Tap-water enema news

One of our frequent flyers comes walking in with paramedics.  

Why did you call 9-1-1?

"I couldn't take a shit, so I shoved a garden hose up my ass and turned it on full blast.  Now my ass hurts!" 

Outside the curtain, I could hear the secretary laughing.

How to make Nurse K go apeshit

Somechick comes in, gets triaged for atraumatic "foot pain" then promptly hits the hay in the lobby.  This was her third visit for this in the last month.  

Meanwhile, I get born yesterday, fall off the turnip truck, open the Fast Track, and, after yelling her name and jostling her around for a bit, take her back with a big, beaming smile on my face.  I mean, nothing is more satisfying than taking care of a sleeping 20-something with atraumatic foot pain.  Really, it's what I got into ER for. 

So, her medical history includes blah blah blah polysubstance abuse blah blah blah.  My Earth-shattering nursing assessment reveals bilateral foot pain on both the top and bottom of her foot for two years! THE HUMANITY!

Of course, she's falling asleep mid-sentence, looking all goofy, and not making eye contact.  It's not exactly a mystery for Scooby Doo what is going on when her AC is filled with track marks.  

The nurse practitioner on that day must've went to the Bloody Gloves School of Pain Management.  We both agreed that she was high as a kite or else coming down off something and, so, for her atraumatic foot pain (3rd visit in the previous 40 days or so), she received Vicodin #10 instead of the usual Vicodin #15!

I then proceeded to go apeshit crayzee.  Hi, we both just charted track marks, that the patient was behaving strangely, and has a shady, unimportant condition with two previous visits for the same, and you just wrote her for some narcs?  I'm not giving her that prescription.  You can if you feel strongly that a high person with a history of polysubstance abuse with current evidence thereof in her ACs should get additional narcotics for a subjective painful complaint.  The reason for the script?  She got narcotics the last two times she was here, so she's not going to be the first one not to give her anything.  She didn't want a complaint letter.

Look, Chica, she can't even sit up straight let alone write a complaint letter and, besides, who cares?  Not even a drug dealer would sell her anything looking like she does right now.  Fuckin' A.

Sometimes it's best not to argue

Mom: "[My adult son] can't take ibuprofen, he has epilepsy!"

Um.  Okay.  

Code blue crayzee

So, if someone goes into cardiac or respiratory arrest, you pull the "code blue" switch.  Back in the day, it sent a message to the person at the security desk, and they announced the code overhead.  Problem with that was, when your units are like 7B 7E and 7C and the person announcing the code speaks English as a second language, there was almost no way to end up in the right place on the first time.   

Someone then comes up with the nifty idea of an automated code system where pulling the code blue switch triggers an automatic overhead announcement with a clear voice.  This still is pretty buggy, and I can probably understand the actual location of the code like half the time.  If you code in my hospital, best to do it at "ultrasound", the "GI lab", or "interventional radiology" instead of 6E or 6C.  If you code in the "stress lab" or "physical therapy", we'll understand the words but have no clue where these are, so best to avoid those.  

Anyway, the other day, a code for the "main lobby" was announced.  Thank God, we'll at least arrive in the correct place for once.  Usually main lobby or cafeteria codes are like an old person tripping over their own feet and falling over or, at times, a seizure patient getting a good start to the day, but, regardless, per policy, the ER charge nurse responds to these codes.  

Charge nurse and doc go barrelling down the hall pushing a code cart all badass and whatnot.  They arrive on the scene to find...nothing.  A bunch of people standing around looking confused.

Where is the code?  Where is it?

Beats me?

People go running around looking for groups of bystanders doing the stand-and-point, but nothing out of the ordinary.   

Turns out, the person who "coded" was outside two blocks over at a bus stop or whatever.   A friend of said "coding" individual had thought it was a good idea to come running to the hospital saying there was a "man down" two blocks over and the front lobby staff pulled the code button like retreads instead of calling 9-1-1.  Of course there was no way we were running out to the main road bansheeing through peri-hospital traffic with a code cart and portable monitors like idiots, so we called 9-1-1 for the passed-out frequent-flyer drunk.

NH WTF

My patient, a 83-year-old little old lady with DNR/DNI status on hospice care for Alzheimers and multiple other medical conditions, was roused from bed after midnight to go to the hospital after the BNP that was drawn 3 days prior came back at 526.  She has a known history of CHF with normal vitals, sats at 99% on room air, clear lung sounds and stable 1+ pitting edema in her lower extremities.  She walked from her room to the stretcher.  She had no clue what she was doing in the hospital*, but kept telling me she was tired and wanted to go to sleep.

* = Which meant, in this situation, she was probably oriented x 3 because neither did we.  

Small victory

The other day, I had a migraineur with the following allergy list:

Depakote

Ibuprofen

Toradol

Compazine

Reglan

Benadryl

Steroids

Imitrex

All of which caused "hives" or "angioedema" or "throat closing".  It's pretty bizarre that one's body would find fault with the chemical makeup of only the standard non-narcotic medications given in ERs for migraine headaches.  Given all the medications out there in this world, the chances that you'd only be truly allergic to drugs from multiple drug classes used to treat migraines approaches zero.  

As we all know by now, this allergy list is that of a typical narcotic seeker.  This is nothing new to my readers.  

Deep breath.

"So you have a lot of 'allergies' to migraine medications.  Pretty much all of them, in fact.  What have you tried so far at home?"

"Oh, aspirin, Tylenol, and a whole TON of ibuprofen!  None of that works, only blah blah balhb albhalbhalbhlbhbalhbalhbalhbalbhlahblb [/stopped listening] works!!!"

My ears perked up and I started to pant with excitement like a dog whose owner is standing there with a leash.  Think Marty and Cooper with Happy putting on his New Balances and pedometer.  That was me.  

"Huh? What?  You have been taking ibuprofen?"

"Yeah! That's what I just said!  It's not working!"

