Maxine Lives!

You know Maxine; the cartoon character that graces numerous emails (especially from my mother- she just LOVES Maxine). She is that crazy old bat with the bunny slippers who dispenses knowledge from the bottom of a wine glass. One of my patients turned out to be a seeming prototype for Maxine, minus the bunny slippers. I happened to pick up the phone for a patient advice call. We get dozens of these every day, and since the bottom line is come to the ER because we aren't allowed to give any actual common sense information, we tend to take turns. The caller said that she had experienced bilteral wavy lines in her vision which lasted about 30 seconds, and she had a mild headache. She said that she called her opthamologist who told her she should get right to the ER because she could be having a stroke. Sound advice. She was looking for confirmation, I guess, and also wanted to know if she would "be sitting in the waiting room for hours and hours". After informing her that the visit would take as long as was necessary, she agreed to think about it.

About 2 hours later she lands in my room. Longish gray hair, hiking boots instead of bunny slippers, but I'd know that sneer anywhere: yup, it's Maxine in the flesh. And cantakerous as hell. Won't get undressed. Won't let me draw blood. Won't let me start an IV. Won't let me do an EKG. Won't even sit on the bed. Stands in the doorway with arms folded across her chest. She is ANGRY. Dr. Dewshe Bagghe takes this one (oh, joy), talks with her for a bit and gets her to agree to 1) an EKG, 2) Labs, and 3) a head CT.

The tech accomplishes the bloods and EKG, but Dr. Dewshe, master of communication that he is, conveniently forgets to tell me the CT is with IV contrast, so in I go to start a good-sized line. That done, it is time for her CT. I tell her she needs to take off her hair appliances, earrings, necklaces, etc. She asks if the CT is "the one that's a tube". I explained the CT, and she seems a bit more relaxed. I told her I needed to take her to CT in a wheelchair, expecting a huge fight, but she relented. I notice a book she has in her lap, and ask her how she is liking it as it is something I have read (some off-beat fantasy about dragons, I have eclectic tastes in lit.). We chat about books on the way to her test, and I tell her I will see her in about 10 minutes.

Upon her return, I check her vitals which are all normal, and comment that at 74, she appears many years younger than that. This prompted a really great conversation about life and living it, how she walks the woods with her 3 dogs daily, is an avid reader, and manages to learn something new everyday. She was afraid she WAS having a stroke, and nothing made her more afraid than the prospect of losing her intellect, mobility or especially her independence. I thought she and my mom would get along great. Now, my mom is 75 and another go-getter who will sneak a flask onto the senior citizen bus trips; they tend not to serve ETOH. God forbid mum and her cronies don't have a little wine with lunch. Actually, I want to be just like her and raise as much hell as she does when I am her age. Her Christmas card was her on the back of a motorcycle on her 75th b'day, an event at which she and 6 of her friends drank the rest of us under the table. And remained pretty sober at that; maybe they were just pickled.

Anyway, Miss Maxine was given the good news that her CT was fine. Naturally she was opposed to hospitalization and signed out AMA. But before she left, she kissed me on the cheek (2nd time in 32 years I've allowed that), thanked me profusely for being so kind, and went on her merry way.

I hope she is out there raising hell.

Idiotic Names

Maybe it's because of all these idiot celebrities naming their kids pretentiously (did it start with Dweezil Zappa?), but I have had a rash of stupidly spelled names of late. Stupid because these kids are going to spend the rest of their lives spelling their names.

Here are a few samples of stupidity:
Jewelly pronounced "Julie"
Jessaca
Pshawn, the "P" is silent (no pshit)
Kortny
Holleigh
Alexeigh
Mykele pronounced Michael
Linsy (did you mean "LINDSAY?")
Khelli

Here is a selection of some plain Stupid Names:
Crystal Snow (the Ice Queen?)
Precious
Princess
Treasure
King (except for my uncle, and the middle names of several of my male relatives--it IS a family name)
Badger (hahahaha! "BADGERS? We don't need no stinkin' badgers!")
Audra and Jared (if you are over 40, remember "The Big Valley" TV show?)
Marvolene (WTF?)
Feral
Maverick ("did your mother not like you?")
Tyler Harley Davidson (a girl, yikes)
Summer, Winter, Spring and Autumn (not from the same family)

Names Guaranteed to Get Your Kid Beat Up:
Boral (combination of Bob and Coral?)
Lexus
Third (yikes)
Juniper
Quita (could never finish anything?)
Juicey (no lie)
Boswin
Storey (Ah, the Story Girl. Welcome!)
...and to go with the above, Anne of Green Gables Johnson
Shiclet (accent on the last syllable; "Chiclet?")

