone can always rush to the ER for narcotic requests or a cough x 1 hour but can never rush to school or work to learn something or make money?

Incidentally, despite a million-dollar work-up the day before to look for everything and anything for "chest pain with turning to the side and palpation" with normal vitals, the doctor repeated everything (8 labs, EKG, repeat CXR) and added a chest CT to rule-out PE despite a negative d-dimer the day before.   

So, an additional few thousand dollars in testing so the guy could get a percocet prescription, which he got because a little muscle pain with certain movements is certainly an indication for that.  

Something that wouldn't happen without welfare

Chief complaint: I had a sore throat two days ago which is better now.  My son tested negative for strep, and I want to make sure I'm negative for strep too.

An emergency department visit for a resolved sore throat.  The first sign of the apocalypse.  

Oh, and of course, the patient was swabbed too which happens to be the second sign of the apocalypse.

Remember kids! Patients don't know WTF they're talking about

A good triage nurse has the ability to see through the BS and kinda figure out what is REALLY wrong or not wrong with the patient.  The new triage nurse will just take dictation, write down what the patient says, go through the 500 Joint Commission-required irrevelevant questions, assign an acuity score, and be done with it.  

Here are some triage summary notes:

1.  Patient: I put in a tampon last night, now I'm dizzy and puking and my friend's mom who is a medical assistant said I should be checked for toxic shock syndrome! 

My triage note:  Patient presents to the emergency department with 4 hours of sudden-onset vomiting and diarrhea.  Abdominal cramping before BMs.  Vitals WNL.  States currently menstruating.  

2. Patient: I think I swallowed something that got stuck because it hurts and is cramping right here in my stomach area.  My potassium pills are really big and one's probably stuck in there!  Oh, and I vomit if I eat, but I can drink liquids just fine.  I took my pills yesterday morning and it started hurting this morning after eating breakfast!  Do those dissolve really slow or something?

My triage note: Patient presents to the emergency department with epigastric pain and cramping with vomiting associated with and withoug eating. Pain "wraps around" upper abdomen.  Patient with no h/o gallbladder surgery nor ulcers.  Appears painful.

The "art" of emergency nursing is cutting through the bullshit to get to the heart of the problem. The job is not dictation secretary and button-clicker.   There is one nurse who will rush everyone back who self-diagnoses with something potentially lethal whether or not the history nor actual presentation has anything to do with that complaint.  You need to know the difference between an 18-year-old with "cough and chest pain" who signs in "heart attack" and the 50-year-old stoic carpenter who goes to the doctor once a decade who signs in with the same thing.

That lady with the "potassium pills" had acute cholecystitis by the way.   When I write in a seemingly irrelevant thing like "no history of gallbladder surgery", I'm telling you what's wrong.

Crayzee administration crap

ERNursey's hospital implemented one of the crayzeest policies/practices that I've ever heard of, and that's saying something.  

Fight it, ER nurses and staff!  That is one thing that for sure is NOT our job.  

I have no clue

Expanding on my tweet that I texted while swillin' a coffee in the break room: In what universe is it okay for an ER doctor to take a whole hour from the time he picks up a chart and sees the patient to enter in his first order?  

You proudly say, "No universe, Nurse K." 

I, in turn, say, "You would be right, oh o perspicacious reader."

You're like, "What the heck does 'perspicacious' mean*?  Do I win something for being right?"

I'm like, "Fuck no.  Now, let me finish my post."  

You shut up and do as you're told.

Then I'm all, "It's gets even worse.  The patient has already been diagnosed with pneumonia, has normal sats/bp/pulse, has her films with her, and just 'doesn't feel better' despite only taking one dose of oral antibiotic.  She reports no change in her condition.  In other words, go home and take your morning dose and watch Price is Right and be patient, patient."

Really, what are you doing in there, Dr. Big Work-Up?  Not only did you put in a full sepsis work-up** including pre-antibiotic blood cultures x 2**, you spent at least 50 minutes doing a full med-studentesque H&P.  

This is not med school, you're not a nervous intern on an internal medicine rotation, this is the E-MER-GEN-CY ROOM (or E-MER-GEN-CY DE-PART-MENT if you're WhiteCoat).  Read this or something, sheesh. You're killin' me here, Big Work-Up.  

