Wednesday, February 23, 2011

Nursing...the Next Generation

For some reason, there are more than a few nursing students who feel the need to read this blog. That's OK, as long as y'all are taking my mad ranting with a grain of salt. Remember that I have been a nurse for a long time. A VERY long time. During that time I have run the gamut from wide-eyed optimist, to rebel without a clue, to union organizer, to leader, to simply throwing my hands up in surrender. Butcher, baker, candlestick maker. I've done....well, not quite everything but near enough. Near enough.

Although I love to teach and am usually on my best behavior when I am toting a student around like a pull toy, I usually have to make a conscious effort not to make snarky comments. Also to conduct myself professionally and to set a good example. It is stressful. I can usually go about 2 to 3 hours before I go off on something or other. Just can't help it.

Tonight I had a student for 6 painful wonderful hours. I was a paragon of virtue for the first 2; shocker.

A satellite ER is not the greatest place to have a first year student. For one thing, we have limited resources on a number of levels; we don't do things exactly by the book, and it is an entirely different environment. Plus, when things rapidly go to hell in a hand basket, it is necessary for students to just get the hell out of the way and for me to try to explain later. Sometimes we just can't use the training wheels, and students are forbidden to ride the bike without them.

Since we can't even let students take vital signs (only second year students can do that, yikes) I hauled my student to triage and back, in and out of rooms for IV starts, and had her hand me stuff. No big deal. I think it was more important to give her a sense of how the assessment process works, but you know kids; not happy unless they have a toy to play with. I had a high school intern who was bored out of her mind last fall, and mainly did her English homework if it was quiet. On her evaluation, you know what she listed as the best part of the entire 100 hours? "Ednurseasauras showed me how to use a syringe and needle to draw up water (saline, actually), and how to get rid of the bubbles". She played with it for about 2 hours.

Really? The best thing you did in weeks?

Tonight I had a good bit of time to explain stuff which makes for a reasonably good experience. I showed her all of our toys "Oooh! Shiny!". I let her listen to lung sounds. I showed her how to take out sutures. She had some initiative and was out of the chair when patients came in to accompany New Cathy and I to triage. I only went off on one of the 3 frequent narcotic seekers who was pissed that she got Tramadol, and even more pissed when Bobo gave her a 'script for Motrin when she complained. But I digress. Mostly I was a good little nurse.

Now that you have finished falling off your chair, you may resume your normal activities.

Oh, when I asked the student what were the best/worst parts of her experience at night's end, she thought that making the beds was the worst part.


Saturday, February 19, 2011

Last Course!

I did it.

Passed my last CLEP, and expected to start my final course toward my BSN at the end of March, beginning of April.

Lo and behold, a call to my academic advisor yielded a lovely surprise; instead of starting a new 11 week course at the beginning of the term, a change in policy allows the start of 11 week courses ALSO at the mid-point. I was immediately enrolled in Holistic Professional Nursing (a day late, but who cares!).


Unless I decide on grad school.....

Wednesday, February 16, 2011

Today's Last Patient of the Night....from the other night...

happened to be the Lady on Elm St. We heard the ambulance tone out for leg pain to her address on the scanner, so we knew what was coming. I looked up her last several visits to see if she had been seen recently: nope, just a bunch of outpatient stuff. Whatever.

The paramedics who brought her in were an interesting team; Drew is somewhat of an ass bordering on douchebaggery, but seems to be growing up a little of late. He is making fewer insensitive comments, actually asks intelligent questions and has been less condescending than usual to the patients whom he deems beneath him, or less deserving of his vast array of knowledge. Or taking pictures with his I Phone of random stupid stuff. ("Oh! Want to see a picture of an icicle that looks like Larry the Cable Guy?", no. But thanks for asking).

Lady was on an insulin that I hadn't seen before along with her 25 other daily meds (not total doses, total meds....not including the PRN pain meds that she routinely takes and just doesn't seem to get around to adding to her med list). Drew took the time to look it up on his fancy phone.

So, Lady had been given an antibiotic for a 2 cm. red area on her leg the day before. Gee, it's not better. Wow.

