Heh

A FDA panel recommends Vicodin and Perccoet (narcotics that are combined with acetaminophen) be pulled from the market due to "unintentional" acetaminophen overdoses associated with these drugs, if you can call grinding up the stuff and snorting it status-post faking a backache unintentional.

Weird fights at work: Facebook

Well, it wasn't really a FIGHT, but a heated discussion. This one chick was all up in a bunch of peoples' grills all buggy-eyed and meth-like because we had a couple of the doctors on our Facebook friend list.

She's all, "Friending doctors? Dood, K, that seems like it violates a boundary issue or some shit."

I'm all, "Nah, dood, we work with these doods and chicks. Since when can't I look at a doctor's cute kid photos or whateverthefuck? Nurses 'n docs togethah on Facebook as a united front against being separate or some gayass crap like that."

She's all, "I dunno, if I friend a doctor, that's just weird."

I'm all, "Fuckin' A. You can totally get some good shit off there to tease them about too. I saw FavDoc young and in bell bottoms the other day. Did YOU get to see FavDoc nearly passed out drunk in bells? No, cuz you ain't got him as a Facebook friend. They can give me shit right back and we have a queer ol time here at work in between crayzees."

Seriously, we argued about this off and on for like hours. She came to the conclusion that it's only bad if a doctor friended a nurse, but okay if a nurse friended a doctor.

So, what do you think? Friending the docs you work with on Facebook? Good? Bad? Depends? Like I say, in ER, it's just DIFFERENT between nurses and docs. We go to the same work parties, baby showers, weddings, court cases, and whatever. Why not, eh?

Yeah, it was those other ER blogs that sound just like me :-)

Dear Nurse K,

Thank you for contacting Lionsgate with regard to our television show “Nurse Jackie”. We appreciate your interest in the show.

We have reviewed your e-mail with the producers of the show and we have been assured that no plots, characters or other material were based upon your nursing blog.

While currently the production is fully staffed, we will keep your information in our files. Thank you for your interest in our show.

Liat Cohen

Liat Cohen, Esquire

Vice-President Business & Legal Affairs

LIONSGATE

2700 Colorado Avenue, Ste. 200

Santa Monica, CA 90404

Direct Line: (310) 255-4986

Facsimile: (310) 564-0360

Cookies

Me: What did you want to be seen for today?

Patient: Well I got this chronic cough and it's getting worse. It may be like bronchitis now or something.

Me: Heh. Bronchitis. You a smoker?

Patient: Yeah.

Me: What's different about your 'chronic cough' that made you want to come in today?

Patient: Well I got all these lung cookies that I keep coughing up!

Me: Uh, lung cookies?

Patient: Yeah, like big, chunky chocolate lung cookies!

Me: You don't normally...bake....lung cookies in your lungs?

Patient: Well, kinda, but the cookies are much worse. Chunkier.

Me: Great, have a seat.

No one addressed it

Apparently, despite it being standard around here and other areas of the country, Happy's hospital doesn't feel the need to put ambu bags in each patient room. At my prodding, he looked for ambu bags in his patient rooms during rounds today and didn't find one outside of the ICU. There is, however, a single ambu bag in a supply closet on each floor that probably no one knows how to locate. I suggested that he use his power as a staff doctor to try to contact the person in charge of patient care (ie nurse managers' boss) and suggest that ambu bags be stocked in all patient rooms since ABCs are the most basic of life-saving hospital care. An ambu bag costs $26 and can be charged to the patient if it is used.

Happy, however, chose to say the following about the lack of ambu bags in his hospital:

Stocking an Ambu bag in every room ain't gonna happen. It ain't gonna happen in just about every hospital in this country, except the really rich ones. It is not reasonable, nor rational to have a fully stocked ICU in every patient room of a hospital, in spite of what some wish to believe. I might also add that Happy's Hospital is a level one trauma center, cardiac center, cancer center, neurosurgical center, whatever center. You can get everything at Happy's hospital. I do not work at a rinky dink hospital in the middle of no where with one ventilator and a part time physician that only works M-F from 8am to noon. We have it all, and we don't stock Ambu bags. That is a reality. Because it is the right reality.

It's hard to bag someone without a bag. I'm ready to accept y'all apologies at any time. Those angry at me for not bagging the patient, have been lead astray by forces not familiar with inpatient medicine. If you want the truth on inpatient medicine, stick with me. If you want outsiders opinions on inpatient medicine, go somewhere else

.