Then, I started jumping up and down.  She could have told me I'd won tickets for a cruise and I'd have been equally as exuberant. 

"Well then.....I'M GOING TO TAKE IBUPROFEN OFF YOUR ALLERGY LIST THEN!  It OBVIOUSLY is not causing you to have facial swelling."  

I then removed ibuprofen from the allergy list and felt like I'd just landed on the moon.  This allergy removal was definitely one small step for man, one giant leap for mankind.  

So this he-she comes in...

...with some random complaint unrelated to the story that I'm about to tell.  I'm not sure of the proper term to use here...pre-op transsexual?  I dunno.  A mannish-womanish guy-girl who had doods' genitals and hair extensions and lipstick was assigned to me as a patient under his legal male name.  YAWN.*  

 

As I'm hiking down the hall with my full-on backpacking gear and tent 'n shit to one of the "ignore" rooms, I wondered in my head whether to refer to the guy/girl as a he or a she:  Pronounal cognitive dissonance.**  I still don't know the Miss Manners official answer on whether a guy who wants to be a woman who signs in under his legal male name (like "Henry" or something) should end up with male or female pronouns...

Anyway, I go in the room finding my patient, a college-aged fella/bella/banana-fanna-fo-fella in the fetal position on the floor wearing one of our distinctively-ugly one-size-fits-all ER diapers (that he obtained from the stock in the room).  After putting on the diaper himself or herself, he soiled it with urine.  No alcohol nor drugs were involved in this situation.  He brushed it off as a thing that happened when he was nervous.  Um.

I don't think he'll pass the psychological exam for the operation.  Something terrible must've happened to him.   I wanted to give him or her a hug.  I'm sorry that happened to you, whatever that was.  You didn't deserve it.

* = I used to do hair/makeup for a drag show, I fuck you not.

**= At the drag show, you were a "she" and referred to by your fake female name...at the hospital?  Beats me.

Swine flu crayzee

A patient comes in wearing a mask saying he wants to be checked for swine flu.  YAWN.  Our area is by no means a swine flu hotspot or anything.  No one has died in our state of the disease and there have been only a handfull of confirmed cases, all mild.  

He says he went to the clinic, was found to be Influenza-A positive, and was started on antivirals.  When taking a history, the doctor'd asked him about possible exposure to swine flu.  It turns out that one of the patient's roommates had Spring Break!!!!!! in Mexico. The Spring Break roommate wasn't sick and hadn't been sick, however.   The clinic recommended  he be screened for swine flu, but they didn't have the capability to screen him and recommended going to the ER for the test.  He told them thanks but no thanks, I feel fine, and elected not to go to the ER.    

This is where it gets crayzee.  My patient politely calls up a couple of his family members whom he'd visited in the last day or two to let them know he was positive for flu and the situation with the non-sick roommate being in Mexico.  One of the family members and another of his roommates happened to work for the same school district.  After hearing a casual conversation about this at work the next day, the decision was made at the school district to keep the family member and the roommate from working until the patient's H1N1 swab came back negative which takes over a week.  Neither the roommate nor the family member had so much as a body ache nor sniffle.  They wanted to prevent any "outbreaks" of swine flu among the children from the two employees who had no signs of illness.

CRAYZEEEEEEEEEEEEEEEEEEE!!  The patient felt really bad about wasting our time, saying he felt fine, but he was only doing it to get his non-sick brother and roommates' jobs back as soon as possible.  

You think I'm crayzee? I think you're crayzee too.

My brother sent me this.  I really like it for some reason.  

Front desk argument

"There is someone at the front desk who has a question for a nurse, can you help her?"

God, I hate that shit.  No, I don't want to give free advice because advice other than "sign in here" is interpreted as an EMTALA violation, but okay.  It may be entertaining at the very least.

Person at front desk: Do I have to sign in to be checked for STDs? [As if the front desk staff couldn't tell them that.]

Me: Yeah.  Right there are the slips to sign in.  [As if I'll just do a pelvic exam and cultures on you for free right at the front desk.  Would you like the whole lobby to see and smell that or what?]

Person at front desk: Well what if I think I have one?  I can't just get medications for it?  Why do I have to sign in?

Me: We don't just give medications out at the front desk.  You'll need to sign in if you want to be seen.

Person at front desk: Well how long is the wait?

Me: About 2-3 hours for something like that.  Maybe a little more or a little less.  It's hard to tell.

Person at front desk: But I just need medications for an STD!!!

Me: Well, you can either sign in or see your regular doctor or there are plenty of free clinics that will check you for STDs if you want.  It's up to you; we'll certainly see you, but there is a little bit of a wait today.

Person at front desk: This is ridiculous!  And you call yourself a hospital!

She's a 4.7

Me: So, why'd you bring you mom in today?

Daughter: Well, she's been getting more confused, yelling, hitting, trying to leave home, saying things like she wants to die.  That's not like my mom.

Me: What has she been diagnosed with?

Daughter: Well, she's had strokes and TIAs.  She tested at a 4.7.

Me: What was 4.7?

Daughter: WHAT, ARE YOU A NURSE?  WHAT'S WRONG WITH YOU?  SHE'S A 4.7! 

Me: I'm sorry, I'm an emergency nurse and don't know what you're referring to.  

Daughter: WELL, A 6 IS A GOOD SCORE AND HERS IS A 4.7. 

Me: Okay, okay.  Let's move on, shall we?

Still have no clue what she was talking about.  Probably one of the 10,000 ways to check old peoples' cognition or functional ability.  If it's not GCS, I don't know wtf you're talking about.  She's a 15 to me, you pessimist!!!

Two Minutes Hate: Happy at the cataract clinic

Happy and Mrs. Happy take Mrs. Happy's Grandma for a follow-up cataract surgery visit:

Now back to the original story at hand.  Mrs Happy found this running magazine in the office full of old blind Medicare patients who couldn't walk without a walker, let alone take up running.  So Mrs Happy asked the front desk if she could take the magazine home with her, thinking it may as well get some good use out of it.