*= It's one of my favorite words, read about it here. 

** = Duhr it's Dr. Big Work-Up

Direct admission confession

Here, I wondered why admitting doctors who have accepted a patient would send the patient seen at another ER to our ER for basically just an exam when inpatient beds are available. I figured it had to do with layzeeness to some degree. Papa Goose, who sounds like an internist or a FP, says the following on this thread:

I've frequently had patients stop in the ER (or ED) before going to the inpatient floor for a couple of reasons:
1. Med surg wards are so understaffed that finding a qualified person to start an IV can be impossible. I'd do it myself but the necessary items are locked up where only qualified persons can use them. Clearly, years of experience and board cert don't make me qualified. But in the ER, there are actual RNs who know how to start an IV
2. Many of my direct admits need procedures before going to the floor: packing, ID of abscess, etc. Have you ever tried to do a procedure on the floor at 2 in the morning? see above

My "payment" for being allowed to use the ER this way? I try to be there when the patient arrives.

In short, he sends inpatients to the ER so that he doesn't have to be inconvenienced with having to figure out how to do a simple procedure like a wound packing or an I&D on a med/surg floor. He's worried no one will start an IV or be able to.

I'm guessing if your med/surg floor is understaffed in this economy where laid-off nurses can't find jobs, then probably your ER is understaffed too. Your patient is not the first "hard stick" that nurses have had, and the average nurse knows who their IV starting resources are, whether it be an official IV nurse, a critical care house resource nurse, or an experienced charge nurse. Lidocaine and a scalpel (or sword)? Transfer to the ER for that? IV stick? Wound care? The reason to transfer to the emergency department is for the services of the emergency-trained physician, not the emergency-trained nurse. While I appreciate the acknowledgment of our above-average IV-starting skills and ability to find scalpels (or swords) and lidocaine quickly, if you have no need for the services of the emergency physician, you should not have the patient stop in the emergency department. End of story.

I have done wound care, dressing changes, and procedures on the floor at 2 in the morning, by the way. The hardest was trying to assemble all the stuff for an emergency lumbar drain insertion on a patient with a CSF leak at 0400, but I got it done. I called around to ICUs until I found a charge nurse who floated to and had access to the locked OR who picked the neurosurgeon's card (which lists supplies) for that procedure and assembled all the crap for me from the central supply. I felt like a rockstar after I was able to get that done, by the way.

Incidentally, we kinda suck at wound care in the ER. If it's not like irrigation, adaptic, gauze and bacitracin, we're kinda screwed. Oh, and our aides do that. Floor nurses do much more sophisticated wound care and dressing changes than we do by a landslide.

Lemme ask you this. Tell me which emergency patient(s) that have a probable or possible life-threatening condition in our lobby that we shouldn't see because we have taken up a bed in the emergency department for your convenience. I appreciate your honesty, Papa Goose, but, really, this is a poor use of resources and this practice needs to be abandoned. The ER is not the same-day clinic nor the same-day surgery unit nor a cache of really awesome IV-starting nurses that can be tapped whenever it is more convenient for you. Our legal and ethical duty is to the screening and possible treatment of patients presenting to the department with a real or imagined emergency condition. As we all know, there are enough motherf'ers looking to use us inappropriately for that alone, without having to deal with doctors wanting to use us inappropriately too.

Reason to admit to tele?

I don't know what ER doctors are thinking when it comes to this crap, but when someone asks what kind of bed someone needs (monitored/non-monitored), every once in awhile, we hear these confusing words:

Oh, they should go to tele so someone checks their vitals.

OR

Admit to tele so the patient doesn't get ignored.

OR

Tele because the patient is 85 years old.

Um, hey guess what? Tele nurses check vitals every 4 hours and med/surg nurses do the same thing. The staffing ratio is the same. I worked med/surg before ER and I can't remember a single shift where I just went through the whole day and was like ,"D'oh, forgot to check everyone's vitals again! Sheesh, really need to work on that."

Here's a friendly suggestion: Admit to tele because the patient needs.......wait for it......wait for it.......

Continuous cardiac monitoring.

