Thursday, October 2, 2008
Monday, September 22, 2008
She is a very sweet girl, 3 years old, part terrier and part beagle. I have had her for about 5 weeks, having adopted her from a family who no longer wanted her for reasons that are unimportant. Tina's picture was on the break room bulletin board for oh, about a month. One day I happend to ask if she had found a new home; nope, and by the way she would be making a visit to the ER that very afternoon. Long story short, to save her from being put to sleep, sap that I am, the dog comes home with me.
Now, I used to have the world's best border collie up until a few years ago when he had to be put down for illness. It just about killed Mr. EDNurseasauras, who vowed never to get another dog for the rest of his life. After a couple of years without one, I was ready. While he never said no, my husband always had good reasons why getting another dog was not a good idea. I never disagreed with him, but still , dog was on my agenda.
Fast forward to 5 weeks ago. I brought the dog home about 6:30 PM. Tina was skittish, fearful, mistrusting....of me. The cat she ignored. She had obviously been neglected and she smelled. I threw her into the tub and spent the next hour petting her and talking to her. She settled in.
Until my husband came home. Tina barked and barked at him as he came up the stairs onto the back deck with a large box. "Well", he observed, "you have a dog". "Yep", I replied, "You have a 37 inch TV. It appears we have a stalemate". I promised myself that I wouldn't fall in love with her, and if it didn't work out, I would try to find a good home for her. I hoped that my husband could manage to make friends with the dog and gain her trust. Believe me he loves animals and wouldn't harm a fly.
Tina continued to bark at my husband, and all males, for the next week. She barked at him if he left the room to get a snack. She barked at him if he got up in the middle of the night to get a drink of water. She barked at him when he got up in the morning. I was the one she ran to, hid behind and followed. She had decided she was my dog, although she liked my daughter a lot. All animals and babies love my daughter so it was not surprising.
"Two weeks", I said. "Let's give it two weeks. If she can't get used to you, well....I'm Gonna Miss You (I sang). Just kidding. We can't have a dog that doesn't trust you, I know that. Just be patient with her".
He was. He worked it and worked it. Coaxed her to come to him, but she was so heartbreakingly submissive I wanted to cry. She rarely made eye contact. After a week she stopped barking.
After three weeks she jumped up on the couch when he called so he could pet her.
Last week she got up with him in the morning and let him feed her instead of waiting for me.
Today she wagged her tail, danced, licked his face, and was excited to see him for the first time.
Hook, line and sinker. He's as in love with her as I am.
Tuesday, September 16, 2008
It's no different anywhere. At my last job at Utopia Med Center, we had a 3 room psych corner which I referred to as Area 51. Each room was equipped with 1. a bed, 2. a TV behind a plexiglass screen mounted out of reach near the ceiling, and 3. a closed circuit TV. It was nice and quiet, all three rooms located behind a sliding glass door that we rarely used. Each of the three individual rooms had a door with safety glass, and internal louvers for privay that could only be operated from the outside. The only design flaw that I could see was that it was a little out of the way for the stupendously drunk, but we did have a good crop of behavioral techs or security (strapping young lads all)to assist us when required.
The integrity of the plexiglass was tested on the very first night Area 51 was opened for business. One of the frequent psychotic flyers picked up a chair and heaved it at the TV...yep, plexiglass remained intact, but the chair broke in half creating a nice little weapon. Miss Thang was treated to four point restraints with a face shield since she was unable to curtail the spewing of spit in our general direction.
One night, another patient literally launched herself at the plexiglass window in the door and...you guessed it...blew it out completely. This thing must have weighed close to 40 pounds. The window struck one of my nurses on the back of the leg, causing a very deep and painful laceration and damage to her achilles tendon which put her out of work for 1o days.