One thing everyone everywhere should know about American health care is that oftentimes something that would seem to be "no duhr" isn't done because, simply, no one has addressed it or hasn't addressed it with the right people. If you as a nurse, aide, EMT, doctor, or whatever think something is totally f'd up in your place of employment, chances are it's f'd because no one bothered to ask to have it the correct or more appropriate way. Many people are like Happy. They may identify a problem (no ambu bags), a possible solution (ambu bags in each room), but stop short of doing anything to affect change because they either don't care (layzee), don't think anyone will listen (power gradient), or assume other people must've tried to get that thing implemented and were shot down for whatever reason, including cost (ie. they're scared of being shot down or don't have correct information). Hey, even if someone tried to get ambu bags in 2005 and were shot down, it's an important enough thing to re-address, doncha think?

Another problem I identify here is someone ignoring another's opinion or suggestion. I'm "not an inpatient doctor" (or nurse [anymore], I guess); therefore, my opinion (and the opinion of the entire blogosphere, apparently) doesn't matter. Don't listen to her, listen to me. She's just an ER nurse. What does she know?

Guess what? We're all dining on the patio together taking a bite of the shit sandwich known as the health care system and no one's reasonably-informed opinion is moot. If the aide tried to bag the apneic patient and coudn't locate the bag in a timely manner, if at all, and she says 'I wish we had bags in the room because I got nervous during the code and couldn't remember where it was' and people disregard her suggestion simply because she's an aide, this is a missed opportunity for improvement. It would be hard to argue that units with any type of medical patient would be worse off if critical supplies to perform basic life support were in reach since early intervention in these types of situations has been proven over and over to result in better patient outcomes.

Incidentally, other than desire to bring up straw men, I'm not sure why he thinks that an ambu bag is a "fully stocked ICU". Hopefully, his ICU has a bit more than an ambu bag at its disposal.

So, if you're the type that just goes into work, does her 12 hours, and goes home, this post isn't for you. If you're the one who says 'gee, it's really annoying that the code cart is all the way down the hall! I wonder if there is a better place for it?' or 'I wish we had diltiazem stocked in the Pyxis' or 'we have all these morbidly obese patients and no extra-large diapers', maybe it's time to take initiative and try to change some of this stuff. Remember, chances are other people are annoyed by the same thing as you, and it simply hasn't been addressed.

How to resuscitate a patient Happy-style

In a word: Don't.

Let me give you a story. I was doing my normal daily rounds on a patient when I walked in and just stopped. I stopped and I listened. I looked for signs of life in my 67 year old man who was admitted with abdominal pain. I stood there. Watching. Calmly observing.

It struck me as odd. For a full thirty seconds I saw my patient breath exactly one time. I turned on the lights and noted a remarkable physical finding (another reason to always turn on the lights). Cyanosis. A physical finding in which the skin turns purple due to an increase in deoxyhemoglobin in the capillaries (I will never forget the cause of cyanosis due to my exposure to one of the greatest pimping attendings of all times).

So I calmly walked out of the room, walked to the nurses station and stated calmly:

"One of my patients is about to code. What would you like me to do?"

This is probably the quickest way to get a nurse to jump out of their chair and come bedside to your assistance. I think in retrospect I lost the golden opportunity of a lifetime to pull the code chord and watch every nurse on that floor flock to my room with me standing there saying

"What would you ladies and gentleman like to do about my dying patient?"

No, Asshole, you lost a opportunity to do your job.

While this situation strikes you as "odd", it strikes me as an emergency. If someone is breathing two respirations per minute, it's everyone's job to bag the patient, including yours. You see, bagging the patient will likely prevent him from going into cardiac arrest Michael Jackson-style, but sauntering up to the nurses' station calmly in your pretty white coat as you check yourself out in the patient's mirror on the way out will not. Any nurse will run if you start hollering 'get in here now!' from the patient's room. Smugly trying to be all "in yo face" to the nursing staff isn't exactly the top priority.

It was nurse administered, not patient controlled analgesia [he repeats this frequently in the post -- ed.].

Great, as if it matters that it was nurse-administered. I don't care if King Fucking Kong gave the drug after bursting through the side of the hospital with Fay Wray in his grip. Your job, if you see one of your patients breathing at a whopping two respirs per minute, is to grabby da ambu bag and baggy da patient. If someone offers to take over, great, but you, yes you, even though you work out and had an internal medicine residency and grow your own tomatoes, still have to start. He's cyanotic for shitsakes. Good God almighty. That's a person.