There's no other reason to admit to tele. Write it on your hands, ER docs. Don't burn up our precious tele beds unnecessarily because I'm not in the mood to hold a half-dozen chest paineurs down here because you sent every person who was "old" to tele so "people wouldn't ignore them."

Dr. Smarmy

There's an icky admitting physician who does icky stuff like flatter unsuspecting med/surg new grads with the intent of trying to get them into bed, corner cute little blonde xray techs in the viewing room, wow them with pointing out infiltrates and fractures and ask them out for "drinks" after work, treat the ER docs like crap, and smarm around like he's some sort of P-I-M-P being all greasy and icky and icky and greasy.

He hasn't tried any of that in the ER though because we're much too savvy for his icky.

ER doc: Secretary, please page Dr. Smarmy.
Secretary: Eew.

ER doc: Secretary, I need Dr. Smarmy for room 3.
Secretary: Eeww. Gross.

The secretary says that every time. Cracks me the F up.

Crass-Pollination Poll: The magical God-like powers of Happy Hospitalist

It's multiple choice, so choose all that apply. If you don't know what I'm talking about, be sure to read at least this. If only I had known that seemingly complex problems could be so simple to solve, I could have saved myself a lot of trouble throughout the years. All I needed was a 10,000-hour internal medicine residency because....

...if you're a board-certified internist, you can do anything.

Okay, seriously, this is a 10/10 on the WTF-o-Meter

I poke fun at Happy Hospitalist a lot, but this post is one of the most WTFishy things I've read in awhile. In short, he posts a long-ass medication list and then, without any sort of explanation as to his rationale, determines that the only right thing to do is force the patient to quit smoking, test them for nicotine in their system 60 days later at their own expense, and if the patient has nicotine in his system, fire them from the clinic just like that.

The reasons why this is f'd up should be super obvious, but I'll summarize:

• Based on the med list, the patient in question has schizophrenia or, more accurately, schizoaffective disorder. It's unethical to "fire" a schizophrenic from your clinic who refuses to stop smoking in 60 days, especially since new research indicates that smoking helps the symptoms of the disease. Schizophrenics gain weight and get type II diabetes from their psych meds too. Maybe if they successfully quit smoking, he'll fire them for being fat anyway. After the patient is fired, they'll bleed out after their INR stops being monitored, and you won't have to worry about all their annoying coughing, bronchitis, hallucinations, and atrial fibrillation.
  
• Happy seems to be so obsessed with smoking that it's creeping me out. Yeah, smoking is bad, but we don't need seriously ill people going around being worried about being "fired" from their clinic for smoking. Fire them for diverting narcotics, but don't fire them for smoking. Sheesh.
  
• Other than some of the medications being for asthma/emphysema, there's nothing in the post that indicates that the patient "doesn't feel well" due to smoking, so this smoking stuff is nothing more than a non-sequitur. As a writer, I hate non-sequiturs unless they're funny.
• He asks "Where do you start? Where do you end?" Uh. How about starting with eliminating duplicate therapies? Maybe the patient has xopenex and albuterol, prilosec and nexium etc etc prescribed because every time a clinic fires the patient for smoking, he or she has to go to a new doctor and start all over again.
  

So, yes, a rare 10/10 on the Nurse K blogging WTF-o-Meter right there. Now it's time for him to show up and tell me I misunderstood the post as per standard operating procedure. Yes, yes, I just don't get it, Happy, I know.

Update: Happy succinctly* tries to defend himself here. My favorite part is when he starts talking about "destroying one's temple". I had a boyfriend once whose dad was a pastor, and he told his son in no uncertain terms to break up with me because I'd "destroyed my sacred temple" (ie my bod) after I got a tongue ring and a tat. Thanks for the flashback there, Happy.

* = LOLOLOLOLOLOL

Assessments or lack thereof

Note to Dr. Bloody Gloves: If the nurse is picking up a lot of stuff that you didn't even consider, there is a lot of stuff being missed. Maybe it's time to get out of medicine.

Directly admit, please

One of the things that chaps my ass besides the winter breeze in light-weight scrubs are doctors who think the Big City ER is the dumping ground or holding tank for all patients who need any sort of hospital service not offered at Little Community Hospital.

