Idiots in Paradise

I

AM

ON

VACATION!

Mr. EDNurseasauras and I are vacationing in Sedona. It is beautiful and alien, so not like the East; we are fascinated by the formations and history.

"I could live here", I commented to my husband.

"Yeah, right".

The people are friendly and helpful. That is the people who live here. The assholes are obviously the same everywhere, driving like idiots, cutting people off, and generally happy to be the oblivious center of their own universe.

Mr. EDN and I took a trolley tour on our first day. It was great, our driver pointed out many interesting sights and bits of history. There were several brief stops for photo opportunities and a 15 minute stop at the Chapel of the Holy Cross, built into the rocks. Regardless of any religious affiliation (or lack thereof) it is a pretty inspiring piece of architecture.

Our driver was clear that the trolley would be leaving in 15 minutes. My husband and I, as well as the rest of the group all managed to do our sight-seeing within this time restriction; two people were not.

We sat and waited. The driver did a head count. Counted again. Called the office to make sure that her numbers were correct. Asked passengers at the back of the bus if there had been another couple.

"Yep", I said. "There were. They are late. We were on time, as well as 90% of the group. Let's go".

The driver laughed uncertainly, not sure if I was kidding.

"No, really. We've voted them off the trolley for being tardy. Leave 'em"

"Yeah, she's right", remarked the man in the Red Sox cap at the back. Red Sox Nation is everywhere. "Leave them here to die. We shouldn't be punished for their tardiness"

Most of the passengers laughed and said "Yeah, let's go", and "C'mon, just go".

Pretty funny, actually. The boneheads showed up just as things were getting interesting, oblivious to the glares of my fellow disgruntled trolley-mates and unapologetic. Hey, thanks for coming.

La, la, la.

One night we went to a Chinese restaurant for some food to take back to our condo. There was a fountain adjacent to the restaurant, with a large bronze statue of Neptune. In the midst of this was a little pond with plants and flowers, and a large bronze chair.

As we emerged from the restaurand with our food, although it was poorly lit (no streetlights in Sedona), a man was getting up out of this chair. Another man, with a flowing grey hair and beard and wearing a bathrobe told him "You are in my chair". He had clearly just emerged from said pond. It is important to note that this little oasis was in the midst of group of shops and restaurants. My husband told me he had seen this gentleman earlier in the day walking along the main road. He was wearing the bathrobe at that time as well.

"I believe that man just bathed in that fountain", I observed.

"Let's go before they argue about the chair and it gets ugly", said my husband. The eccentric are everywhere too.

Mr. EDN and I went to the Grand Canyon, just one of the most beautiful and awe-inspiring sights we have ever seen. We had some fun taking pictures of ourselves and using the timer on my camera to get some shots of us both. Mr. EDN is an avid hiker (something I am not) and he got into it, spying the perfect outlook or rock for "the picture". One particularly challenging

shot involved climbing down a fairly steep slope and rock-hopping. For me, with not-so-great knees, it was a challenge.

"This could well be the last photo of me ever taken. Getting here is only the half-way point", I huffed as my loving husband assisted me to our perfect photo spot. "I wonder if the National Park Service will recover my body?"

"You are being dramatic. You did it, and you will get back no problem"

"Okay, fine. Remember, I trust you. And I will haunt you forever if this adventure goes south"

We did get our picture, and it is sensational if I do say so myself. Another brave soul (whose well-dressed wife had remained at the rim) climbed down to join us and was happy to trade photo-taking with us. My husband will talk to anyone, anywhere, and engaged this gentleman in conversation. Turns out we would have been neighbors in our former Massachusetts home as he lives not far from where we lived. Very small world indeed.

On our walking tour along the Grand Canyon rim the idiots continued to mass, their individual orbits colliding with others. One guy on a motorcycle rode along the pedestrian path. On the motorcycle. Where there were kids and elderly people off tour busses by the hundreds. Where's the NPS police when you need them? Speaking of tour busses, many of these people seemed unaware that there were other people trying to walk. On the right side of the path. Hello? This is America, please follow the rules of the road where we drive and walk on the right.

