Saturday, April 30, 2011

When Stupid is Not a Concealed Weapon

New Cathy and I worked last weekend and I think we might have seen about 10 patients total, which amounts to DEADLY slow shifts. Wednesday, Thursday same thing. I managed to read about half of "1984", which I can't remember having read in high school but know that I did; I picked out lighting for my new kitchen and did most of my schoolwork for the week. And was bored out of my gourd, having to resort to watching a rerun of a ridiculous singing version of Gray's Anatomy; we saw in total 5 patients in 8 hours. All that quiet we have more than made up for in my last few shifts; it has been pants crappingly busy with actual REALLY SICK people.
I like to work with the Talker, he doesn't hurry people, which is why they love him.  He has no urgency to to boot them out the door no matter what the complaint.  This goes equally for dental paineurs (they get antibiotics only if they have more than one visit for same), antibiotic-seeking mothers whose kids have had a temp of 99 degrees for 10  minutes, back pain (chronic), and not-magically-better boo boos and viral illness after 12 hours. 

Of course this can backfire when it is really busy.  He largely ignores Bobo's mandate that all patients be seen within 20 minutes.  Sometimes it is as much as an hour.  Or more.  It gets complicated because the Talker doesn't automatically get xrays or order labs simply because the patient expects it; it is definitely not "Have it Your Way" ER when he is on.  If it will not affect how he will treat the complaint, he is all about not exposing patients to radiation or paying tons of money for lab work.  Have a UTI?  We dip it, he treats with antibiotics.  The common sense approach rules.

There were about 7 patients sitting in the waiting room; Ellen was buzzing around, dealing with a lot of non-emergent whining "how long is the wait".  This really bothers her because she hates to ask us when we are busy, and is just not hard-wired to be firm with the idiots.  Generally she is stuck in the middle where she never wants to be.

At 9:30 PM I looked over the charts in the rack:
Cough x 1 week in an 8 year old.  Not worse, just not better.

"Asthma attack" in a tween girl (drama, drama, drama).  Not wheezing, not coughing, not short of breath, sats 100% on room, lungs clear. Take a number honey, and get off your fucking cell phone.

Vomiting x 2 in a 20 year old frequent flier female who has been seen 8 times for "menstrual cramps" and always gets vicodin.  WTF.  Does not look sick and is drinking an iced coffee

Laceration in an 18 year old male.  Microscopic.  Will not require stitches.

"Flu-like symptoms"; nausea, no vomiting, no fever, no cough, no other symptoms except "I don't feel good".  History of fibromyalgia.

Dental pain, first visit for same; accompained by 23 year old boyfriend who has had innumerable visits for same

Dental pain, 10 visits between the us and the Mother Ship.  Known to have altered a presctiption in the past.

Of the patients in rooms and getting workups, two were being admitted with all the bullshit that entailed.  At least they would be gone by 11 PM.  One is getting antibiotics for cellulitis and is ready to leave.  One is awaiting disposition for a UTI.  Two kids with earaches waiting to be seen.  The Talker usually doesn't prescribe antibiotics for all earaches automatically. 

He spent 20 minutes in a circular argument patiently explaining to a woman who was strongly advocting for her 24 year old daughter for antibiotics for yet another viral illness.
"But we had them last time"
"She is not better so she needs them"
"If she doesn't have antibiotics how is she going to get better"
"But she had them last time and got better"
"She is sick, so she needs antibiotics"
"Couldn't you just give her some samples"
"She needs antibiotics because she is sick and not getting better"
"We will just come back tomorrow and get them"
You can't win any of these arguments when people are stupid

It may be time to start looking around for a new job.  At least in a regular ER, most of this time-wasting crap and parade of idiots would go to the fast-track.  Where I never want to work. 

Thursday, April 28, 2011

Blast from the Past

I was flipping through the channels just now and came across an episode of "Marcus Welby, MD". This show is a time capsule of stuff that happened in the 1970's when I went to school.  Get a load of those caps and white uniforms!  Of course, the nursing stereotypes were pretty extreme.

