Throw Out Your Dead (Year, that is)

Working holidays usually sucks, especially on Christmas; goes with the territory. The ones who get paid through a pea-shooter are forced to be away from their families at least half, if not more, of all of the paid holidays. Clip board nurses get every paid holiday off; every bean counter gets every paid holiday. Off. According to a notice on our bulletin board, the electricians, maintenance workers, and general stores people are also having a paid holiday. Forget that on New Year's Eve day, every single primary care office closes up shop and abandons refer their patients to the ER. As I frequently say, the usual sick and stupid become the very sick and the galactically stupid. Today's mixed bag included constipation, ear wax, spotting 4 days ago x 1 in a 24 year old who is 10 minutes pregnant (no insurance), vaginal bleeding in a 24 year old 5 weeks post partum who is not breast feeding, using birth control and who didn't tell me that she took Plan B 5 days ago. Also no insurance. Oh, and a little girl "rushed" in by her grandmother with fever. "101!!". "But I gave her Benadryl, and it was climbing before I left the house!". Trouble was, Grammy didn't know any of the girl's health information including the date of birth. She didn't notice that the kid's respiratory rate was around 50, and wouldn't have known anyway that her o2 sat was only 88% (should be over 95 at least). Fortunately Dad arrived shortly thereafter to add to fill in the blanks; what a brain trust that was I tell ya. Dad had to be told to carry the kid out to the car with her pneumonia; "yeah, Dad, you probably should give her little lungs a break for the next couple of days, maybe keep her quiet and minimize her activity? mmmkay?". Yikes.

So, I'm working New Years Eve and New Years Day (by choice to be honest; Mr. Ednurseasauras and I haven't been out in about 100 years, and I would prefer to actually be in the ER than out with the Crayzees). We had the good luck to work with The Talker, for whom commonsense rules in all things. Love it. We were busy all night though, but our Last Patient of the Night left before 10:30 PM so we did get out on time. Now, shortly before midnight I sit and reflect on the last 12 months (Mr. EdN has gone to bed). I am briefly distracted by New Year's Rockin' Eve, how can they allow that poor Dick Clark to continue? It is just so.....wrong. This has to be his last year, huh? Isn't he about 106 years old?

Anyway, back to my reflections. I rarely make New Years resolutions; it merely sets me up for failure. But I can think about changes without actually committing to them, that must count for something, right?

So, I imagined that I would have completed my BSN and be working on my MSN by now. I have 2 CLEP's and one course left to take. I WILL complete these in 2011, but as for the master's degree, forget it. Everything I have to teach is clinically oriented. I just couldn't imagine myself in a classroom. Therefore, teaching is down the drain.

I need to return to a busier ER before I become old, befuddled, and lose all of my skills completely. I have too much time on my hands, see way too many drug seekers and other pathetic souls, and lack an opportunity to use my clinical skills in a positive way. Besides, there is just way too much physician interference with the nursing part of nursing care at this facility; I understand the patriarchal culture of a religious hospital, but I have ever chafed at this kind of authority. I have become increasingly unhappy and will do my best to change that in the coming year. No promises, see.

I will try to keep my writing more positive, finish my novel (or scrap it and start from scratch), blog more frequently, read more books, and continue to get more exercise. I actually managed to lose weight during the holidays this year (5 pounds is not a big deal, but I see it as not weighing 10 pounds more, not too shabby). I will keep on making healthier eating choices because at my age, every calorie counts.

I continue to do synchronized skating, albeit badly; I expect every week for the coach to tell me I suck too badly to continue since I am probably the worst skater on the team. I cannot get any better at my age though, more's the pity. I do have fun though, most of the time.

I cherish my family; my husband is active and healthy, and we remain best friends after nearly 33 years of marriage. My kids are awesome; gainfully employed and doing well on their own, both college graduates. My four brothers and their families are happy and healthy, busy with their lives as my 10 nieces and nephews grow and thrive. My mom is 78 and has every last one of her marbles (not to mention her original teeth), is remarkably healthy and active, living on her own with a busier social life than mine.

I have wonderful friends, anyone of whom would be instantly by my side if I asked (as I would to them); the kind of friends who would wordlessly and without argument bring the lime along with the requested shovel. I laugh a lot with these girls; some were nursing school friends, some from various jobs, some from skating. Circles within circles within circles, what could be better. We might go weeks/months without hearing from each other some of us, so I will try to keep in touch more.



I could think about being nicer, stop terrorizing SIC, be less critical....nah. That's enough New Year's reflection for one night, besides it's almost 2011. Happy New Year!

12 Days of Family Christmas Sayings

After hearing the "12 Pains of Christmas" and getting a chuckle, here is a list of 12 quotes from my childhood, usually from my Mom. My four younger brothers will remember many of them I'm sure:

12. "Stop shaking those presents!"
11. "Don't you dare go into the attic / basement / bedroom closet / car!"
10. "Will you PLEASE stop putting the baby Jesus on TOP of the manger?!"
9. " Place the tinsel strand by strand, DO NOT just throw a handful!"
8. "Wait 'til your father gets home!"
7. "Please take the cat off the tree".
6. "Santa won't come unless you are asleep"
5. (On Christmas morning at about 5 AM): "NOBODY is to move past the top step and proceed to the living room until Daddy has turned on the (heat, tree lights, movie camera, coffee)"
4. "Unwrap your little brother right this minute; no, you can't give him to the Salvation Army"
3. "No, you can't eat chocolate Santas for breakfast".
2. "Please let the cat/your little brother out of that box right this minute, I don't care if it has air holes!"
1. "So much preparation, and it is over so fast"

FaLaLaLaLaaaaaaaa....zzzzzzzzzz

Today was the day I was going to get everything done as far as shopping for gifts.

I started the day early; I had my lists. I checked them twice. Family. Friends. Skating buddies. An impoverished family that my co-workers and I have adopted with a miles long wish-list of necessities. I had my plan of attack, mapped out in order of location along with what items I needed. But first I had to work a four hour princess shift from 11 AM to 3 PM.

Dr. Cruella had the duty today; she really isn't cruel, just decisive and focused. She is a favorite amongst the nursing staff because she has no tolerance for drug seekers and generally sends them packing without narcotics.

Cruella had a cold; a really bad sneezing, sniffling, stuffy head, Rudolph-nose, gravelly voiced, gonna-give-this-shit-to-everyone kind of cold. I honestly didn't even want to touch any of her paperwork because they were literally crawling with microbes. I kept a supply of masks on the desk for her to use along with a 50 gallon dispenser of hand sanitizer. She probably should have stayed home since she was likely sicker than any of the patients we saw, but we in health care in general fail to use our sick time for actual illness. It is a lose-lose situation; nurses/docs who call in sick are vilified by their co-workers, and if a weekend or holiday, it is never forgotten. Yet if they show up sick, people complain that they are sharing their illness. Go figure.

I had the pleasure (gag) of working with Second in Command (SIC) today. She told an interesting (yawn) story of her first year as a nurse working a double shift on New Year's Eve; she coughed so badly that one of the patients was overheard saying, "I don't know which nurse is coughing, but I hope she isn't mine". So true on several levels I'm sure.

My first Christmas as an RN began with emesis so severe that I think I vomited several internal organs. Of course I dragged myself to work at 3 PM; I was the only RN on along with one LPN and 4 aides. However, since I was an unnatural shade of green and a whiter shade of pale combined, my co-workers immediately started making panicked phone calls to summon a replacement as I lolled semi-conscious at the nurses station, vowing to start giving meds "in just a minute". Ho ho ho indeed.

So after a quick stop at home to burn my scrubs and boil my skin, off I went to shop 'til I dropped. I did get a lot done, but not quite everything. I started running out of gas about 5 hours into my marathon because I was starting to sneeze and feel sniffly. Stuffy headed. And very, very tired. Yawn.

Thanks, Cruella.

I stopped at the pharmacy for cold remedies instead of shopping for stocking stuffers. Guess I will have to rely on the fact that I will live to shop another day.

Wow....

.....must have been a REALLY slow news day in China.

Rapid Door- to- Doc Update

I had no small amount of fun with Dr. Roboto the other day as I did a 4 hour Princess shift. Because he disdains hanging out at the nurses' desk with the rest of us lower life forms, he always scurries back to his office in the back between patients; we use an intercom to call him; me more obnoxiously than others, obviously.