Update: Happy responds in the comments. Be sure to check it out. It's...interesting.

Weird work-up of the day

An otherwise healthy, athletic non-smoking middle-ageur presents with subjective complaints of shortness of breath (although the patient is in no visible distress) with the following vitals: BP 138/86, RR 20, HR 62, Temp 97.6, sats 99% on room air. No cough, no dyspnea on exertion, no orthopnea, no fever, no recent travel, no chest pain (nor pain anywhere), no sweating by itself (ie gallbladder disease LOL), no GI bleeding, etc. Reports feeling more stressed out lately with inability to sleep.

Work-up was as follows (all ordered at the same time):

1) Cardiac ensymes

2) CBC, chemistry panel

3) D-dimer

4) Chest CT to rule out PE

5) EKG

6) Chest XR

7) Cardiac monitor, Q15 minute vital sign checks

I'm all, woah, time out, what the holy fuck.

The doctor says he has to work the patient up for a PE due to his respiratory rate of 20. Since the patient was sleeping soundly, I poked my head in his room and updated his sleeping respiratory rate as 14 after watching for the full minute (usually most triage nurses count respiratory rates for those in no distress over 15 seconds so the most common numbers are 16 and 20, if they bother to do that at all). You still want to do these tests? Yes.

You'll never guess what happened in the CT scanner during that PE study.

How to make a co-worker feel appreciated

Cath lab doc on the phone: "Good catch, doctor. Hard case. 99% blockage of [whatever the vessel was]. He's on a balloon pump now..."

ER doc to cardiologist: "No, that wasn't me, that was [my full name]. I thought he was septic..."

The doc was slipping in a central line as he explained sepsis to the patient, and, after an aha! moment, I asked if I could get another EKG right away and perhaps, yah know, stop the rapid fluid infusion and maybe dobutamine would be a better choice for the hypotension --- a rather cryptic way (since we were talking right over the patient) to say 'cardiogenic shock, yo'.

I'll never forget the look on the doctor's masked face after I asked that question.

As I threw off his automaton central-line groove with my uncharacteristic-for-a-nurse detailed question, he, transiently bewildered, stopped talking and looked right at me at the head of the bed as I fussed with a high flow mask. He ever-so-slightly bugged out his eyes while he reciprocally raised his eyebrows and said:

"Yes, K, stop the fluids and get another EKG right away." He trusted me and my judgment.

BAM! Cath team was down there in no greater than three minutes.

Nurse Jackie writer spends "a lot of time on emergency room blogs"

I've mentioned here and there that, hey, this Nurse Jackie show sounds like something I'd write, like creepily so, in fact. Here is an article featuring Nurse Jackie head writer Liz Brixius:

We got this very diverse group of writers, rented a room in Hollywood. Linda and I then mapped out the big pieces of the season. We knew that [Jackie's] drug use was going to escalate, for example. We knew we had 12 episodes. So then we collected [anecdotes] from our writers and spent a day saying: “We want medical scenarios. We want your stories from being in the emergency room, things you read about online.” I spend a lot of time on emergency room blogs.

As the #1 nursing blogger in the country who also happens to be an emergency room nurse, she's likely been around Crass-Pollination. When I am thinking 'Nurse Jackie is just me with a drug problem', I'm probably right to some extent. Hi Liz! Would you like a talented writer to add to your team? EMAIL ME FOR SH*TSAKES.

What do you think? Me? I mean, even down to the conversation taking place in the XRay-viewing area.

Stupid fights with "experienced" nurses

I get into a lot of weird tiffs at work. When I started in the ER, I was the youngest nurse in the department, with the average nurse being in their mid-40s or older. There are a few select nurses in this world who are older than a fossilized dinosaur turd who would rather die than miss an opportunity to berate a young nurse for no reason. I'm sure you know a few, those for whom the phrase "nurses eat their young" refer.

Here's an actual stupid tiff I got into over IV TUBING of all things.

Me: Hey Val, I'm looking for the non-pump free-flow tubing...the clamp-only IV tubing...you seen any or are we really out?

Val: Just use the pump tubing and hang it to gravity. There's a ton of it right there.

Me: Nah, I want the other tubing; I need to run a couple bags of normal saline fast...

Val [condescendingly]: Well, the pump tubing and the other tubing run at the same rate, K.