Thinking the asking was only a formality, she was shocked to learn that not only is the waiting area "low on magazines" (which no one can read anyway), but they asked she bring it back next week.  Almost offended that someone would even ask.  

How about that.  I find good humor in it all.  An office raking in the dough like a blind puppy mill filled with senior citizens who can't see, let alone run.  And yet they can't seem to find enough cash to stock their front office with magazines.  And when they do, they pick a magazine that will find no use amongst the blind and disabled and find annoyance that someone would ask to take it home.  

Um, yeah, offended because, hey, that's not your magazine.  Sorry, but it's not a "formality" to ask to take something that doesn't belong to you out of a waiting room.  It's never occurred to me to steal a magazine from a clinic because those are obviously not for you to take with you; they are for the people in the clinic and their friends and family members.  It's none of your frickin' business who can and can not read them.  Based on that alone, Mrs. Happy should be able to steal everything written above a 5th grade level from my lobby.  

Note that he finds it shocking that offices that house physicians that do eye procedures would ever be "low" on magazines (despite people like Mrs. Happy trying to steal them all) , but he can't throw down the $1 per magazine for a year's subscription.   What a douche.  Seriously.

PS I frickin' hate it when people swipe magazines from the lobby.  FU, we don't have some secret cache of magazines.  Once that copy is gone, it's gone until the next issue arrives in the mail.  The fewer the magazines, the more people up to my desk interrupting me to ask about the wait and show off their personality disorders.

Update 5/22/09 11:23 am Happy responds in his comments:

As for not buying the magazine, it was an old issue, I believe 9 months old. Not something you can purchase off the rack. 

Old magazines eventually get thrown out or stolen. That's what happens to old magazines. 

You do have a point about taking it. My point however was not that it was the right thing to do, only that it is an expected side effect of placing them in the lobby. Some of you argue that it isn't. I'm saying it is. And I'm fairly certain few people ask before taking.

So, it was an OLD magazine.  I guess old magazines belong to the people they belong to less than recent ones.  I think antique stores, used book and clothing shops, the Goodwill, and used car lots should be worried.  It's not your job to decide what should come of other peoples' things, Happy. Your job is to sit there, shut up, read the thing and return it to its proper place when you're done.  If they want to have old magazines in their lobby, that's their right.  

Update #2 6:32 pm  As if this situation wasn't already a trainwreck, it gets worse.  Here is MRS. HAPPY's response:

I was in the office for grandma's f/u appt early in the morning, and I did not ask for the magazine at that time. After grandma went home, I spent the afternoon checking Barnes & Noble and other places, without finding this special edition for beginners, May 09 (although they did have both the regular May & June issues in stock). 
So, I stopped back by the office after 3pm, told the receptionist that I was interested in this magazine, and, was a little surprised by her response. 
I, too, have worked in a clinic, and we had/still have magazines there for people to take. 
I am more than happy to pay the $5 for it, that's why I searched the city looking for one. 
Also, I have read many articles on the Runners World website. However, there were several things in this magazine that I was interested in & a few things that I wanted to share with my sister. 
So, the receptionist wants it back on Tuesday. I hope she'll accept a new June issue (or something similar) instead.
--Mrs Happy

Oh my God.  She went back like 7 hours later to try to take the magazine. She wasn't even a customer, remember. "Hi, I drove someone here seven hours ago.  Would you mind if I took this copy of Runner's World?  I enjoyed the articles!"  No, get out!  Sheesh.  Note that a May 2009 magazine to the Happys is an "old" magazine (or else, more likely, Happy just straight-up lied that it was an older magazine to make the offense seem less icky).  Has the world gone completely mad?!?!  

Something I'd never thought I'd write as an ER nurse

So, when I applied to be an ER nurse, I was rather, if not completely, unaware of the concept of ER abuse.  I didn't read any ER blogs, and all the patients I got from the ER were rather sick.  I don't have any friends nor family members that make a habit of routine ER visits.  I've been like once, and that's when I randomly fainted during an anatomy final.  I'd have probably laid there for a bit and drug myself home like I usually do when I faint (the number of times I fainted in college was too numerous to count), but by the time I came to, I was already in an ER bed at the university's hospital.    Huh, I did what? Did I finish the exam?  Apparently I had finished, and I got an A in the class and on that particular final, thank you very much.  

Anyway, that's the long way of saying that I thought that ER was all or almost all sick or injured people when I started.  I had no idea this whole subculture of non-acute ER visiteurs even existed.  

The other day, I assessed a patient and wrote the following, something that exemplifies the whole problem with EMTALA and ER abuse:

Patient's chief complaint is "itchy scrotum yesterday".  States scrotum was itchy for a couple hours yesterday.  Denies current discomfort, swelling, redness, difficulty urinating, and penial discharge.  

In other words, he came in for a concern for jock itch.  Not even actual jock itch, but just a worry that he may have had it yesterday.  I was just fascinated with the whole concept of this visit.

I have no money.   I have no insurance.  I have no doctor.  But, given all those things, I decided today to come to the ER because my nutsack itched yesterday. Why?  Why did you do that? 

Interesting discussion alert: What's a real ER?

Start here: Scalpel and ERP battle in the comments on the topic of whether a freestanding ER is a "real" ER and how this fits in with EMTALA.  Does the mere presence of other employment options other than EMTALA-following emergency rooms (ie any ER that accepts Medicaid or Medicare) attached to hospitals negate the argument that ER docs are treated unfairly because they are mandated by law to provide a service without being able to ask for payment in advance?

Scalpel writes a full-on rebuttal here.

Shadowfax, who doesn't piss me off and actually has interesting things to add to a discussion only when he sticks to his area of expertise (like all bloggers should--ahem),  drops a huge bomb, saying you can't, according to CMS rules, work simultaneously in ERs that do and do not take Medicare.  So, in essence, ER docs who work in a freestanding ER have to either work only in freestanding ERs/clinics for two years (even if their business venture fails), the time in which you can re-apply to take Medicare, or hope they don't get caught by CMS if they work at their usual hospital and at their new freestanding clinic.  