I asked my husband to shoot me if I ever expressed an interest in:

1. wearing a fanny pack

2. using a walker with wheels that could fit a dune buggy.

3. any kind of group bus tour to anywhere.

4. wearing a scarf in 100 degree heat. Sheesh.

We met some lovely people, such as the couple from Scotland who fostered crack babies and other poor substance abuse victims. The were fun people. I was happy to see that the wife's view of the idiocy of the world was much the same as my own. Then there was Barbara, a retired high school teacher who traveled on her own, comfortable with her choices and happy to meet people along the way. She wound up in our rail car because hers was crowded with families who let their unruly children run up and down the aisles, spoiling the experience for others. I love kids, but I just wish that their parents would take responsibility for them.

"Welcome to the adult car", I said. "I saw a sign somewhere that said unattended children will be given an espresso and a puppy. That's almost as good as the guy on the Disney train that said unruly children would be tied up, taken to Small World and made to sing until they are 15". We had a good laugh over that one, and the Scots couple, Barbara and my husband and I became fast friends for the duration of the trip.

Yet, even the idiots couldn't dampen our enthusiasm and we had a truly great time. All vacations must come to an end and I will shortly be back in the real world. Sigh.

This was a great vacation.

My New Baby

This is Tina, my new dog. She is a ton of fun, energetic, smart, LOVES to run and chase a ball or frisbee. She is the only reason I get up and walk a mile before I go to work in the morning, something I have just not been able to motivate myself to do.

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.

Violence in the ER

I know it happens in every ER; someone gets the shit kicked out of them by a patient or visitor who is unruly and abusive, usually under the influence of drugs or alcohol, or because the voices tell them to do it. Granted it is an unpleasant and inevitable aspect of the job, but it sucks to go to work and fear for your physical safety particularly if the security guards are elderly and not in the best shape. I thank the Psuedo City PD for their always prompt response to our 911 calls.

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.

But.

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.

No Words

At 12 noon, those of our rooms that were filled looked like this:
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.

Compassion Saturation

Burnout. We have all experienced it, and if you haven't you are either 1) Lying, or 2) haven't been a nurse that long. Sometimes it is helpful to take a step back, step out of the department, take a vacation, or take a break from your particular brand of nursing insanity.

I have always had at least two jobs, sometimes 3. It always gave me a bit of perspective and, I think, made me a better nurse; or at least better emotionally equipped to handle the crap du jour, knowing that the same stuff goes on everywhere. The grass may not be greener, but it is possible that there may be a bit less crab grass if ya know what I mean.

While I have always worked in the ER, some of my other "day" jobs have been a Visiting nurse, school nurse, working at a tiny ER on my days off from Utopia ER. I also taught CPR and First Aid courses as a road show with other ER nurses. Hey, it got us out of the ER and kept us off the street. Besides, my students were always mad for ER stories of brave saves by Community CPR trained civilians. Plus they wanted to pump us for gory ER dirt. There but for the grace of...well, you know the rest. Anyway, the point is not to fear change. It's a good thing every now and then.

When a change of venue isn't possible, letting off a bit of steam is always helpful. ER staff are nothing if not creative when it comes to inside jokes in order to cope, and every ER I know has their own moronic brand of humor. Heck, every corner of the hospital has their own coping mechanisms. It's universal.

The other day one of our new ER attendings, a Hopkins trained lad, was discussing his plan for one of our frequent flyers. Now, I could have told him that she has had 16 visits in the last 90 days, but he has that information at his disposal with a mere few keystrokes. I could have told him exactly how many milligrams of Dilaudid it would take before she would ask for a turkey sandwich, the TV on channel 13, 5 warm blankets, and finally to go out for a smoke. But hey, I don't want to appear jaded in front of Dr. New Guy (whom I really believe will be a tremendous asset) and since he was most sincerely telling me his plans, which none of the old fart docs ever do unless I back them into a corner, I didn't want him to think I was uninterested in what he had to say. So after he rattled off the labs he wanted, I very sweetly asked "serum porcelain level?"**

With that he bellowed with laughter and dragged me over to the department's only copy of the Harriet Lane Handbook, the pediatric bible (which, by the way, came from Hopkins). He showed me that it did in fact have the normals for serum porcelain.