Me: No they don't. I have a septic guy, I need the fast tubing.

Val [more condescendingly]: Look, I've been a nurse for 27 years. I think I know better than you.

Me [shocked at the low threshold for busting out the 'experience' trump card]: Look, do you know where the tubing is or not? If you don't, I'll call materials.

Val: No, I don't know where the tubing is, K. I don't understand why you're getting worked up when it's just the same as the pump tubing.

---

Of course I'm right about the other tubing being faster, but why argue about stupid IV tubing? There's no way she'll listen to me anyway.

This fight is in follow-up to the fights entitled (1)"Yes, Val, you can use a pump to push lasix" (2) "Not all generic medications in the world are $4 at Wal-Mart, they need to be on their list" and (3) "Gastroccult and Hemoccult developers are not the same thing, so don't throw away the Gastroccult".

I even offered to show her how to hook up the lasix to the pump and she flat-out said you couldn't do it. It's like she's just stirring shit up for its own sake.

No one likes nurses like this, so don't be one. Plus, no one likes it when you think you know it all and say shit that's just plain wrong along with your rude comments.

The inpatient shell game

So our hospital has the highest inpatient census that I've heard of, and, of course, we're holding inpatients in the ER for 12 hours or whatever. What's funny is that there are unseen surgical patients which need beds, there are direct admits, and there are ER patients. Of course, ER patients are last in line behind those other two patient populations.

Never fear, however, because we have the inpatient shell game!

• 65-year-old chronic alcoholic with alcohol withdrawal. Receiving IV ativan, confused, impulsive. Patient is being admitted to telemetry.

Okay, place your bets!

There are no medical nor telemetry beds, but a medical patient goes home later on. A telemetry patient is downgraded to medicine and claims the open medicine bed. Oops! A new surgical takes the telemetry bed. You lose.

Later, another telemetry patient gets transferred to the rehab unit. A patient in the ICU is downgraded to telemetry and takes the bed. You lose again.

Meanwhile, twelve hours go by. The patient's alcohol withdrawal is in better control with oral medications and the doctor switches the bed to medicine. Still no medicine beds, but one patient is discharged home. It's change of shift. Now it's evening shift and the charge nurse says they will not take the patient because they are already working short-staffed due to the high census and can't take a patient that needs closer monitoring. You lose again.

Thirteen hours. Your patient is checked for presence of alcohol in her system. Maybe if he was trying to lick the alcohol wipes or hand sanitizer while you were gone, he can be transferred to detox. Nope, still no alcohol in his system. Dang. It was worth a shot.

Fourteen hours. Time to start asking Jesus for a death. Nope. None.

Fifteen hours. Patient attends his first AA meeting.

Sixteen hours. Someone codes on telemetry. The ER doc goes up there, looks me in the eye, and crosses his fingers.

Seventeen-and-a-half hours. Patient admitted after a medical patient is upgraded to dead person's tele bed.

Now there are 12 more admits being held. Time to rinse and repeat.

My funny line-up of patients from today

Patient #1 chief complaint: Tired

Patient #2 chief complaint: Weak

Patient #3 chief complaint: Dizzy

Patient #4 chief complaint: Fall

If you'd have lined all my patients up next to each other and told them to play-act their chief complaints, it would be like a flip-book or some shit.

What would you like to OD on today, madam?

The Nurse K Award for Appropriate Withholding of a Narcotic Prescription goes to the outpatient doctor who refused to give a Percocet prescription to one of our first-name-basis frequent flyers who, as was described in the chart, "stumbled in to [the clinic] demanding to speak to the doctor about getting a Percocet prescription and subsequently fell asleep on the waiting room floor." Oddly enough, after slurring her speech and having "trouble maintaining a sitting position unassisted", he denied her request and told her neither he nor anyone in the clinic would be filling any narcotic prescription for her now or at any point in the future for any reason. [Pause for applause!]

So, later that day (after she sobered up, I guess), she came to the ER and received a Percocet prescription from Dr. Big Work-Up after they had a discussion about her narcotic preferences at the nurses' station for her negative work-up fake pain* Couldn't believe my ears. The world has degenerated to doctors politely discussing which narcotics work best for known drug addicts with no identifiable medical problem. Is my life starting to mock my blog? You may be afraid of complaint letters, but helping your patients to die swiftly and tragically is NOT good customer service.