Here's a doozy or two from when I used to babysit a million years ago:
Tamsen Olivia Freelove Jones. Yikes!
Teena Bean (just sounds weird)
Peter Lapin (Lapin means rabbit in French)
Bambi. Yup. Went to high school with her.

You need a license to drive a car, but anyone can have a kid; and they can name said kid anyting they want to

Survivor Waiting Room

At times of high volume at Pseudocity Medical Center the waiting room often seems like a combination of bus depot, bomb shelter, and the morning after a party gone horribly wrong. Regardless of the complaint that brings them in for their non-emergent emergencies one thing is certain: they all know where they are in the queue. Never mind that various posters remind the huddled masses that patients are not treated on a first-come, first-served basis.

It is a high stakes, competitive game that is run in the waiting room; the frequent customers all know the rules and have developed a Survivor: ER mentality. Alliances are developed, a few with outstanding warrants are "voted off the island." They never tire of challenging the system.

On a recent very busy shift, I was in the penalty box (AKA triage box, otherwise known as goal-tending). The truth is, I really like being in triage and would rather do that than anything because it is the shortest possible contact with complete idiots. Also, it is a challenge to get my really sick people into a treatment room ASAP which I sort of enjoy. But I digress.

One of my patients was SICK. Pale, sweaty, nauseous, looked and felt like absolute crap but with pretty normal vitals. He was of the scary category of patients who are Young Enough to Die, so I wanted him back into a room. I got a wheelchair, but he would have none of it, so I explained my strategy in the Survivor: ER game:

"Look, sir, I know you want to be all macho and walk out back, but the truth is the natives out there are pretty restless. Now, I could let you walk, but an angry mob scene would be really bad for business, and they would probably do some serious damage to me when I come back; not to mention IF we even get out of this box in one piece. The only way I can protect you is if you sit in that wheelchair. I know you can't keep up with me walking, and the triage motto is "No One Gets Left Behind". I'll draw their fire: you go in the chair, it's our only chance".

The patient took the chair; his wife was laughing so hard she could barely walk.

Another strategy to avoid the "I was here first" scene is to call a patient from the door and tell them they have a phone call, or that there is some problem with their insurance, or that we made a mistake and they are supposed to be in XRay. We have a non-urgent side that is strictly first come, first served, but for a returning wound check, IV antibiotic etc (and they are nice people who don't deserve to be sitting with the rabble) we can try to expedite their visit. Hey, it makes us feel good, and scores one for us. There isn't much we can control so we take it when we can.

Granny Dump

It happens every day, but is never more poignant than over the holidays. Families from afar visit Grandma or Grandpa to drop off the annual fruit cake to find that the Poor Dears are living in utter squalor and haven't bathed in 2 months. There is not one scrap of food to be found except for a can of peaches that poor arthritic hands can't manage to open; the last refill of medication for heart conditions, hypertension and diabetes hasn't been filled since October.

Well-meaning but clueless families bundle off their confused, dehydrated, foul-smelling relatives to the nearest ER where they procede to make demands, hover over their demented loved one who doesn't know them from Adam, and generally try to make themselves appear loving and caring (as opposed to guilt- ridden). At least until you put them on the spot:

Triage nurse: Do you know what medicines your grandmother (aunt, uncle, etc.) takes?

Loving Family: Well, we brought the bottles. Don't you have her records? Do you have any juice?

Triage nurse: Do you know what medical problems your grandmother is treated for, surgeries, allergies to medication?

Loving Family: I think she is diabetic? Can you get her another pillow and blanket?

Triage nurse: Any idea when she last saw her doctor?

Loving Family: Is there a cafeteria here?

Triage nurse: Does Grandma get any services? VNA, Meals-on-Wheels? Lifeline?

Loving Family: We just don't know. You have to do something, she can't live in that house with nobody to take care of her.

Triage nurse: (innocently). Based on what you have told me about the conditions she is living in, I have to agree. Will she be living with you when she is discharged?

Loving Family: Um, er, well, ah.....Don't worry Grandma, you're in good hands. We will be back later. (Running for the exit)

With Loving Family gone, we get Grandma undressed, cleaned up, made comfortable, hydrated, and diagnostics accomplished. She really is a cute little thing, and becomes something of a favorite in the 8 hours she is with us. Loving Family makes a brief cameo appearance to "check in", leaving their number and disappearing for good.