In addition, Scalpel says he will essentially decrease costs at his freestanding ER by not having an ultrasound tech (docs can diagnose everything with a bedside ultrasound, right?*) and make the RNs run all the labs.  Unless all you do is iStats (which, at least at my ER aren't always accurate), that's a recipe for disaster.   Hi, I'm a pretty bitchin' ER nurse, but I have no f'in clue how to run a lab machine, calibrate everything, etc.  nor do I especially want to be doing that in lieu of monitoring/treating my patients while they, like, die on me.  Hire a lab tech, dood.  

So, my lovely, charming, and dashingly handsome readers, voice your opinions.  Is a freestanding ER nothing more than an expensive walk-in urgent care taking advantage of the variability of what an ER is or is not and billing loopholes or a "real" ER just like any other?

* = Laughs hysterically

Overheard in pseudoseizure patient's room

Patient's sister (using her 'outside voice'): YOU STOP THAT FUCKING SHIT RIGHT NOW!  YOU'RE EMBARRASSING YOURSELF!

Ah, she has her fingers right on the pulse of the sentiments of the ER staff.

Good blog alert

Maybe it's because I have a special place in my heart for neurology, but I like this dood.  I think a completely non-indicated functional MRI done in some ER somewhere (after a video swallow study) would find out that both my and Dr. Grumpy's brains are built quite similar in that we both are excited to share tales of assholes, idiots, crayzees, and what-the-fuckery with the world.   

Check him out and revel in the crayzee. One downside to his site is moderated comments which are 15.5/10 annoying, but maybe the fact that I mentioned that moderated comments are annoying will make him change them to non-moderated.  Ahem.

Huge WTF

A couple of imaging studies ordered recently c/o Dr. Controlfreak:

1) C-spine MRI on a patient with atraumatic pain in trapezius muscles as well as numbness in fingers for one day after doing heavy lifting.  No weakness.  A bulging disk was found.  Then the patient was discharged home.  

2) Video swallow study on a patient with some weird neurologic thing talking on his cell phone.  There's a first time for everything.  

You know you over-order if you've EVER ordered a video swallow study in the ER to be done in the ER.  I didn't even know ER docs knew what a video swallow even was.

Actual conversation w/personality disorder patient

"My hand hurts and is swollen, I think my dressing is too tight."

Kay, I'll take it off then.

"No, you can't do that.  It's supposed to stay on."

Nah, it's cool, the doc said I could take it off.  

"Well you need to, my fingers are numb."

Kay, lemme see your hand.

"What are you doing?"

I'm going to take the dressing off.

"No you're not, the doctor didn't say you could."

Yes he did.

"Well, okay, you can take it off then."

All right, this is getting silly, let me take the dressing off to see if that helps your numbness.

"Well, my doctor said to leave the dressing on for a week, so I want it to stay on.  I think you really need to take it off though.  Why are you arguing with me?  I want another nurse."

Friday night girl-on-girl asswhoopin' news

Medics roll in with a disshelved female wearing her full-on nightclub gear, screaming, carrying on, eyeliner and mascara all over her cheeks.  She had little indentations on her arms and forehead, each about the size of a pencil eraser, a strange pattern of injuries that were a bit perplexing as to how they were obtained.

"What happened here?" asked the charge nurse as she rolled into a room.

"Oh, a status-post bitch-stompin'.  Another girl stomped on her with the spiky end of her high heel then beat her upside her head with the same."  

I like that.  Status-post bitch-stompin'.  High comedy right there, and from a fire medic, no less.

Universal health care: Part quatre

"My friend's grandma had debilitating trigeminal neuralgia, called "the suicide disease" because of the level of pain it creates.  At age 80, she was put on a wait list in Norway to see a neurosurgeon to sever the trigeminal nerve to make the pain stop.  Five years later, she was able to see the neurosurgeon who told her that he didn't perform any operations on people age 85 or older.  Going to see a neurosurgeon there is like meeting the President.  She got dressed up and everything.  She's 90 now and still suffers with the pain.  There are so few neurosurgeons that almost all their time is taken up on trauma and brain tumors, so those who need elective procedures wait years."   

Universal health care: Part Trois

"My colleague Dr. _____ was on vacation in Russia in the mid-90s and, unfortunately, got into an auto accident while in a cab in Moscow.  He had some neck pain, so he went to the hospital.  They did some C-spine films which were read as normal.  He looked at his own C-spine films and saw a C2 and C3 fracture.  The doctor told him 'Oh, you better get home then.  We can't do anything for you here.'  The doctor in Moscow wrapped a bath towel around his neck to 'immobilize his c-spine' since the ER didn't have any c-collars and didn't know of anywhere else to get one.  He called ahead to ____ Hospital saying he had a c-spine fracture and would need a halo.  He got on a plane with traumatic C-spine fractures and flew home to the US where he was put in a halo."

Universal health care: Part Deux

Another co-worker who has many relatives in Poland:

"During communism in the late 80s, my Dad was admitted to the hospital with pneumonia.  They treated him with IV fluids only the first two days because there were no antibiotics at the hospital: No IV, oral, nothing. He had to wait until they received a shipment.  He lived, but, by the time the antibiotics got there, he was much worse.  It was frustrating because there was nothing you could do about it.  You just wait and hope that the hospital gets chosen to receive antibiotics.  Yes, everyone got "health care", but that didn't mean you got the health care that you needed.  People here don't know how good they have it."

Universal health care

A story about a co-worker's relatives in Denmark:

"My wife's brother-in-law went into the ER with chest pain with almost all activity.  "I can't even go 10 feet without chest pain nor getting short of breath."    The relative, a dood in his early 50s, was admitted to the hospital where he had a markedly positive stress test." 