You know you're going to look it up. Be sure to check out the foot note, too.

** serum porcelain level =fictitious blood test.

Means that the patient (or the complaint) is a a crock of shit.

Psych Pup

A while ago, I posted about a woman whose service monkey had been banned from various establishments because he was a bit of a biter. Yesterday we had a patient with her own psychiatric service dog. These are apparently legit, and are trained for a range of functions; check here for more information ( I am especially intrigued that the animal is capable of "reminding handler to take medication")

I have discovered that there are criteria for determining legitimate disability and therefore simply saying "I have a psychiatric disability" doesn't entitle one to disability status. By the same token, announcing that your skittish Irish setter, whom you have dressed in a Celtics cap, green sweater, and a hand embroidered scarf declaring your canine a "service dog" does nothing to further either your cause or that of your animal.

Unless these actions simply make your case.

Packing 'Em In, and Stacking 'Em High

Sigh. The beancounters are at it again. I truly believe that there must be some kind of...well, prize, or premium for winning whatever idiotic beancounter contests they are involved in.

During times of high volume Upper Level Management,who watches the ER board from a computer waaaaaaaay up above us, keeps a close eye on the Scoreboard. This Eye in the Sky so to speak really knows whats going on in the ER. Really. They know how to find it since they were there for the rededication after the renovation 2 years ago. Said Management, having read all of the People Magazines as well as "How to Manage a Hospital for Dummies" knows how long each and every patient has sat in the waiting room. My, they truly seem to have the Big Picture, don't they?

I'm thinking that there must be some kind of beancounter Sweeps Week, because the Eye in the Sky has been particularly vigilant this week. MANY calls to the ER to let us know that patients ARE IN THE WAITING ROOM FOR A LONG TIME.
So?
Eye: Patient 1 has been in the waiting room for 2 hours. He needs to come to a treatment room NOW.

Me: Um. Well. That individual has been in the ER 4 times this week for Insincere Detox (translation: homeless, it's hot out, and the shelter is not airconditioned).

An hour later, the Eye in the Sky, omnipotent, omniscient, and omnipresent calls down again.

Eye: Patient 2 has been in the wating room for 2 hours and 20 minutes. He needs to get into a treatment room NOW.

Me: Well. Ahem. We have just had 7 ambulances roll in over the last 25 minutes, one is a v-tach arrest who is having the Big One, there is no cath lab available today, so the patient has to go down the highway. Oh, and we got an overdose, 2 more chest pains, a DKA, the police with a guy in shackles, and possible stroke. Scary Catholic Medical Center is on diversion and we are getting the overflow. We're a little busy. Stop calling me.

An hour later, the beancounter and entourage decide to make a Cameo appearance in the ER to Size Up the Situation, and Make a Plan. This is accomplished by the most insidious of all creations, the Ambush Huddle. Never has there been a more time-wasting activity than having the beancounters assess the situation, THEN tell you how to do your job.

Imagine the ER as a game of Monopoly. There you are, playing the game according to the rules; you are going on your merry way, buying up Utilities and Railroads, landing on Park Place and putting up houses and hotels. You are regularly passing Go and collecting $200.00. You have your strategy. It's cool.

Now imagine that in the middle of the game, sitting there with your hotels on Park Place and Boardwalk, you are told that the rules have changed. Now you are told that you will no longer be able to collect all of your $200.00; or only get it sometimes. And you have to put houses on the railroads and utilities too.

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.

So, with Beancounter Sweeps week shaping up, the good news is that we have managed to shave a whopping 2 minutes off the average waiting time.

Wow.