I don't know if these things run in cycles, because here at Pseudo City Med Center there has been a proliferation of violent acts. One nurse was choked near to unconciousness by a crayzee. Another lashed out with a heavily booted foot at a pregnant nurse; fortunately his aim sucked. A couple of the chronic paineurs have become bored with the usual whining and become quite threatening; one actually went nose to nose with the security guard (an ex cop, bless him) and shoved him. This act just bought him a ticket to Psuedo City police station.
This increase in violence has spread to the inpatient units. Yesterday there was an overhead page for a code green, for employee distress up on one of the floors. One of the chronic insincere detox / suicidal regulars threatened a nurse and got up in her face. She was backed into a corner of the room; this is a paricularly tough cookie, so for her to push the panic button must have meant she was shaken to the core. When an employee distress code is called, the plan is for every able bodied male in the place to respond. Unfortunately, the only able bodied males who didn't respond was security. The individual was subdued and the nurse was safe, so it all worked out.
There is a problem here. Clearly, security is used to responding to the ER, but not to the inpatient units. With more crayzees and violent individuals being admitted medically instead of to a forensic psych unit where they belong (and where there is adequate trained staff to deal with them SAFELY) the security staff is stretched pretty thin. Assuring the safety of the staff does not seem to be a priority for the the Bean counters; when an incident occurs, they are all about damage control, but it seems to be more of a case of following protocol than actually caring about what happens. Having a nurse choked nearly to unconciousness was not enough of an incentive to clamp down on violent offenders nor was the sign in the waiting room "Zero Tolerance Policy for Physical or Verbal Abuse of Hospital Personnel" much of a deterrent.
I would be happy with a Taser purchase for ER use PRN. With proper instruction, of course.
Sunday, September 14, 2008
Rm 2: ETOH (BAL 390)
Rm 3: Seizure (from ETOH withdrawal, from jail)
Rm 4: Seizure (ETOH withdrawal, not from jail)
Rm 10: Depression (with suicidal ideation)
Rm 11: Depression (without suicidal ideation)
Rm 12: Depression (from jail; made slashing with finger across throat, and mimed a gun pointed at head. Suicidal ideation
Rm 13: Abdominal pain (17th visit this year for same)
Rm 15: Abdominal pain (2oth visit this year, 3rd in last week. Known for narcotic seeking behavior)
Rm 16: ETOH abuse, depression, and thinks he might have a seizure. Oh, and chronic back pain.
Rm 17: Intoxicated man found sitting on the curb in downtown area. He quite charmingly pisses on the floor. Lovely.
At 12:20 PM we get a patch for "37 year old female. Hearing voices"
At 12:50 PM, we get what appears to be our first actual emergency patient of the day, a 52 year old female with hypertension and severe headache. This turns out to be a frequent flier who routinely doesn't take her antihypertensives, cranks her BP up to a nice healthy 220/120 and complains of intractable headache in order to get Dilaudid and hopefully admitted for more Dilaudid. Or at least she did until admin. devised a treatment plan that included admission only if her BP doesn't come down. I love lopressor.
At 1:30PM we get advanced notification that we are getting a code: 62 year old male, witnessed cardiac arrest after complaining of shortness of breath. Bystander CPR initiated immediately by co-worker who also happens to be an EMT. This sounds as promising as such things do when the right things happen in a tmely manner.
At 1:42 we get the patch: Pt in PEA (pulseless electrical activity), and IV access is two IO's (intraosseous).
By 2:10 PM we have done all we can do. The patient does not survive.
The worst thing is that in order to see their loved one, the poor man's family has to run the gauntlet of alcoholic assholes yelling for food, cigarettes, their rights, their lawyers, and cab vouchers.
Sometimes there are just no good things to say. So I won't.
Monday, August 25, 2008
Saturday, August 23, 2008
Thursday, August 14, 2008
Eye: Patient 1 has been in the waiting room for 2 hours. He needs to come to a treatment room NOW.
An hour later, the Eye in the Sky, omnipotent, omniscient, and omnipresent calls down again.
It is chaos. The halls are lined with people who have not yet been seen by a provider, as well as the really sick ones who are in rooms. The beancounters don't tarry long; obviously their place is directing the battle from a position of safety.