Bobo gave her another antibiotic and I dispatched her via comped cab to her home in near record time, a happy camper. But since it was the night before Valentine's Day, I decided to have some fun with Bobo in case he had received a funny bone transplant recently.

Lady had given Cripes a Valentine the week before; a nice long, flowery valentine, for which he received an enormous ration of shit. Lady just LOVES Cripes, and even gave him a big hug to prove it.

I took a plastic heart off the wall and wrote:
"Dear Dr. Roboto,
You are the best doctor in the world. I am so glad that I had you to take care of me today. If you give me your schedule, I will come in every time you are working.
Love and Kisses,

After she left, I handed it to him
"Here, Lady left this extra special valentine for you"

He took it, read it, blushed and said, "She really did this?"

Me: (laughing) ".Um, no, not really. I just knew that Cripes had received one and didn't want you to feel left out".

He had the good grace to laugh. "Guess I'm a little slow on the uptake. That's pretty funny".

Me: "I'm going to put it in your call room for everyone to see".

Bobo: "Haha, they will all be jealous".

Naturally I left it for Mikki and Sherry who called me early in the morining when Bobo was back to work the early shift with them Not thinking or believing that I had the guts not only to do it but to show it to him, they left it for Bobo along with a chocolate heart. It kind of backfired since it was already played. But they did get a laugh out of it.

Saturday, February 12, 2011


Bobo: Did you triage room 2?
Me: Nope. Why?
Bobo: I can't read what's written under "LMP"*
Me: It says, "wrist"
Bobo: Ummm.....
Me: You're welcome!

* last menstrual period

We are Here for You!

My co-worker, Lisa, moonlights at other ER's. Today, she was at the Bear Went Over the Mountain Regional Hospital ER about 20 miles away. Many of our more mobile, but less intelligent, frequent med seeking individuals with the Holy Trinity* of narcotic-gettin' complaints will shop there. Unbeknownst to them, Cripes occasionally works there as well as Lisa and a few other nurses from the Mother Ship. That is three of the four hospitals in the immediate area; guess we have surveillance covered.

Lots of times the individuals will take one look at either Cripes or Lisa (or others) and skedaddle like a rat leaving a ship on fire; sometimes they will swear to God they have never been seen for this or any other problem. That is pretty stupid, but then these aren't the brightest bulbs in the box. Just add it to the list of Great Moments of WTF-ery.

Lisa just happened to mention that one of our more challenged narc-seekers came up with a particularly tasty little nugget during her triage interview at Bear Went Over the Mountain ER. He had been seen at my ER (by Lisa) over the weekend.

"Oh no, I couldn't have been seen over the weekend (where he received a 'script for Percocet) because THAT ER is always closed on Saturdays and Sundays".

Note that we are open 365 days per year.

Lisa just wanted to know if she was going to be paid for working the weekend if we were closed, and how that would affect her every-other-weekend committment.

*Holy Trinity = back pain, migraine, dental pain.

Friday, February 11, 2011

Stuff I Found Behind the Ice Machine

As pretty much everything in our ER is old, old, old, it should come as no surprise that our ice machine is a model about 30 years more elderly than this specimen. It works pretty well, though and we always have a steady and abundant supply of ice cubes (not that crushed crap). These are solid particles that weigh heavily in a plastic bag and conform nicely to those swollen body parts; not to mention providing refreshing iced coffee whenever we need it.

There are only two problems; it occasionally makes a helluva racket and takes up a ton of space. The first problem is easily rectified with a well-placed kick just below the grate; the second is not rectifiable. But since there is so much room behind and next to it, I made a couple of amazing discoveries when I dropped a sleeve of cups behind it; really, it was like a trip in a time machine.

Apparently nobody ever cleans in there.

I found a box of gloves; they were latex which we haven't had in a long time. A few of old souffle-type med cups. An ice pick. 17 cents in change. A dessicated cookie. A garter (ha! haha!) do you even know what that is? A bottle cap from RC Cola. A golf tee (WTF?) A couple of pens. Lots of dust. Several old washcloths and one slipper sock. An old, old, wooden ship (nah, just kidding).