I can't say as though all of this was the norm because I trained at a pretty progressive teaching hospital. Well, marginally more progressive than most I guess.  "Natural childbirth" was hip in 1975, and fathers were part of the birth team functioning as the labor coach.  But, only if the couple was married; no "baby daddies" allowed at that time.
This episode took place in 1975 and featured Gena Rowlands as a 36 year old professional woman, busy, successful and having it all except a baby; she had been struggling with infertility for years.  In real life she was probably 45 and looked it.

Upon declaring her about four weeks pregnant, the mother-to-be phones up the husband to tell him the ecstatic news.  The proud papa rushes over to old Marc's office with champagne, whereupon ALL THE DOCTORS, NURSES, HUSBAND AND PREGNANT WOMAN COMMENCE TO DRINK.  Yikes.

A group of pregnant women, Marcus Welby's nurse and a couple of nursing students take a tour of the "Maternity Ward".  First they get a look at the labor room, where "a nurse will help you time your contractions for the first stage of labor".  Guess L&D nurses didn't have much to do in those days, at least until it was time for delivery.

Next, the group of scared looking women, clad in white OR gowns and caps moves on to the delivery room "where you will be moved for your second phase of labor".  Scary damn place.  "This is the table where you'll bring your child into the world!" Nurse Lopez says brightly

"Where do we first get to see our baby, Miss Lopez?", asks a scared primip.

Nurse Lopez looks strained, takes a breath and says, "Well, maybe in here Susan...if you're awake in time.  You may be just under a local anesthetic if there are no complications.  Then, you'll hear your baby's very first cry right in here".  Camera pans to incubator, OR green-covered equipment, stirrups and scary shit as the young mother looks terrified.  "Something to look forward to, isn't it?", Nurse Lopez asks gently and unconvincingly.  The group is ushered out, no doubt to view other medieval implements of torture.

The rest of the show is pretty crayzee, but I don't have time to see it.  I'll DVR it for later.

Sunday, April 24, 2011

Stubborn, all of them

I thought some of those tough old Yankee birds were a trial when I lived in Massachusetts; they were nothing compared to these stubborn NH Yankees.

I got a 70 something year old man by private car for "trouble breathing", who needed a wheelchair assist from the door.  He was gasping like guppy; his O2 sats were in the 60's.  According to his daughter he had been having increasing shortness of breath for about a week.  He wasn't eating or drinking, and couldn't get off the couch for the last couple of days.  His daughter said "He has emphysema and his inhalers aren't working.  He has refused to come to the hospital, and wouldn't let us call an ambulance; I had to call my brother to help me get him out of the house when he finally relented".

No shit.  He was frail and cachectic, a bearded, grizzled old guy.  He was not on home oxygen.  He did not have nebulizers.  And he continued to smoke (until a few days ago).

"He refused nebulizers and oxygen, well, he is a smoker so even if he didn't refuse it he would probably blow himself up or start a fire".

We managed to turn him around without intubating him, but it took awhile and he was pretty tired.  I assumed he would go to the ICU, but apparently the hospitalist didn't think it was necessary. WTF.  The doc was a stubborn as the patient

Our doc was Arnie,who only works with us one or two shifts per month; in four years I have probably worked with him maybe 7 or 8 times.  I appealed to Arnie that, c'mon, he needed a higher level of care than can be provided on the medical floor. "I think he'll be ok".

Yeah, right; time for an end-around.

I called the nursing supervisor and told her that even on 100%, he desatted to the 80's with minimal exertion and in my opinion, nurse to nurse, (code for the doc doesn't see it that way) he was not appropriate for the floor.  She agreed.  But, since nurses are considered idiots who can't make decisions at this joke of a hospital we had to play games;  nursing supervisors at this religious institution being all female don't have much influence. 

We decided to have the hospitalist see the patient in the ER but still keep him a direct admit. Cripes was the doc downtown and was also given the heads up.  His wife is a nurse and he is one of the few who actually thinks nurses have anything to contribute.

"He's going to the unit", said Cripes.  "Cripes, he's on a non-rebreather!"


I took the shotgun approach to report and faxed it to everyone; the ER nurse I talked to.

"Oh yeah; he's going to the unit".

Like I sad.