I really wonder how some people can live with themselves. It sucks to get old

Ho, Ho, HO

Well, Christmas has come and gone, and for once I didn't work one second of it. Not Christmas Eve, not Christmas Day. What a treat it was, and well deserved as I have worked each and every Christmas since I was 13 years old; believe me that was a LONG time ago. I must say I did not miss being in the ER and having to take care of the usual sick and stupid. Actually, on Christmas it is more like the critically ill and the galactically stupid; extremes are the norm.



In addition to not working on the holiday, I am also on break from school until the middle of January, so I had a nice relaxing few days. Returning to work today was a pleasure, right up until Last Call when a member of the Better Living Through Chemistry Club came in with a migraine and demanded the only drugs that work for her: Toradol, Demerol and Phenergan. I work at a couple of ER's in the area so I poked my head in the room just to say hi. Her reaction can best be summed up by a parody of a credit card commercial:
Cost of ER visit to the patient: $Zero
Cost of ER visit to you and I because she has Medicaid: $400.00
Meeting the nurse who took care of your worthless ass last week in another ER: PRICELESS.

Old Nurses Never Die..They Just Go Back To School

At the age of...well old, I have gone back to school to get my degree. I went to nursing school when the choice for nursing education was a 2 year ADN program, a 4 year baccalaureate program or a three year hospital based diploma program. I chose the three year route. Good or bad, it was over 30 years ago. Now that I am old and creaky, I realize that I do not want to spend the waning years of my career pushing around stretchers containing farm animals. I believe I would have a lot to offer in terms of educating the next generation of nurses, so I am pursuing my BSN and then my masters in nursing. Unless I just decide to work at Chilli's.

To date, in addition to the 45 credits I was given for being an RN, I have taken five courses and received credit for two others that I took a few years ago. I get no credit for any of the lab science I took, and I have to take chemistry and two math courses. Not looking forward to that. At the rate I am going, it will take me 2 more years to get my degree, and who knows, 2 years for a masters. Why is this made so difficult?

With the looming nursing shortage and the paucity of masters-prepared nursing educators this country is going to be in big trouble in a couple of years when nurses my age retire. Or work at Chilli's. I realize that I need to get the necessary degrees, but sheesh.

There plenty of programs for individuals with a BA or BS in another field making it significantly more easy for someone who has never worked in the field to get into nursing as a second career. It is even possible, in 2 years, to become a nurse and get a masters degree. Does this make any sense, a brand new nurse with a masters degree? To do what? Certainly not teach! I interviewed one for a position in the ER at Utopia Hospital. She had literally no clinical experience and would have been a disaster; not to mention it would have been setting her up for failure in a fast-paced ER where, I'm sorry to say, my little friends were famous for Eating Their Young.

Psychosis is the Reason for the Season

The holidays are always a time to anticipate seeing more of those lost souls who Cannot Cope With Life. Like the bag on old St. Nick's sleigh, the ER's are filling up with with the depressed, the suicidal, the drug seekers, the alcoholics and the true psychotics. Now, before you get on your high horse, I have such individuals in my own family. They cannot cope with their lives either. They are the drug seekers, drug addicts, and other people who exist in a world that doesn't understand them and is sick of trying to help them because they are incapable of helping themselves. While this is sad, it just sucks the life out of ER staff to have to see these same people day, after day, after day. It is a waste of resources, really. The Scary Catholic Medical Center in Pseudocity where I occasionally moonlight (the crucifixes in every room creep me out a little, quite frankly) lets them sleep in the waiting room; they are allowed to sit and wait about 8 hours until they are sober or get bored and wander away. The genius is they have a warm place out of the weather, but the ER doesn't really have to take responsibility for them.

Icing

The first (of many) winter snowstorms in Frozen Tundra of NH always brings out the best and worst. The newly fallen snow covered treacherously hidden ice, causing many to go to ground. In the first 90 minutes of my shift in Tiny Satellite ER, local EMS delivered an ankle fracture and two shoulder fractures, a coccyx fracture, shoulder sprain, scalp lac and a variety of bumps and bruised egos. Naturally, it brings in someone for a med refill ("I know the pharmacy screwed up and didn't give me ALL the Ritalin I need, so now I've run out"), drug rash ("My three year old has had it for THREE DAYS, and it's much worse since our PCP saw it the last 2 days, what do you mean it's a two hour wait??"). It never fails to amuse and amaze that these people would take their lives (and their children's) in their hands, put on the galoshes and go out and drive around with the rest of the crazies here above the Arctic Circle.



