Tuesday, July 6, 2010

CRNA and Cellulitis

In my youth, about the time that dinosaurs roamed the earth, I had a tendency to be intimidated if I had health care types for patients. Docs and nurses are not the best patients. For myself or my family, I don't (unless I am wearing scrubs) come right out and say I am a nurse with about 1000 years experience simply because it can be intimidating.

Case in point; my husband was admitted last year for a cellulitis in his hand. Since he was being discharged with the need to have IV antibiotics at home he required an IV change (yeah, that one: the one I had put in 2 days earlier). I gave the young nurse 2 tries, then I (nicely) bullied her into fetching me a warming pack and put the damn thing in myself. I really tried to stay out of her way but my husband is a hard stick; I was just looking out for him, not judging the nurse.

So a guy came in over the weekend with a pretty nasty infection; he would require IV antibiotics for a couple of doses, but could come to the ER for his medicine; hey, we're a full service ER.

As I looked over his arms for a suitable spot to place his IV, his wife helpfully shrieked, "You can't put it in that arm, that's the one with the infection!".

Um, ok. Gee ma'am, don't know what I would have done without that useless bit of information. I quickly intuited that she was some sort of health care person and she wanted me to know it.

In my experience, the degree of effort expended by an individual to inform me in some roundabout way that they are in health care:

a. is inversely proportional to their level of experience or years of practice

b. has no relation to the level of acuity said individual practices

c. is a clue that they are either a student or an LNA


d. just want me to know that while they may not be a kick-ass ER nurse like me, they are indeed a kick-ass school nurse, office nurse, camp nurse, etc.

Second case in point: the aforementioned unhelpful wife, once I had decided on my target vein and was moving in for the kill, asked, "will you put in a butterfly since he has to come back tomorrow? They are so much smaller".

This tells me that unhelpful wife is an idiot since a butterfly, while small and perhaps really useful for short term use (ie, minutes) under direct supervision is inappropriate for longer term use. People who exhibit health seeking behaviors such as migraneurs who capriciously use the ER for their chronic pain condition will often ask for a butterfly. I usually don't make an issue out of it, but explain that those are METAL needles which are not good for extended use. Then I promise to use a baby needle, usually inserting something like a 20 gauge. This is a good size stick and certainly not a baby sized needle unless the baby is a full grown adult. Which they are.

I decide to ignore unhelpful wife and address my comments to the patient who was being very quiet. I explained that the site I had chosen in the middle of his arm would not be as compromising to his lifestyle as one in the hand or the crook of his elbow.

"Oh, he knows all about it, he's a CRNA"

Ah. A nurse anesthetist. Cool. Scary damn specialty, though. Too much chemistry and opportunities for it all to go horribly, tragically wrong.

Mr. CRNA looked up at me and mused, "How am I going to work tomorrow?"

"Well, I'm pretty sure you have sick time; use it".

"Oh, he never takes any sick time", said unhelpful wife.

"Well, think about it, do you really want to go into the OR with this raging cellulitis? Hmmm? Is that a good idea?" I asked, hanging his bag of IV antibiotic.

"Guess not".

Unhelpful wife accurately intuited that I had lost interest in her and chose to regale me with tales of her horrible experiences in ER's. This not only bores me, but in most cases, this sort of discussion is about as tactful as telling me about the time you farted in church. It tells me a lot more about the kind of person you are than "scaring" me into believing you are an astute health care consumer or that you have any native intelligence at all.

To his credit, the CRNA patient was cool. Maybe he knew he was kind of screwed with that albatross of a wife.

"So, what what do you do for work?", I asked unhelpful wife, "are you a CRNA as well?". I knew she wanted me to ask. Really.

"Well, I work in dermatology".

"Wow, really, you're a dermatologist; that's great" I gushed, knowing damn well she was not. It is less than full disclosure, sort of like me saying I'm in MEDICINE; I work in the medical FIELD, but to say I work in medicine might lead one to believe that I was a physician. You can see my point, I'm sure.

Unhelpful wife squirmed noticibly and replied, "Oh no, I work in a dermatology OFFICE".

I moved in for the kill; "Oh, so what do you do there?"

"I'm a med tech, but I run the appointment desk".

Uh huh. Thought so.

Sunday, July 4, 2010

July 4th Patient Parade Notes

With the 4th of July being my weekend to work, I was naturally despondent that most of my family were partying up at the lake.