Roboto is absolutely insistent that patients are put into rooms and he is called immediately; no problem. There is, as previously noted, quite often a lag between the completion of triage and the completion of registration. This was remedied by simply putting the unregistered patients in the rooms and calling him to come see them. We were really busy; so, after awhile he was so confused he didn't know whether to shit or wind his watch since, say it with me TRIAGE IS MUCH QUICKER THAN REGISTRATION. I had every room filled and nobody registered. Not that I was trying to prove a point or anything.

Not having anyone to blame but himself for this, he tried to take it out on nurses, shocker. All these times are noted on discharge; triage time, time to room, time of doc visit, etc., etc. Many of the docs note their times on a worksheet which is usually kept with the chart; Roboto, being the secretive weasel that he is, prefers to keep his notations to himself and hides them in some secret pocket of his prissy little lab coat. Then he keeps it for quite awhile, many times until long after the patients are discharged off the computer, which is a nursing task. For sanity's sake, we nurses try to keep track of the time that the doc visits. Or we make it up. Whatever. I am usually pretty good about those notations, but Roboto, now pissy because we are pummeling him, said we shouldn't be putting any times down unless it coincides with his exact time. I said we can't do that because you hide your notes it slows everything down on our end, besides, I can look at a clock to see what time you enter a room.

Challenge time; says he, "What time did you put for that patient I just discharged then, since you weren't at the desk?"

I looked at my note; "1:46 PM. What did you write?"

(Addressing left clavicle)"mmm, hrmm, mumble mumble....1:46 PM".

Maxine Lives!

I have nothing especially newsworthy or bizarre enough to post about. I offer an older entry for your perusal and enjoyment.

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 bilateral 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 cantankerous 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.

Addendum: I saw this lady recently, she is alive and well, and raising her own hell. Good for her! Also, she remembered me and made it a point to tell me how much she appreciated my effort to keep her informed without making her feel like an idiot. Good for me!

??

Triage complaint of the day:

"Not Better"

The 16 year old with the hysterical mother had a sore throat and had been on antibiotics about 16 hours, was not febrile, drooling or sicker; just not better.

Guess you didn't actually fill the prescription for the "Magic Pills"

Today's Last Patient of the Night....

...had been "allegedly assaulted": translation, someone beat the crap out of him; says he, "they cheap shotted me". Uh huh. He had a bloody nose, a lacerated lip and the beginnings of a nice shiner. Nope, he didn't want to report it to the local constabulary. It was a struggle for New Cindy to triage him because he was on his phone. Incessantly. I loathe this type of behavior and don't tolerate it myself. Must be the school nurse in me, but I have no problem telling a 24 year old to quit acting like an ass. Since we were looking at xrays and sutures we wanted to get this show on the road so we could finish and leave sometime before 1 AM. Keep in mind that we won't hurry through care, but we do like to actually get to the treatment part of the festivities expeditiously. For those of you with a cell phone glued to your ear and who can't go more than 4 seconds without texting your oh-so- important minutiae, listen up: unless you are Steve Jobs, Bill Gates or are on the verge of discovering either life on Mars or a cure for cancer, IT CAN WAIT. Seriously.

We were working with a relatively new doc, Parvati; she is so great. She loves having the opportunity to work in a less frenetic ER because it gives her time to actually talk with the patients. For someone who has been working in a ER for years and years as I have, her viewpoints and attitude towards patients and patient care are refreshing. Many people are so impressed with her that they ask if she has a private practice.

Parvati saw the patient immediately and ordered the appropriate xrays. The whole time the phone was hanging off his ear like an appendage. Mary took him around the corner to get started on his films.

10 minutes later, Mary came out, clearly frustrated. The patient was not cooperative and had been putting her off in order to "take this one call, it's important". Um, no. You do not have a job, children or anything going for you at present. Your "cheap shot" was likely the result of a drug deal gone bad.

Now pissy, I marched down to the radiology department and in my bitchiestmost persuasive command voice advised him that he needed to put the phone away NOW, and that the doctor was waiting to treat him. Besides, I told him, "you are being extraordinarily rude". He put the phone away and Mary got to work.

Since our doors are literally locked at 11 PM, I was quite surprised to hear the outer door open. The patient's mom and dad had opened the door to let in an equally annoying younger brother. I admonished them not to open the door for anyone without checking with me first since we were actually closed; besides we just are not comfortable with random people wandering around when there is no secretarial staff to keep an eye on things in the waiting room. Secretaries get to leave at 11 PM unless we really need them. Along with windows, we nurses just don't do registration, it's complicated and frankly, I don't want to learn it since I already have a fair amount of secretarial work that takes away from nursing tasks.

Parvati had a happy little talk with the idiots parents about what she was going to do and mentioned how rude and obnoxious talkative he was on his phone. It should come as no surprise that the idiot parents thought it was funny; "Oh, that's our moronic progeny little darling, he LOVES to talk, haha!".



Um, did I mention that he had no insurance? 1 hour of weekend and night shift differential at time and 1/2 for 2 nurses and an x-ray tech as well as high quality medical care for which we will not see one thin dime. Yeah.

God Bless America!

You Want Me on That Wall...

I am the gatekeeper; now, apparently, I am the timekeeper as well.

It has become the (marketing) rage to tout "Door to Doc" times in the ER under 30 minutes. Essentially, this means that you are GUARANTEED (Ha! Hahahahaha!) to see a provider in under 30 minutes from the time you walk into the department. I am frankly amazed that this declaration is not immediately followed by "....or your visit is free!". Assuming that the patient is one that actually pays the bill.

Rapid Door to Doc is not a new concept, just one the many stupid bandwagons that Suits (and other disguised boxes of hamsters) utilize when they worship at the Altar of Customer Service. It was being given a trial run along with copious billboard advertising at Utopia Medical Center before I left there 4 years ago. We had a fast-track, but the 30 minute "Door-to-Doc" was a bit of a joke. Under an hour, maybe; but unless you were really sick, had chest pain, were holding a severed extremity in triage or bleeding from your eyeballs in general did you have any hope of being placed in a room in under an hour. Never mind seeing the provider. We did much better on doing EKG's in under 5 minutes since we just did them in triage, although we then had to do a room to room search for a provider to initial it. Shouldn't that count? I thought so. Anyway, while the average ER employee would love to have every patient sitting in front of a doc within 30 minutes of hitting the door, in reality, it isn't practical and merely serves to set us up for failure.

I have been told that our Door-to-Doc times need to be 20 minutes, per Dr. Roboto, our medical director; this is the same individual who lacks adult social skills and has been the cause of 6 docs quitting in the last 1 1/2 years, but doesn't see this as attributable to his lack of leadership qualities. Naturally, the first thing to be looked at is NOT the registration process, but triage. It is not the fault of registration clerks that more idiot questions are added to the registration process on a daily basis; I feel badly that they have to ask really stupid questions such as "do you receive Black Lung benefits" and "if a monkey can climb a greased pole in 10 seconds, how much does a pound of butter weigh?, and "do you like cheese?". I get that these are very important to the kind of treatment patients receive. Really, I do. But registration generally takes at least 10 minutes if patients haven't been to our facility and if Helen is doing the registration. Subtract about 1/2 of that if anyone else is doing the job. To add to the mayhem, on weekends and after 5 PM there is only one registration clerk who must also register out-patients. However, Dr. Roboto now says that triage, not registration needs to be streamlined. The man is a rocket scientist I tell ya.

Naturally there are patients with complicated medical histories that are the exception, but by and large an experienced ER nurse should be able to triage quite rapidly; it takes organization and the ability to multitask. In our ER we are all very experienced; with the possible exception of Southern Cathy and Sherry who like to engage people in conversation about their kids, pets and past lives, most of us are very efficient.

To prove my point that the problem lies with the registration process, for the last week I have noted my triage time, as well as the time triage was completed. This has averaged 5-6 minutes for me; I can do a frequent flier dental paineur or migraineur in less than 4 minutes if they aren't on any other meds. After triage, the patient is registered unless it is someone who needs to go right back to a room; that time gets noted as well as the time the provider actually picks up the chart and enters the patient room.