*= Actually, in real life, I talked to him about this script and he agreed to allow me to tear it up. He wrote it though and ka-klunked the chart for discharge. No fucking way that chick is getting a narc when I'm anywhere in the department. I'll keep her from croaking whether she likes it now or not.

What the fuck

"Patient sent by EMS because patient's doctor phoned in a prescription for him to start today as an outpatient and no staff were available at the patient's group home to help him obtain the prescription. The patient was sent in to obtain the medication. Patient has no complaints."

So a $4 outpatient prescription becomes a costly ER work-up (to verify that he really needed the med and that no emergency condition existed, of course, despite having documentation that he needed it) and EMS transport because some nurse couldn't get off her ass and fill a script or whatever they do at the group home. She did, however, have time to sign a sheet sending him to the ER.

A chief complaint that will get you no sympathy from nurses

Chief complaint: "I stand on my feet all day at work, and they've been HURTING lately! I think I need pain pills or new shoes or SOMETHIN..."

Wow, dood, welcome to the club. Be prepared to wait a longgggggg time. Shoulda gone to Smyrna with this shit where they care about nonsense. Call ahead for 12 hours and you can get there in time to be seen probably faster than I'll be walking you back; yes, you'll be walking, no wheelchair.

Ethics and obesity

There has been a lot of talk recently about how obese patients make their and our lives more difficult when it comes to medical care. Whether it's the two or three full fire crews needed to transport them to the hospital, the difficulty with intubation, the inability of docs to find markers to insert a central line or nurses to place an IV, obese patients are obviously more difficult to treat than a normal-weight person with similar problems.

What I'm wondering is what ethical obligation do we have to put ourselves in danger to treat these patients? Giving CPR to a morbidly obese patient causes wrist injuries. There was one patient who caused two staff members to be out on workman's comp for these injuries with less than one minute of CPR each. If I know this and someone says "K, your turn", do I have to give this patient CPR? Do I have to injure myself too?

The patient may be parked in the lobby in a wheelchair. The amount of force needed to propel them to the ER is crayzee for someone like me, a skinny-armed thin nurse. Even going from the lobby to the ER hurts. I'm at a 45-degree angle doing something that looks like a Flintstones-car run and going slowly despite. If they're having chest pain, what do I do? Wait until I can get a lift to lift them to a motorized cart to bring them back? This might take 10 or 15 minutes to get enough people together, putting the patient outside of our door-to-EKG time, not to mention occupy my time while other patients could be getting triaged.

Sometimes a patient needs a boost. I can optimistically find seven people to help me, but I know that it is unsafe for someone who weighs 400 lbs to be lifted by seven people. Should I tell everyone to let the patient's feet hang off the side of the bed? Having a patient like this positioned improperly often compromises their respiratory status.

What if the patient pees or poops on herself and is refusing (or unable) to help turn so we can clean her up? The amount of force needed to turn a patient like this is also staggering, but it's not nice to let them lay in their own excrement as well. If she is unwilling or unable to turn herself, are we still ethically supposed to risk ourselves to clean her up? What if she has a personality disorder and deliberately defecates on herself for attention? This happens more than you think.

So, what do you think? Yeah, there is some lift equipment, but in the ER, we have crappy carts and no real great way to turn/boost anyone. Big people need CPR. Despite the knowledge that basic cares can hurt us, do we still do them?

You think I'm just being melodramatic, but I've had staff from the floors (and my co-workers as well) in my ER with herniated disks, radiculopathy, wrist injuries, shoulder injuries and the like all from dealing with obese patients. These types of injuries can end your career. People who come in with assaults and status-post asswhoopins often have lesser injuries than nursing staff who merely turn or help to boost an obese patient in bed.

No new orders

We're supposed to chart each time we alert a doctor to a critical lab or change in patient status. If you're a doctor and you see something like this...

Patient's blood pressure taken on both rt and left arms, 82/49 on rt and 84/52 on left. HR=124 in a sinus tach. Patient alert with sats of 92% on 4L via NC. RR stable at 24. Temp 101.2 two hours after tylenol. Pt states he feels "more weak". MD reminded of markedly positive UA and alerted to change in blood pressure. No new orders.

...just be aware that the nurse is pissed at your ass for not doing anything. "No new orders" is the passive-aggressive medical charting equivalent of "Patient's doctor is being a tool and needs to order [pressors, fluid bolus, central line, etc]."