Yep. 2 minutes. And for what? The waiting room is empty, the ER halls are full, the nurses are overwhelmed, the docs are overwhelmed, it is crowded and unsafe; it is difficult to navigate around all of these hallway dwellers and their posses who want a warm blanket and a turkey sandwich. The most pitiful thing is that the patient's have been sold a bill of goods by being placed in a hallway bed. It's like Disney World; you wait 2 hours in the queue, and when you finally get to what seems like the entrance to the ride, what do you find?

Another queue; another 2 hour wait.

Excuse Me??

Overhead page:

Code Brown, ICU! Code Brown, ICU!



Easily 8 heads pop out of various rooms in the ER.

"What?"

"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!

The Best Hospitalist

I loooooooooooove our hospitalists! I've said it before, I'll say it again. And again. And Again.


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!!

You Are All In My Book...No, Really

Most of my colleagues think I am either A) Shitting them, (not) or B) Scared shitless (you should be, especially you, Dr. Dewshe Bagghe) that I am writing a book about the ER and they are all in it. It has become such a joke that when someone is observed doing or saying something funny or idiotic, or we have an especially interesting night, I get "well, that's a chapter for your book right there!". Indeed, some people could be an entire chapter. There are a few patients who could be a complete book; nay, an encyclopedia. Here is a chapter or two:
Medical Mysteries
"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)


Heartbreaking

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.


Headbangers
"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"


Exemplary Patients
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.

More Fun Than....

I've never heard of an agorophobia monkey, but a service animal, is a service animal, isn't it? This woman has sure opened up a can of worms with her service monkey, having been banned by her hometown Wal-Mart as well as other establishments, particulary those that sell or serve food. Her local health department is responsible for this monkey business, and it looks like it could get ugly.

Turn on, Tune in, Drop out

What is up with people in their 50's, 60's and 70's smokin' weed? And every day at that? The sixties are over, man. Timothy Leary is dead (to quote the Moody Blues).

I have gone months using the Admission Screening tool without anyone copping to recreational drugs. People admit to smoking, but I just can't believe that the entire state of NH are just casual smokers. Patients will tell me "oh, 3 or 4 cigarettes a day". Yeah, right; you just naturally smell like an ashtray. Drinking I just automatically assume they are underestimating, unless, as I did yesterday I get a response of "I have 4-5 beers a day and 3 highballs". One guy told me he drinks a 5th of vodka a day. I'm sure he is pickled, and that his BAL ALWAYS hovers around 300. But hey, their honesty is refreshing and we can at least anticipate withdrawal and do something about it.

Very Bad Things

For many years I worked at a really tiny community hospital. The ER was miniscule, only 6 rooms. We used to say "a river runs through it" because the main corridor bisected the ambulance bay, waiting room and 1/2 of the treatment rooms from the registration desk and the remainder of the patient rooms. Even though it was small, we would still get the occasional "really bad thing" that kept us nurses honest, as well as serious about maintaining and upgrading our skills. In fact, 98 percent of the nurses (12 of us) were CEN's (Certified Emergency Nurse). No small feat I can assure you.

I was thinking that this summer is the 20th anniversary of the murder of a local woman by a man who lived in town. There hadn't been a murder in about 60 years, so violent crime was not a mainstay of this bedroom community. The murderer mutilated and partially ingested parts of the corpse (eww) prior to the arrival of the police, and subsequently complained of chest pain and was brought to our ER. It was a media circus for sure, yet we maintained our professionalism and composure even when the police were bagging the vomit for evidence (double eww). The very evil man went to prison for a few years, and eventually died of cancer.

Choosing the ER: Surviving and Thriving

Braden at 20 out of 10 asked me to write a bit on why I chose ER nursing out of all the kinds of nursing that exist. Actually, it was one of many I tried out, but I have done it the longest. I thought back over 30 years to my exposure to various specialties, and it was like Goldilocks' take on the 3 bears house:

Critical Care? Too long in one room with one patient!

OR? Too cold, and too long in one room with one patient!

Pedi? Did that. School nursing, too. Loved the kids, parents were all nuts!

Psych? NOOOOOOOOOOOOOOOO!

Med surg? Did that, but not enough action! Gave me good assessment skills though.

