Monday, January 31, 2011

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

was a 20 month old brought by mother for "vomiting".

Me: When did the vomiting start?

Mom: A half hour ago. He was with my ex. I think he might have gotten into some medicine.

Me: What makes you say that?

Mom: Well it was blue and green and had chunks in it. Nyquil is blue.

Me: Did you speak to the Dad to see if it was possible, or that he had been given any blue foods?

Mom: What?! There are no naturally occuring blue foods!

Me: Rainbow Goldfish? Skittles? May not be natural, but they come in green and blue.

Mom: Oh. I didn't think of that.

Note: the child had eaten a lot rainbow colored Goldfish crackers when mom checked.

Sunday, January 30, 2011

Little Mr. Man...

...was 94 years old, pleasantly demented and was a "surprise" roll up via ambulance from a local nursing home. "Oh, didn't they call you?" (Do they EVER?).

He had an infection in his finger, more specifically a paronychia. He had been a nail biter for most of his 94 years. Mr. Man was also blind, very hard of hearing and was wearing headphones that disappeared into the front of his shirt, connected to I have no idea what....something. Perhaps a poor-man's hearing apparatus. Maybe it was just a cassette of a mother's heartbeat, the ocean, yoga music or jungle sounds.

Still, he was very cute.

Even when he wandered out of his room without clothing while Jane and I were busy wrangling a toddler who needed stitches.

Poor Ellen. She would much rather avoid any nudity or sexual references altogether, but recognized that we were both busy so she kindly threw a sheet on him lest he scandalize the old ladies in the waiting room.

This was on the heels of her latest discovery of vandalism. And on her very desk.

Ellen was tired of people walking off with her pens. So, she artfully decorated a few pens with large plastic flowers; the kind that people generally do not walk off with. Next, she placed said pens with a bunch of tiny decorative pebbles in a little glass jar which she labeled "PENS"in bright red.

Some wisenheimer clandestinely placed an "I" between the "N" and the "S". You know what that spells.

Now relabled, the "N" and the "S" are so close together you could not possibly get and "I" in there. There will be no nasty penis references on Ellen's desk at this Catholic hospital, you can bet your boots.

And nobody walks off with the pens, either.

Ellen, controlling crime, nudity, and inappropriate sexual references in the ER. What would we do without her?

Saturday, January 29, 2011

The Best Defense....

The Talker got a patient complaint, and since I was working that night I was interrogated about my culpability asked what I remembered about it.

The complaint went something like this:
The doctor said he thought I was addicted or selling the drugs since I have had a few ER visits recently. He made me feel bad. He wouldn't give me any drugs and it was a waste of my time.

Oh, yeah. I remember alright.
The patient wanted Vicodin for her complaint and said her doctor had sent her over. She had just been seen in our Downtown facility the night before for a different pain related complaint, where Parvati (being relatively new) had given her the ol' IV fluid and IV med routine that we have come to expect of her for every patient with a chronic pain complaint. She has been notified that we don't routinely do this on every patient, much to her surprise. Anyway, the patient refused a CT scan and left the department before her care was completed.

The Talker got the patient's covering physician on the phone, who was well aware of this patient. He told The Talker that the patient had a long history going from ER to ER, abusing narcotics, had a pain contract, and that she wasn't to receive any prescriptions for narcotics.

The Talker spent at least 25 minutes with this patient discussing harmful behaviors but never said anything about the patient selling drugs; it is not part of his "Narcotic Avoidance" speech, so I can' only imagine where she got that.

My boss was a little bit at a loss for how to handle it.

I suggested that she just call the patient and tell her everyone involved with her care has been fired; it has at least as much truth as her complaint.

Friday, January 28, 2011

We Do This To Ourselves

So with New Cathy gone, I have had a few days of working with SIC (Second in Command). She's not too bad to work with as long as we are busy. I have figured out that I am somehow threatening to her, or that my experience makes her feel inadequate. The sum total of her ER experience lies within our small 6 room facility. That doesn't make her a bad ER nurse, she is actually a very good nurse and I have never knowingly said or done anything to make her think that I felt she was incompetent, but people can be so weird. Having worked in larger, busier ER's where nurses have more autonomy and/or standing orders, (and flow rather depends on it) I sometimes chafe at waiting to get things started when I know that they are going to be required anyway. I appreciate that we all come from different backgrounds, so maybe she is finally getting comfortable enough to let her guard down instead of always being on the attack. Anyway, we were working with Bobo, who is still, apparently on his meds and willing to have a laugh or two.