Saturday, April 23, 2011

This Could have been bad

Telephone caller: "Hi, would it be possible to get rabies shots there?"
Me: "For humans or animals?" (I wasn't being a wise ass, really)

A while later, a woman came in who stated that she had been bitten by a skunk; well, that got my interest.

The middle-aged woman had been raking in her back yard and didn't notice the mangy, dirty skunk until it was right beside her.  At that point, she was too afraid to move and scare it into spraying her.  Unbelievably, the skunk sort of rolled on her foot; then bit it.  It wandered off and then sprayed.

Not normal skunk behavior for sure, and it occurred at 4 PM when it was still daylight. 

Fortunately, the patient was wearing a heavy boot at the time; the skunk never broke the skin, luckily for her.  She skated off without getting rabies prophylaxis after our doc got some advice from the state Board of Health.

The skunk was not found according to police.

Friday, April 22, 2011


For some reason, I had a high school student intern one day last week.  I thought it was very odd since high schools are usually trying to accomplish internships early in the school year.  Plus, my boss Jane was on vacation so I had no idea she was coming.

She was very quiet. Painfully quiet. It was an effort for her to get out her name.
"Annette", she whispered after I had begged her to repeat it three times; she looked about 12 years old.

"So, are you planning on going to nursing school?" After thinking for awhile, she responded with a barely audible, "Medical school".

It was a long four hours.  She did not initiate conversation; she only  responded to my questions after struggling to come up with an answer.  I have never met anyone so pathologically shy.  I found out she is going to Big Boston Institution of Higher Learning, (BBIHL) having achieved early acceptance.  Talk about jumping into a shark tank wrapped in a Lady Gaga meat suit. 

I took her into triage with me a few times, but since it was a pretty quiet night (as it usually is when we have a student) I just stopped trying after awhile and read a journal.  I was kind of relieved when she left.  I always ask students what the most interesting part of their experience was in order to put it in some kind of perspective, or get some of my own as to how to improve the experience for the next student.  Annette responded: "Nothing".

Jesus tap dancing Christ.

Jane and Second in Command and I were finishing up a little business at the start of the shift and Annette came in;  crap, not again.  I greeted her and introduced her to Jane; I directed her to put her things in our back room.

Jane looked at me quizically; "Who was that?"
Me: "Student. She was painful the other day, could barely get a word out of her"
Jane: "She looks like she's about 12!  Is she even in high school?"
Me: "Yep, graduating in June.  She's been accepted to BBIHL and she wants to go to med school"
Jane: "Holy Crap!  She'll get eaten alive!"
Me: "I know, she will never survive orientation"

Nothing rattles the Talker. Usually.
There are always exceptions.  He is good with teaching, but I could see that he was having difficulty conversing with Annette.

"So, is any one in your family in medicine?"
"So, what made you decide to think about med school?"
After thinking for about 20 seconds, "To help people?"

He asked a lot of the same questions I did, and I had to squeeze my lips together to keep from answering for her, it was that uncomfortable.  It was a little busier so we at least had some things for her to see.

We had her watch the Talker put an orthoglass splint on a little girl with a fractured wrist.  He explained everything, showed her what he was doing, gave her a piece of orthoglass play with.  She was silent; the Talker just looked helpless.

I had a thought that maybe her guidance counselor should have given us some kind of heads up on this one; not all fragile people come equipped with a "Handle With Care" stamp.

Annette planned to spend her final four hours of her mini-internship at the Mother Ship.  Yikes.

Thursday, April 21, 2011

Walk This Way

The Lady on Elm St. has been suspiciously quiet lately.  There are some ER docs that she just doesn't like.  Let's see, that's....everyone except Cripes and Henrietta.

Lady arrived by ambulance with her usual abdominal pain complaint.  She was brought to us in spite of Lisa's advising them over the radio that "Dr. THE TALKER strongly advises that this patient go to the Mother Ship for evaluation".

That is because Lady and the Talker do not get along.  The Talker finds it necessary to tell it like it is; Lady finds it necessary to take offense.  The Talker has been known to remind Lady that her morbid obesity is a hazard to her health; Lady has written complaints about the Talker since her morbid obesity, in her opinion, is none of his business.