The best was the Hover Mom: you know, standing in the doorway, asking for something every 5 minutes so you know she's concerned about her 9 year old who fell in the driveway and has a head bump. No LOC, but their PCP assured her that "a head injury would be a top priority and seen immediately" (um, your pediatrician is an idiot who lied to you, and he WAS seen immediately and appropriately triaged. I'm pretty sure he's not herniating). What posesses these PCP's to say make such blatently stupid statements and get everybody all riled up?



Anyway, after casting, splinting, slinging, stiching and icing all the boo-boos, it got very un-busy. I hesitate to use the Q word, because you never know when it will come back to bite you. And I have to work tomorrow, so I'll play it safe.

Meet Dr. Dewshe Bagghe

Since leaving Utopia ER, last year, I have come to accept that quality care (and quality ER docs) are a matter of perspective. One individual who should just hang it up I will refer to as Dr. Dewshe Bagghe. Cranky, sour, condescending, everything the experienced physician was, oh, say 35 years ago; which is about when he should have retired. He is just plain mean. Honestly, I feel sad for the patients who have the misfortune to have him for a doc. He actually said, not only in my presence but IN FRONT OF A PATIENT, "I hate this fucking job, it sucks". Nice. He hates me because I have a brain, 30 plus years of experience, and usually anticipate what he's going to do. If I get out a certain med, he won't want it. If I draw blood, he won't order any tests for awhile. If I order a cardiac workup, he'll cancel it. If I ask him for pain meds, he'll dance around the issue. He makes it the most unpleasant place to work. One night I had a sick 2 year old, a tough stick with a fever, vomiting, and a nervous mother who was used to getting her child's emergency care at Big Metropolitan Children's Hospital and not Regional Pseudocity Medical Center. A master of communication and a real team player, old Doc. Dewshe Bagghe told me to put a line in the child. OF COURSE he was going to order cultures and labs, he just neglected to tell me (or was waiting to give me enough line to hang myself with so he could confront me). And OF COURSE as I was drawing the blood anyway after a successful stick the Charge Blond comes barreling in to tell me to draw the bloods. Sorry, already on that. Ha!

I'm pretty sure the rest of the world has progressed to the point where this kind of behavior is not tolerated. I throw him under the bus whenever I can, though, so that's fun. When the patient's complain, I give them the name of my boss, the name and phone number of the administrator and encourage them to complain. Guess I will have to come up with something else though, because he's still there.

Supersize Me

The official start of the holiday season brings a week for caring for the morbidly obese. Now, I have no problem with people unless they refuse to take any responsibility for themselves, but I'm frankly getting tired of spending a lot of effort stepping around people's motorized scooters because they are so overweight they can't walk.

One guy (no scooter) weighing in at over 300 pounds presented with increased urination and insatiable thirst for about a week. To nobody's surprise his blood glucose was 620. I was kind of worried about this guy because all he could think about was going home to eat the cheesecake his wife had made. Sheesh! Guy, you are a walking heart attack and a stroke waiting to happen.

Supersized contestant number two was a woman weighing in at over 400 pounds who comes in by ambulance (EMS, you are my heroes) with an ankle injury one day after sustaining a fall in which she broke her proximal humerus. Truly, I don't know how this individual functions. She was clearly hygienically challenged. Her ankle was merely sprained, but a family member wanted her admitted. WTF! Don't you love how the family members are all over the patient in the ER, but when it comes down to taking care of the patient at home they trip over each other heading for the hills. I had PT do a safety evaluation and she failed because 1) the patient lives in a 2nd floor apartment, 2) the family had REMOVED THE BANNISTERS AND THROWN THEM AWAY TO GET FURNITURE UP THE STAIRS, which means, 3) she couldn't safely or QUICKLY leave the apartment in case of an emergency (!). Are you kidding? That woman had no prayer of leaving that apartment quickly for the last 10 years with 4 good limbs and wings. Yikes. The bottom line is that the patient gets admitted so someone else can take care of her. But the family drove her, I'm sure out of the goodness of their hearts.

The ER Waiting Room: Too Many Squeaky Wheels

It is at Triage that many of the problems dealing with the public begin.

Not understanding or caring that the ER is not Burger King where one may very well not have it their way, the triage process is of little importance to the patient who insists that his problem is worse than anyone else’s. The consequences of the “squeaky wheel” mentality on a waiting room full of frustrated, anxious, sick, and angry patients can best be described by envisioning the abandon ship scene in the movie, “Titanic”.