Note that I am more than willing to paint a picture that accurately describes the condition that you're ignoring with redundant vital-sign charting and things of that nature. Nurses, it's very important to use "no new orders" sparingly so it doesn't lose its bite. Under no circumstances should "no new orders" be deployed in a situation where writing no new orders is the proper thing to do.

Compare the first example to something along these lines:

Lab called to inform me of critical lab of glucose > 1000 in urine. MD alerted to this expected finding per protocol. Blood glucose pending.

This is another way of saying "this is a retarded thing that we have to tell doctors. Why don't they call us when the blood glucose is 742? Sheesh." The doctor may have also not added any new orders, but, obviously, I'm not charting "no new orders" because why would I want to tell the doc to F off when I'm in agreement with his or her treatment plan?

Finally, here is the ultimate "F you" using a variant of the same example as above:

Patient's blood pressure taken on both rt and left arms. 82/49 on rt and 84/52 on left. HR=124 in a sinus tach. Patient alert with sats of 93% on 4L via NC and RR of 24. Temp 101.2 two hours after tylenol. Pt states he feels "more weak". MD reminded of markedly positive UA and alerted to change in blood pressure. MD reminded that patient has already had two liters of fluid with a decrease in blood pressure. Lungs clear. Asked for central line and vasopressors. No new orders.

When a nurse charts redundant vital signs, a "reminder" like a markedly positive UA, every intervention that she asked for, and follows that up with "no new orders", you may as well get out your boxing gloves because she's about to slug ya or, if you're lucky, write you up. We're not allowed to write "MD informed patient likely in septic shock, no new orders" because nurses can't officially diagnose septic shock (even though we can in practice), so we have to be all dancy around the issue-y, hence, the need for passive-aggressive charting to get our points across.

So, in summary, if you see "no new orders", that's a cue that a nurse thinks you're missing something and/or hates you.

Random comment WTF

Someone named Nursezilla says the following on Scalpel's blog:

 Nursezilla said...

From what I see most of these comments are from Nurse K in which case i found out that the K stands for Kabooki. The word Kabooki not only suits her as a name but also explains her state of being. If anyone needs a reminder or explanation on what Kabooki is please read my definition:
A Kabooki is a painful sore typically found in the groin during the advanced stages of Bubonic Plague, which will burst from slight pressure to discharge white or yellow pus with an extremely foul odor. Kabookis should only be lanced by medical professionals in special cases, because the vulnerable site will usually fall prey to parasitic infestation. 
Example: Nursezilla wanted to popp Nurse K kabooki with a help of a scalpel but didn't- she would have been covered in squishy yellow shit that smelled like bleu cheese.

Nurse K a.k.a. Nurse Kabooki

6/09/2009 11:50:00 AM

That is one strange comment there, my friends.  

Call holding on 6-2

We have these phones where you can answer a call, "park" it on a certain line then announce the call overhead in the ER for the nurse/doctor/aide or whatever.  

Dr. Made-Me-Cry: Hey, [secretary] Cheryl, line 6-2 is for you.  It's [your pal] Andrea [the other secretary]. 

Cheryl [picks line 6-2]: You're beginning to be a huge PAIN IN THE ASS, you know?

[Silence]

Cheryl: Oh, hi, Dr. Attending.  Sorry, I thought you were Andrea.  I'm so sorry about that!! No, madam, you're not a pain in the ass!

Funny shit.  

This week...

...was the worst week of my ER career.  The city pulled every patient on death's door out of its bowels and expelled them somewhere in my hospital.  

I may be running around, I may be stressed out, I may cry, I may punch the desk, I may unsuccessfully beg to go on divert, I may be pre-syncopal from lack of eating, but I can still identify and run the girl with limited English skills, normal vitals and the RUPTURED ECTOPIC back right away, taking all the criticism for bumping a young woman with abdominal pain ahead of everyone else in stride.  I can get that repeat EKG despite the doctor saying it was septic shock and not cardiogenic, and identify the evolving acute MI.  I can prevent patients from crumping before they do.   I can find point tenderness on a C-spine in a patient with no complaints of neck pain. I can look at a grandma in my chair and say "bowel obstruction" in my head. 

I've been doing this three years full time, and haven't really missed anything terrible yet, but it's only a matter of time until I do given what I have to work with.  

God help me.  I don't want to fuck up.  