Whatever the Talker said this time caused Lady to storm out of the ER; if a person of her sizable girth and wearing a nightgown, robe, and fuzzy slippers can storm anywhere.

Lisa waited awhile and then, when she didn't return, called the police to see if they could see her.  It was a long walk to Elm St.  Surprisingly, she had called someone to pick her up and it wasn't an ambulance.

The Talker expects another letter of complaint.   I expect Lady to come in on my next shift.

Wednesday, April 20, 2011

What, Me Worry?

You have probably noticed the "Days 'til Gradution Ticker" to the right over there. Yes, I am finally, actually, really finishing.  My course ends officially on May 4, but I expect to have all the necessary work finished before then. It is a PAINFUL course; Holistic Professional Nursing.  Really, it is just Public Health Nursing redux.  Same book with the same professor; and the same no-nonsense attention to detail.


It is an 11 week course.  I have, on average, two discussion questions weekly and an installment of the Capstone Project.  To date, I have passed in every single assignment late, copied and pasted the same response to a discussion four times (with minor tweaks), and lifted entire sections of papers I had written previously to fulfill an assignment.  I have a 100% average in this class in spite of copying the Gettysburg Address and citing Alfred E. Newman and Mad Magazine as a reference. "Great job!  Keep up the good work!". Yikes.

The entire class is in the same boat; we are all suffering from, dare I say, Senioritis.  My kids know what it is like to be a SEEEEEEEEEEEEEEEEEEEEEEENIOR.  I guess we are all grateful that we have the most laissez-faire instructor on the planet for our final course

About friggin' time.

Mr. Ednurseasauras, my biggest cheerleader, is thrilled (we really haven't talked about grad school). My boss is overjoyed (she is encouraging grad school, but I think for now I prefer to get my kitchen renovation completed and tackle that next fall/winter). Nana wanted to go to my graduation (in June, in Georgia, where it is very hot) but thought she would enjoy staying home and minding Tina instead; they get along great, and Tina LOVES going to visit Nana). My kids, K and J, having finished college 8 and 4 years ago respectively, have always been in my corner, gave back to me those words of encouragement I spoke to them when they were taking their academic journey:

K: "Mom you are so close!"

J:" Just think about how good it will feel when you are done!"

K: "Party!"

J: "No more college tuition"

K: "Now you are a SEEEEEEEEEEEEEEEENior!"

J: "I guess you will be wanting your Kindle back" (I let him borrow if for an extended period while I finished school; it was a distraction otherwise)

I plug away, and look forward to not having anything hang over my head in a couple of weeks. So close, so close.  But first, I must write up the intervention on a  family I made up for Smoking Cessation; although made up of various people, they are not a family.  The matriarch really did light up a butt while she was on oxygen, hilarious hijinks ensue.  Not.  I think I will throw the Bill of Rights in the middle of it and cite Wikipedia just to see if my professor is paying attention.

Tuesday, April 19, 2011

Parenting is Only a Part Time Job

We were having a nice, steady night with Brian.  Brian works quickly and unfailingly manages to get all of his dictations done right after he finishes with the patient's care.  This strategy assures that when 11 PM rolls around and there are no patients, he is out the door.  Works for me.

We had already sent two patients with abdominal pain down to the Mother Ship for CT scans and seen three garden variety frequent flier dental paineurs who got antibiotics and Percocet (the only thing I really don't like about's like feeding squirrels, they always come back for more).  He had put Orthoglass splints on two little girls with buckle fractures and it was only 5 PM.  Wham, bam, thank you ma'am.  In and out.

My next triage was a plus-sized young woman with 10/10 abdominal pain that she had been having for the better part of a year.  No other symptoms. No insurance.  She was supposed to have followed up with her gynecologist, but apparently paying for her artificial nails, her IPhone, and her Coach bag were more important. 

Me: So, what is different about your pain level today?
Pt:: I just thought it was time to do something about it.
Me: Uh huh.

The woman had with her an adorable 3 year old whom she consistently parented poorly. 