Keep in mind that we are do not have electronic charting in our ER, and probably won't until the end of the present century, so that is a lot of time notation.

Five to six minutes worth of quality triage time. And if there are no other patients I triage them right in the treatment room and have the secretaries register them whenever. Right back to a room, how great is that?

Dr. Roboto doesn't think it's so great, but that is no surprise to me; anything that is actually, well, nursing is trivial; particularly if it requires any skill or concious thought other than blind order-following. A nursing assessment? Insignificant. Nursing process? Unimportant. Critical care skills? Inconsequential. Any nursing input at all? Trifling, unnecessary, worthless.

Roboto's actions scream contempt for nursing in a big way. No wonder nobody likes him. I think a couple of my co-workers have actually switched shifts so as not to work with him. I doubt his own mother can stand him; can't imagine how he can be married and have kids. But hey, he brings on a lot of his problems himself; who can take a man seriously who uses a pocket protector, never wears scrubs because he thinks they are unprofessional, has a fussy little circum-oral beard (door knockers?), talks to his clavicles, wears glasses attached to a little chain and wears a little teeny kid's backpack (probably filled with Fruit Roll-Ups, juice boxes, and jelly sandwiches with the crusts cut off). Also he lacks a sense of humor, which, to me is the worst offense. I am at my best and most passive aggressive self in his presence.

None of the other docs are committed to this lunacy, which is just as well; why put the extra pressure on people for the sake of another marketing ploy with unrealistic expectations? Sicker patients will always get seen as quickly as possible, most in well under the arbitrary 20 minute time frame.

Dear (fill in the blank), an Open Letter

Dear Parent who Smells Like an Ashtray:


Get real. When I ask you if your asthmatic child is exposed to second hand smoke at home and you reply no, please know that I think you are full of shit. You may claim to only smoke outside your home, but I will be needing a nebulizer treatment after spending three minutes in your presence. You reek, as does your child who is presently wheezing like an old Chevy.

It is your choice to improve your chances of developing lifelong respiratory ailments and/or lung cancer; it is not your child's. Grow the fu#k up.

And please refrain from the sob story about not being able to afford your child's inhaler, it just lacks authenticity when butts are over $5.00 per pack.

Yes, I know the irony is lost on you.

Disdainfully,

EDNurseasauras

Ya Gotta Use Bait

There has been some talk about how to increase (insurance having) patients at our ER; that is, without spending a ton of money. Marketing came up with a health fair to accomplish this.


Our recent weekend health fair (Mandatory Participation, haha!) took place on a beautiful Saturday; all of the components were in place. There were bike helmet fittings and $10 bike helmets available for purchase, what a deal. The usual giveaways that people love. Fingerprinting. Free bike inspections. Free car seat inspections. Drawings for free stuff. A farm stand with awesome looking fresh veggies for sale. Free vision checks and BP checks. FREE healthy turkey hotdog (Jennie-O, DELISH) and veggie burger lunch with all the fixin's, and a CRAZY rock climbing wall that was a useful babysitting device for one of the marketing divas. And the face painting was very popular with the little ones.

All of this good stuff in place right next to a playground where kids were involved in soccer and baseball. Yet, we had basically nobody attend. Why?

1. Poor advertising.

2. It was held IN BACK of the building where nobody goes. NOBODY. EVER.

The rock climbing wall was a crazy hit among the kids who did attend. I managed to sell 10 bike helmets. The bike inspection guy only did one bike inspection, and I think that was for one of the marketing people who felt bad and went home for her own bike.

Not one person from marketing asked those of us who lived and worked in the community for input on what might work to get people to attend. I just don't understand that.

You can bet that the first thing on the list for next year is have it OUT FRONT where people can see it.

Oh, and balloons. That was my idea. Balloons and much bigger writing on the sandwich boards that can be seen while driving.

What? Just 'Cause I Don't Drink the Koolaid?

A couple of weeks ago I was looking at the schedule and noticed that I had not received any charge pay for the entire month of Sept, and was apparently not in line for any in October. We are such a small shop that it is just "gimme" cash and is usually distributed equally among us. It is not a ton of money, but since they pay us through a peashooter anyway, an extra $20 or $30 a week at least pays for coffee or a manicure. Whatever.

I also noticed that SIC had received wayyyyyyyyyyy more of it than anyone.

It was a moment of WTF-ery that I felt deserved investigation. Since it was on a weekend and my boss wasn't around, I left a note.

The next day I got a call from Mikki. Apparently, at the last staff meeting my boss announced that charge pay would be withheld for anyone not up to date with competencies, a fact that was not shared with about half of our small staff. SIC sure got the memo, I observed; how convenient.

Our competencies are fairly useless, consisting of a monthly rhythm trip, like so:

So the idea is to identify the rhythm, count out the distance between each of the little teeny squares to determine the intervals and a whole bunch of other useless shit, then declare if/how it should be treated. Waste of time.

I hadn't done a single competency for the whole year; or the year before that. I think because I was in school, my boss sort of gave me a bye because I always do my certifications like BLS, ACLS, PALS, and TNCC. Now she was changing the rules of the game and drawing a line in the sand: if you want money, cough up the competencies.

Mikki knew I was a little pissed about this, not so much as holding charge pay hostage but how it was a big secret that seemed to benefit one or two people; she was practically hysterical. "Don't quit!", she begged, "you can copy mine, I just gave then to Sherry 'cause she hasn't done them either. Really, I mean it!".

As if I would quit over this. Or copy. I just didn't do 'em because I thought they were stupid. Sue me.

My contention is that surely, other knowledge might be more useful, such as inservices or competencies for stuff that we hardly ever see BUT MIGHT ACTUALLY NEED. Like what's in the delivery kit, how to prime the fluid warmer, or how to set up and maintain the IO (intraosseous) equipment (you really don't want to know what that is if you aren't medical, trust me). Other knowledge it might be good to know is specific to our unique facility such as a review of what to do with a deceased person after hours, or should we share our supply of lactated ringers with a local vet for use on a horse. Yes, we actually had a request for a case of IV fluid, unfortunately we only stock about 4 of that kind.

Did I break down and do competencies? Yep. We had 3 (THREE!) patients last Saturday night and I did every one of them, then stuffed them in the the boss's inbox which effectively pre-empted my written rant. Money talks and bullshit walks; OK, so I drank the Koolaid. If for no other reason than to prevent SIC from getting more $$ out of it.

Triage (defined)

Triage: a process of prioritizing patients based on the severity of their condition

Now I not only have to contend with patients who challenge my 30+ years of triage experience, now I am having to defend them to people I work with. In my small facility, there is a triage process as it pertains to the order in which patients are registered by the secretarial staff. In a perfect world, it would be first come first served. This would be followed by the ones with the biggest mouths, the most dramatic, or the most whiney.

ER patients and outpatients alike must register with the same secretarial staff. There are two until 5 PM, then there is only one. Helen, lord love her, is thorough but slllllllllllllllooooooooooooooowwwwwww. The lab and xray outpatients are sometimes bumped for registrations, appropriately, for patients who need to be seen in the ER sooner rather than later. Sometimes the docs are just antsy to see patients; sometimes we just want to get them in and out because we can.

Yesterday, I triaged a pale 6 year old with a head bump; he had vomited several times. Aside from a mildly elevated heart rate, he looked about as OK as he could. Still, I didn't feel I wanted him to sit in the waiting room while Helen registered several outpatients. As I exited the triage area, Helen intuited that I needed this child registered without delay and kicked the outpatient xray in front of her back to the waiting room.

Several minutes go by; Lee,the xray tech was in my face, abrupt and inappropriate as usual; "Do you ever think about how the patient might have felt? He was already seated. I know we are supposed to give preference to the ER patients, but do the outpatients always have to be bumped for every dental pain and boo-boo?"

Whoa, back off there. I waited for my blood to stop boiling, took a deep breath, calmly looked up as she loomed over me, then let her have it

"Lee, I understand your frustration. I am sure you got endless shit from the outpatient; not to mention it makes your numbers look bad, so I am sure there is a certain amount of self-preservation here. The reality is, it is my decision and mine alone when it comes to the order in which patients are registered; it is based on my clinical judgement. It is my license but more importantly it is based on doing what is right for patients who need care sooner rather than later, as well as common sense which you seem to be lacking today. Before you stick any more of your foot in your mouth you should know that this kid is head injured, pale and vomiting, which handily trumps your outpatient. That's all you need to know. Don't you ever question my clinical judgement again; you will lose, I assure you. Now get out and go fill in some forms or something".
She left sputtering but firmly in her place.