Blog battle links

I started a flame war by accusing Scalpel of selling out and ripping on ERs who take appointments.  Since then, other people have chimed in as well:

• Whitecoat here and then here.  Do you think bumping paying patients to the front of the line for non-emergencies constitutes an EMTALA violation?  
• TK at ER Stories who seems to think appointments are okay as long as they are for a separate urgent care only.  
• Midwest Woman, a med-surg nurse, thinks it's just a load of crap.  How can ER staff be expected to keep such rigid appointments when not even a primary care doc nor hairdresser can?  She also flames me here without linking.  Come on, if you're going to flame, at least be courteous enough to link me!

Finally, Shadowfax, who would rather have commune-sex with the entire Democratic party (smelly hippies and all presumably) than accuse them of any wrongdoing, sums his thoughts up this way:

No need to take sides: it’s Scalpel and Nurse K. They’re both wrong by definition! It’s axiomatic!

Pretty funny for a humorless liberal.

I think I'm going to puke

A classic middle-of-the-night clutching-one's-chest walk-in case. Wheelchair. Come on back, dood. Immediate EKG and BAM! 

Not a hard STEMI to call as you will note by the huge-ass ST segment tombstone on the far left of the strip there.

After a brief assessment, O2, IV, and aspirin, I kinda hung out in the patient's room trying to get as much info about him as possible while the other nurse grabbed an armload of drips.

Dood's there about five minutes and his sats start going down to 90% despite me trying to fight this with increasing his nasal cannula, but he's still alert and breathing about the same and whatnot. BP is reading like 100/80, kind of a weird BP reading. He was a pretty classic heart attack patient, looking pale and shitty, but still answering our questions without much fuss. He'll be fine once the cath team gets here, waving at the nurses in the station as he rolls by them like they all do.

By the way, hurry up, cath team, sheesh, it's been five minutes!

I was setting up the high-flow mask when he goes, "I think I'm going to puke."

Then. BAM. He gags a couple times, a sound you'll never forget, like trying to suck in air with a tongue blocking your way, his eyes roll back, and woah, what the fuck, he's arresting!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! No bradying down, no ectopy, no warning (other than the general risk associated with a heart attack), just v-fib arrest.

Now, you're saying, yawn, you're an ER nurse, right, people code on you like every day, right? Well, not really, actually. We get far more people already in cardiac arrest who come in with CPR in progress or who were resuscitated by paramedics in the field than people who just randomly arrest five minutes after walking through my door and chatting me up.

Then that thing happened. I don't like to talk about that thing, but it happens. Tunnel vision. Shaky hands. The tunnel vision thing is an interesting phenomenon. I heard it's similar to when police get a gun pulled on them: All they see is the gun, not the perpetrator nor their surroundings nor the perp's sidekick in the bushes. Instinctual. That thing right there is about to kill you. Look at that thing. Focus all your energy on avoiding the thing that is about to kill you.

I'm a human, this is a human who talked to me. This is a human dying right next to me. Instincts. Adrenaline. Must save the human. WHOOSH! Tunnel vision. There's no one else in the room but me and this patient, no other noises, nothing. There is no animal coming at me, no gun pointed at my skull, just a guy lying here....NOT BREATHING!!!!!

The EMT on duty happened to be drawing bloods, so he started doing CPR like a few seconds after I screamed out that he was arresting which was probably only a second or two after he actually started arresting.  Out of nowhere a paramedic who'd just dropped off another patient came in to help. I wish I could remember her name. YES! HELP!

BAG BAG BAG BAG BAG BAG!!! is all I could say with my hands pointing at the ambu bag on the shelf near the paramedic. She didn't care that this wasn't her patient, she just jumped right in to help.

CAN YOU BAG! No? Shit!  

UM GET A THING A THING AN ORAL AIRWAY, HERE GIMME THAT! RIGHT BEHIND YOU!  Turns out that the other nurse had returned with the drips and was also in the process of helping.  Not that I saw her come back or anything.  

Shoved the airway into his clenched jaw and hey we can bag now, great.

Then Shaky-Hands K, who has been reduced to shouting out one and two-word phrases,  pulls the code button after loudly commanding herself to do so ("PULL THE CODE BUTTON!!!") and powers on the defibrillator. Elapsed time in reality? Probably 45 seconds. Turn around. Code cart.  Tunnel vision. Defib pads. My eyes locked on a bag near the defibrillator and ripped it open. Oops, nope, the bag containing extra monitor leads. Fuck fuck fuck. Bad bag gets thrown on the floor.  Defib pads. Defib pads. Oh, there they are. Rip, slap, slap. Shaky-Hands K then connected the defibrillator pads while 500,000 people from the hospital-at-large come charging in.  Not that I knew any of them were there.  