As the boats are filled with women and children (think of these as the really sick people), the men (people who are not as sick, have chronic conditions, and are well enough to sit in the waiting room for hours) are left on deck hoping for rescue and singing “Nearer my God to Thee” while the stewards put out more deck chairs. Much as these patients believe it, however, the ER waiting room will not sink; this means it is pointless to storm the triage nurse to explain how badly one needs to be seen as soon as possible (consider this clamoring for a spot on the stern of the ship). Eventually, there will be a boat for everyone, even it is takes 6 hours. If a patient is likely to require a kidney transplant by then,he/she will be seen sooner. Otherwise, the waiting area is a little like Disney World: just when you think you are getting in, there is another 2 hour wait before you actually get on the ride. Alas, there is no "baby swap", and sending your 7 year old to inquire for the fifth time in 20 minutes how much longer it will be just wont' fly. And it doesn't matter if you have another appointment, dinner reservations, a meeting with your parole officer (pimp, ex-boyfriend, drug dealer, your child's teacher, life coach). Remember, patience is a virtue.

Day After Thanksgiving

I usually work the evening shift, I just like it better. There are generally fewer suits to mess with and you can do your own thing. The only problem is that when the ED Nurse Suit goes home at 4 PM, there is the problem of poor staffing, no techs, and no paramedics. Oh, and no transport. It is not ok to leave the shift with the highest volume of patients without adequate means to provide for the hordes, especially the day after Thanksgiving when the PCP offices are closed. I was quite pleased, in an evil sort of way, to hear that the day shift was so busy "we could only sit for about an hour!" Oh, really. Pardon my sarcasm, so sorry you couldn't enjoy the entire paper AND your latte.

Well, my day after Thanksgiving was something to be thankful for. I had nice, normal, appreciative patients. I really felt like I did something good today, even if it was nothing more than being able to REALLY do some patient teaching, make someone actually feel better, help my colleagues and take a bathroom break before ascites set in. Whoo hoo!

All Aboard the Toradol Express!!!

I wish I had a nickel for every time I have heard, "You have my records" (sorry, I don't, and I'm not interested enough to go look for it), "I take that little blue pill for my high blood pressure, don't you know what it is?" (nope, it's one of thousands) "My doctor knows what I take"(yes, but your doctor pawned you off on the ER, now, didn't he?). I bet the average ER nurse spends at least 1/3 of a shift doing what patient's should be responsible for. I feel bad for the pharmacists who have to take calls from us to verify a patient's meds because they were too lazy to write them down. Come on, people, it takes 30 seconds. And if you don't know what you are taking and what it's for, you probably shouldn't be taking it.

Don't get me started on the drug seekers. Tonight we had an impressive attendance of the "Better Living Through Chemistry" Club. Everyone got a shot of Toradol. I admonished the doc that we only had a limited supply even though IT IS A MIRACLE CURE. The woman who came in cradling her shoulder with 10/10 pain had no trouble lifting it to give an obscene gesture on the way out. And that guy with the hip pain who limped in had such a spring in his step as he slammed out that door (probably on the way to the other hospitalin town. Guess they didn't get the memo that Dr. Nonarcs was on duty.

Having a family member become a hospital patient really makes you think about your own practice. My physically active husband returned from a pre-op appointment for elective shoulder surgery with symptom-free "changes in my EKG" and was turfed to his cardiologist. Another EKG, an Echo, and next thing you know, he's headed for the cath lab. While on the table (and after finding a couple of significant occlusions) he now has a choice of the metal stent or the medicated stent. Choice A means ASA and Plavix for a few months. Choice B means ASA and Plavix for over a year, and by the way you can forget about that shoulder surgery. Since I happened to have a friend who worked in the cath lab, she drags me back to help my husband with this decision. This is a problem considering he is one takes 3 trips to the store to decide on a pair of jeans. I will say the interventionalist was VERY patient with him; decision made, medicated stent.

In the ICU, Jane, his nurse, seemed to understand my husband's "what the hell just happened here", deer-in-the-headlights look and promptly got him some Ativan. She patiently answered all of my husband's questions and got him settled in. She signed out to Leslie at change of shift, who handled my husband beautifully with the right mix of humor, authority and caring. My husband had some leaking around clip in the artery, so in comes the Resident Twins. This is an equal opportunity teaching hospital, so they neither speak English nor posess people skills. Oh, and they travel in pairs for added fun. I refused to leave until I made Leslie promise that she would turn my husband over to someone more than competent at change of shift, and keep Frick and Frack away from the patient.

I picked husband up at noon the following day and all was well. He is home now, testing me at every turn, angry that he can't have his surgery and not yet grasping that the ticking time bomb in his chest has been defused. A little perspective is useful.