"Sit down.  Sit down!  SIT!  RIGHT NOW!  What did I tell you?  Do you want mommy to spank you?  I told, Aaron, don't do that!  Get down off there!  What did you...did you just put something in your mouth?  Spit that out!  How many times do I have to tell you to....come here....come over here right now.....AARON!  GET OVER HERE!  You are such a pain!  I can't take you anywhere!  AARON!  Are you listening to mommy?"

Clearly he is not.
Aaron continued to terrorize the treatment room, and all we could hear was mom yelling at him behind closed doors. Brian ordered some of the usual tests; pregnancy test, urine, etc, but I knew the pelvic exam was coming, and I tried to mentally prepare myself.  I was having some trouble with that, though.

To Brian: " I would rather have you professionally poke out both my eyes with an 18 gauge needle than chaperon you with that pelvic exam".

Brian, laughing: "I know, I'm not looking forward to it either".

When the time came, Aaron had parked himself on the stool at the business end of his mother. He could not be budged, not even with the Beanie Baby that we keep for emergencies.  Brian got tired of coaxing darling Aaron, so he finally picked him up and deposited him on a chair; he immediately scrambled out and stood, again, in a posture of interest in front of his mother's crotch.

Me (to Brian): "Is he trying to crawl back into the womb?"

Brian finally just nudged him out of the way and did what was necessary. 

She left with Vicodin.  Yikes.

I understand that not everyone who gives birth is an ideal parent, in fact  some are downright appalling  as evidenced by the number of screwed up kids in the world.  But this just bothered me.  Having children is enough of a crap shoot as it is even with good parenting.  I just couldn't help but think that this kid is doomed.

Monday, April 18, 2011

Manic Marathon Monday

I'm sitting here watching coverage of the Boston Marathon on TV while avoiding schoolwork and Tina-walking.  Pretty crayzee stuff, that.  These are super human beings.  I have friends who have worked in the medical tent at the conclusion of the race, but have never done it.  It might be fun to do sometime, though.

Years ago when I worked at an ER close to Boston, we would occasionally get a Boston runner hours after the elite runners had finished.  These runners were not world class, but had run their race in 4, or 5 hours and had muscle cramping or dehydration.  It was fun to hear about the start in Hopkinton.

About 8 days ago we had a gentleman who had fallen in his yard and opened up a nasty gash on his knee.  He was training for Boston.

The Talker and he bonded over a mutual love of running while he stitched the wound.  As I bandaged it with my usual somewhat bulky first dressing, the patient wondered how he was going to run with it next day; with 8 days to go before the marathon, the distance running was done and now he was doing shorter training runs.

Me: I imagine that you would be putting a big band-aid over it if you are running tomorrow, hmm?

The patient laughed and admitted that was his plan.  That's ok, it's his first marathon; it is a big deal for New Englanders because the weather is such a factor in training.  We had a most miserable winter in New Hampshire, so I can imagine the adverse conditions that he faced.  He was not going to let a little laceration stop him.

We wished him luck and, as always, invited him back for (free) suture removal in 10 days.  I've been looking for him, but since he is not an elite runner I will not be seeing him on TV.  I hope he does well.

Thursday, April 7, 2011

Goodbye, Mikki

Well, Mikki quit; she's moving on to be a bum-look-up-nurse in Endoscopy full time for a little bit of money but no nights, weekends or holidays. I would rather work at Chile's, frankly, but it is a good move for her. Naturally the vultures are fighting over her day shift hours. They can have them; I hate working days, given that SIC is about to become even more unmanageable. Jane has taken on some added responsibility and will be helping out at the hospital's version of VNA (visiting nurses) to get their dismal leadership situation in hand. Yeah, good luck with that. Jane hates confrontation. Me and the other cool kids have vowed to quit en masse if SIC is given any responsibility that even whispers at a management role.

So, we on the evening shift will be acquiring a new player. The rumor is that it will be someone from the Mother Ship. Is it me? I lost one co-worker who died, my work husband quit, now this. Perhaps I should buff up my resume.

Both Cathys, Sherry, Mikki and I went out to lunch to wish Mikki bon voyage and good luck with her new job; Kerry and Lisa were both working. We did invite SIC but she chose not to come.