Bobo had the misfortune of having to deliver (for the first time since his residency) a baby several months ago at our treat 'n transfer station and Taco stand. Luckily, he was working with Mikki who has some OB experience and the midwife showed up to "coach" over his shoulder. Mom and baby did fine, but Sherry and Bobo were shaken up since nothing strikes fear into the hearts of ER personnel like the sight of a gravid female in active labor. At Your Cervix, I know this is your thing so hats off to you.

You can maybe understand why the 39 week pregnant female who "just wanted a labor check" (we don't do this) was not an especially welcome patient, especially since she didn't want to have to drive to the Big House downtown. You should know that, especially anxiety provoking for us, she was Gravida 10, Para 7.*

And no ma'am, she didn't call her OB. WTF.

Some creaky, squeaky memory deep in my brain from about 40 years ago whispered that with that number of pregnancies and deliveries, she was the most fearsome and feared of all OB patients, the Grand Multip

She was having inconsistent contractions; or maybe they were Braxton Hicks. No rupture of membranes. No history of precipitous delivery. She just "didn't want to go all the way downtown to be told just go home, you're not in labor".

As if.

As she was using the toilet she remarked, "Gee, I almost feel like I have to push".

"No you don't!", I shot back. Saying it makes it true, right?

Finding a fetal heart rate is not my strongest skill set, but I managed. This was followed by quick check by Bobo who insisted on sending her downtown in an amb'lance even though she was only 2-3 cm.

I know, I know. Why?

L.I.A.B.I.L.I.T.Y. The bottom-most rung of the bottom line.

Rather irksome in an otherwise successful turf was the bored and superior-sounding L&D nurse to whom I gave report. She had no idea that we are in the sticks without so much as a baby warmer which is why the hot-potato treatment.

When I was younger and inexperienced, I might have been made to feel badly. Now, I just recognize this kind of behavior for what it is; the "Eat your young" mentality rears its ugly head. We all have our strengths and weaknesses, comfort levels, and skills; it is important to remember that. Different specialty and critical care areas require different knowledge and education. In the ER, we have lots of knowledge and a variety of skills; we know a little bit about some things and cover every age from cradle to grave. That doesn't make me an expert on everything, but it does give me enough knowledge to have a healthy respect for what is most dangerous, and, most importantly, what I don't know.

In fact, that is kind of the point, isn't it? Every patient we see in the ER, every patient we triage we think, "What is the worst case scenario here?". Then we go about ruling it out, right?

Chest pain: having a big MI, or costochondritis?

Shortness of breath: pneumonia, PE, or anxiety?

Rectal bleeding: a big GI bleed, or hemmorhoids?

Rash: poison ivy or necrotizing fasciits (flesh eating disease, so called)

This is why most people go to the ER in the first place, they think of the worst thing it could be(or have determined that they have it, thanks to the magic of the internet) and count on us to rule it out. We often don't have to hunt Zebra,** the patient has conveniently done it for us.
But it's nice when we can help minimize their fears and allay their anxiety.

We certainly would never tolerate anyone who made the patients feel stupid, no matter how trivial the complaint may seem at first glance. That is one reason why it is sometimes so difficult to calm people with non-urgent complaints who can't understand why they are being made to wait. We don't make them feel stupid. It would be really nice if the culture of nursing was such that we go out of our way to extend the same courtesy to our colleagues.

*10 pregnancies, 7 births. This would be her 8th child.
**Zebra hunt: "If you hear hoof beats think horses and not zebras". A rephrase of Occam's Razor: All other things being equal, the simplest answer is usually the best.

Thursday, January 27, 2011

Winter, sigh.