The Talker had heard the whole thing; "Wow", he said, "Well done".
Yeah, see definition.

Today's Last Patient of the Night.....

....arrived at 10:30 PM. His complaint? "Vomiting Blood"

He and his two adolescent girlfriends giggled and texted and acted like idiots in general. I wouldn't dream of revealing his last name, but let's say if I had to pick a name out of a hat, it would rhyme with "Douche" (as in douche bag...which he was).

His triage note: "ate at Wendy's, then started vomiting blood. Pt. states he always vomits blood when he eats at Wendy's".

Yes, I know, I know. ...but why state the obvious here? You know me better than that, so I shall be withholding my comments; however, Meredith Grey has a few words to say on this issue. I will step aside to allow her perspective:

"Maybe we like the pain. Maybe we're wired that way. Because without it, I don't know; maybe we just wouldn't feel real. What's that saying? Why do I keep hitting myself with a hammer? Because it feels so good when I stop".

Thank you, Dr. Grey. I suppose your discharge instructions would include opening a nice big can of this:

Remember Essie?

From a few days ago? Well, my stroll down nursing Memory Lane jogged another nugget.

Essie got a new roommate at some point, who was ambulatory. And sneaky.

Bessie used to roam around at night. In those days we didn't have fancy patient alarms and monitors when patients went on the lam; we used a device called the the Posey Jacket, or Posey for short. This was a little mesh vest that zipped down the back and was tied to the bed; the patient had the ability to roll to either side, but it kept them from getting out of bed and into mischief (or going to ground and breaking a hip). It was, for all intents and purposes, a restraint device, although it sounds like a torture device, which I suppose it was since we aren't allowed to use it anymore. But it was never meant to be punitive, merely to keep the patient safe.
I have a point; I promise.

Posey's were difficult to get out of, but not impossible, in fact many of the elderly were quite adept at it. Bessie was what we referred to as a Houdini, master of the art of escape. One night all of the staff were involved in two simultaneous crisis situations, and Bessie's frequent bed check was missed. Sure enough she was on the loose.

But instead of raiding the pantry for sugar packets as she usually did, Bessie had another mission going; she had collected the dentures of every patient she could find and had placed them in a pillowcase. One dozen sets of dentures had been liberated from their Efferdent soup. To make matters worse, we were alerted to Bessie's larceny by the yelping from one of the male patients with whom Bessie was trying to get in bed.

THAT went over well. I don't really know how the day shift managed to reunite the teeth with their owners, but they did.

Mini Around Town, Part II

Milltown is just full of people this weekend. There is a Pumpkin fiesta on the town round with food and frolic; the economy can't be that awful since people and families are out in droves spending money. Just a ways out of town is a pumpkin launcher, hay rides and a corn maze. It's a beautiful fall weekend, just perfect for being out of doors. Mr. EDNurseasauras and I went out for breakfast, then tooled around for a couple of hours. Alas, I am working the entire weekend so I have a lot to squeeze in today.

As it is fall, we dog walkers must now share the woods with hunters. Of course I dress Tina and myself in the kind of day-glo orange color not found in nature at this time of year; still, I just don't feel safe on weekends frequenting areas in which hoards of individuals in full dress camo and toting weapons of mass destruction pile into pickup trucks and swarm over my usual hiking spots. That's OK, I just avoid the high-profile areas on weekends; not many hunters around during the week a-shootin' at Bambi and all his little friends.


Today I went to an old historic village site from colonial times that has been converted to public domain hiking. It is truly a beautiful area with miles of maintained trails, rolling hayfields, and wetlands. There was not a cloud in the sky as Tina and I made the rounds of all the rock walls where chipmunks hide.


Tina spotted a man coming up the path accompanied by a dark grey toy poodle. I recognized this as "Killer Poodle", owned by the property caretaker whom I've never met. "KillerPoodle" is a yappy little thing who resides at the caretakers cottage. He is infallibly found outside in the front yard, and barks and growls at anyone who passes by. Hence the name; I refer to him a "KP" for short. After our dogs had greeted each other in typical doggie fashion, Tina was off digging a hole on the other side of yet another rock wall. I made conversation with the caretaker dude about the usual New England topic of conversation (the weather) and asked him the usual questions about his canine friend.


"Well, he is about 8 years old. This in Niki II; Niki I is on the other side of the wall. He sort of came with the property, he was here before I was", said caretaker dude.


I was pretty sure I had only seen one KP on previous trips to the Village and looked over the wall to see if Tina had found any other little companions. As caretaker dude continued to speak, I realize that Niki I was, in fact BURIED on the other side of the wall. Typical old yankee humor. Niki I's grave was complete with a headstone with the obligate dates of existence. It was decorated with an engraved bone and pretty little pebbles; "Good Dog" was engraved on the bottom. Stay. Good boy.

KP ran off with his master, and Tina and I continued our search for chipmunks before I had to go to work.

Note: when we arrived home, the cat had caught a chipmunk. Tina prompty comandeered the catch. Sharing: good girls!

Today's Last Patient of the NIght....

.....was in his mid 30's, had a host of medical problems including stroke, alcoholism, diabetes and, since he was with his mummy, I am assuming he also had an impressive list of social deficiencies. It was 10:45 PM.

He needed a note because he missed his court-ordered community service.
The reason?

"I just didn't feel like going".

uh huh....

What Does That Mean, Anyway?

People often talk about how nurses are doing "God's work". Most days I disagree.

I do not believe it is "God's work" to take verbal abuse from a 39 year old with back pain (chronic) who plays football (every Sunday) and shows up the following Monday (every week) with excruciating pain. Why were we getting verbal shit? The physician, having looked up the patent's last five visits prescribed possible chiropractic treatment, ice and heat, ibuprofen and to moderate his activity; it was suggested that perhaps playing tackle football was not in the patent's best interest. Further, the patient was told that the physician was reasonably sure that none of the Patriots presented to the ER on Monday after a game looking for Vicodin. The patient was, of course, outraged and demanded the name of the physician's boss so he could complain; and, since he didn't get any treatment (except for some common sense advice) had no plans to pay for the visit. Oh, and he left his free-care application in the room.

I sure don't feel like it is "God's work" to look up the number of Medicaid for an able bodied 18 year old female who didn't have insurance but was too old for Healthy Kids and not in school. She had presented for a lump and bleeding "down there"; turns out it was a friction injury. Naturally she insisted on having her skanky boyfriend present for the inevitable pelvic exam. Why do these young girls go for these bozo's? Blecch.

For that matter, it surely cannot be "God's work" to put up with morons who twist a toe, ankle or elbow, or break a fingernail and high-tail it to the ER without first attempting ice, elevation or ibuprofen. If you are walking on it, using it to hold your cell phone to text message the world that you are in the ER, or slugging down a gallon of iced coffee from Dunkin's, it most likely NOT fractured. Especially if this is your 5th or 6th visit for a silly complaint this year. It is disheartening that there is so little common sense in the world.

You cannot convince me that it is "God's work" to document 30 (THIRTY!!) allergies for one patient, relatively few of them actual allergies; the only things that were missing from the list were "clouds" and "dirt".

On the flip side, there are some instances when I feel that, while perhaps not "God's work", I can glean, ever so slightly, a sense of satisfaction or accomplishment. To be honest, it is precisely those instances that keep me doin' what I do; in a sea of rude, unappreciative, nasty, stupid, violent, threatening patients and family members that strain my sanity and keep my eyes in a continuous roll, I am occasionally able to use my experience and skill to achieve something positive.

I kinda have a tendency to hold on to those moments like a lifeline on those days that I want to slap the ears off someone.

(This is my 100th post by the way, and I wanted to keep it as upbeat as possible!)

"Pink is My Signature Color"

Oh, lord, did I have a flashback.

I was asked to do a blood draw in the outpatient lab on a "tough stick", something I am always happy to do; if it can get done in one rather than repeatedly poking the patient, I am all for it. As is the patient, I'm sure.