I will miss Mikki. But it does put me first in line for getting July 4th off.

Wednesday, April 6, 2011

Some Things Can't be Unseen

Kerry called me on my cell the other day while I was driving and caught me in a weak moment; could I PLEASE work 4 hours on Saturday morning so she could go to her son's playoff game, pretty please, please, puh-leeeeeeeeeeeeeeeeeze???! Sigh. OK. At least I got to work with Lisa who is funny as hell; we are a bad combination attitude-wise but usually manage to have more than a few laughs. What I didn't count on having to work with Parvati, who is painful to work with and who just feeds into people's drama unnecessarily. "WHAT? YOU HAVE VOMITED ONCE AND BEEN SICK FOR 15 MINUTES? YOU NEED IV FLUIDS AND LAB WORK TO MAKE SURE YOU ARE NOT DEHYDRATED!!". Um, no. You really don't. What you need is a prescription for common sense. With Parvati, everyone is treated as if they really ARE as sick as they think they are.

Like Whiny Cough Lady ("I have really bad roll-y you have to put the IV there?....IV's don't ever hurt me that much..... can I have another straw?.....I don't liiiiiiiiiiike being siiiiiiiiiiiicccccccccccck......Don't you think I am the sickest and most pathetic creature on the planet who had bronchitis everrrrrrrrr??!!). Bleecch. She really didn't need to tie up my last remaining bed for two hours; didn't need any of that. What I needed was a bed for a teenager with a broken ankle. We are an ER, not a hotel.

Then there was Migraine Lady #1, 298 who was apparently put out that her 10/10 headache was not treated immediately with Dilaudid. She walked out prior to the completion of her care without a word to anyone, although she got IV fluids, Toradol and Compazine. I did all the things I was supposed to; offered her crackers and juice, took her vital signs, dimmed the lights, got her a toasty warm blanket or three, and reassessed her pain after I had medicated her. Too bad she left, because Parvati had just written an order for her to have her much desired narcotics. She scarpered when I was busy with an overdose, but unfortunately with the IV still in her arm. Her Skanky Neighborhood phone number was.....disconnected, surprise, surprise. Oh, no work number because she is unemployed. Ah, no insurance so you and I will take the hit on this.

But it is bad when people leave with IV's in their arm; liability.

So I called dispatch to see if they could send a police officer or animal control officer to politely ask her to return; we really don't want IV drug users running around unsupervised with expertly and hygienically placed venous access. Not that she was, but still.

Me: 'Hi, this is EDNurseasauras at the ER. One of our patients left with an IV in, her phone number is disconnected and I was hoping you could send an officer to her house to encourage her to return for its removal"

Dispatch: "Sure, no problem. What's her name and address?" I gave him the particulars; he said he would get back to me. We heard the call go out on the scanner. A short time later, the dispatcher called me back:

Dispatch: "I guess she hasn't made it home yet; what was she wearing?"

Me: "Is this a recorded line?"

Dispatch: "No, it's not".

Me: "OK, good. She was wearing a horrendous neon pink jogging suit, the likes of which should never be seen in public, never mind being displayed on a woman that size"

Dispatch: (muffled laughter), "OK, um. Ok. Hold on.. (more muffled laughter). Is it pink on top and bottom?"

Me: "Yes, except for the parts where the material doesn't cover the tattoos on her muffin top"

Dispatch: (strangled noise, muffled snorting), "Um, OK, sure. I'll send and officer to see if he can spot her on foot".

Me: "Shouldn't be too hard to miss".

She never showed up, another big surprise.

Jane calls all the patients who leave before they are discharged; most of the time it's because the wait is too long, or they have to pick up their kids, or they see who the doctor is and realize they will probably not be getting any Vicodin this visit. Migraine Lady said "we were mean to her and didn't care about her pain". Translation for the uninitiated: "I didn't get any @%^&!ing narcotics!"

Jane: "Oh, it's too bad you left before getting the Dilaudid that Dr. Parvati prescribed for you; the ER was very busy at that time with a critically ill patient that, unfortunatley tied up the nurses; sorry for the inconvenience. Hope you feel better, have a nice day".

Translation: @%^&! off.