Monday, January 1, 2018

Tidbits from triage


Happy New Year!  Count down to retirement!  In 3 years, sigh.

Holiday weeks are either crazy busy or crazy slow.  This past week was the
Worst.  Week. Ever.

Limited office hours at overwhelmed primary care locations, urgent care and doc in the boxes just sending everybody with a pulse, stacks and stacks of people.  At no time was there any less tan 10 people awaiting triage and a four, five hour wait for care.  22 in the rack waiting to be seen by a doctor.  Thanks to protocols and docs trusting us nurses, the sickest were seen first and the kind-of-sick had EKG's, labs and X-rays in progress or completed.  It didn't exactly streamline things, but it was helpful to get stuff going.

Of course, when people are that sick in the waiting room, the squeaky wheels just make life more difficult.  Complaining about the wait.  Embellishing their symptoms (adding chest pain to the mix did not expedite their visit).  Fake vomiting didn't work either, there were no beds, just none.

I had one man voluble complaining that his 78 year old mother had been waiting 3 hours.
"Our doctor called about this!  It's ridiculous!  She's old and sick and needs to see a doctor right now!"

In response, the family member of another patient told him to sit down and be quiet.

"My mother is 85 and she's just as sick, and we've been waiting longer than that."

Hilarity ensued.  I called security and ducked back into my cubicle.

Drama alert.  I was told there was a woman who was in the bathroom and was screaming for a doctor right away.  A 17 year old was on the throne, moaning that her intestines were on fire, she couldn't get up, and wanted to have diarrhea and throw up at the same time.

I sent a couple of barf bags over the top and advised her that I would see her in triage when she was ready.

On the subject of "my doctor/urgent care/ called ahead":
We probably had 50 notifications on 3-11 shift alone.  Yeah, your doctor may have called.  Our doctors don't do what they say, they make their own decisions.   It changes nothing with the process of triage, and we are going to repeat most of the tests anyway, so there's that.  Also,
1.  I don't have a list of your medications.  You should
2.  My computer doesn't have the same information as your doctor.
3.  You are not getting an MRI today for your back pain.
4.  You may be admitted, or you may not.  Please leave your suitcase outside.

At five hours into my shift I elected to use the bathroom and eat some food.  Naturally, the next patient  gave me a snarky "Did you have a nice lunch?".

I responded pleasantly, "What kind of work do you do?"
He told me some office type occupation.
Me: "Oh, so you don't get lunch?"
Him: (haughtily) "I do, but I don't deal with life and death"
Me: (narrowing eyes and leaning forward slightly): "Exactly"

He was there for man-cold.  Enjoy your 5 hour wait.





Saturday, December 16, 2017

Ghosts of Christmas Past

It's not that I lack the holiday spirit, most years I just don't have the time.

Last year was a stressful time around the holidays.
My tree was barely up, and if not for the snowy day that kept me indoors it would probably have been naked through Christmas.  I spent the day preparing the house and all, so it was spiffy and festive.  Then the whole business came down New Year's Eve day.

We had been doing the necessary prep for putting our house on the market right after the new year.  Oh, yeah, we moved.  Downsized.  To our dream house in our dream neighborhood.  I just wasn't into  the added burden of making the house show ready.

My friend (you know who you are) has her holiday home set up just after Thanksgiving.  She is a decorating genius, and although that is not what she does for a living she definitely should.  Gorgeous.  She puts a lot of thought, time and effort into her decorations and changes them up a lot from year to year.  Her house is a wonderland, something beautiful in every corner. Nothing too big or too small, everything is perfect.  Really, it's so good you have to just say "YES, this is it, this is exactly how I want my house to look at the holidays", and then you just give up because it's just too much pressure.  But you're ok with just your own inexpert attempt at decorating.  She amazes me, really, good at everything she does.  And I don't say that just because I know she will read it.  Anyway, her house was still beautifully festive at Little Christmas.

I did all my shopping online 2 weeks before Christmas and not one minute before.  Including a kitchen table and chairs for one of my kids, why the hell not, free delivery.   No need to go to the mall,  I made that mistake on a Wednesday about one week after Thanksgiving.  A week day.  It took me a long time to find a parking spot, and there were too many people inside anyway.  I can't stand crowds and have no patience.  I just left and found a spot to eat my lunch before heading to work at 3PM.    I can't even remember what I wanted there so I must not have needed it too badly.   I spent one day running around for odds an ends I needed 4 days before Christmas and went to all local stores.   I wrapped and was ready 2 days before, never have I ever.

And I had a week off.  That was nice, not working Christmas.  So I said to myself,
"Self, you have worked it for over 40 years, saying no from here on out.  Deal with it, bitches".