She was elderly and was decked out completely in pink from head to toe, including a little pink cloche hat (who even knows what a cloche hat is, anyway?). Sorta like this:

In fact, exactly like this but with only one flower.

Mae was so cute and tiny. Pink flowered blouse, pink sweater, pale pink pants and pink flats with a clip-on flower. She had on bright pink lipstick and had the most beautiful clear blue eyes with a devilish twinkle.

Mae was sporting a sassy pink cane with pink breast cancer stickers, and a pink ribbon breast cancer pin or three. Because she'd had a mastectomy some years ago, we were only able to use one arm--hence the difficulty.

I introduced myself and told her that I was there to help Lynn, the lab tech, get her blood test done.

"So, they called in the top dog, eh?", Mae said with narrowed her eyes and a slight curve of her lips to indicate she was teasing.

"Well, let's see what we can do; no promises, OK?"

She studied me with her little head tilted under the cloche, glancing at me out of the corners of her eyes; the last time I saw an expression like this, it was done by Essie who tortured me in my very first job as a nurse.


************************************************************************************

I had taken my State Boards (now called NCLEX) out of my home state, thanks to our nursing school director giving us the wrong deadline for application...idiot. So, I was able to take this two-day test (now done by computer with the results immediately available) in the state of NH where I went to school, I could take it with my friends which was a bargain. The downside was that the tests were only given twice a year in those days. If you failed, you were done for six months. In addition, the results took about 4-6 weeks, which was torturous to say the least. But, if you were fortunate enough to get a job, you worked as a glorified nurses aide and could do everything except pass meds; it was worth the crappy pay, and you could also do charting and sign your name "EDNurseasauras, GN" (for graduate nurse).

Since I was back in my home state of Massachusetts, I not only had to wait 4-6 weeks to see if I had passed or not but had to apply for a reciprocal license so I could practice in Mass., which was another 4 weeks or so. In the meantime, I was hired at a rehab hospital. One day of orientation, one day following the RN around, and then I was on my own for the next three weeks, expected to take a full patient care assignment of 6 or 7 patients, which my nursing program had prepared me to do (yeah, diploma programs....the bottom of the food chain as far as education, but prepared to be a nurse right out of the box). Management was biding it's time until I received my Mass. license so I could be in charge. Yes, as a puppy nurse with merely a couple of hundred hours of experience I was to be the sole RN on the floor with one LPN and 4 aides. Three months of 30 hour weeks as a charge nurse in my Leadership course, the finale of my education had also prepared me for this as well. Hind sight only makes me realize how potentially dangerous it could have been, however, it all worked out and we all managed together to give good care.

Although it was a rehab hospital, there were relatively few patients with rehab potential on my floor. We had head injured young people in comas who were complete care and needed tube feedings, etc.; respiratory patients who were basically sent there to live out the rest of their lives on oxygen; a couple of men with cerebral palsy who were wheelchair bound and total care because of their contractures; one woman with some mysterious paralysis-type of thing with a bed-sore that needed to be packed a couple of times per day. There was one brain-injured man who had tremendous mood swings and angry outbursts caused by prolonged oxygen deprivation. He had experienced a cardiac arrest and survived, but in those early days when we had just started not letting people die by doing CPR there was perhaps a lag between the the length of time he was "down" and when he was "saved". He certainly was not the same 43 year old person he had been before he was admitted to my unit as his anguished family constantly reminded me.

I also experienced my first death as an RN. With a nurse's aide who was afraid of dead people, I performed post-mortem care using the directions in the shroud kit. Yes, we used a toe tag. Heidi, the aide, was also my roommate at the time. She had nightmares about this.

There were several older adults with dementia; these days, such patients would not be placed on that kind of floor, but that was the 1970's after all. One of these was Essie Poisson, who was in her late 80's or 90's. In her occasional moments of lucidity she would talk about her days dancing in the Ziegfeld Follies, elaborate Broadway musical shows with gorgeous young women, beautiful costumes and headdresses with towering plumage. Essie, like Mae, was usually dressed all in pink.

Of course, in Essie's less than lucid moments, everything was a fight. The most stressful part of my evening was 1) getting Essie into bed and 2) getting Essie's dentures out.

Essie would give me that side-glance, narrow-eyed, "bring it" devilish look and challenge me to remove those dentures; it may have been stressful for me, but damn if it didn't seem like the highlight of Essie's day. I do believe she looked forward to it.

Essie would resist the removal of those dentures with more enthusiasm than I thought possible in a woman of her frail appearance; underneath lurked steel armor and determination to match.

She shrieked "help, police, murder!!" with all the gusto she could muster, but the dentures ultimately spent the night in a denture cup in a marinade of Polident; she never drew blood but that didn't stop her from trying.

Once in her nightgown, fluffed, puffed, lotioned and soothed, Essie behaved as if nothing was amiss and would always politely ask for a cup of custard before she went to sleep. I retreated, drained, to the nurses station for a cup of coffee and begin my charting. What I really felt like was a stiff drink.
************************************************************************************
So with nostalgiac if not fond thoughts of Essie in my mind, I drew little Mae's blood.

But out of habit I kept my eye on those teeth....

Convention

I needed a little time to process and think a little before writing about this topic. Southern Cathy and I headed to San Antonio last week for the Emergency Nurses Association (ENA) annual convention. It was a first time occurrence for us both; we had heard that it was very much a carnival informative and a party atmosphere great opportunity to network with other ER nurses. Although not a Texas native, Cathy spent a few years there so she was a great resource for getting around and seeing the sights; as it turns out, we had a blast. I didn't count on the doing as much reflection on my nursing practice as I have.

We basically spent 2 full days in lectures; all were interesting, informative and provided new knowledge we otherwise would not have been exposed to. Some were clinically oriented, some were skills-based, many provided food for thought. I had an opportunity to hear about the experience of a combat nurse who had spent time in Iraq, an excellent speaker who deserved and received a standing ovation after her presentation. I wound up (quite by accident) in a class that taught us how to care for the Transgendered patient in the ER simply because I was in the wrong place at the right time, but had listened two of this nurse's previous lectures and LOVED her. There were classes about policies that supported staff against violence, how to protect yourself from lawsuits (documentation, documentation, documentation), and sudden death in young athletes. I especially liked "10 Ways Not to Get Fooled at Triage".

Cathy and I chose different classes and exchanged what we had learned about during breaks. I came out of the experience with with a somewhat new attitude towards ER nursing in general and my own practice in particular. It was empowering to be among my peers, many with fewer years of ER experience, some with many more than my 34 years. There were nurses from small ER's such as mine, and others from enormous medical centers and Level 1 trauma centers. Yet at the end of the day we were all pretty much doing the same job, had many of the same concerns, and want the same things from our managers and administrators.

The common theme among the nurses that I met will come as no surprise: nurses are nobody's priority. We, as a group, are consistently being asked to do more with less, forced to follow the agenda and direction of individuals who make the rules but have nothing to do with clinical decision-making or patient care. I dare say that if they ever knew which end of the bedpan went where, it has long since been forgotten. Nurses are at the bottom of the food chain, the first to sacrifice or be sacrificed. Yet we are at the front lines of patient care, often in spite of of administrators, managers, and individuals who have been placed erroneously in leadership positions. Yet all of the nurses that I met were committed to being better, learning more, providing top-quality care. And you know, the lecturers had a mountain of alphabet soup after their names but had great ideas for us front-line nurses. These are movers and shakers that seem to be missing in the work-a-day life of a nurse, absent from the front lines but working behind the scenes. These are nurses who are intelligent, confident and get things done; their leadership inspired me. As I listened, something struck a chord with me.

I am not a manger, but I am a leader; I can be mouthy and negative, bitching about how unloved we are when I'm frustrated, or simply caught up in small bull-shit annoyances, such as sticky notes that berate nurses for missed secretarial tasks. I can be a Pied Piper, whipping my co-workers into a frenzy of indignation, or soothing them when they are over the top and overwhelmed. I can go hog-wild with practical jokes and suck others into my vortex of lunacy. I can cajole people into doing things they might not think of or even consider doing without my encouragement.