Monday, August 11, 2008
Code Brown, ICU! Code Brown, ICU!
Easily 8 heads pop out of various rooms in the ER.
"What was that page?"
"Did I really just hear that?"
"Did someone really just page a Code Brown to the ICU???"
FYI, a Code Brown refers to........how shall I put this delicately........an emergent, usually accidental, generally explosive, and often voluminous emission of fecal matter which requires some assistance for cleaning. Or when someone puts on the emergency call light in the bathroom.
A quick call to the page operator served to clarify the following page:
DOUG Brown, ICU! DOUG Brown, ICU!
Friday, August 1, 2008
Dr. Tulango (his real name is kind of the same as a dance, so when he is is on we say something like 'today, we dance the Tulango with joy, for Andy is with us and we celebrate!" Silly and stupid, but what fun is work if you cannot have a laugh or two?
One of the frequent fliers was on his admit list. This patient is manipulative and abusive. She refrains from taking her antihypertensives for days at a time, then comes to the ER with a BP around, say, Patent Pending/120. She complains of severe headache, gets dilaudid (a lot for her 15 out of 10 pain), Zofran, a whole bunch of labetolol and gets admitted to the ICU. They kick her out when her BP is back to normal and they are tired of giving her narcotics (allergic to toradol, etc. You get the picture). So she figured out a nearly foolproof method to buy herself a couple of days of room, board, and narcs. Administration eventually came up with a plan: if her BP was within a certain range, she would get oral antihypertensive meds, a visit with the case manager, and no narcotics.
This time there was some kind of loophole, because although her BP came down to an acceptable range, the ER doc felt compelled to admit her. Enter Dr. Tulango. Always very concientious, he went over the medication reconcilliation with the patient; it included a HUGE dose of methodone as well as oxycontin. Hmmm....... After some investigation and a chat with the patient's PCP, it was confirmed that no, there was no oxycontin prescribed by him and the methodone was 4 times what it should have been. Dr. Tulango was anxious to speak to the provider who scripted her these meds, but when she was confronted for the name of the provider she ripped out her IV, made disparaging remarks about Dr. Tulango's parentage and ethnicity, promised to go straight to the mayor's office...and stormed out. Normotensive, non-narcotized and feeling abused. OK, so you lied about it and got caught. Get over it.
Like I said, I looooooooooooooooooove our hospitalists!!
Tuesday, July 29, 2008
"I swear I have no idea how that device became lodged in my rectum!"
"There is no way in hell I could be pregnant" (32 weeks of 15 year old not pregnant)
60 year old man, father of 3 and grandfather of 8 becomes pedestrian vs. auto casualty and dies 7 days after being struck by an unlicensed man having a seizure while behind the wheel because he chose not to take his anti-seizure medication.
"Why the hell should I wear a motorcycle helmet? This is New Hampshire"
(no helmet laws+ idiots= head injury)
Sick vs. Stupid
"I fell down and laid on the floor for three hours. Then I got up and called the ambulance because I didn't have any way to get to the hospital to pick up my Klonopine prescription"
Shocking tales of patients who say please, thank you, and don't piss on the floor. Ok,there aren't many of these.
The Cheeto's Challenge
Clinical studies show that 16 year old's with abdominal pain and vomiting improve spontaneously by ingesting Cheetos in the wating room.
(Not) Catering to the Surgeon's Neighbor....
who gets to wait in the waiting room with sore ankle that she has had for 2 weeks. "If you truly believe your condition is worse than I have assessed and warrents more immediate attention, I will put your chart in the main ER. FYI, fast track is running 2 hours behind, the main ER is 4 hours behind. Have a nice day, and lose the attitude"
Tales from Chicken Little School of Nursing Management "The Sky is Falling, The Sky is Falling!!" Many tales of charge nurses who are willing to go on diversion because there are 15 people in the waiting room. Decisions based on quantity, not quality...erm, acuity.