New Cathy is off on a cruise somewhere warm; how dare she leave me to the cold, arctic north. Mr. Ednurseasauras has been in Arizona with the guys (OK, Vegas too..but he doesn't drink, gamble or do any of the stuff that normal people do in Vegas). Before he left, he spent 20 minutes teaching me how to use the snowblower in case of a Nor'easter while he is gone. It is a brand new snowblower. Let the record show that I have now used it more than he has. With another storm dumping more of the cursed white stuff yesterday, I am glad he is back and ready to resume snowblowing responsibilities. And that I didn't screw up the snowblower by putting in gas from a small container intended for the leaf blower.

There is so much snow we are having trouble getting rid of it in some areas. Last Friday I told Jane, my boss, that the pile of now in our parking lot had completely covered up the handicapped parking signs by the patient entrance. I thought that this was a problem because people without handicapped placards were parking there indiscriminantly, even people who come in 3 times a week and KNOW that they shouldn't park there. That leaves the little old ladies to park in Hip Fracture territory, and wouldn't that suck if one of them fell. She said she would put in a work order to have the signs unburied.

That was 2 storms ago. Now the snow pile is higher than the top of a full sized pick up truck. I worked a rare day shift today and was pretty surprised to find one of the building and grounds guys driving in. He came in laughing and wanting to know if we were smoking crack because those signs were gonna stay buried for a good, long time. He offered to drive back to the Big House to get some sawhorses and put some makeshift signs up. I can only imagine what kind of violations we would be racking up when someone with a placard complains.

Tuesday, January 25, 2011

The Lady on Elm Street

One of our least favorite frequent fliers individuals well known to our facility is a very large lady (over 400 pounds) for numerous non-emergent complaints. In fact, she utilizes the town ambulance service several times per week for her free taxi ride transport to the ER. On one less than joyous occasion, the ambulance stretcher malfunctioned, causing this plus sized lady to plummet to the ground. Never mind that two of the EMT's sustained injury. Now, when the ambulance is toned out to a medcal call at number x Elm Street, an entire batallion of responders is activated. Self preservation. In addition, if transport is required, there is call service who sends a bariatric stretcher. More self preservation, as well as shielding the town from a lawsuit.

Once her care is completed (usually some minor dressing change, an xray of a wrist, elbow, knee, ankle from fall, or abdominal pain that she suffers from chronically) she is ready to go home. On the return trip, she invariably asks for a taxi voucher. The local taxi service is reluctant to take her because she rarely wears more than a nightgown and robe, her fuzzy pink (or used to be pink) slippers that smell like pee, and she leaves the back seat of the cab a mess. Since the single cab company knows the address, there aren't many who are willing to risk their backs to heave her out of the cab. We don't have the authority to give the cabbie a whopping tip, but usually they deserve it; consider it combat pay.

Sounds like this lady is a pretty sad case, doesn't it? That because of her size we are reluctant to provide care? Consider her problems her own fault? Don't care that she has nobody to care for or about her?


So wrong.

We have all tried so hard with her; most of the doctor's have had caring heart to heart chats with her about how dangerous her weight is for her health, discussed options ad nauseum, services, alternatives, health promotion. The Talker has spent hours with her; Cindy Lu Hu has spent hours with her; Gil has spent hours with her; Cripes has spent hours with her; even Bobo has spent hours with her. Her response was to lodge a complaint against each and every one of them because they discussed her weight.



How can you help someone manage their health by ignoring (forgive me) the elephant in the room? Can't be done.

Kerry got written up because she tried to arrange a home health aid. Why? It was none of her business what her home was like; never mind that she smells like a goat. Kerry did it out of concern for her well-being and she was repaid by getting a complaint. So has Sherry who has seen her as a home-care patient. So has Mikki. So has our boss, Jane. Jane had this little gem to share:

"I was putting ornaments on the Christmas Tree in the waiting room and I dropped one of them. It landed on the floor and shattererd. The Lady from Elm Street was sitting in the waiting room and said to her companion (with whom she had managed to get a ride for an outpatient blood draw), "Did you see that? She threw that at me! It's lucky we didn't get cut! I should complain"

I gave her a steely glance and said I hope you are kidding, in a deadly voice.
She backed down and said she was. "

I learned that there had been no less than 20 complaints over the last two years; she must have Patient Services on speed dial.