He was put on the two-month wait list for an angiogram and sent home.  

He calls over to America for advice on what to do as he was essentially a cardiac cripple, unable to go more than a few feet without having to rest.   Should I wait the two months, or spend a fuckton of money to get one on the private market sooner?

"What the fuck," so says my co-worker, "You need that angio NOW or you'll die."

So he took out a huge loan, got an angiogram on the private market which showed that he needed bypass emergently, which he received.  

---

Some people who can't afford to go to the private market die waiting.  And that's the price you pay for "universal health care".  

The EMS Secret Society of Epigastric Pain

There are a lot of superstitions out there...if you say the name of a frequent flyer, they will sign in (and you'll have to take them because you uttered the name).  If you use the "Q word",* a bus of AIDS-suffering hemophiliacs will crash a block away from your hospital and every other hospital in the county will be on divert.  The full moon makes all the crayzees come out of their subsidized apartments and rush right down with paresthesias and toenail fungus.  

However, and maybe this is because I'm a nurse, I've not yet figured out why EMS fears using the words "epigastric pain" or "abdominal pain" or "right upper quadrant pain" on a patient report.  This is always euphemistically called "chest pain" even if the pain is clearly localized to a part of the upper abdomen.  It's almost like an EMS equivalent of the "Q word".  Do not say "epigastric pain" to anyone under any circumstances or you will be hazed, newbie.

For instance, you'll get a call for a 45-year-old female with 'chest pain'.  They roll in and everyone swarms them with monitors, EKGs, IVs while the medic describes their chest pain and treatments given.  Within four seconds of their arrival, I am like:

Yo, I'm K, where does it hurt?

Oh, right here. [Pointing clearly to the upper abdomen.]

Okay, I'm going to listen to your abdomen.

Kay, now I'm going to push on it, tell me if it's tender anywhere.

No, No, YEOOOOOOOOOOOOOOOOOOOCH, No

Does it hurt in your chest?

No.  It never hurt in my chest, just here in my abdomen.  I've been telling them that.

So, like, before the patient is even in a gown, I've figured out that this is a right upper quadrant abdominal pain patient and the pain is not in the chest at all just by doing 4-6 seconds of questions and assessments.  Wow, food intolerance, nausea, vomiting.  No risk factors for heart disease. They've, however, received aspirin, a line, three nitros en route along with 2 of morphine.  Again, I think, the Secret Society of Epigastric Pain has reared it's ugly head, protecting the cause of never uttering the words "epigastric pain" to anyone.   Are the acute coronary syndrome protocol orders a part of The Society's way of protecting The Secret--that the patient really has upper abdominal pain?  Is the American Heart Association in on it too?  

Now, you're probably wondering, does this society also protect the use of the words "abdominal pain" in general?  The answer is no.  If the patient has mid-abdominal pain, they have mid-abdominal pain on report.  If the pain is right lower quadrant, they have right lower quadrant pain.  There is no EMS Secret Society of Abdominal Pain as far as I know.

Additionally, by now, there are like 1653** unique visitors per day screaming "but sometimes epigastric pain is an anginal equivalent!!!"  I realize this, but, still, a nurse or doctor will verbally identify this as epigastric pain but treat it as an anginal equivalent in practice if such a thing is suspected.  There is no ban on utterance of the "E" word for nurses and doctors.  

So, give it up, people.  What sort of signals should I look for when a medic crew rolls in with a "chest paineur" to know that it is, in fact, an upper abdominal paineur and can go to the non-critical side?   Is there a special clicking sound medics make with their boots?  Do they remove one of the patient's socks?  Is there something with rolling up their right sleeve but not the left?  Do medics mention wanting to go out for "coffee and donuts" after they drop the patient off? I demand to know.  Feel free to email if you're uncomfortable discussing this in public for fear of retribution.  

Or...are there no signals?  Are we expected to discern said abdominal pain from a basic exam despite getting a report designed to throw us off the trail?

* This is so important as to not even utter it on a blog

**=My average is 1654, but I assume one of those is Happy who doesn't believe in possible anginal equivalents being worked up

Crayzee Happy quote

I know you're probably sick of my Happy quotes (10/10, feel free to skip this one), but this quote is the blogging equivalent of a 20-car freeway pileup.  Can't. Look. Away.  

He's commenting on a case where parents are fighting doctors' recommendation for chemo and radiation for Hodgkin's Lymphoma in their 13-year-old child, a treatment which is 90-95% curative for the disease, based on their desire to try herbs and some other ineffective shit instead.  The county attorney has gotten involved and is looking to order the child to receive the chemo and radiation without the parents' blessing, which is an excellent use of taxpayer money to protect the welfare of a child.

Anyway, on an otherwise-interesting issue, Happy comes rolling out with another WTF quote:

Perhaps the belief that the Hodgkin's lymphoma represents a life-threatening endangerment makes the county attorney feel obliged to get involved in this case.  However,  if you're going to force a family to give chemotherapy to a child, you also must force them to stop feeding them McDonald's.  Or to force their obese children to exercise on a strict government regimen as both conditions are killing their children as well. Or to make them go to bed on time.  Or not to fight in front of them. 

Yes, because letting your children stay up late to watch Robots is the same as allowing them to be a martyr for your weird religion, and feeding a kid a cheeseburger is also right up there with assured death too.  What in the unholy reaches of Hell are you talking about, doctor?

With this degree of obsession regarding food and obesity, 2:1 odds that Happy's future child has an eating disorder or huge self-image issues by age 13 regardless of how thin, athletic or handsome/beautiful he or she is.  Is it important to encourage healthy eating and exercise in children?  Um, duhr, of course, but it's not healthy to compare eating McDonald's to something like a parent denying a life-saving treatment for Hodgkin's Lymphoma.  That's just f'ing bizarre.  