So this year I said no to working Thanksgiving and took another Christmas week off.  And I don't feel one bit guilty.

Tomorrow I will get my tree up.  I have some stuff left from my old house but have some ideas for decorating around the new one.  Snowy day today, after walking the dog I spent the afternoon gluing sparkly embellishments on some mantle decorations and futzing with the twinkly lights.  Very Hallmark.

My wacky ex neighbor always has his ridiculous lawn display up in time for Thanksgiving. Last year he barely managed to get his light-up menagerie set up about a week before, and only did  about 1/2 of the lights.  I still couldn't figure out if there was any uniformity  or theme.  And I did kind of miss the one-eared moose.  Oh, sorry that was his wife.  I passed by last night to discover that his menagerie is now one hundred percent dogs.  I had no idea there were that many decorative light up dog displays to be had, but he managed.  Fascinating.

There will be no display my new neighborhood.  Just quiet, tasteful window lights (white), mine are on order.  Door wreath, of course.  Some have a little tree or festive greenery in an urn on the front porch. Very low key.  Yesterday I came home from work at 1 AM to discover that someone had placed identical red bows on each of the 18 identical light posts in the neighborhood.  Today I discovered that one of them was blue.  One.  I wonder if it is an acknowledgment of a non-christian belief system, or a random act of rebellion.  Don't ask, don't tell.  It is a condo association, they are mostly older than I am except for the Asian family across the street who have the only child on the street.  They have a red bow.  Not that it matters.  The phantom bow-er knows, which is important information for clandestine midnight bowings.

I worked a few hours at the Medde Center this past week, and the Christmas Madness Project continues.  It's just as out of control, only now with fewer contributors.  They are still asking people to give more while providing less to staff.  I was handed a hospital "Christmas Gift".  A $15.00 gift card to a local supermarket.  In past years they gave out free turkeys, a $25 gift card, and a $50 cash gift from the physicians.  It's a sign of the times for this hospital.  At my main job at Pseudocity, I was handed bonus check for several hundred dollars and a gift card for a free anytime meal at the cafe since I'm not working Christmas.  I'm so excited I might even make the cookie exchange this year.

Wednesday, November 15, 2017

Forty and fabulous

Musing on 40 years since I graduated from nursing school.

What a different world that was.

Nurses caps required at my first job. It sailed off my head when the day supervisor left for the day.
Also a white dress, white stockings, ugly Clinic shoes. Hair up and off neck.  Just like nursing school, only without the striped pinafore.
Metal bedpans and urinals.  Bedpan washer.
Glass IV bottles.
Smoking allowed in patient's rooms.  Emptying the ashtrays part of PM care routine, along with back rubs and changing pillow cases.
Smoking allowed at the nurses station (at night)
No wearing gloves except for sterile procedures, or possibly for a gone-by-the-wayside iced saline lavage for  a GI bleed.
Stryker frames.
Paper documentation.
Med carts and bottles of pills.
Narcotic count.
3 bottle chest tube drainage system
Setting up a science experiment to determine glucose levels in the urine on the ward.
clinitest tabs would turn 10 drops of pee blue, for no sugar or on the normal side.  I loved doing those.
Eyeballing the number of drops per 15 second for a 100 ml per hour IV drip rate. (6, for a 15 gtt tubing by the way).  No pumps.
Patients needing post op narcotic pain meds were given IM injections.  Think about that and the current opioid crises.
Admitting next-day pre-ops between 3 and 5 PM (for cholecystectomy, hyst,  or TURP,  for example), then pre-op teaching, prepping (enemas, shaving nipple to knees on abdominals)
Waking surgicals at 5:30 AM for IV starts.  Or more enemas.  Good morning!
Verbal report from charge nurse.  Led to taped report, and you had to listen to the report on all patients. In a smoke filled room, everyone smoked.
Being forced to take a 30 minute meal break AND a 15 minute coffee break.  Actually go to a cafe or sit down in a nurses lounge and have a break.
The night supervisor was a battle axe.
Being a brand new nurse and in charge of a 40 bed floor 3 months after getting a license.  Because I could.  And I was incredibly lucky.
Being a new ER nurse with 18 months of nursing experience, 8 hours of orientation,  alone on 11-7 with a doctor who was allowed to sleep.  And expected to register patient's to boot.

No wonder I'm tired.








Wednesday, October 18, 2017

Name Game, vol. 3...or 4...or 3. Can't remember

Eyden (pronounced "Aiden")

Karsyn

Salee

Jaxson

Dawna

Kylla (no, it does not rhyme with "Thriller", or "Thrilla" if you are from Massachusetts)

Derec

Jacen

Jaryd

Mycal

Deserey

Kimmberleigh, Kimberlee, Kymberlee.  Ach.