CHARGING! CLEARRRRRRRRRRRRRRRRRRRRRRRRRRRR! I lit him up.

No worky. PULSE! Some wacky non-perfusing rhythm that went back into v-fib. Okay someone else take over this damn code.

When I looked back at the charting, he only received CPR for 4 minutes and 30 seconds and was defibrillated twice. I would have estimated the CPR to have lasted at least 15 minutes.

After the second shock, he woke up and asked us what happened.

This patient, by the way, saved another one of my patients via experience. Maybe I'll tell you about that sometime too.

Spelling bee WTF

My 3rd grader just came up to me to tell me he placed 3rd in his school's spelling bee (he goes to the brainy-kids' school, so that's no small feat).

What word did you miss?

ENTITLED.  

As of now, I've disowned my own child.  I thought any child of mine would be BORN knowing how to spell that particular word.

Announcement, in brief

If you missed it on Twitter....

Scalpel has sold out.  

Don't drink the Scalpel Kool-Aid.  Going to the ER for seasonal allergies or other benign complaints, whether you're uninsured or insured, is irresponsible and inappropriate.  The emergency thingy (room, department, doc-in-a-box) is still for emergencies, not the expected annoyances of Springtime.  Pollen!  My goodness!  The last 30 years it's bugged me, and this year as well!

He's been reduced to trying to encourage people to go to ERs for routine care (and, apparently, diss people who work in regular ERs who are annoyed with system abusers) to drum up business for his freestanding ER.  

Update: Scalpel writes a cheery rebuttal.  I remember when Scalpel was cool...making fun of crayzees with me.  :-(

Hi, I'm your 11:15

Student Nurse Cracker alerted me to this WTFity in the comments of my hose-up-the-ass thread.  After getting these links, it's unclear what is more WTF: The garden hose up the ass or making appointments to be seen in the emergency room.

Apparently, a few ERs such as this one are allowing patients to schedule appointments to be seen for "non-life-threatening conditions".  

Check it out.  Apparently, as of right now (8:15 pm), Smyrna ER has a 3-hour wait to be seen for a non-urgent condition, so you, oh lucky you, can pay $24.99 to reserve your spot in line to be seen at 11:15pm or later.  If you have some stuff to do tonight, hey, may as well get a slot for 8 am tomorrow.  

They should use this software to determine whose insurance should refuse to pay for the emergency visit because, obviously, if you (presumably a prudent layperson) sign up for this, you are attesting that you have a non-life-threatening condition.  Note that it lets you sign up to be seen up to 12 hours in advance.  

Here is a choice patient quote from EMS1 about the service:

It worked for Bob Neal, a Smyrna resident and sports broadcaster.

Neal, an allergy sufferer, woke up one day feeling like he was walking around with a bucket on his head.

He had heard about the service from a neighbor who works at the hospital. While still at work, Neal went online and made a reservation for 40 minutes later.

"It's absolutely worth paying $25," he said. "I have a regular personal physician; however, I can't just show up at his office and say, 'Hey, my ears are plugged up.' He has back-to-back patients. If I did, I would just be sitting there waiting."

Wow, Bob, yeah, allergies suck, but it kinda doesn't sound like you even tried to get an appointment.  Telephones of various types are in widespread use these days.  You have land-line as well as cellular models available.  Payphones are a third option.  Also, there are only like 50 OTC allergy meds, including some that used to be prescription a few years ago, so you can probably wait a couple days, doncha think, dood?  Having your head clogged up from allergies is NOT an emergency.  If you weren't such a self-important tool, I'm guessing your doc could even have referred you to an urgent care clinic if he was full and you still wanted to be seen that day.  Your emergency seasonal allergies didn't even keep you out of work for fucksakes. 

Appointments to be seen in the ER: The end is nigh.  

Patient/victim request

Elderly female patient with real problem: Nurse, I'd like to make one request, if I may.

Me: Sure, what's up?

Elderly female patient with real problem: If Dr. Bloody Gloves is working, I'd like someone else to be my doctor.  He nearly killed me once.

Obviously, my empathy towards that request was maximal.  I asked Favorite Doc to go in and see her and he, also, was more than willing to honor that request.  

Teach an old dog old tricks....

You know it's a sad day when the whole ER is shaking with excitement and disbelief when they see you tube someone (who is normal weight) and you've been out of residency for 25 years.