I have encouraged some of my coworkers, mainly Mikki, to be less fearful and intimidated by one of our physicians. You know the type: the all-powerful demi-God who fails miserably as a team player and was most certainly voted Most Likely to Get the Snot Beat Out of Him in high school; generally unhappy, lacks adult social skills, etc. He's just a guy, kids. Not likable, not an especially good doctor, and not good for nursing. But get on your big girl pants and stop giving him the power to lord it over you for heaven sake!

My take-home from this conference is this: I have learned that leadership is a powerful thing, especially if it is used for good instead of evil.

Procrastination

I have been taking courses to finish my BSN for 3 years now. Since I had a busy summer planning my Alaska trip and also needed to take 2 CLEP's, I put off my final course until October.

October looms; I had a wonderful trip to Alaska with Mr. Ednurseasauras, got out in my kayak a bit, spent lots of days at the lake, and studied very little for the CLEP exams. Lazy? Maybe.

I could spend the next week studying like mad, and probably pass both CLEP's so that I could start my course the first week of October and then graduate in December.

I just can't face it. I'll take the CLEP's then start the last course in January!

Quickquotes

"I just remembered that I am allergic to oxycodone; could I get Percocet instead?"*





*same thing

Beginning of Flu Season?

Since last week, between a local epidemic of Salmonella and perceived flu-like symptoms, I have washed my hands 7,542 times (they are ready to fall off). I have lost one really nice pen thanks to the assbag who sneezed on it while she signed her discharge instructions; now I religiously use hand sanitizer on my pen after anyone uses it. If they are really grubby individuals I use another pen and throw it away. If I don't even want them to touch the pen at all, I scribble something indecipherable myself in lieu of their signature and hand them the copy. Yeah.

I have also de-bugged my stethoscope and shoes (don't ask) approximately 3345 times, had to chaperone too many pelvic exams to count for STD's, and collected several stool cultures. Therefore, I am so not looking forward to mining flu swabs once it is determined that the flu season has officially begun. How does one collect a flu swab? I'm glad you ask. Please keep this in mind before running to the ER with a cough and sniffles.

We wear a mask, of course, and gloves. Then we take a slim Q-tippy apparatus on a very narrow bendy wire and PLUNGE it deeeeeeeeeeeeeeeeeeeeeep into the nostril where it stays for about a minute. It sucks big time, although I will say most women tolerate it better than men for some reason.

Everyone is far less afraid of Swine flu, or more accurately, the H1N1 flu (thanks to the pork industry and their SWHIning) than they were last year. CVS has advertised the availability of flu vaccines in their stores for about a month now, way ahead of the primary care offices; who knows when they will begin booking appointments for that. I think it is still too hot out for people to worry about flu in this neck of the woods, but come the first lighting of the wood stove the onslaught will begin with a vengeance.


Yes, it's nasty. Yes, people feel lousy. For the most part it is not the end of the world; regardless of how much you feel like you are dying, the odds are good that you won't.

We've had a number of patients with fever, cough, sore throat. None sick enough to be seen by their PCP, and certainly not sick enough to go to the ER to be told to rest, take Ibuprofen, and drink fluids 'til you are better.

So we put a mask on all the coughers, and have resurrected the Altar. Gotta protect our secretaries.

Today's Last Patient of the Night

At 10:41 PM, a 20-something female wanders in to be seen.

1. Cold symtoms 2. Foul vaginal discharge, and 3. Sore tatoo

She had no primary care provider, no insurance, and no driver's license or other identification.

Pick one, please; "Have it Your Way ER" closes at 11:00 PM

Second in Command (SIC) has some issues. She has no authority over anyone except by virtue of being the boss's best friend. Lisa, Mikki and I can't stand her. Lisa has a tendency to make snide comments about the number of "love notes" SIC leaves for everyone. WTF? There are 10 nurses who work here. There is absolutely no need for most of these idiot notes.

I don't mind an occasional reminder if I've forgotten something, but you can usually count on SIC to leave a mountain of notices; they are never about clinical issues, but about the myriad busy work/ non-clinical/ secretarial-type tasks that have been simply forgotten. Believe me, none of these things are terribly important, at least when you compare them to taking good care of the patients and getting that part right.

My typical I-don't-give-a-shit attitude occasionally gets me into trouble. After finding about 1/2 dozen notices one day, I started leaving little notices of my own; I pretty much went postal with Post-It Notes.

On a memo: "who writes this shit?"

On a notice reminding people not to clock in before 5 minutes prior to the start of shift (we have two, day shift and evening shift mind you): "if the day shift insists on clocking out at ten minutes of 3, I will be clocking in to take report. Thanks again for withholding raises this year".

On a sign up sheet for a hospital sponsored community health day (thank you, marketing) on a Saturday: "do we get paid for this fiesta? and will that include weekend differential?". The response was an exasperated "YES!" by my boss.

On a reminder for a UAC (Unit Advisory Meeting, more Magnet bullshit):
"boycotting UAC's until raises are reinstated".

On a note reminding nurses to keep the blanket warmer filled: "sorry, we ran out of blankets so we just filled it with paper towels; hope it helped!"

On the Wall of Death (there have been a number of deaths of staff and relatives in the last couple of years; some of which I have written about in previous posts. All the death notices and pictures of the deceased are on a bulletin board in the kitchen, which is macabre and depressing. I made Dan promise me that if anything happened to me that he would prevent any posting on the Wall of Death, but the bastard quit): "please, this place is depressing enough. It is time to remove this memorial"

Note: the Wall of Death was dismantled. In its place is now the "Circle of Life", which has graduation pictures of some of our staff and kids. Much better.

One Saturday when SIC was off, Sherry and Mikki surprised me with a GINORMOUS sign, decorated with stickers and art work "EDnurseasauras, please sign the narcotic sheet! Thank You! Love, Mikki and Sherry. This was clearly a case of ragging on SIC.

I laughed for 10 minutes, I thought it was hysterical. Mikki and Sherry were a little nervous that I would be offended. Me?, Nah. In fact, i told them that we should leave it up except for the fact that it was covering the opening to two cabinets. Too bad!

Douche Baggage and Luggagegate

Mr. Ednurseasauras and I were en route home from a fabulous vacation in Alaska and waiting in Seattle for the second leg of our flight homw. We were slaphappy from lack of sleep as we observed the antics of a full flight of dip shits as they try to weasel out of paying the baggage fee on Continental with their over sized, overfilled, truly non-regulation sized "carry-on" bags.

First of all, I just have to say that every airline that charges a fee for baggage sucks; if they also charge for carry-on bags, they suck doubly.

Mr. Ednursesauras and I are flying on Continental, which deserves the "Profiles in Customer Disservice" award; the so-called customer service representative directed a woman with a cane to go AROUND the podium and into the cattle chute instead of letting her save a few steps and cutting across. Booooo! You get an F for that.

The other gate keeper announced that since the flight was full, EVERY carry on suitcase would be required to be properly sized in the, well, sizing thingy.

Mr. EdN and I amused ourselves by predicting which bags would get the heave-ho into the dungeon of checked baggage.

Seriously? Some of the bags were TWICE the legal size; no way was it fair to have them stuffed into the overhead. Yet people were actually ARGUING about, which is when it got really funny. To us, of course.

One woman had a purple trapezoid shaped bag; yep, I said trapezoid. She kept insisting, "but really, see? It's squishy, it'll fit!". This was after she had removed a computer and some dirty laundry from the bag.

Lady,no matter if you put brought that bag into the cabin empty, the base is STILL too wide to fit. NEXT!

"Oh, look. This next one is huge! No way that gets in. I think it weighs about 50 pounds."

"I think it probably contains frozen fish; what if it melts and starts stinking?"

"What is wrong with these people?"

It occurred to me that these are probably the same self-centered and needy people who frequent ER's, and that it would probably be fun to compare notes with some of these airline people. Over cocktails, of course.

The pseudo-sick public sucks. The traveling public sucks equally. I think, though, that because flight/gate attendants have the final say on who gets on and who doesn't they might have the advantage over ER nurses. At least they are being evaluated on customer service, not nursing care which has somehow been lumped into customer service. Not to mention the advantage of having air marshalls who REALLY have the last word. It is no wonder that a veteran flight attendant, after a verbal altercation with a passenger that should have been ejected/arrested/flogged, made a public farewell announcement, grabbed a couple of beers, and fled down the emergency chute. He deserves a fecking medal.