Without me. That included Mr. Ednurseasauras and Tina, my daughter K and her boyfriend, Rockstar, my mom, two of my brothers and their two kids apiece, a random niece of my youngest brother who is a firefighter and my hero (an who, like me is a lowly public servant destined to work weekends for the rest of our lives) and about 1/2 ton of legal fireworks. A good time was had by all, except perhaps for Tina who hid under the house for most of the fireworks display, and K's new kitten, whom Tina apparently wanted to eat. I can't blame the dog, the cat is about the size of a chipmunk, and probably good eatin'. It is, after all, the Other white meat.

My weekend partner and second nurse is New Cathy, who replaced Dan. She was an even trade from the Mother Ship for Dan, whom I liked but others didn't warm to; he liked to play with his iPhone, but was a good nurse and I had fun working with him. He worked at the Mother Ship for about 3 months, bitching the entire time because it is disorganized and lacks leadership, then moved on to greener pastures. I have said there are no Utopias in emergency nursing, but anyway, good luck to Dan. New Cathy is great to work with and enjoys patient care. The Mother Ship cannot have her back.

July 4th is a funny holiday. Sometimes it's busy, sometimes not. I'm 3/4 of the way done with a four-day stretch, Friday through Monday. The first two days were pretty quiet, seeing only 18 or 19 patients for the entire day; that doesn't exactly pay the rent when you consider that we need to see a lot more than that. Probably double that considering many of our patients use our ER as a free-care clinic, and some days as a public toilet. The usual complainers, worriers, and nothing-better-to-do's who frequent our delightful establishment on mundane weekends apparently had other plans, were on vacation, or visiting other ER's.

There are several overnight summer camps who like to use our facility as much as we like to have them; for them, it is 17 miles closer than the Mother Ship, and for us, lots of lovely, polite young campers and counselors. Also they have insurance, not that that is really an issue but it is a refreshing change.

One day last week I kept track of how many of our patients had no insurance, private insurance, or Medicare and/or Medicaid which reimburses at a ridiculous $.30 on the dollar:

Out of 30 patients for the day, 7 had private insurance 4 had Medicare, 1 had Healthy Kids and 6 had Medicaid. That translates to 23% of patients whose treatment would be reimbursed at an inflated rate in order to make up for the 40% who have free care (ie., no insurance and no intention of paying) and the 36% whose treatment would be reimbursed at pennies on the dollar. Also, 4 other kids were eligible for Healthy Kids, but the parents "hadn't gotten around to it" yet. Which is really asinine, considering it is free and the social workers will pretty much do the paperwork for you if you have less than a 5th grade reading level.

Yesterday business picked up; it was a day for bringing families together in the ER for mundane reasons. Just a few observations here; all of the mothers were smokers as evidenced by the reek of tobacco, had artificial nails, didn't work, and requested such items as free sample of drugs, money for the vending machines, coloring books, crayons, stickers, took several pairs of gloves to make balloons, and had the nerve to ask for syringes to make squirtguns. The unruly kids trashed the waiting room, triage room, exam rooms while the oblivious parents chatted on their cell phones. White trash tornado.

On rare occasions we have patients who are interesting. One really nice young guy came in with a red banadana around his knee; he had sliced himself a tasty gash with a freshly sharpened chain saw; a running chain saw. I have seen some pretty chewed up flesh in my time from these dangerous things, but somehow he managed a clean laceration; it must have come in contact with his flesh for a milisecond, luckily for him.

New Cathy and I were working with Dr. Cripes (cause he says it all the time) who is fast but thorough, decisive and funny as hell. He usually has a running dialog going, but you have to really listen to hear the funny bits because they come out so quickly. Witty guy. Fun to work with, plus he lets us play with his iPad when he isn't using it; I LOVE that thing.

"Whatcha got?" he asked as I wandered into the treatment area from triage.

"Chain saw massacree", I replied. "It's gnarly but neat".

"Carving ribs, was he?". Cripes is so droll, isn't he?

"Nah, carving up the neighbor who borrowed his rake last fall. He didn't return it", I grinned.

Cripes chuckled. "You let him sit in the waiting room?".