Karen Carpenter is rolling over in her grave.  Food is not the enemy, Happy.  Hopefully, you chill out before you make your future kid feel so guilty over McDonald's that she makes herself puke it all up.

Impressive Fast Track PA

In the ER Fast Track, for the unindoctrinated, we see patients who have minor complaints or simple, straightforward complaints for the most part.  We've hired a new PA with whom I've been particularly impressed.  

There are a lot of loser drug-seekers, but then there are the worried well: People that think a little back pain means they need to be rushed off to surgery or something like that.  For the worried well, she is about the best that I've seen.

For instance, a 14-year-old boy and his worried well-to-do mother came in for back pain.  Kid lifted something heavy earlier in the day and had intermittent tingling down one of his legs lasting a few seconds with certain movments.  The PA did a thorough neuro exam, reflexes, bowel/bladder changes, etc, and explained cauda equina syndrome to the mother and patient.  She then, out loud, reiterated how he had no symptoms of cauda equina syndrome nor trauma which are the only reasons why someone with back pain would need imaging in the emergency department.  She discussed how rare it was for something like this to need things like surgery and the importance of time, following up with a doctor, rest, and a lifting restriction.  She then explained ice and ibuprofen. 

Everyone was relieved that he was not in any immediate danger, and they were happy with their referral to a primary care doctor as well as the recommendations for ice, rest, and the anti-inflammatory properties of ibuprofen.  

All this in about five minutes.  With each complaint, a very similarly-thorough history, exam, and a discussion of rationale for testing or lack thereof was had with the patient. 

We'll work on narcotics for chronic "migraines" which she pulled a couple of times (in her defense, one of the patients was already on narcotics for "migraines"), but, for now, I'm into her skills.  

Chronic pain and gray hair

Me: This patient has been here eight times since the beginning of the year for chronic pain.  Do you REALLY think he needs an IV with dilaudid and another belly CT?  This falls under the chronic pain policy where he shouldn't be getting narcotics.  He's not even in any distress.  He's had three negative abdominal CTs and a couple negative back CTs as well just since January 1st. 

Doctor: This doesn't fall under that policy.  It's greater than three visits for pain complaints in a twelve-month period or any pain lasting longer than three months.  

Me: What do you mean?  I just said he's been here eight times this year for chronic pain.  There's even drug-seeking behavior documented on the chart as a diagnosis.  

Doctor: Just do it, K.  I'm the doctor.

---

In other news, I found my first gray hair the other day sometime after I slipped a #22 IV in this guy's shoulder.  FML.

All together now: "It's not your license, K, so why do you care if he gets cancer or gets high on narcotics?" 

Natural beauty

Elderly female patient: You're a beautiful girl and have a lot of natural beauty...you don't wear a lot of makeup, do you?

Me: Nope, not at work anyway, just a little foundation....do you want to be seen for your blindness today as well as your belly pain?

Obviously, that got a good laugh, then I proceeded to load in all the medications followed by the medical history.

Me: So....hypertension, high cholesterol....anything else?

Patient: Well, after you mentioned it, I have recently been diagnosed with macular degeneration.

Me: Um, so you are going blind, huh?  I feel like a jerk right now.

Patient: Hahaha, no honey, that was a good joke, and it's not that bad...

What's the point of even showing up?

Me: So...why didn't you take the penicillin you were prescribed for your strep throat?

Patient: I didn't have any money.

Me: Well, that's a $4 prescription at Wal-Mart or Target.  Do you have $4?

Patient: Well my boyfriend loaned me five bucks, but I used it for cigarettes instead.

Me: And so is he going to loan you some more for your penicillin?

Patient: Well I don't want to ask him for money for pills because I need to ask him for money for gas for the car.

Okay then, the doctor will be right in to see you.

Mothers' Day PoopTweetz

Random Twitter thread going on right now:

ernursekMy best friend informs me she gave her mom a new toilet for Mothers' Day and the old one is "sitting out on the driveway".

18 minutes ago from web

Christina1973@ernursek LOL....she must be flushed from the excitement of such a gift!

16 minutes ago from TweetDeck in reply to ernursek

ernursek@Christina1973 She was overflowing with joy!

15 minutes ago from web in reply to Christina1973

Christina1973@ernursek Well, I hope the good feelings swirl around her all weekend long. :)

11 minutes ago from TweetDeck in reply to ernursek

ernursek@Christina1973 Since it's not quite Mothers' Day yet, the good feelings are sure to be only semi-formed.

8 minutes ago from web in reply to Christina1973

Christina1973@ernursek Do you feel like a stool-pigeon telling us about this on Twitter? Perhaps a gift like this isn't all it's cracked up to be!

5 minutes ago from TweetDeck in reply to ernursek

ernursek@Christina1973 They're going to have a bonfire later on too--I hope they drop enough logs in the pit.

less than 5 seconds ago from web in reply to Christina1973 

Miscarriage

We have a frequent flyer who is in her 20s, has had numerous kids taken away by the state (none living with her), lives on the street or with some random guy, and likes to get pregnant and miscarry.  

Since I've started my ER career, she's been in to the ER with four rounds of real or feigned miscarriage symptoms.  Each "miscarriage" she milks for numerous ER visits, complaining of severe pain, getting narcotic prescriptions and ultrasounds each time.

One time, a doctor decided that it was inappropriate to give her more narcotics for her "cramping".  She started screaming at staff, carrying on in the hallway, and demanding "another shot".  My boss took her into the conference room and asked her "what we could do to make her happy."  

She then told the doctor that the patient just wanted one more shot of dilaudid for her severe pain, and that she felt as if her severe pain was not addressed.  She did the whole scripted "I'm in severe pain no one here wants to help me!" song and dance.  Numerous staff members told my boss that she was a seeker, there all the time, and it didn't matter.  She "advocated" for the patient's narcotic addiction until the doctor finally just said "fuck it" and gave her more narcs.  

We encouraged abusive and threatening behavior to staff in order to fuel a drug addiction, but at least we made her happy, right?

