Wednesday, June 22, 2011

One for the Bucket List

So, last weekend I graduated.  The culmination of countless (but probably millions) of hours in front a computer; countless (at least a hard-drives full of) papers, essays and projects; weight gain and lack of exercise; many thousands of dollars; working at a less than optimum job for far less than optimum pay to make time for study; spending less time with my family, especially when sequestered for weeks at a time for some courses; ignoring the laundry and most other household tasks.  While all my family supported me, only Mr. EDNurseasauras was able to make the trip with me, and he watched with pride as I walked across the stage to accept my diploma.  It was only fitting since he was, above all, the one who bore witness to my daily struggles, frustrations, and personal achievements of the last four very long years.

From others, I heard an endless chorus of comments:  "are you STILL in school?", "what are you going to do with your degree?", "are you going to get any more money?", and "is it worth it?".

The short answers are: yes, teach I don't know, probably not, and yes. 

I had second thoughts about attending graduation, it was a lot of money I thought I probably shouldn't be spending.  Airfare.  Hotel.  Rental car.  Meals.  A recent out of town family wedding that, while a wonderful occasion, meant more travel in only a few weeks time.  And, we just had our kitchen remodeled as well. 

But, I did go, and it was worth every penny to have taken the opportunity to celebrate.  I would not have experienced the joy, personal satisfaction and sense of achievement by simply opening a large white envelope
containing my diploma.

There were maybe 350 graduates in total, but only 75 nurses; it was about half and half MSN graduates and undergrads.  My early flight on Friday morning allowed me to attend the pinning and hooding ceremony shortly after my arrival in town.  It gave me an opportunity to connect with some of my fellow graduates in a more intimate setting, some of whom I had "met" in classes.

First was Bill, who had been in my Ethics class and hailed from Arkansas; I had enjoyed his sense of humor in the online classroom, and he was wickedly funny in person.  Of course he was an ER nurse.  He watched with envy as the Masters degree candidates milled about, carryng the hoods which were soon to be placed around their shoulders and remarked, "That's going to be me some day".

He had already started taking his courses in January; "Well", I said, "Mine will not be in nursing, if I do continue on for my master's.  If I never take another nursing theory course I will die happy.  If I was younger I would go to law school".  Bill, Erica who was a local, and I  talked about what we would do with our shiny new degrees, the merits and challenges of a graduate degree, and when we would be receiving our honor cords for commencement.  We wondered if there was any food around since it was mid afternoon, and most of us had been traveling since early morning.  "They could at least have thrown us a couple of granola bars", Diane complained.  She was a  nurse I had gotten to know in Nursing Research; she was from Chicago.  "I HATED that course", she said. "That instructor was brutal, then with two weeks left she up and quit!"

"I actually thought that was one of my better courses", I said, "but I took it right after statistics so I think it made more sense to me.  I had one instructor who had a family emergency, but he was replaced right away so it didn't disrupt class.  That is miserable to have an instructor quit like that".

Bill commented, "I took statistics at a ground school, and I did really terrible in it".  The three of us discussed the challenges of online math courses, the reason my GPA was 3.91 and not 4.0.  Diane had required a tutor for College Math; somehow I taught myself Intermediate algebra (there are rules, imagine that!) AND statistics. 

Other classmates included Donna from Atlanta who was considering going on to be a nurse practitioner, but who's husband had died about 8 months ago; it was a bittersweet moment for her, and she was clearly trying to make the occasion as joyful as possible.  Mark from Tennessee was an OR nurse manager who didn't have much to say until he found out I came from the northeast; turns out we grew up about three towns away from each other.

The pinning ceremony was presided over by the Dean of the College of Nursing, who introduced the other nursing movers and shakers of the University.  Her comments were personal and inspiring and made me really appreciate my nursing education, both my diploma program and the RN to BSN program that I had completed.

"Tomorrow, you will march in with your fellow graduates from a variety of different programs.  Commencement speakers usually address their remarks to young men and women who have not yet begun their careers, however you, as nurses, are already experts in your field.  Continue to learn, grow, and mentor others".   

I didn't mind that I was 4th from the end to receive my diploma, it was worth waiting for.

Thursday, June 16, 2011

Thanks for the Access

I was already suspicious when the patient listed Ultram and Tramadol as allergies (same thing).