Oh, and THAT's were the MAST trousers went! ERP, I have them if you need them! Haven't used them since the 1980's, or maybe the 70's.

The HVAC apparatus is also elderly. It provides heat in the summer and refreshing air conditioning in the dead of winter. It is essential to dress in layers.

The duct that lies directly above our heads in the nurses' station was rerouted while I was away last week so that it continuously blows either freezing cold air or cool to lukewarm air. All. The. Time. The HVAC monkeys, I swear, just mess with it. There was also a new digital thermostat in the waiting room that I'm pretty sure does absolutely nothing.

Mikki and Sherry tried taping cardboard over it. Unsuccessfully.

Lisa adhesive taped a folded towel over it. Unsuccessfully.

I took a staple gun to it and unloaded a full round onto the edges of the towel. Somewhat successfully. Then I found a bunch of screws and pounded them into the squishy ceiling. That looked GREAT. But it worked, that towel nice and tight.

Today I came in to find that the duct had been rerouted again, so no more breezes. I am afraid of what will happen this summer.

Thursday, February 10, 2011

Reel it In

As reams of mandated, useless, and repetitive paperwork take more and more time away from patient care it becomes increasingly difficult to sit with patients and discuss their discharge plans. One of the best things about working in a smaller facility is that we generally have plenty of time to spend with patients doing the kind of teaching that is rapidly becoming a thing of the past. We do our best to provide detailed instructions and an opportunity to ask as many questions as needed.

Sometimes, though, it just doesn't matter because the public just lacks manners and common sense.

Me: (entering patient's room): I have your discharge instructions and I would like to go over them with you.

Patient: (speaking on cell phone) I have to go, the nurse is here with my discharge. What? No. How did that happen? (to me): Just a sec. (to cell phone): What are you talking about? No, I don't have any prescriptions yet......

Me: (Leaves the room and closes the door).

Patient: (10 minutes later, opens the door). I thought you were going to give my my papers, I've been waiting for 10 minutes.

Me: I was waiting for you to finish your phone call so that I could have your undivided attention (restrains an expletive as co-worker kicks me under the desk).

Wednesday, February 2, 2011


I just love that we have video cameras that capture all the drama of what is happening around our ER. There are, in total, 11 separate views that include our 3 parking lots, entry way, and waiting room among others. Other than a bit of unfrosted glass to peer out of in our ambulance bay that is adjacent to the main parking area and a small window in triage, there is not a greater opportunity to observe incoming than what our cameras capture. I can sit comfortably at one of two chairs at the nurses desk, pull up the camera program on my computer and, with the mere push of a button, visualize up to eight separate views simultaneously. Most patients are unaware of this, so we frequently have some fun with it.

Occasionally I will see a severely debilitated, limping patient come in complaining of severe back pain. What a thrill to see (on camera) the very same patient miraculously straighten up and walk with a rapid and steady gait through the parking lot to a waiting vehicle with his magic prescription for narcotics. A Miracle!!!

Equally miraculous is the patient who arrived by ambulance with the knee injury; no fracture, but it could definitely be a ligamentous or cartilage injury. Good thing it felt so much better after application of knee immobilizer and careful crutch walking instructions that the patient was observed to have removed the brace and THROW IT AND THE CRUTCHES INTO THE BUSHES AND WALK NORMALLY!! I was so impressed with our physician's ability to heal with just a 'script for Tramadol!

We call the biggest bush "The Giving Tree" because we have found that sometimes the afflicted who have experienced a miracle healing will heave unto it their slings, wrist splints or ace bandages like those who are healed at Lourdes. HALLELUJAH!!!

Lots of times people who shouldn't be driving home because we have given them medication are caught in a lie observed getting into the driver's side of a car; we like to let them know that they are impaired, and since we have no way of alerting every driver on the road, they will not be allowed to drive. Or we call the police. Decide.

One night we had a couple of cars broken into with the theft of some items such as a GPS, backpack, and money (who leaves money in a car?). I was able to pull up video evidence for the police that resulted in the apprehension of some less than scrupulous individuals; and since one of the individuals was attending a meeting, SNAP! Gotcha piture purty lady, heh heh.