I'll let you guess the "insurance".  

Scary quote from Shadowfax

"Never waste a good crisis, they say.  Universal health insurance was a good idea two years ago.  It's becoming a better idea every single day." --Shadowfax

---

Communism and fascism sounded good to a bunch of down-and-out workers at the time, too.  What he's really saying is that it is a good idea to use the tough economic times to take away more of our freedom because when people are doing well they would not otherwise choose to do so.  Use peoples' emotions and fears to take more control of peoples' lives, up to and including their personal health....before it's too late.

Meanwhile, if you haven't heard, stocks are on the rebound, the biggest 2-month gain in the last 35 years.   Ultra-liberals like Shadowfax are probably going to call the economy a "crisis" no matter what until it gets them their socialist utupia.   Don't listen to those who think every little economic downturn is a reason to give up more of your freedom to the government to "help" others.   

The reason employers provide health insurance now is because it's a huge incentive to stay at the company.  If it were no big deal to just go on the public doles, employers will cease to provide coverage, and public programs will increase until we are just like England and health care is fundamentally different and far more ineffective than it is today.  

If we're really lucky, we can have the government do little "studies" (which they want to do now) and then tell doctors what is the most effective way to treat a problem and withhold payment for treating the patient the way they see fit.  Of course, from the people who brought you "give antibiotics within six hours of arrival to the ER for pneumonia or else your hospital sucksass and we're going to not credential you", we will be forced to give treatments that have never been proven to make a lick of difference, over-treat, or under-treat (if treating appropriately is too expensive, etc).   If you want to lose your freedom to practice medicine as well as benefit from it, vote for "reform", Shadowfax.  You think it's bad now, it gets worse as government gets more involved with the payment.  The power will go from the free market, capitalism, and voting with your feet to bureaucrats more and more until we just give up and scrap the whole private system all together.  

For a little touch of what our "leaders" are really planning, check this brief video clip out.  

If we adopt a more far-reaching government "option", I give freedom in health care a good ten years before it is defunct and we are stacking ambulances outside to keep our numbers looking good instead of the free market building more hospitals to accomodate the demand for services.  Cheerio!

Layzee central

Another Nurse: Hey K, you need some help in here?  

The alarm was beeping with a BP of 66/28.  The patient was febrile, in DKA, tachycardic, vomiting, and obtunded with a fast respiratory rate.  My resuscitation plan was to bomb the patient with approximately a pallet of IVFs going into like 12-15 #18 G IVs while also pushing antiemetics then starting an insulin drip at like, oh 200 units/hour.  Or something.

Sadly, with such a lofty plan, there was little chance of getting it all done with my current #20 gauge medic IV and like zero peripheral veins, so, yes, I would like a little help, thanks for asking. 

Me: Yeah, I would!  I grabbed all the stuff, it's all right there on the tray--can you just access the patient's chest port for me please?  

Another Nurse: No, I'll let you do that.  I accessed a port yesterday.

Then she left and talked to the third nurse and the secretary at the desk for the next 30 minutes.  Thanks for your help.  How utterly BOLD of you.   I guess I was absent from nursing school the day they said that you can't do the same thing two days in a row. 

If you don't really want to help me, then just park your ass at the desk and do nothing.  Don't even bother to piss me off by asking if you can.

You know you have a drinking problem when...

...you write the following on the triage slip:

Twisted ankle

Needs Plan B pill

Vomiting

Headache

Hurts to pee

Yes, but did you have fun?  Sounds like a solid evening to me.  

I should have framed that slip.  I regret not having done so already.

EMS vocabulary issue

Me: Hey, you guys have the hyperkalemia patient?

EMS: No, we have a patient with a potassium of 6.7.

Me: *Sigh*

In his own little world

"I don't even really think he knows what he says to people is offensive or is even trying at all to piss people off...He is just...in his own little world in there."  -- Dr. WTF concerning an ex-colleague asked to resign for being an ass

Yes, he accurately described the terminated doctor, but he also accurately described my arch-nemesis, Happy, who has another choice quote I'd like to share with you.  This is just too good to pass up.  

In his bizarre attempt to try to profoundly point out the huge shocker that doctors live like hobos while in residency and don't instantly, if ever, become millionaires when finished, he did his usual "let's compare apples to oranges and be amazed that they are both totally different fruits"-style comparison.  If you're unfamiliar, in general, he's about as effective at explaining his thoughts as Helen Keller wearing a muzzle, but he really went crayzee on the following comparison of retirement incomes between the unrelated careers of cop and doctor found in his comments section [bad grammar corrected because it's less irritating that way]:

So the cops collecting $80,000 per year forever in pension money go back to work as consultants or [do] other off-duty type work and double/triple-dip the system. [They] often pull in more than the physicians that take care of them when they get shot.  

Take a minute to compose yourselves.  Read that quote again.  Yes, you read it right.

Yes, folks, he thinks that it's terrible that a policeman getting a pension after 30 years or more of putting himself directly in harm's way to keep your ass from getting randomly mugged on the street at gunpoint should be able to enter to the private consulting market and possibly, if he is a successful entrepreneur, make more than the doctor taking care of him.....................................wait for it..................................when they get shot.

Dood.  It takes a lot of balls to whine about your income and compare it to the 1 in 50,000 policemen who successfully uses his experience as a cop in the private consulting market and refer to that as "double/triple-dipping the system".  What, "dumb", brutish policemen shouldn't be successful in a capitalist society because they didn't go to med school like you, o holy Speaker for Internal Medicine and Great Arbiter of Distribution of Wealth Among the Huddle Masses Yearning to Breathe Free?  