Yet, today was the day that she decided to be seen in the ER for her long standing pelvic pain for which she had already been worked up.  She had the pain for months and months.  Her pain was no different than it had been for the last months even though she routinely took absolutely nothing for it.  She had never called her primary care or GYN for follow up since her last million dollar workup for the exact same thing (without finding) nine months ago. Since she had a generous insurance plan paid for by you and me she obligingly submitted to the usual battery of tests:

Urine test=normal
Lab tests=normal
Pregnancy test= negative
Pelvic exam= some vaginal bleeding although she claimed she "didn't know she was bleeding since she had her period last week"
Pain relief with Toradol=not so much

The next plan was to send her to the Mother Ship for the obligate and gratuitous ultrasound which we do not have available on evenings.  Or weekends.  Or Mondays.

Although it is the SAME facility and we are merely an extension, for some reason we are required to do transfer paperwork.  The nurse do this.  And because we do NOT have electronic charting in this turn of the century (20th century) state-of-the-art health care environment, we have to copy everything.  When we are also caring for other patients, this takes a chunk of time.  Lastly, we have to call the nurse at the other ER for a report on everything we have done; safe Hand-Off.  All this takes a good 15-20 minutes. 

We usually leave the IV in place, just, you know, in case.  The patient left with a boyfriend that apparently had waited in the car for all of the festivities. 

Two hours later a call from the Mother Ship nurse: "Hey, that patient never showed up".

I HATE when they leave with the IV still in and none of their phone numbers work, and their address doesn't exist.  It just creates paper work.  I should have listened to my spider sense, it is rarely wrong.  Damn.

Wednesday, June 15, 2011

"Can It, You Nit!"

It as absolutely not, not, not necessary to relay every single, solitary, minute detail of your medical history when you come to the ER.  It is also not necessary for us to know your background, education, likes and dislikes, job history, the kind of car you drive, ability to speak a foreign language, or if you are able to sign your name with your toes within the first 2 minutes of your visit.  Trust me, if we want to know we will ask.  During triage the information that is required is need-to-know.  That is to say the information that I NEED, not necessarily what the patient is compelled to tell me.  I am speaking about that all-important first bit of information the REASON FOR YOUR VISIT.  It is most beneficial to be as succinct as possible, and least likely to piss me off. 

New Cathy and I spent 15 minutes jointly trying to triage a woman who WOULD NOT SHUT UP. All we knew is that we had to haul her ass out of a minivan (and she was not a light weight...are they ever?) because of a knee or leg or foot or ankle injury.  We had no idea because, again, she WOULD NOT SHUT UP, this bag of wind, bigmouth, blabber, blowhard, chatterbox, gasbag, jabberer, motor-mouth, etc, etc, get the picture.

Me: What did you injure exactly?
Verbose Patient:  Well...(I am always wary of responses that begin witht this) THIS is my bad knee, I have had surgery on this one, well both of them really, but this one was never as good as the other one since I was hurt at work I am, well, was, a nurse and I worked in (can't remember what type of nursing she did) until 2 years ago so this was originally a work injury, but I have some arthritis in my back, but I've been getting around pretty good even though I can't work anymore....
Me ( interrupting) Excuse me, what is it exactly that you have injured TODAY?
Verbose Patient: My knee.
Me: Which one?
Verbose patient: Well I was looking for Windex, we are visiting my son and his family, we are on from Florida and like I said I was getting around pretty well lately, we made the flight from Florida fine, no problem, so the Windex was on a shelf but the shelf was down a few stairs and I didn't see the stairs and next thing I know I was in space and fell.

This went on for 15 minutes.  I pride myself on being able to triage something like a knee sprain in no more than 6 minutes, and that includes individuals with 75 different meds and an equal number of allergies.  Of course, her allergy list was predictably long and included aspirin, tramadol, all 'cillins, sulfer, six different antidepressants, milk, whey, strawberries, kiwi, any medication beginning with the letter "Q" or the number "7", snakes, air, dirt, rum, black magic, pirates, and clouds.  All of which were, thankfully, on a computer printout that included every doctor's visit for the last 3 years so I didn't have to wait for her long-winded explanation on any of them.

I was fast running out of patience so I finally blurted, "you know, you're delaying your own care!  You're the only patient in the department and  could have seen the doctor 10 minutes ago....and already had an xray by now!  Let's just have the Reader's Digest version for now, okay?"