"Nope", I assured him, "he refused a wheelchair. He missed the femoral artery, though if he had hit it, I would have insisted. Just to be thorough. Besides, Helen likes to keep her registration desk free from pesky bodily fluids". Today Helen was harboring blueberry cupcakes somewhere, with little American flags. They looked yummy, too.

After Cripes injected lidocaine into the young mans knee and went off to examine ather patient (to give the lidocaine time to work) the young man was trying to take a photo of his laceration with his cell. The first two were in shadows.

"Here, let me adjust the light", I offered. "It really needs some perspective, I think", as I got a ruler out and placed it next to his knee.

"Yeah, that's great; much better shot. You're really into this, aren't you, sick like me!" he mused.

Busted. "Oh sure, that's why I love my job so much. We'll take another picture after it's fixed, OK?", I said.

15 staples later, another photo-op and a nice dressing and he was on his way. I just love things that we can fix.

One man came in and was immediately whisked into a treatment room; he had been experiencing weakness, lightheadedness, palpitations and chest tightness as he lay on the living room floor. For two hours. His EKG and all other tests were normal.

"He's wound tighter than a drum; if you poke him he would probably vibrate like a tuning fork. Can I give him some Ativan? And maybe some for his wife, every time I walk into the room she scurries into the corner", I asked Cripes as the man lay rigidly on the stretcher.

"Sure; I'm going to give him a 'script for some anyway. Man, he is anxious", said Cripes.

This patient, being a typical Type A personality was:
a. dentist
b. college professor
c. bike mechanic
d. engineer
e. landscaper

If you guessed anything other than choice D, you are wrong.

Mary, Diana, and Helen were very unbusy toward 8:30 PM. I thought it would be nice to put the July 4th Boston Esplanade concert on the TV, but they were engrossed in Extreme Makeover. Move that Bus indeed. "I just want to see how it ends" begged Diana, who is our lab tech. She is fast, fast, fast. We are spoiled when she works because our lab results are done at lightening speed.

"Music haters!" I accused. I really didn't care, I had other stuff to do. I do like Toby Keith, though.

The Milltown fireworks, we anticipated, would be visible just over the tops of the trees across the park adjacent to our ER. About 9:20 PM Mary and Diana had commandeered wheelchairs, popped corn and were settling in for the show. New Cathy and I finished up with another camper with a broken finger and, since we had no more patients, thought we might get to see the show.

Nope. The floodgates opened; the parking lot started filling up before the first shell was fired. Non-urinating 8 year old; fractured wrist; firework cinder in the eye (no corneal abrasion, but she got Vicodin for it) and the idiot who let a pack of firecrackers explode in his hands.

Fireworks + alcohol= stupid.

He had mostly 1st and 2nd degree burns; I gave him a big tub of water and some face cloths so he could bath his burns to his face and hands. Also to wash off the aloe that he stupidly put on.

Within moments his "bathing" had saturated my entire treatment room. Really, he was splish-splashing like it was a giant bird bath. Soon he had abandoned the tub of water (and the saturated side of the room) and proceeded to saturate the other side of the room by running the sink at top (and continuous) speed.

"Dude, please. You are saturating equipment and other things that should remain dry, and now we can't use it. Please (just grow the fuck up)be more considerate; I will give you something for pain as soon as Dr. Cripes has had a chance to look at you".

After two injections of Dilaudid, a handful of Vicodin to take home, and 50 gallons of water covering every surface of my treatment room AND two bathrooms, he left. Hopefully to think about what he had done and how not to repeat it.

Finally, at 10:50 another bonehead comes in for a non-healing wound he has had for 2 weeks. It wouldn't have been so bad but the idiot had called at 7:30, presumably to make an appointment or try for "call-ahead" seating, like Chile's. Yikes.

The poor lady with the wrist fracture was splinted, given pain meds and sent on her way to follow up with ortho.

New Cathy and I scurried around for 10 minutes putting things back together, leaving witty notes for the day shift (which is notorious for leaving tattle-tale type notes and reminders for evenings- I thought I would return the favor).

Hope all of my friends had a great 4th, especially Anne and Debbie who watched the Boston fireworks from Debbie's new apartment overlooking the Charles River. Hate you, mean it! Oh, and Happy Belated Birthday to you, Ps2ue!

Happy 4th of July to us. Wonder if Cumby's has any Coffee Heathbar ice cream? Nah, I'll just have a beer.