Can't you just picture him looking at a wounded police officer, maybe paralyzed from the waist down from a random gang shooting while he thinks, "This permanently paralyzed cop is going to get his $80,000 pension early, and I'm only making $200,000 per year and will have to work 'til I'm 65 when I went to school way longer than he did AND drove a crappy car during residency!  This guy may even be able to suck some money out of people doing a motivational speaking tour and make about what I do.  Sure, he's incontinent of bowel and bladder and has a nine-year life expectancy before he succumbs to urosepsis, but that doesn't mean he should make more than I even in a capitalist society."  I mean, most people are a little more kind and appreciative to people like this.

Lemme ask you this, Darling Happy: How much would someone have to pay YOU to go fight gangs or raid drug houses or be an initiation target for thirty years, day in and day out? Seeing children abused and dead in their cribs, people all strung out on drugs lying all over the place, people drunk and disorderly, gang members firing off random shots at you, arresting the same wife-beaters time and time again...

Would the promise of an $80,000/year pension after 30 years of this be good enough for you?

Oh, wait, that's another irrelevant thing to ask because you, sir, don't meet the minimum qualification to be a cop: That being, of course, having balls outside of the Internet.  

Career-ending injury

The non-healing wounds of the pornographically fake young lady were strangely distributed almost like she'd been riding a horse without pants on or something.  

No, I haven't been horseback riding.

Someone's cellulitic heroin addiction must've carelessly rubbed off onto the offending fomite, ending my patient's lucrative career as a sex object that you have to pay to not touch.   You see, the weeping, MRSA (+) inner-thigh chafey-looking pus-draining areas of joy with an extending cellulitis were acquired from the stripper pole at the "nice" strip club downtown where she worked. 

If you are in a similar situation, I advise against trying to slather on a ton of cover-up over them too.  It's just not going to work.  Lap dances?  Um, let's not even go there.

Oh, and one more thing: Ew.

The many faces of a virus

I had case after case after case after case last night of patients coming in with the most benign-sounding cold symptoms known to mankind.  Here are six patients diagnosed with "virus". Welcome to the new trend of everyone with a basic "rest in bed, tylenol/ibuprofen for pain" virus coming in to the ER:

1) I'm stuffed up, my head hurts, I'm dizzy sometimes, my throat is a little sore, I have a dry cough, scratchy throat, and my entire belly hurts.

2) I woke up with a scratchy throat and a dry cough.  My left ear hurt last week, but my right ear hurt yesterday.  It doesn't hurt now though.

3) My throat hurt a little, but I'm really here because I felt a little dizzy when I stood up and I had to lay back down.  Yeah, I'm feeling okay now, but my throat has been hurting for a day!

4) I'm dizzy, my stomach hurts, I'm not eating very much because I don't have an appetite, my back hurts, I'm tired (it was like 3 am when she got there), and vomited once when I coughed.

5) My chest hurts when I take a deep breath and cough, and I think my throat and sinuses are acting up.  I sound pretty stuffed up and can't breathe through my nose!

6) I have a scratchy throat and I want an antibiotic so it doesn't turn into pneumonia.  

All these patients I personally saw in a single non-Fast-Track overnight shift.  Just the physicians' fee alone to tell you that, yes, it's 4 am and you need to go back home and lie down and go to sleep for your cold is $350.  

Poll answer

Congratulations to the 51 pessimists who correctly guessed Dr. Bloody Gloves' choice of "enlarged cervix" to explain classic pyelonephritis symptoms and lab findings. 

This is one case where, obviously, I begged him to tell me why the patient DIDN'T have pyelo and he just kept talking about the enlarged cervix that he saw on a completely unnecessary pelvic exam.  He treated said enlarged cervix, fever, and UTI with morphine and, oddly, the pain kept coming back.  Second place goes to the 83 pessimists who guessed "muscle strain" because that was his original diagnosis (ie he was treating her like a typical back paineur) before he offiically admitted the patient with pain control and enlarged cervix.

In retrospect, I should have probably paged his boss to come down from his office to kick him off the case since it was day shift, but, I waited for him to admit the patient and just paged the admitteur immediately who came down and made the correct diagnosis in 0.00000001 seconds.

It was a sad day that the other ER doc wouldn't talk to him and make the correct diagnosis as well.  Yes, it's his patient, but just please order an antibiotic for the pyelonephritis.  No?  

So, no harm befell the patient, but that was the first day that I knew I had to watch my ass and my patients' around Dr. Bloody Gloves.  Prior to this, I had been walking around blissfully ignorant of the fact that there are people out there who shouldn't be practicing medicine right in my midst.

The Crass-Pollination Donation Drive and Advertising Bleg

STICKY POST FOR A WEEK! NEW CONTENT BELOW!

Hey, didja know that you're reading the most popular nursing weblog (that I know of) based on traffic in the entire United States of America....for free?  Did you know that you don't have to be reading it for free?  

I'm a single mom with little disposible income who loves to write about the strange thing that is THE ER.  If this little blog has done anything to brighten your day or if you, as my brother says, find me amusing, consider donating to me, Nurse K.  Any amount that you think would compensate me for the laughter and entertainment I provide for you is acceptable.  Please click the Paypal button below to send money to crasspollination@yahoo.com.  As always, your name will be kept to myself.  

Also, the contract for my scrubs ads on my sidebar expires 4/30/2009.  I'm getting about 51,110 pageload and 39,500 unique visitors per month.  If you are at-all interested in advertising on the most popular nursing weblog in the US, please email me.  I will have only 2-3 ads at a time at the most, so, as always, highest bidders win.  

Normal human physiology EMS abuse

A non-retarded middle-aged patient was watching TV when one of his children made an unannounced visit to his house, knocking on the patient's front door, causing him to be "startled really bad because I wasn't expecting anyone to come to the house".  His heart "sped up". Upon arrival he was back to normal (by his subjective standards thereof). 

You think there's more to the story, but, nope, that's it.  He called 9-1-1 for the flight or fight response status-post being startled by an unannounced visitor.   I had to explain to him that his body does that just in case the unannounced/unexpected thing at the door is a bad guy, a burglar, or a monster or something.  He was relieved that it was normal to have a "racing heart" for a little while after being startled.