I can't take credit for this one, but one of the nurses at work suggested a chapter How Nurses Are Stupid to Other Nurses by including some of the moronic incident reports by individuals with a vendetta and poison pen. Usually ICU nurses.
...oh, and in the Idiocy at the Top section, read about the medical CEO whom I encountered on a day when there were NO empty beds on the floors, I couldn't place the 5 boarding telemetry patients who eventually stressed and went home from the ER, as well as 6 post-ops, 1 Remicaid infusion and 2 blood transfusions; she thought that one solution to getting bodies out of the ER so we could get the 20 or so out of the waiting room was to ask pedi to take the demented 90 year old with pneumonia and MRSA. Sure!! Great idea!! I'm sure the little tykes and their parents would really benefit from that experience, not to mention the moms and babies there who overflowed from post partum. Sheesh.
************************************************************************************* I could do several chapters on Leadership.
Even though I have assimilated at Pseudocity Med Center, and the folks at Scary Catholic Medical Center satellite often beg me to come work for them, I continue to think often (and fondly) of my people at my last job. I had the best boss, truly a leader. She may not have done a ton of patient care, but she was out of her office and on the floor several times a day. She almost always knew what was going on, how long people had been waiting in the waiting room or in the treatment areas. It was a big ER, 35 beds and many staff, but she knew the strengths and weaknesses of every nurse, tech, unit coordinator, paramedic and even the docs. I haven't had a lot of mentoring in my career, but Jane was an inspiration to me. She encouraged me to take on more responsibility, and helped me to find my way as a leader.
I guess coming from such a, well, nurturing environment makes it that much harder to flounder around sans leadership. Yeah, the current boss is an RN with an MBA which is impressive; but I find the emphasis is more on the MBA portion. Don't get me wrong, she is a lovely person, and the business prepared nurse is, in my opinion, the future of nursing management. How else to be able to swim with the big fish and not get eaten by the sharks? It must be hard to have taken this path, there can't be a ton of RN's with MBA'a out there to mentor others.
However, without strong leadership from a nurse manager I can see the entire department slowly going to hell in a handbasket. Poor retention, call-outs, no shows.....some days it is downright painful to go to work. A recent nursing course had me write a "Dream Job Description" for a project. I wrote about my current job, with all the things I liked about my last job. That is a no brainer, cause I like my actual job, but wish there was more support for nursing to actually do the job. Is everybody stretched this thin?
I may never get the book off the ground, but it is fun to think about it. The next best thing is blogging. When the interesting/challenging/funny/ unbelievable/shocking/horrifying/ disgusting/exhilarating occurs at work, it pops into my mind "oh, I need to remember that". It's addictive, really, and a great stress reliever. It also occasionally helps to put things into perspective, which is more than I can usually hope for when I get home at night and Mr. EDNurseasauras is asleep and not available for debriefing. It sucks that most of my friends are now working the 3P to 3A shift and aren't available for 'Rita Rounds anymore, but my liver is certainly in a happier place; and, I'm sure the Pseudocity Police who would prefer seeing me working in the ER as opposed to being a patient.
Sunday, July 20, 2008
Saturday, July 19, 2008
Tuesday, July 1, 2008
Wednesday, June 25, 2008
I fell in love with the ER the first day. It was different. It was fast. The nurses were assertive, smart, confident. They were taking care of babies, kids, teens, adults and grannies all at the same time. The nurses in the ER seemed to magically juggle 3 bowling balls and a chain saw while starting IV's, giving meds, giving instructions, and actually making people better so they could go home. The docs not only worked with the nurses, they were depending on them; clearly they couldn't do their jobs without them, and there was none of that "handmaiden" crap that was beginning to go out of style in the 70's. Finally I had found a home where collaborative practice existed. Wow
Tuesday, June 24, 2008
The others were floored but excited that I want to teach, and were full of encouragement. I never thought I was very smart in nursing school, but it turns out I just never studied. Imagine that! My classmates, I discovered, thought I was brilliant cause I didn't crack the books. Turns out the actual "being a nurse" part of nursing school was easy for me, and I took to it like a duck to water; guess I was something of a nurse savant.