OB? Um, not my cup of tea.

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

If you asked 20 ER nurses why they do what they do, you would probably get 20 different answers. Variety. Adrenaline. Challenge. The need to know about a lot of different kinds of nursing, and nursing care across the life span. Some would tell you blood and guts, and it may be partially true; the real answer is probably closer to really helping people when their lives are hanging in the balance, to REALLY make a difference.

ER nursing is physical, demanding, often overwhelming, frequently frustrating, sometimes heartbreaking; the patients flow in endlessly, and the floors often can't/won't take the admissions which creates a bottleneck. What keeps an ER nurse going back day after day, year after year? Well, for me the answer is being part of team; knowing that I can always do better; making a point of learning something new everyday; and choosing to make CARE the most important part of Emergency Nursing Care. That's what makes me an ER survivor.

I'm Back (Part 2)

Where else have I been? Attending graduations, taking two killer courses that I am thankful are over (and for my 2 well deserved A's), having a stress echo, and seeing old friends. I seem to have left a lot of people in my wake over the years, and just reconnected with people from three groups from my past. I spent a weekend at a lake house with four gals I graduated from nursing school with. I had not seen 3 of them in 20 years; it's been 30 since I saw the other one. Let me tell you, we did nothing but laugh for two solid days except for when we were asleep. We did a fair amount of drinking of course, and talked and talked and talked. About family, husbands, life, death of parents, kids and kids, antidepressants, menopause, sex--you name it, no subject was taboo. We even took a drunken canoe ride on the beautiful lake and annoyed the neighbors with our off-key singing. Ah, memories. Nothing better than renewing old friendships. What an amazing group of women.

Naturally we talked about nursing; 5 nurses together of COURSE we talked about nursing. Here I was thinking I am the only diploma nurse left on the planet, yet two of my closes friends in nursing school have also not completed their BSN either. One is 30 credits shy of her degree, the other has only taken 2 courses. I am just about 1/2 way through. The other two each have masters degrees; one is a director of nursing, the other is a nurse practitioner (she went back for that after she got tired of attending meetings as a Clinical Spec.). Of the remaining two, one is still a staff nurse in the ICU, and like me did her share of being a manager. The other works in Quality.

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.

Regardless of our education since graduation, we all agreed that we wouldn't have traded it for all the 4 year degrees in the world. We learned the art and science of nursing by taking care of patients 24 hours per week, and preparing for at least 2 hours before every clinical the night before by reviewing labs, nurses notes, meds, care plans and meeting our patients. For us diploma dinosaurs, critical thinking is something that was developed over the years, not crammed into a four year course.

Anyway, it was great that after 30-odd years a group of friends who "grew up" with each other fit right back together without skipping a beat. Naturally, we scheduled two more get-togethers sans spouses before we said goodbye.

Renewing old friendships: priceles.

I'm Back (Part 1)

Like the proverbial bad penny, I'm back after a 2 month sabbatical. Where have I been you wonder? For one thing, I celebrated my 30th wedding anniversary with Mr. EDnurseasauras in a lovely warm climate for a week. Aruba was beautiful, everything I could have wanted in a relaxing vacation. The second hut from the top in the second row from the right is where I spent most of my time gazing at the water and taking in the sights.

And there were many. Although Aruba does not have clothing optional beaches (and this was a VERY nice resort) Mr. EDNurseasauras and I were treated to the vision of Naked Girl every afternoon. Hubby missed her first appearance since he went to work out. Very concious of keeping up with his exercise program since his Near Death Experience last November. Anyway, he didn't believe my Naked Girl story until he saw for himself the next day. It was pretty funny watching groups of guys walk by and do a double take, then find a reason to stick around for a good long look. So predictable.

We had our own Near Death Experience on a jeep tour around the island. Our driver was one of the clients! This stuff would never happen in the US, yet we bunch of sheep just went along with it. To her credit, the gal who was driving did a great job. We all survived the 45 degree rock climb and return ascent with the loss of nothing more than a couple of buckets of adrenalin.