Liar, Liar

We have been seeing a young man with escalating frequency for several years for breakthrough migraines; he is always brought in by his father, who is aggressive and impatient. He berates the staff if his darling boy has to wait his turn or is not seen ahead of chest paineurs, individuals with difficulty breathing or other mundane complaints such as diabetic emergencies. The kid is polite but suffers from the father's bad behavior; Daddy is a doorway-leaner and hallway stalker, frequently interrupting us by demanding to see the doctor and telling us how much pain the kid is having. Therefore,we keep them in the waiting room, bringing them to a treatment room at the last minute when we are sure the doctor is ready to see them, and not one minute before. The father has only himnself to blame.

I noticed that his visits in the last year were actually down; only 6 or 7 compared to the 22 visits the previous year. I realized that the kid had been away at college and his ER visits coincided with Winter, Spring and Summer breaks. Interesting, yes?

Demerol was the kids usual poison until we stopped stocking it. Now he gets one shot of morphine and is immediately sent home. Every case is different, of course, but this is how most of the frequent migraineurs are treated; they are told up front that we give them one shot, then it is out the door. It is their responsibility to follow up with their provider for definitive long-term management of their chronic problem. We have learned not to sit on these because it always turns into a tug of war. Give a shot of narcotic, wait 30 minutes (usually while they sleep), wake them up for vital signs, "pain still 20/10", start an IV, give them a liter of saline and more narcotics, etc, etc,. Generally after a couple of hours the docs will get tired of it, give them just one more med and send them home to sleep it off. An argument always ensues because their pain is not completely gone. This just sucks the life out us, drains our energy, and often our last remaing reserves of compassion. It is best for the patient and for us to be clear on what the patient can expect, disabusing them of the notion that what they want is not necessarily what they will get; this is especially important when the expectation is enough narcotics to easily tranquilize a bull moose.

On this particular day we were working with the Talker. He is a great doc; he loves to spend lots of quality time teaching. His sincerity and genuine caring is apparent; he does not automatically give the patient what they want and/or thinks they need, and is very patient with the Web MD self-diagnosticians. He does not automatically xray every boo boo that walks through the door, even though the patient expects it. He does a careful exam, and if the mechanism of injury does not warrant, he will not expose the patient to radiation needlessly just because they think they should have it. He spends lots of time talking about ibuprofen, ice, elevation, etc. He spends lots of time with his patients in general, and many ask if he has a private practice because he listens. I love to work with him because I always learn something new. Also, because his goal is always good medical care and not necessarily good customer service it makes me think a little before I just order patient tests before the patient is seen by the doc. Thinking, "What would the Talker do?" frequently guides my decisions; also common sense.

The young man with the migraine came in alone for this visit, which was really unusual. He was seen and examined promptly because 1) it wasn't busy and 2) his annoying father was not present. After the Talker spent about 15 minutes, the patient received morphine. He assured us that his father was in the car waiting, which was proven to be a lie since he was observed getting into the drivers side and driving off.

But he had left his wallet behind; a call to the boys home was answered by the father, who said the kid was at work. We told him that the Talker would like a word with his son when he had the chance.

Two Men Enter, One Man Leaves

Um, yeah. This was WAY too much drama me.

Man and woman, let's call them Dick and Jane, were brought in with relatively minor injuries from a car crash. They had been out drinking. Jane was driving. Jane was sufficiently toasted, wailing, "Where is my boyfriend Dick? Is Dick Ok? Why can't I see him? I'll kill myself if anything happens to him!"

Another man, let's call him Bob, came in looking for his wife; he had come across the wreckage of his wife's car, and was told by police that the driver had been taken to our ER. That would be Jane.

Of course, it was news to Bob that Jane had been out on a date instead of at the movies with girlfriends; needless to say the existence of Jane's boyfriend came as a complete surprise. Hearing Jane yelling drunkenly for her boyfriend was the tip off. Ooops. I was glad the police where there, even though we didn't need them.

I will say that Bob handled himself with aplomb; he never once raised his voice. He was dignified even though he must have been hurting terribly. I felt badly for him, but what can you say. He advised Jane that she was not welcome at home, and that he would contact her when she could pick up her things. Jane's response was to feign unconsciousness, if that is possible if you lack a conscience to begin with.

In my opinion he is well rid of her.

No Scabs Here

I had a phone message from some nursing agency calling for "nurses in all specialties" to work at a northwestern Mass. hospital for, get this, STRIKE coverage.

The offer included guaranteed 36 hours of pay, per diem, housing, travel, meal allowance, heck, probably even manicures and pedicures. My response?

DELETE.

Other than starvation (which,regretfully, wouldn't be happenin' anytime soon for me) there is not a single reason in the world that would entice me to cross a picket line. Not even for a million bucks.

Well, What DID you think was gonna happen?

Jay Leno had a rather amusing segment called "What Did You Think Was Going to Happen?". There was a video clip with a young man straddled between the front bumpers of two facing cars, with his, er, um...junk.... stationed directly over a lit bottle rocket. Predictably, the bottle rocket lodges in his jeans at Ground Zero; hilarious hijinks ensue. What Did You Think Was Going to Happen indeed.

I silently ask the same question of many of our ER patients. There is a great dearth of common sense out there. A vast wasteland devoid of both common sense and, frankly, any sense at all. Of course, the patient's own agenda frequently defies any kind of sense or even native intelligence. Many simply have no brains at all.

It never ceases to amaze me how frequently ignorance is eclipsed by galactic stupidity.

There is no cure for the common cold. Only bonedheads and the uninsured/free care/I'm never gonna pay my bill crowd anyway show up at the ER for antibiotics to cure said cold. Two nights in a row. One guy was seen twice in 24 hours because his pneumonia wasn't better after 1 dose of antibiotics; he wasn't worse, just not miraculously better. Dumbass.

As you know from previous posts, many days I feel like the Narcotics Elf who works with Dr. Santa Claus. We see the same people over and over and over. Sometimes they hit the right doc, sometimes they leave with nothing but their pud in their hands. These are the "Pitch 'til You Win" repeat offenders. One of our more routinely presenting frequent drug-seeking flyers has apparently pushed even Dr. Santa Claus over the edge.

She had been seen by Gil earlier in the day for her really bad (yawn) migraine. He went off the board and gave her Fioricet, which is an OK drug for migraines but which does absolutely nothing at all for someone who just wants their vicodin or percocet. "Vikes or perky Percs" as my colleague Kerry calls them.

Anyway, she sent in one of her frequent flier co-dependents to scout out which doc was working and was busted by Sheila, the secretary. "Oh", she said, "I just wanted to see if Dr. Santa Claus was here tonight; I thought I would just say hi". Sheila kicked her out and told her that she was trespassing unless she wanted to see the doctor. Riiiiight. Way to go Sheila, booting her out, quite rightly. Well, what did you think was going to happen?

Play along with me now as we delve into the world of
"What Did You THINK Was Gonna Happen?"

You may vote for the most stellar example.

1. For three months in a row, the same idiot has come to the ER requesting refills of his extensive list of psychiatric medicines. For three months in a row, we have refused. He couldn't seem to understand why the result was not different for month four.

2. One woman has refused to take her antihypertensives or antidiabetic meds in six months. She is five foot nothing and weighs over 300 pounds. She smokes about 2 packs of cigarettes a day; everytime she comes in she has grande mocha Frappucino and a charming new tatoo to show us. Is anybody shocked and appalled that her BP is Patent Pending/130? I certainly am not. She routinely refuses admission (and yes, we have had a psych eval done) and claims that with all of her other expenses she can't afford her meds. Maybe holding off on the tatoos and Frappucino's would help, but I doubt it.

3. One young man came in with back pain; I often look up the previous visits when the story doesn't quite match the way the patient behaves in triage. For example, they might whine about how tight the blood pressure cuff is when they are texting with 10/10 pain. Or, not realizing that we have a camera in several areas of the building, we often watch patients exit their vehicle and walk normally across the parking lot, only to turn on the drama once they hit the door. I never say anything though I often will comment to the doc that I had observed a normal gait before entering the department. Hence the "look up".