We all know how this will end.

She will have need of care for a life-threatening issue when she calls 911.

More likely, one day EMS will find her dead in her house.

Saturday, January 15, 2011

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

....was 22, had no insurance, had presented 16 times in the last 8 months for the Holy Trinity of Pain Complaints* and wanted oxycodone for menstrual cramps.



*migraine, dental pain, back pain

Friday, January 7, 2011

When Spidey Sense Kicks In

The patient had presented with mid-lower back pain, more in the flank area, rated as maybe 4/10. He felt a little uncomfortable. His BP was a little high, heart rate in the 80's. Dr. CindyLou Hu pounded on the area but the patient said nah, that doesn't hurt, it feels like it is DEEP inside. Hmmm...

Back pain? or something worse?

Dr. CindyLou elected to do a CT instead of sending him home with pain meds. It showed a HUGE dissecting aortic aneurysm (click here to read about it). This would be a bad thing, but there are two types.

One type requires surgery like, yesterday; if it ruptures, it's all over. The other can be treated conservatively with medication. It was an overnight shift so CT's are read remotely by an on-call radiology service with whom the hospital contracts; I believe they exist in bunkers somewhere, perhaps in Antarctica, or in rainforests, possibly connected with the Dharma Project and sharing office space with Keebler Elves while alternating searches for Sasquatch and the Loch Ness Monster. Normally there is a little bit of a lag for readings (hey that happens during the day as well). Fortunately this guy had the NOT IMMEDIATELY FATAL type and was admitted to Higher Level of Care Medical Center where he did well.

As Dr. Cindy Lou and most nurses would say, sometimes you just gotta go with that gut feeling. Not all BAD THINGS slap you in the face and say they are a BAD THING; but experience helps, and sometimes the patient just can't say for sure what is going on beyond (and this includes parents regarding their kids), "there is something that just isn't right".

I once had a 38 year old with nausea who said he just didn't feel right; except he LOOKED like he was going to die, literally, right in front of me. An EKG confirmed that he was having the BIG ONE. Some nurses never develop that sixth sense that prods immediate action, but most do. Gotta trust that Spidey Sense.

Wednesday, January 5, 2011

A Comment on Drug Seeking Behavior

A while back I had the predictable response from one of my posts about drug seeking individuals; the respondent took issue with my attitude and begged me to consider that all patients with chronic pain complaints are not, in fact, drug seekers. My response:

"Yes, but why are you out of meds? Surely with a chronic painful problem you would make it a priority to contact your provider well in advance so you DO NOT run out; this is what reasonable individuals do who are taking responsibility for managing their health care. "I've run out of my meds and haven't had time to contact my doctor" is often how individuals seeking narcotics present to the ED. This is not to paint everybody with chronic pain issues with the same brush, I am merely pointing out why you may be treated like a drug seeker when you say you have run out of meds. You must understand that most of us working in emergency departments see the same individuals all the time with the same chronic complaints; most of these patients could be well controlled with medication if they are diligent. But that is my point, so many want only the narcotics. Their histrionics and constant drama suck the life out of us and take us away from legitimately sick patients. No, not everyone is a carbon copy, however when 9 out of 10 individuals with these chronic types of pain issues IS a carbon copy perhaps you can begin to see the problem".

For example:

Today a gentleman arrived with a complaint of "Getting a Migraine". No headache, but you know, he says, I've had these visual "bubbles" for a whole 20 minutes now and that's how it starts. He has had 25 ER visits in 2010 for pain-related complaints; most were without trauma, and those that involved a fall, lifting furniture, banging his thumb with a hammer were all without clinical findings. Of course the majority were for the Holy Trinity of pain complaints: Back Pain, Migraine, and Dental Pain. Amen. He had been prescribed 15 Percocet for 10 of those visits, 10-15 Vicodin for 6 visits, and Ibuprofen for 3 visits. He declined a dental block for two visits and just took the antibiotics.