Her husband burst out laughing; "Guess she told you!  You always talk too much!  Just answer the questions!".  Little did I know that he was a windbag as well.

We eventually shipped her off to xray.  The husband chose to stand in front of our desk and give us a 15 minute commercial for their over-fifty community where they reside.  The golf, the hospitals, the restaurants; the types and prices of every house available, and on and on and on and on.  I eventually excused myself and went out to the desk where I called New Cathy, just so she wouldn't have to talk to him anymore. 

The wife was given a knee immobilizer, crutches and a prescription for Vicodin for her knee sprain.  The Vicodin because she only brought exactly enough of her own Vicodin to last exactly the number of days she expected to stay in town.  Oh goody.

At 6:00 PM I went in to fit the knee immobilizer, assess her crutch walking technique and give her discharge instructions, a task that should take no more than, oh, ten minutes being generous.  Even for a completely uncoordinated yutz.  I said to New Cathy, "It's six o'clock; I'll bet I won't be done with this discharge until 6:45 PM.  At the earliest".

It was exactly 6:40 PM when I shut the door of her minivan, two hours from start to finish.  She would have been in and out in less than an hour from start to finish if she would have just SHUT UP.  Thank you.

Saturday, June 11, 2011

Dear Parent, an Open Letter

Dear Parent,
First of all, I want to congratulate you on your adorable children; all six of them.  I can't see that many of them resemble you; perhaps they take after their father(s). How nice that you have brought them all with you tonight so that you could get that painful bunion examined.  I know what a chore it can be to make doctor's appointments for yourself when you are so busy; it is no wonder you haven't had any time in the last 3 months it has been bothering you.

I regret that I am unable to feed / water / toilet / or otherwise entertain them.  I would give you a book to read to them while you wait, but since you assured me that TV takes care of all of their literary needs there is no point.

They certainly are a spirited bunch, aren't they?  Not everyone is as effective in your style of free-form parenting; they sure don't like to hear the word "No", do they?

I would like to just point out that making a fort out of the waiting room furniture isn't the best idea since many of our other patients would also like to sit down.  Out of common courtesy, perhaps you could remove one or two of the younger children so that our elderly patients also have a seat; I know you were there first, but I am merely suggesting it as a token of good will towards others.  Think of it as a teaching moment.

In addition, I regret to tell you that your children, while enthusiastic, have no talent for origami, so would you please discourage the destruction of EVERY magazine?  Yes, they are old, but we have a limited selection as it is.

I have, in conclusion, one small request that you refrain from referring to your children as "little bastards; I understand that is a term of endearment, but the majority of our clientele don't see it that way.

Again, thank you for sharing your delightful children with us today.

Friday, June 10, 2011

An ER Match Made in Heaven

Kate and I hosted a remarkably busy night, notable for the overwhelming idiocy of the clientele. Same crap, different day.

The 17 year old boy walked in with his mother and stated, "I broke my hand".

Me: "What happened?"

"I got pissed off about some shit punched a fucking wall in school.  I've done it before"

Me: "Charming".  Note that it is 9 PM; the incident occurred at 1 PM.

Ten minutes later, a 15 year old girl comes in with HER mother with a similar hand injury.

"I punched a door"

What a delightful pair; I put them both in the waiting room until they had been xrayed since I had bigger fish to fry.  Fish that didn't punch walls.  The two apparently struck up an immediate and life long relationship based on their mutual interesting hobby of self-mutilation.

I overheard the boy: "Yeah, I came in for a cast"
Girl: "So, you broke your hand?  What happened?"
Boy: " I punched a wall"
Girl: " Oh, weird.  Me too!"
Boy: " Wow, we have a lot in common".

Me: (to myself) Please do not let them breed.

There were no broken bones, just to be clear.  Now, where did I leave those fliers for anger management classes?

Thursday, June 9, 2011

Stuff I See on the Camera

MANY people have no idea, although the warning is clearly posted, that we have surveillance cameras which cover about a dozen views of the building both inside and out.  The real-time  display on our computer can be programmed with our favorite views; everyone has their own.  My own particular choices include the two front parking lot views which cover the ambulance bay and the walkway to our patient entrance, the waiting room, the inside entrance to the patient door and the outpatient registration area.  Once I saw a cat so big walk across the lot I though it was a fox.  I have seen a family of skunks walking across the back parking lot; this was a revelation, I did not know that skunks travel in packs.  Do skunks spray other skunks?  Do they, too, find the odor noxious?  Curious...