Huge red flag: "Hi, we're sending you a stable dood with open fractures to be repaired by Dr. Orthodood, who has accepted the patient." Hi, good to hear about it. Directly admit him then.

No, sorry, he should stop in the ER so I can see him.

Huge red flag #2: "Hi, we're sending you a patient who needs surgical repair of a ____ and he should stop in the ER so Dr. Surgeon can see him. He doesn't need to be seen by the ER docs." Great. He can stop in pre-op or an inpatient surgical bed too, then.

No, he should stop in the ER.

So, in summary, if the patient "doesn't need the ER docs to see" or there is an accepting admitting doc then they---gasp---don't need to stop in the ER like we're some sort of highway rest stop with good coffee and pancakes on the way to Grandma's house because the ER is the place where you see an ER doc. Remember this and tell everyone you know.

We're too busy for your inpatients. Directly admit. It's as hard as making one phone call to the bed placement secretary saying you need a bed. Honestly, the reason I believe this happens is receiving doctors, especially non-hospitalists, don't know how to directly admit a patient from another facility or they want us to baby-sit until they can come out of the OR or finish their lunch. I can't think of any other explanation.

Random thought

You know your hospital is a cluster when inpatient units are sending their people that need to be transferred to the ICU to the ER (the first rule of ER is inpatients don't go to the ER) and, on the same day, more layoffs of nurses are announced.

ED vs. ER update

As you all know because every last one of you reads my blog daily, I frequently tease WhiteCoat about his hard-on for using "ED" instead of the more popular "ER" for the place that we work.

I must confess that I just finished writing a proposal for a policy change in our department, and it has "ED" in it four times and "emergency department" spelled out twice.

I just puked a little in my mouth.

Just another day at the office

A doper covered in bruises and track marks has one hand cuffed to the siderail care of our fine men in blue. The other arm is all cut to shit from some sort of fight on the street.

The dood, high as a kite on whatever, throws up his free Hep C arm, blood flying everywhere, towards the cop and goes, "FUCK YOU MOTHERFUCKING PIG!" while flipping the bird.

Then the doper turns to me and goes, "Hey baby, how is it going tonight with you?"

The volunteer

Our ER* has a fair number of volunteers. Most are ages 16-22 and want to go to medical or nursing school or something similar and are volunteering to pad the resume/application or whatever.

The other day, a new volunteer spent a little time following me around. We went to go room a patient from the lobby. I showed her how we check the name band, led the patient back to the room, and I gave our sample patient a gown and told him to strip, etc. etc.

"Okay, now let me show you where the blankets are kept. This is something nurses might ask you to do---give patients blankets." I showed her the blankets, and told her to go give the patient the blanket.

"Um. So what do I do? I can go in there? What should I say?"

"Uh, well, just say 'hey, it's the volunteer, and I'm coming in with your blanket' and go on in."

She took the blanket, walked over to the room and stood outside the curtain pondering the fact that she was about to interact with an actual patient in an actual room who might actually be sick. In short, it was obvious that she was nervous about the blanket. She asked me if it was really okay to go in there, and I'm all, "Of course, the guy wants a blanket, he'll be happy you have one." She took a deep breath, said something like 'here's your blanket!' and quickly busted out of there and smiled, relieved the whole traumatic experience was over.

These little two minutes in time brought back memories of my first clinicals where I had to go in patients' rooms and talk to them, and I was sooooooooo nervous that I'd say something wrong or screw up or not know the answer to a question or whatever. Stomach turning, me standing outside of some poor patient's room in my silly little brand-new nursing school uniform scared to go in. I'd kind of forgotten about that.

* = Or blah blah White Coat blah blah

Random late night nursing-station discussion

There's some unwritten rule that if the ER is the Q-word and it's between 0300-0500 that any topic is up for discussion. Latest topic of discussion:

"What is the difference between a tool, a douche, and a choad?"

My answer: "A tool is a douche without the hair gel. And a choad is the same as a 'Dick'. A choad is like a generic, undifferentiated tool or douche."

Another answer: "A douche is an orthopod or a drug rep, a tool is a fake, back-stabbing administrator, and a choad is, well, I don't know what a choad is..."