From the "Strange Tales" Files

Patient complains of abdominal pain x 5 days and comes to the ER.

Since said patient was wearing pink zip up hoodie with some kind of girlie logo, pony tail with pink scrunchy, and named Kelly, I naturally asked the date of the LMP and was told "I don't have periods, I'm male".

Pregnant pause.

Oh. Sorry.

Thirty-odd years of nursing intuition should have told me that if it looks like a duck, walks like a duck and quacks like a duck, it must be a...rooster. Damn, I'm a bad mind reader after all!

Salt 'n Pepper Nursing

EDNuresesauras' gradution photo, circa 1888. That's me, top row, 4th to the left.

The caps that we used to wear, once the hallmark of the profession, have been obsolete for longer than many of the nurses I work with have been on the earth. I can remember wearing my cap for the first few years. I can also remember sailing said cap into a corner as soon as the nursing supervisor left. I don't miss the cap, they were probably pretty germy, but I do wonder at the changes since I started doing this job.

A young colleague, a nurse with two or three years of experience recently asked my opinion on how to deliver a complicated bit of nursing care. After I had explained what he needed to do, he looked at me admiringly and said, “You salt and pepper nurses know so much, I hope I have that someday”. I thought he was referring to actual gray hair, although I have none. He explained that he was speaking of “my years of accumulated wisdom”(haha!), clinical excellence, a desire to share it with others, and a non-threatening way in which to share it. This meant a lot to me, and I was quite touched to have been thought of in this way. The respect of colleagues is a pearl beyond price.

So much in nursing has changed over the years. ERNursey hit the nail right on the head with her back to basics nursing observations. I do think that we, as nurses all want to do what's best for patients, but there are so many obstacles to providing even basic care well that it has become increasingly frustrating. Dealing with difficult patients, demanding family members, unruly drunks, drug seekers, and violent psych patients are only part of the problem. What breaks the heart and ultimately the spirit is the "do more with less" mantra from MBA's who don't know a bedpan from a party hat. What we are hearing is "we don't care about what you do, you are only as important as high satisfaction scores". Good nurses are leaving the bedside in droves because they are sick and tired of compromising; literally the care is being forcibly extracted from nursing care. You can only do so much before something has to give.

So, excuse me while I "close the curtain for privacy" and shed a tear or two over the poor prognosis for nursing care.

Human Piggy Bank

I really thought it was an April Fools joke.

The father of an 18 month old in triage stated his child had swallowed a coin.

18 month old promptly vomits 28 cents. One quarter and three pennies.

"I feel all better. Can I hab gum now?"

Would You Like Some Cheese With Your Whine?

As the acuity in the waiting room plummets, the drama factor rises exponentially. There must be an equation for this; please post it if you can think of it. Whine, whine, whine, that's all I heard today. What is wrong with these people? I spent eight hours in my beloved triage box, and it was one bonehead after the other. A number of people presented with cold symptoms. Has there been some new ad in Good Housekeeping that encourages people to go directly to the nearest ER with a runny nose lasting more that 2 days? There were quite a few with vomiting. Tough call on vomiting and when it is appropriate to go to the ER, but I will say that nausea and vomiting x 1 before heading out will bump you down the acuity list. It will further be downgraded if you are asking for change for the snack machine or eating Cheetoh's.

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.

Dream Sign for Triage (well, it IS customer service, isn't it?)

Heh, heh. I had to chuckle at Girlvet's triage warfare.

Here is my dream sign for triage:

1. Please do not ask how long the wait is. We are doing our best to serve you.

2. Patients are seen in the order of severity of illness or injury, not "first come, first served"

3. Lack of planning on your part does not constitute an emergency. If you need a prescription refilled or have a chronic problem, please see your PCP.

4. Triage is not a popularity contest, nor does the person who wails the loudest automatically get in ahead of someone who is legitimately ill or just very quietly suffering.

5. Save the drama for your Mama. See #3.

6. If this is your third or more visit with the same non-urgent complaint this week and you have not followed any of your discharge instructions from your previous visits, we probably can't do anything more for you. Most of our advice is based on common sense, and there is no prescription for a congenital absence thereof.