This particular young man has not been seen in about 10 months; prior to that he had been seen at least 8 times in two months with various pain related complaints. On the final visit, he was give a script for 15 Percocet by Dr. Santa Claus. The pharmacist called, concerned that the "1" had been changed to a "4", so it looked like Santa Claus had written him for 45 Percocet; it's just not done. Nor do we give out narcitic 'scripts with refills. With a different colored pen. The phamacist was instructed to tear the 'script up and advise the patient that tampering with prescriptions was against the law. Dr. Santa Claus was kind enough to document this fact in the patient's chart for future reference. He is lucky he was not arrested. You can imagine that the kid was pretty pissed that he did not get any narcotics this visit.

4. Here's one from the lazy EMS from my own town, who called on the land line to say that they were bringing a 23 year old who had taken an overdose of Zyprexa (used to treat schizophrenia and bipolar disorders). He had stable vital signs and seemed "OK". That was the report. Are you fucking kidding?

Um, no, you won't. For one thing, any overdose is presumed to be a suicidal attempt until proven otherwise, regardless if it was accidental, ESPECIALLY with a history of psychiatric issues. That means that the patient must be watched continuously to assure his safety until he is determinied to be safe. Or shipped off to inpatient treatment. That means a security watch, which we emphatically do not have. We also do not have any social workers available at our facility to do an evaluation. The physician instructed them to take the patient to the Mother Ship. Lazy, like I said, to presume to do otherwise.

5. We actually had a teenager come in with testicular pain, brought in by his father. This occurred after the teen had some physical contact with his girlfriend; apparently not enough. He was diagnosed with blue balls; Dr. Cripes said he had to give a little birds and bees lecture to the mortified teen. I thought the father should be the one who was mortified. Cripes was at a loss as to how to come up with a medical diagnosis for blue balls; Google to the rescue. It is called vasocongestion. Don't try this at home.

Alaska Tails

Sherry is safely back from her annual back-country paddling trip in Alaska. You may recall that last year, she had a real problem being stalked by grizzlies. Her husband subsequently failed to keep his word by purchasing, and learning to use, the necessary weapon that would ensure their safety.

Fortunately it was a remarkably griz-free adventure this year; except for the last day.

Sherry and her husband are dropped off by a bush plane, paddle to a certain point and then rendezvous with the pilot at a pre-determined time and place. This year, because her husband was doing some type of observation for the Park Service they were given a satellite phone (and a Jr. Ranger badge). This would serve to be a fortunate happenstance.

At the end of their trip, Sherry and her husband Dick were awaiting pickup on the appointed day by a small float plane; a little pond was to be the landing area. Sherry told her story:

"The wind was blowing a gale, and there was quite a bit of chop on this pond; it was relentless. These float planes have to land precisely, otherwise they would tip over and crash. The pilot made three or four passes, and I knew he wasn't going to be able to land. Sure enough, he called us on the sat phone and said there was no way. He has to come from two hours away, so he said he would come back the following day, and for us to call him at 6:30 AM to let him know about the wind conditions".

"I didn't sleep all night. The wind kept howling, and I was concerned that we would be stuck another day. It was so bad we had the tent tied to the gear bags so it wouldn't blow away. Finally, just about 6:00 AM the wind died down. Dick called the pilot who said he would arrive about 9:00. I was relieved and settled back in to get a couple of hours nap at least".

"At about 8:30 I got up, and Dick and I packed up the tent. We were pretty much out of food, but had a couple of granola bars so we pulled them out to eat while we sat on the gear bags and deflated canoe to wait for our ride. That's when we saw it: a giant grizzly. It was down at the end of the pond eating a caribou. Dick and I kept our eyes on the bear, but he seemed pretty engrossed in his breakfast and didn't seem to notice us".

"About this time, the wind picked up again with a vengeance. Now I was nervous, as if I wasn't when I spotted the bear. Maybe 10 minutes later we spotted the plane. I was thinking we were in some pretty serious trouble if he couldn't land, because the wind was gusting."

"The pilot had to come in low, right over the bear in order to land, so I know he realized we had a serious situation. The bear was pretty pissed off about it, too, roaring and waving a paw at the plane. The pilot tried to land, twice, a third time, then a fourth; each time the bear was roaring. I really didn't think we were going to get out of there; I had no idea how much fuel was available to burn on failed landing attempts, so I was feeling pretty desperate by this time. All I could imagine was spending another night with this really angry bear in our back yard".

"Finally, there was a lull in the wind; I had a feeling that this was going to be the last attempt. The plane came in so low I thought it was going to hit the bear, who was definitely not happy. At this point,the bear did something really odd; it THREW the caribou at the plane! I have never seen this before, nor had the pilot.

"The plane landed safely, loaded us in and we were on our way. The bear retrieved the caribou and continued with his meal, paying no attention to us at all. It was a great trip, but boy, was I glad to get out of there".

We are all happy to have Sherry home safely, but the phrase "when caribou fly" has become our new favorite saying.

We saw 24 patients last night. This, in a 6 bed ER with two nurses and one doc. Plus, the doc was Gil. Lord love the guy, but he is a cautious soul and we had some sick patients. Plus at least 6 dental paineurs, of which two left because the wait was at least 90 minutes. Can you imagine?

The campers from the several overnight camps kept coming. I don't know, perhaps it is the first time in a year many of these kids have been outdoors; they have fractured fingers, been stung by bees/mosquitoes/ spiders and one camp hamster (a campster?). As my son used to say, "ham comes from a hamster".

One day a week we offer a free walk-in blood pressure clinic. Not too many people use it, maybe a dozen or so. But for some of these crusty Yankee old-timers, it is perhaps a day out; and free to boot. One of the cranky old ladies never remembers to bring in her little booklet, so she gets a new one every week. We give these out gratis; I envision her house with about 3,000 little booklets, each with one or two blood pressures written in it. I seriously doubt that her PCP ever sees these readings. Or anybody. She is a little ritualistic, needing to sit for at least 5 minutes to "settle", then another 5 minutes to rummage around for the booklet she does not have. Several minutes are expended in divesting "only the left arm!!" from about 4 sweaters. Finally, she will squint up at me suspiciously and ask me who I am, and if I am new. We go through this every week. After taking her blood pressure and writing it in the new booklet I have provided, and she clucks and mumbles and frets her way back into her clothing, she is out the door, pushing a walker sporting 4 tennis balls in the legs.

Having your triage area tied up for 20 minutes on a free service: priceless.

One woman came in who just wants me to check her O2 saturation. Why? "I just had an asthma attack and if the reading is normal I don't want to be seen".

OOOOOOOOOOkay. We offer a 15% discount on ER co-pays that are paid right away; we take major credit cards even. But, you can't collect on this type of time-wasting activity which included informing the patient to return if she stopped breathing. Or whatever.

New Cathy emerged from an extended visit with one patient. "Well, she wanted to know if I had found Jesus, and I couldn't get out of the room; any suggestions for next time?".

"As the token atheist at a Catholic hospital, I am perhaps the last one to ask; I could give you some talking points from my perspective, but I doubt it would go over well", I said drily.

Gil says, "That happened to me once; the patient was jumpig up and down, waving his arms and yelling, "Praise Jesus! Praise Jesus!", so I just started jumping up and down yelling "Praise Jesus!" too. Then security took over".

"My son suggested that this might be an effective way to deal with telemarketers; I can just imagine. 'Hello, I am calling from XX Loan Corporation, are you interested in refinancing your home?'. 'Why no, but have you found Jesus?'. Could work pretty well", I said.

The hits just kept on coming. One little guy, I don't know how he managed this, fell off his bike and cut the soft palate in his mouth pretty badly. The rubber grip on the handle bar was mostly worn away, exposing much of the hollow metal edge, which wound up piercing the roof of his mouth. He was so scared, but did OK. It could have been so much worse.

The Last Patient of the night (whom we finally saw about midnight) was actually having an anxiety episode. She insisted that it was "overactive kidneys". I was too tired to pursue that she perhaps meant "overactive adrenal gland" that is located ON the kidney. The adrenal gland produces cortisol, a hormone that is important for several body functions, such as blood pressure regulation and release of insulin; it is also released in increased amounts in response to stress. Also, it is responsible for anxiety reactions, which is pretty much a "flight or flight response" gone haywire. That is tonight's science lesson, class.

Ativan helped, and she left with happy adrenal glands.