I argued over whether an orthopod is a "douche" or a "tool". Obviously orthopods are tools because they're all ex-football players or bodybuilders, duhr, come on. I do, however, agree that most administrators are tools and not douches, and this transcends hair gel status, but I can't really figure out why that is.

Replacement

Me: You leaving at 4 o'clock?

Doc: Yeah, thank God.

Me [Sense of dread and worry]: Who's replacing you? Just tell me if it's someone I like.

Nurse saves doctor's ass, Part 109250904930

I don't have a 10-million hour residency. I don't have a medical degree, but I can still save your ass. So you bess be respectin' yo nurses.

An ultra-old but functional patient came in with sudden syncope. She passed out at dinner and her family called 9-1-1. She was alert and oriented upon arrival. The doctor was unimpressed with her "paced rhythm" and no other concerning symptoms were noted such as chest pain, shortness of breath, dizziness, nor neuro symptoms. Vitals were all good. The doc ordered a couple of screening labs and went on with her day.

"Are you going to address the patient's atrial flutter? She's not even anti-coagulated with aspirin." Maybe no coumadin/heparin for the oldie, but aspirin?

The doctor had just looked at the interpretation of "paced rhythm" and didn't bother to look at the flutter waves, never seen on previous EKGs. Atrial flutter is a huge risk for stroke and other flying clots of death-related problems. Maybe said rhythm was even the secret underlying cause of the patient's syncope. Who knows.

Another ass (and patient's ass) saved.

ER doc fashion report

There was a little in-service recently taught to us by one of the ER* docs who'd come in on his day off. As we all know, ER** docs dress like some sort of picked-over thrift store fire-sale mess.

Dood showed up wearing the following:

• Sweat pants like what you can pick up at the "fashion" section at Walgreen's (located near the cheap plastic toys from China that you buy to get your kid to shut up section)
  
• Matching plain hooded sweatshirt
• Plain black knit ski cap with hood OVER the ski cap as he chilled at the conference table teaching the inservice
  
• Tennis shoes

So, basically, we learned about CO2 monitoring from the frickin' Unabomber.

* = You know what this star means by now
** = If you don't know what the first star after the 'ER' was for, it means "or ED if you're WhiteCoat".

Reminder to always search your psych patients

I took over a cooperative, voluntary psych patient from another nurse with the report of "they'll take report on him in 30 minutes" and scrolled through the notes. Blah blah blah.

I looked and noticed that no search had been documented. It's standard for anyone coming in with a mental health complaint or otherwise labile behavior to be searched. It's like beaten into your soul in training. If I die today, my soul will be searching the belongings of other souls and locking them up in Pandora's Box or something.

Charge nurse: Why is this guy still down here, send him up?
Me: Oh, no one documented a search, so I'm just CYAing and waiting for security.
Charge nurse: On him? He's cooperative and voluntary, just send him up!
Me: Nah, gotta do it.

Charge nurse kinda is like "whatever". Security finally comes down, searches the dood, and removes a huge pocket knife off the guy. I'd have been hung out to dry (possibly actually killed in town square by administration to serve as an example) if I'd listened to her advice! I don't think the guy was on the verge of slashing his own throat or anything, but still...

Boyfriend/girlfriend team visit

People need people, you know what I'm saying? It's always such a lonely time in the ER when you don't have a good friend, girlfriend, cousin, husband, niece or nephew signing in with you for your clinic, I mean, emergency department visit. I mean, if you're the only one emergently sick in your sphere of influence, you are bound to be feeling like you're the only ill person around when everyone you know is carrying on, gay as a chirping sparrow in the Springtime.

It never hurts to poll the neighborhood prior to going to the ER or send out a group text to see if anyone know wants to "get something checked out" since you're also "getting something checked out" today too. You're bound to find someone else with Medicaid or a false ID and/or no intention of paying who is unconcerned about the cost of the emergency department for non-emergency problems, and you get to hang with someone for your 5-hour wait!

Recent boyfriend/girlfriend team visit:

Boyfriend: "My ass hurts" (wants narcotic refill for supposed tailbone pain after a fall last week, seen at some other hospital)
Girlfriend: "Popped a boil on my armpit".