7. If you are checking in with abdominal pain or vomiting, please do not avail yourself of the delicious snacks in the vending machine. For that matter, please do not eat the Big Mac you have brought with you.

8. Please be courteous to the staff and others who share the waiting area; screaming and using foul language only serves to piss us off, and Pseudocity Police station have way less comfy beds in their holding cells. And your bail will be more than your co-pay. Not that you'd pay it anyway.

9. Please do not inquire as to why someone has been brought in to be seen ahead of you. The triage nurse is very experienced, and if she thought you were as sick as you think you are, you would be in a bed too. Besides, it is none of your business and privacy laws exist to protect, well, privacy.

10. If your condition has changed or become worse, please do let us know and we will be happy to reassess you. Please be aware that the decision of the triage nurse is final, and faking a seizure is not cool.

11. Please watch your own children and be responsible for their needs. We cannot give everyone a turkey sandwich. Your medical care may be paid for by the government, but if you can afford cigarettes, a cell phone, and a videogame for each of your 5 children, you are expected to feed them.

12. "Pregnancy test" is really not a reason to come to the ER.

Operators Are Standing By....

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?"

I Guess It Takes a Full Year For Some People to Feel Friendly

Wow, Hell has frozen over and I'm expecting the sun to rise in the west tomorrow. Dr. Dewshe Bagghe has condescended to make eye contact and engage me in actual human conversation. Will wonders never cease?

Aww, are you feeling all left out an lonely because I ignore you?

I'm sure.

Must be you are all impressed with what an AWESOME job I am doing as admissions coordinator. If not, see above image and follow these directions:

"First shalt thou take out the Holy Pin. Then, shalt thou count to three, no more, no less. Three shalt be the number thou shalt count, and the number of the counting shalt be three. Four shalt thou not count, neither count thou two, excepting that thou then proceed to three. Five is right out! Once the number three, being the third number be reached, then lobbest thou thy Holy Hand Grenade of Antioch towards thou foe, who, being naughty in my sight, shall snuff it." (Idea shamelessly stolen from Monkey Girl--I love Monty Python!)

Ear Enemas 'Til Clear

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?

Why?

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.

We Have Met the Enemy...and We Don't Like Him (Part 2)

Noun 1. bean counter - an accountant or bureaucrat who is believed to place undue emphasis on the control of expenditures

Usually, the last thing in the world the bean counters want is for the ER to go on diversion- it's a money thing, or course. It always is. They will micromanage the hell out of what is going on in the ER to the point of silliness. The latest silly thing is "the Huddle". What is the Huddle, you ask? Simply stated, it is a meeting of the minds--the ER doc, charge nurse, admission nurse (reluctantly), and a couple of useless bean counters to "look at the board", or as I like to call it the ER scoreboard. How many patients, how many admissions, how many potential admits/transfers/discharges, where in the process are the docs/hospitalists on dispo's. Instead of asking "what can we do to help you", we get "what are YOU doing to get these 40 people out of here so we don't have to divert. It's all pretty senseless, because it's all just math; too many patients + not enough beds = diversion, a monkey could do it.

On Fridays, when the bean counters and managers go home, there seems to be an assumption that nothing happens in the hospital, that life goes smoothly on, and it is a happy little utopia for patients, nurses, docs and everyone. I humbly say this is complete bullshit, and Friday was business as usual. I am trying to get these people out of the ER, I really am. I have beds for everyone, including the suicidal 1:1. I am finding the charts for the hospitalist. I am communicating my ass off to the ER docs, admitting, and at the same time addressing the 5PM direct admit requests (you couldn't do this at 2PM when the patient saw you? Yes, I know about that). But I am only one person. The ER charge nurse is panicked and won't be talked out of the tree. We are on a help alert (does no good if you don't have orders). I get a call from the medical director who grills me on what the hospitalist is doing, how many admits he has (um, 6), why hasn't he called for a backup hospitalist--I simply hand to phone to the hospitalist who happens to be the only one in the whole hospital, not good. The medical director calls me back to let me know that she is flabbergasted that he is all alone, and it will be addressed on Monday, "in the meantime, there is nothing I can do about it", NO SHIT. And for the record, I didn't ask. It's Friday, inexperienced ER charge nurse, no techs, no volunteers, no paramedics, no LNA'a. Guess what? We are on diversion. Monday morning there will be an Ambush Debriefing: a surprise meeting, complete with white board, QM, and whoever was working on Friday to figure out how it all could have gone so wrong. Since everyone else worsk 3-11 and the meeting will probably be at 8:30AM, looks like I will be the only one there; I worked 4 hours past time to leave to try to straighten things out, but they don't care about that. Want to know how it could have been fixed?