I love observing people and catching them n the act of doing something ridiculous.  I have spoken about people who leave with the Miracle Cure: the lame who walk without a limp, the bent-over who walk upright.  I submit for your amusement those who appear to misrepresent their maladies for whatever reason.  The most common is, of course, drug-seeking, followed by work avoidance/workman's comp claims, and attention seeking.

One young man and his female companion were observed walking across the parking lot.  They paused in front of the walkway to the front door patient entrance, crouched, and enjoyed a cigarette while remaining in that position.

Between the end of the cigarette and the walk in the front door, the young man developed a pronounced and painful-appearing limp.  He had been seen 3 days earlier for knee pain and his Percocet was gone.

He didn't get anymore because it was pointed out that we have hidden cameras.  He stormed out threatening to call his lawyer and crying bullshit.

Another gentleman was observed getting out of his car, leaning against it and having a 10 minute or so cell phone conversation.  He gesticulated, paced, and otherwise seemed to be in control of himself.

Then he walked in the door holding a bloody handkerchief to his eyebrow, moaning and groaning dramatically.  I asked what happened between the end of his phone conversation and his walk into the department to make him so miserable: had he been attacked by wild dogs perhaps?

"You have cameras?"
Um, yeah.

One couple stood right under the camera making out for the longest time; I really wanted to tell them to get a room.  When they finally came in, the woman was having 10/10 abdominal pain.  She wanted a work note.

One guy proceeded to wax his car while his girlfriend was being seen for a wrist injury.  When she left with a wrist splint, she took the wrist splint off and helped him finish his waxing.

I worked a day shift (shudder) and saw that a police car, lights a-flashing, was in the front lot.  The officer was applying handcuffs to the driver of a car that had pulled in ahead of him.  When backup arrived, the second officer advised us that the car would be there for awhile, and the animal control officer would arrive shortly to take custody of the detainee's dog.  Said dog was to remain in the car: Sit.  Stay.  It being a hot day, I was more worried about the dog, but animal control arrived promptly and he, too, was hauled off to jail. 

Early in the spring, one woman sunbathed on the hood of the car.  In a bathing suit top.  Do I REALLY need to tell you that it wasn't a pretty sight?  Hmmmm?

I watched a girl come in for a wheelchair because her boyfriend had "a really bad leg injury and couldn't walk".  He, like so many, was observed walking around the car in a perfectly normal manner, and take a carton of cigarettes and a gallon of windshield washer fluid out of the trunk.  I though he was going to drink it, but he popped the hood and casually poured it in BEFORE he sent the girlfriend in for the wheelchair.

Better than TV.

Wednesday, June 8, 2011

Just Shaking My Head

One of our frequent fliers with a host of chronic, pain related and narcotic-seeking complaints came by with her 30 year old son.  His complaint today was back pain, shoulder pain, leg pain, leg numbness, knee pain, neck pain (from no trauma that he could recall), and dental pain.  Really.  Sonny has apparently not been able to work since he was 18, had no insurance, no job, no doctor, and nobody to grease the wheels of government sponsored care due to his inability to work.  And that, my friends, is the real reason for his ER visit; per mom, "He needs to have this documented and fill out forms or whatever and get him serviced (her words, not mine). Somebody has to do something for him!"

With all of these chronic pain issues and his 10/10 pain, he is on no meds.  Takes no pain meds, not even ibuprofen or Tylenol.  I took a look at his old record to see if his past visits were as numerous as I suspected.  I was pretty shocked that he had NOT ONE ER visit since 2006 for a sore throat.

Well, well, well.  Interesting.

The Talker spent a good long time with Ma and Sonny.  They left with a prescription for Tramadol and the social worker's card.  What was the story?

As I suspected, Sonny couldn't seem to hold a job, although he has had plenty.  In fact he had worked today at the Happy Mart pumping gas.

"So what was that bit about not being able to work in 12 years?", I asked.

"Well, it's not that he hasn't been ABLE to work, but other issues have precluded his ability to WORK WELL", answered the Talker.

"Like what?"

"Oh, sleeping late and not getting to work on time because he was out late with his friends.  Just not feeling like working.  Not liking to work on weekends. Being hungover.  You know, all the usual issues the rest of us struggle with".

Um, yeah.