Sunday, April 13, 2008
Tuesday, April 8, 2008
EDNuresesauras' gradution photo, circa 1888. That's me, top row, 4th to the left.
Tuesday, April 1, 2008
Friday, March 14, 2008
It is a sad commentary on the art of triage that one's flair for drama sometimes gets a bed before others when all else is of equal (and low) acuity. By far the Academy Award went to a young woman who moaned, groaned, wailed, cried, carried on as if an alien baby was about to burst forth from her chest. I guess vomiting for 5 months will do that to a person. Her enabler / mouthpiece husband was right there to lend support and advocacy. Although she had normal vital signs, I had to get her out of the waiting room because she was Causing a Scene. Later I found out that she Caused a Scene about being discharged, and was admitted with an order for NO NARCOTICS OR BENZOS, and a psych consult. Good, I am glad her problems will be addressed and that she wasn't just kicked to the curb with more pain meds.
Friday, February 29, 2008
Thursday, February 28, 2008
We get lots and lots of calls from people who are looking for advice, as I'm sure most ER's do. Here is today's top ten:
10. "How long is the wait?"
9. "If I took Tylenol at 2 hours ago, how soon can I take Motrin?"
8. "How long is the wait?"
7. "I cut my finger with an Exacto knife, do I need stitches?"
6. "I saw Dr. Dewshe Bagghe last week for my back, and my prescription for Percocet ran out, can he just call me in a script for more?"
5. "What are the symptoms of food poisoning?"
4. "Should I bring in my 2 year old for a high fever? It's 100 degrees"
3. "Can you talk to my husband and convince him to call an ambulance? He twisted his ankle yesterday and it's swollen and black and blue. Yes, I have a car, what does that have to do with it?"
2. "Can I make an appointment?"
1. "If I can't make an appointment, can I put my name on the list so I don't have to wait so long? Like at Chilli's?"
Wednesday, February 27, 2008
Friday, February 22, 2008
This could be the next big thing in ear lavage
I have never understood what compels people to come into a busy ER for a problem with earwax, never mind be willing to wait for a couple of hours to have them blown out. These are people who do this regularly. There is generally no infection, just diminished hearing. What?
Do PCP's not offer this service?
I really hate to irrigate ears, at my last job I simply refused to do it. Is squirting warm water into an ear with an 18 gauge IV catheter really a nursing task? Is there not the potential for perforating the ear drum? Hmmm?
You can soften up those big hunks of black gunk all day with mineral oil, the juice of two freshly squeezed ripe Colace gelcaps, or Debrox, whatever is lying around. You will still need a big honking squirt of warm water to make that puppy exit the orifice. Really, after more than 30 years there are few tasks I hate more than irrigating ears.
This guy has all the answers (and seems to enjoy it) so if you want to avoid a trip to the ER, check it out.
Sunday, February 10, 2008
Saturday, February 9, 2008
It is also good to see how the other half lives. I am responsible, in part, for getting the ER admits out of the ER, in addition to floor to floor transfers and direct admissions. I have identified quite a few items which will impact my own practice when I work shifts in the ER. It puts a face on the nurses who get my faxed report. It puts more human in the interaction process, if you know what I mean. I have a better "global picture" of the hospital and it's workings, which is good since I've only been there for about a year. The only bad ("only" ha!) is the micromanageing bean counters and their Ambush Debriefings. Talk about being thrown under the bus. I will have to relate that tale in Part Two.
Tuesday, January 15, 2008
Tuesday, January 8, 2008
Charge Queen: We need to get security down here, I put him and the mother in the family room but he's a flight risk.
Me: Flight risk? Is it because Red Bull gives you wiiiings?
Charge Queen: EDnurseasauras, that is bad! But funny.