1. More than one hospitalist. The floors were ready, willing and able to take their admissions, they just won't do it without orders. Can't blame them, why should they hang their butts out on a line?

2. Full nursing staff--it still is NOT OK to leave at 3 PM if you are a manager, without appropriate staffing levels. Come on, people, the same thing happens every week!

3. How about a little support for the nursing staff? LNA's, techs or paramedics to assist us in getting patients out of the ER and into their cozy floor beds. It's a no brainer- if the nurse is doing an EKG and mixing critical drugs, do you think she is going to transport the patient? Ridiculous!

Want to know what doesn't help? Constantly talking about the same damn thing over and over!!! I guess I can look forward to a heaping helping of bullshit tomorrow. Maybe I'll just call in sick.

We Have Met the Enemy...and We Don't Like Him (Part 1)

It's been a looooong few weeks, having started school again (Comp/Lit, LOVE it, but it's a ton of work. Is there any call for an aging BSN with a minor in English?). I have also started a new job as an admissions coordinator. On the plus side, it is a lot more days, or at least until 8 PM some nights. No weekends or holidays. I have been orienting to this job for about a month now, and am getting the hang of it, at least the mechanics of where to put the admissions. For example, it has been 30 years since I have worked on a surgical floor. In those days, patients for an elective cholecystectomy were admitted the night before, had enemas until clear, were shaved from "nipples to knees", and stayed in the hospital for about a week. Now it's day surgery. Goes to show you what-all I don't know, but hey, I ask a lot of questions and generally trust that the floor nurses aren't going to 1).Make fun of me, 2)JAFE me on admissions (Just Another Fucking Excuse) 3). Throw me under the bus or 4). Try to lead me down the garden path. So far, everyone has been great, really helpful. And I'm reasonable; to use the SeaBee motto, "if it's difficult, we might do it; if it's impossible, fuck it".

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.

You Guys are Killing Me

I happened to be one of only 2 female nurses in the department this shift. The other 4 were guys, all the docs were guys, the medic was a guy. The other female was in triage which left me to chaperone all of the many pelvic exams, female rectal exams, and any other exam the docs thought they needed a chaperone for. This is a somewhat unusual situation, and escaped nobody's notice that I was becoming increasingly annoyed to become the "crotch nurse in the land of testosterone". Hmmph. Big Mick (he is Irish, and big, but this pseudonym is not meant as a slur, believe me) noted that it was going to be a long "boys night". I predicted that the testoterone would literally drip off the walls. Eamon thought the boys might surprise me by getting in touch with their femininie sides. I told him I really didn't want to work in Brokeback ER, to which he plaintively replied "I just can't quit you!" Eamon, I don't know which is more disturbing, the fact that you know the reference or the quote or both. Whoo hoo! Let's talk about huntin' and fishin'. Which they did. Interesting night, I never thought there was that much to learn about ice fishing, snowmobiling, and potato guns. Ah, well. After all, this is New Hampshire

Fear of Flight?

Well, this was an interesting bit of fun. Local EMS brings for our entertainment an "out of control" 16 year old male with a history of ADD, no Ritalin for 10 days, who has been on a two day Red Bull bender. Mom and Dad have been unable to do anything at all with him, his usual impulsivity and anger issues having been exacerbated by the caffeine and sugar.

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.