Tabbethya (I pronounced it "Ta-BETH-ee-ya" just for fun.

Please, please, new parents of America, stop this trend.


Monday, October 16, 2017

Nuggets of Awesomeness

There are usually two nurses in triage but I am frequently alone.  Just me against the world.

"You are out there alone again?!", gasps the Queen of Fast Track as I pass her station enroute to the triage area.  "Unacceptable!" she exclaims.  She is there every day.  She sees all, knows all, and it makes her crazy that anyone has to triage alone, especially when it's really busy.

Me:  "Walking the Mile, walking the Green Mile".

After triage each patient is escorted to an open room….as long as there are rooms open.  Thereafter the charts go into the rack for the charge nurse to room, pending bed availability.  I like this system a lot.  But it adds a layer of responsibility for the triage nurse, aside from finding the elusive open room,  to a). assess the acuity level (in general) of the department and find an available nurse who is b). in the rotation for, and willing, to take a patient (another post in itself) and c). provide a bullet report.  This occasionally works seamlessly.  More often than not there is a bit of salesmanship involved, such as, "You love to take care of sick babies!", and "I already did the EKG, and I put in a chest pain order set".   Sometimes nurses just check the board, anticipate the arrival of the patient, tell me "I read the triage note, I've got it".  This is a rare but most welcome occurrence.

My coworkers are a curious bunch and just can't help asking "why".  The most often asked question "why didn't they call their doctor?" The answer to that is one of several stock responses,  1. "they did and were told to go to the ER", 2. "they don't have a doctor", or 3. I respond with a rhetorical question of my own, or create a diversion, such as "Look!  Hayely's Comet!" and then sprint back to my box.  Sometimes I just say, "Why ask why?", usually accompanied by  slight shrug of the shoulders and a wry smile.

Occasionally I say it in French for added amusement.

Often there are requests for "nuggets", little bits of information about patients that aren't really all that important for triage.  Mostly patients are anxious to share every aspect of their illness and when I am really interested/amused/intrigued I like to pass on said nuggets of info.

Like, what was the kid's temperature at home?
"She felt warm to the mother, but I didn't ask to what she compared it.  Warmer than toast, perhaps?  Puppies?  Day old rice?"

What was the exact dose of Tylenol?
"Some.  A bit.  A bunch.  I'm pretty sure there was no tylenol given, actually"

My personal favorite is, "What does the urgent care expect us to do about that?"

Duh.  We get probably 40-50 phone calls daily from various free-standing urgent care type places, Convenient Doc in the Box, Drive Through Care, Taco Doc, etc.  There are lots of them in the area, some are good about faxing such important information as EKG's,  which we repeat anyway, and occasionally we are offered some amusing zebras to ponder.  But our docs like to make up their own minds, perhaps fashion their own zebra hunt.  They are funny that way.

Famiy members love to chime in with nuggets of their own, which is particularly frustrating when they contradict each and every statement made by the patient.

Me: "Do you have any allergies?
Patient: "No, I don't have any allergies"
Well-meaning family member:  "Yes he does, to key lime pie, birch trees and Legos".

Me:  "When did the pain start?"
Patient:  "Oh, about an hour ago"
Well-meaning family member:  "He has had this pain for 6 months!"

Me:  "I see that you have a history of opiod addiction, are you still in recovery"
Patient:  "Yes"
Well-meaning family member:  "No, he is not, he took 4 oxy's today and drank 12 beers".

With these nuggets comes a good bit of he said-she said along with the inevitable arguments, as you can see.

Sometimes I  manage to come up with few bite-sized nuggets to pass along.  Mostly I just give a bullet and run back to my cube to start the next one.

A young girl was sent from an urgent care for a cast on her broken tibia-fibula.  She arrived in a wheelchair.  With the leg hanging.  I was confused and asked the mother why she did not have a splint, an ace wrap, or even a piece of cardboard.

"They don't do casts, that's why they sent us here".  Like I'm the idiot.   Helpfully (not) they sent along a disk with a single view film and not so much as a Tylenol on board.  Poor kid.  Our PA called their PA to rip them a new one and suggest that they need a tutorial on splinting, or failing that  perhaps simply using an ace bandage, a pillow and some duct tape.  Well done.

Here is one more nugget:

"Why is the patient soaking wet?"
"She was having a seizure.  The family poured water on her to stop the seizure"
"That actually works??"
"Only if they are faking a seizure.  Then it works quite well".