Another well known individual with many, many visits for back pain always has the same story; my doctor is not available. In 18 of the last 19 visits, he has arrived at 5:15 pm ALMOST TO THE MINUTE. Of course his PCP's office is closed at that hour. He asked for oxycodone without the acetaminophen, which is oxycontin pretty much and very powerful stuff. He claimed that the Tylenol hurt his stomach; note that for 19 out of 19 visits he received a prescription for percocet. The ER physician informed him that she never prescribes pure oxycodone in the emergency setting and wasn't about to start now.

Both of these cases involve individuals with chronic pain issues who have either not been up front with their physicians about how much medication they are taking, or are simply lazy. Lack of planning on your part does not constitute an emergency.

Tuesday, January 4, 2011

Welcome to the Dark Side, Bobo

Apparently, Dr. Roboto has thrown in the towel, conceded my cynical superiority, and has decided if you can't beat 'em, join 'em.

Yep. He's rolled over and realized that I'm no pushover, have no respect for him, could care less if I am fired and, more importantly, my sucky attitude toward him has spread to the other nurses. Pied Piper rulz; no one has called him Dr. Roboto in weeks, we now all call him "Bobo".

Oh, Bobo is still going full tilt on the rapid door to doc. But, if the nurses are busy he will greet the patient at the ER door and see them before they are triaged. Great! Now you're beginning to understand teamwork! I am a powerful ally, but a formidable opponent as he has discovered. I have caught him trying to make jokes, along with uncharacteristic human emotion, an occasional eyeroll, and actually CHATTING with nurses. I told him, as he considered having one of us give a constipated individual and emergency enema, that there was a special place in hell for ER docs who order either ear irrigations or enemas in the ER. The son of a bitch actually laughed and didn't order it. Another social lesson well learned (or he is at least on the right combination of meds), but my work is not yet complete; now I just need to get him to talk to his clavicles a little less as he does occasionally backslide on that issue.
I rarely work with Mikki, and had an opportunity to do so with her today on an infrequent day-shift appearance on another busy shift in which we ran our little legs off. Everyone got hydration, labs, meds and instructed in how to collect a sample of the alleged diarrhea that a many had claimed to have experienced for days, which somehow mysteriously resolved upon arrival to the ER. We had Dr. Cripes today, which was a happy bonus. Gotta love him. Working with Mikki is a trip because she has been very insecure in the past, and frequently looks to me for...I don't know, courage, leadership, approval-whatever. She gets better all the time though, I'm happy to report. I tell her the cool kids like her and not to worry about what Second in Command says or does, because she is unhappy, unliked, and uncool. Who needs her?

I had been given a yellow pen with a duck head that lights up and quacks when you push it on the noggin; very annoying, but I LOOOOVES me my ducky pen. It goes well with my yellow scrubs; the yellow submarine in da house.

I emitted a cheerful "quack" with my pen as I greeted Mikki and Cripes. "Hey, what's with the duck", Cripes asked. "It annoys Bobo, what could be better?" I asked.

"I used to be a wreck when you and I had to work with Bobo", Mikki said. "I'll never forget the time you said you wouldn't respond to anything he said unless he called you by name and looked you in the eyes".

Cripes and I laughed. "That was also the day I told him he was needy. And because he took the time to write 'suture set, 1% lidocaine, 4-0 nylon, normal saline, Zerowet and set up for sutures' on an order sheet which took 4 times as long as it would have for him to just do it, I put 1/2 the wrong stuff up on purpose".

"I wanted to disappear", Mikki cringed.

"Nurse Passive-Aggressive on the job that night?", Cripes grinned.

"Yep, guess you will never have to meet her since you are pretty much the pinnacle of ER physician role models. We all change shifts so we can get to work with you".

The highlight of the day was that my boss told me that I would be receiving the first raise of the new year since my anniversary date is January 4. WOOT!

Sunday, January 2, 2011

"I Like the Christmas Jesus Best"

New Years Day was just as much fun as New Years Eve, with record numbers of patients. It was apparently a good day to take care of all of those annoying little symptoms people have had for months; colds, back pain, dental pain, rash. Not the most challenging night.