Mikki likes that we can see if the police are parked in our back parking lot (she is a 'fraidy cat) to ensure our safety as we walk out.

Ellen wants to be able to tell all of the patients without ID or insurance, "that's quite alright, simply look up into that corner while our camera captures your likeness for future reference".

Me? I just have my eyes glued to the screen to make sure that no cars pull in at 10:57 PM. Then I lock the door. Good night!

Groundhog Day

The only way the groundhog would have seen his shadow around here is if he started digging a week ago.

I can't find my car, let alone a groundhog hole.

But the good news is, he did not see his shadow, thus, spring is on the way.

Tuesday, February 1, 2011

Readers Guide to Triage

Triage is the part of the ER visit with which the general public seems to have the most difficulty.

When in triage, I usually greet patients by asking, "What can we do for you today?". I think it is so much more friendly than saying "Why are you here" (just sounds too confrontational), or "What brings you here today" (because the average asshole will say, my car, my mother-in-law, or a taxi. It is unfunny and unproductive and makes the patient look like an idiot, frankly).

By asking "What can we do for you", it is opportunity for me to collect information and to create a dialog about why the patient is in the ER, and and gives the patient an opportunity to state their expectations. We are in the business (and business it surely is, make no mistake about that) of helping people, but it does require a little bit of effort on the patient's part.

What is not helpful are the following responses:

1. "I don't know, you tell me"

2. "My doctor told me to come in" (also the school nurse, trainer, day care provider, home care nurse, my neighbor who is a nurse's aide. Oh, and my mother is also a big one)

3. "Kill me" (also I want to die, or simply lying on the floor moaning while texting all of your friends)

4. "I'm sick".

Each of these answers will earn at minimum a withering glance, such as the one Nurse Jackie is offering. I don' t even respond anymore, except to possibly say "Is there anything you'd like to add to that?"

Other less than helpful responses include:

5. "Well, it all started with _______ in 1998.....".
Please, just keep it to a single compalint if possible. Sore throat. Migraine. Shortness of breath. Chest pain. Cold symptoms. Vomiting. Very simply, I don't need to know every aspect of your medical history. And, you will just wind up repeating it to the doctor, who also really doesn't need to know you had a colonoscopy or a mammogram in the last 5 years. Sheesh. Plus being long winded in triage only delays your care.

6. "You have my records"
I might, but why should I look them up? It takes time away from other patients. If you don't have the ability (are short of breath, mentally debilitated, or require resuscitation) I might look them up. But, if you don't care to provide me with the information or it is too much of a chore, consider that may also be for me.

Things triage nurses never say, but are always thinking. If thought bubbles were visible, we would all be screwed:

7. It's not nearly as bad as you think. (Actually, I do say this quite often for things like lacerations especially for frightened kids. Especially if I'm pretty sure they won't need sutures)

8. You aren't as sick as you think you are. (Mostly for the Man-Cold; a blog in and of itself)

9. Did you call your doctor about this chronic/long time/insignificant issue?

10. If you already have percocet and oxycontin at home, what more did you think we could do for you?

11. You aren't really wheezing if you are consciously making the noise yourself in the back of your throat.

12. You are not unconscious if you are merely lying with your eyes closed

13. You have got to be on crack if you think I believe that you weigh only 250 pounds/smoke 3 cigarettes per day/have no money in your Coach bag next to your Iphone to buy an inhaler .

14. Did you think to try ice/Tylenol/ibuprofen?

15. You injured this a week ago, have been playing sports and going to school, it's not swollen and a bone isn't sticking out, but it's just "not better". Are you an idiot?

16. You have had an antibiotic for 24 hours and you are not all better. Are you an idiot?

17. You don't know any of your medications; don't you think that you should? (For this I usually offer a handy little plastic sleeve and a medication list card; people love giveaways)

Also: if I offer you a wheelchair it is because I am concerned about liability, not necessarily that you shouldn't be walking on it since clearly you have been walking around on it for days.