New Cathy, whose Christmas tree and decorations came down on Christmas Day before she came to work, was all about ridding us of the holiday decor. I spent about 30 minutes in triage and when I got through with about 6 patients, she had taken it all down. Most of the stuff is pretty old, so I 86'ed the wreath that looked awful; executive decision.

Of course, there was the scandalous Nativity Scene crime. It all started on Christmas night.

It was pretty quiet; we were hanging out in the waiting room watching a very boring movie and chatting when I noticed that the ancient, chipped Nativity set on the small table next to me seemed somehow incomplete.

"Hey", I said to nobody in particular, " did this Nativity come with a Baby Jesus?".

Ellen sat bolt upright. "What?! You gotta be kidding me. I put that out myself! Maybe it fell on the floor?"

We searched around, but it was nowhere to be found. "It's really gone! Who would do that? Who would steal the Baby Jesus? Who would be that low?", said Ellen.

"Well, maybe someone just took it for a joke; you know, like those lawn ornament thingies?", suggested Mary.

"You mean garden gnomes; people would pose them in vacation spots and took pictures? Then they sent the people pictures of their gnomes on vacation?", I said.

"Yes, just like that. Maybe someone took Jesus on vacation", offered Mary.

“Why not?" I said, "to quote my daughter K: 'I like to think of Jesus as wearin’ a Tuxedo T-shirt, ‘cause it says,‘I want to be formal, but I’m here to party too.’"

"That is just terrible. I'm very upset about this", said Ellen in a huff.

I just think it is kind of ironic that someone took the very symbol of one of the most holy days of the Christian calendar from a religious hospital. But that wasn't the end of it, which brings me around to the Christmas decoration sweep over the weekend. Not only was the Baby Jesus MIA, but so was the Mary figurine.

Now Ellen is nearly apoplectic.

"Oh, more crime; what kind of person steals pieces of a Nativity scene. REALLY! People will stop at nothing these days, it is so sad."

“Dear Tiny Jesus, in your golden fleece diapers, with your curled-up, balled-up little fists pawin’ at the air…”

But wait! There's more. During the Christmas cleanup it was discovered that the nativity scene was also missing a farm animal.

Where has Donkey gone? Is he on vacation as well?

Donkey: Oh, man! Where do I begin? First there was the time the farmer traded me for some magic beans. I ain't never gotten over that. Then this fool went off and had a party, and they all starting trying to pin a tail on me. Then they all got drunk, and started hitting me with sticks, yelling "Piñata! Piñata!" What the hell is a piñata, anyway?

This news nearly puts poor Ellen over the edge until Chris from the lab offered an explanation.

"Oh, that. The head broke off, so since I couldn't find the head, I threw the rest of it away".

It is with some effort that I restrain myself from any comments regarding the business end of a donkey. And we have not as yet received any vacation photos, just saying.

Still, I was a little surprised at the lack of quality of the entire sorry set anyway, it should have been long retired. No manger, just a bunch of wise men, a donkey and the holy family sitting on a TV table in the waiting room. Not even in a place of honor.

When I actually put up a nativity set in my house when my kids were small, it went on top of the piano (which I also no longer have). It was the highlight of the Christmas decorating routine, with my kids placing the figures in various positions which were rearranged on a daily basis.

You may recall that my mother was scandalized when the baby Jesus was found to occupy a position on top of the manger when I was a kid, however, that was normal for my family. Often, the scene was embellished with one of the many dozens of Fisher-Price doll people, as well as Match Box cars, Transformers, plastic toy soldiers, boats, china animals, and a fence from one of the 50-pack plastic farm animal sets, many of which also joined the fun. The 3 wise men were plenty crowded; it was quite a party in there. My mother just shook her head.

My daughter drew the line at the plastic He-Man and other Masters of the Universe that my son J would add. "That's not 'propriate", she would say.

"He's guarding Jesus", J would explain.

Usually, though, at the end of the day Jesus was on the roof, but He-Man was at his post protecting him, and all was right with the world.

Next year I'm gonna bring in that He-Man in case Jesus returns. Just sayin'.