Saturday, September 24, 2011

Get Off the Phone

I may put on a happy face in triage, but when things get ugly I can take it right back off.  Nothing ticks me off more than people who just can't put down the fu**ing cell phone. So sorry to interrupt your oh-so-important text messaging so that I may triage YOUR emergent ER visit for say, dental pain or rash.  Fever of 99.4 ("My normal temperature is 97.5, so that is BURNING UP  for me!")

 Me: "Hi, what can we do for you today?"
Loser: (continues with phone texting activities and doesn't respond)
I waited exactly 7 seconds.
Me: "Excuse me".  I walked out of triage.  I was really busy, so I made her wait awhile.
When I eventually went back in, I said "Are we all done updating the Facebook status?"
If they are too stupid to know they are rude, it is unlikely they will notice if I am....annoyed.

I do not sit in a triage room eagerly awaiting your visit.  I have other patients upon which to do EKG's, clean wounds, and start interventions along with myriad other technical, secretarial and janitorial tasks (beds don't make themselves, and I certainly don't mind emptying trash and linen when it is overflowing).  There may even be one or two patients with ACTUAL EMERGENCIES for whom it may be necessary to transfer out in a hurry.

I shouldn't have to tell people to shut off their damn phone, but common courtesy is non-existent.  Hell, MANNERS are non-existent.  Parents certainly aren't teaching the basics at home, and teachers are too busy just trying to get the little shits to sit in their seats without damaging their fragile self-esteem.  Don't get me started on HATS.  The last time I was at a public event where the National Anthem was played, the announcer actually told men to remove their hats.  Pathetic.

I never never encourage people to answer their cell phone in my presence in fact I just don't even acknowledge their moronic ring tone.  Like the Rocky theme.  If it is a teen or a kid playing a video game I tell them to put it away.

What happened to respectful human interaction?

Gone by the wayside:
1.  Saying please, thank you, and excuse me.
2.  Waiting your turn.
3.  Making eye contact 
4.  Teaching kids to have respect
5.  Taking responsibility for your actions

Thus ends today's rant.

Friday, September 23, 2011

Feed Me

You have 35 (WTF!) visits to our ER alone this year for migraine, I have no doubt that this is drug seeking.

Gil: "Well, I know he's here a lot.  I'm suggesting that he make his own appointment at Up State Big Hospital, and keep a log of his migraine activity.   I think he  really does have  migraines"

Me: "That makes one of you".  

We nurses know who has had at least one visit per week, sometimes multiple visits in one day.  We know all of your little dramas, which lies you have told, and when you park your car around back after telling us your ride will be "right along".  

 I dutifully prepare your dose of the "d" medicine after ascertaining that your usual cadre of medication allergies was unchanged.  Toradol.  Tramadol.  Codeine.  Phenergan.  Imitrex.  Fioricet.

Within seconds of the administration of your meds, your photophobia has resolved.  You are a magically a different person and you try to engage me in a conversation about the Patriot's.  I get it; you really are just normal, friendly  guy. 

I'm sure you are.  But I don't give you anything to work with.  I'm sorry to be in a hurry to wrap this up as I have a vomiting 80 year old with an anxious family to deal with, as well as an infant with an uneducated single mother in need of teaching.  You understand.  Neither you nor the doctor has any interest in addressing your addiction, we are rubber-stamping this visit and leaving it for the next person to handle.  You have gotten what you wanted, so really, my time is better spent on caring for someone who actually wants help.  Sorry, but that's the way it is.  If you actually asked for help I would go the distance for you, and I mean that sincerely.  But until you have burned all the bridges and hit rock bottom, there is little I can do.  And it makes me feel like an ass each time you come in and play your little game. 
Feeding squirrels.  If you keep feeding them, they will surely return.  What happens when the acorns run out?

Thursday, September 22, 2011

Cuts and Cutting Remarks

New Hampshire hospitals have been scrambling to come up with millions of dollars in budget shortfalls.  The state legislature in its infinite wisdom voted to cut Medicaid reimbursements along with many other cuts to state and local agencies and programs.  The impact to hospitals involves money that had been counted on during budget planning for the coming year, but now the rug has been pulled out from under. 

The state  taxes hospitals 5.5 percent on  patient revenues, but returns the amount of the tax in matching federal Medicaid funds so they effectively lost no money.  That's out now, and hospitals have been cutting jobs all summer, the latest round of layoffs occurring about a week ago. 

We lost a number of positions, none of which were clip board personnel or Suits in Charge of Stupid Shit, not surprisingly.  I get to keep my job.  But there were several LPN's who lost their jobs.  Just axed.  Some genius in the public relations department of another hospital, who also cut their LPN's, justified cutting them  since, "LPN's are really just glorified nursing assistants".  Really??  Talk about adding insult to injury.

I have never worked in a hospital that employs LPN's in the ER, but I have worked with my fair share in many other areas.  Some were good, some were great. 

The first one I ever worked with was Mrs. Maccaione.  I don't know if she had a first name, you either called her Mrs. Maccaione, or "Mac".  In 1973 she had to be in her mid-sixties.  Mac wore whites from the top of her starched cap to the polished perfection of her white Clinic shoes.  She was as broad around as she was tall, and at 5 feet was an imposing and intimidating poster child for Crusty Old World War II Nurse.  With her rolling bandy-legged gait and the whoosh! whoosh! of her pudgy thighs in their snow white support hose, she bore down on me and the other two nursing assistants like a ship under full sail; usually with guns a-blazing.   She was NO NONSENSE in the flesh.  She really did try and bounce quarters off of draw sheets.  Mac was well known for her scrutiny of top sheets for precise hospital corners.  Woe to you if you were caught resting a pillow under your chin to apply a pillow case.  You would hear about it in spades if your patients weren't  bathed in a timely manner or their immediate environment was not spotlessly clean.  We were scared to death of her.

In the early 1970's, day surgery was non-existent.  If you had a cholecystectomy or appendectomy, you were in the hospital for about a week.  A tonsilectomy?  Two nights.  Wisdom teeth?  That involved checking in to the hospital the night before your surgery and staying all day.  Sometimes patients went home, sometimes they could "elect" to stay another night, like if they were vomiting or whatever. 

Mac always greeted the patients and oriented them.  This was a job that needed to be DONE RIGHT.  She strode into the room and  stood at parade rest. 

"Good afternoon!  Welcome to Unit F.  I'm Mrs. Maccaione-call me Mac.  You are scheduled for _____surgery tomorrow at 0800 hours.  Today, you will be getting a visit from the anesthesiologist and having whatever testing may be deemed necessary, if any.  You will be signing a surgical consent if you have not already done so.  For today, you will be given a regular supper, served between 5 and 5:30 PM along with a light snack at approximately 8 PM. Visiting hours conclude at 8 PM, so plan accordingly.  At this time, the switchboard will not put through any incoming phone calls to the rooms.  Lights out in this unit is generally between 10 and 11 PM; you will be needing your rest.  At 12 midnight, you will be NPO: Latin, Nothing By Mouth until after your surgery.  You will be awakened at 5:45 AM to prepare you for your surgery.  Questions?"

This monologue was delivered  rapid-fire.  I'm sure most patients didn't dare ask questions of Mac. Most of the doctors were scared of her. 

But you should have seen her in action when it came to encouraging a fresh post-op and making them feel cared for.  Or getting another 6 feet of corridor out of a tired newly ambulatory patient with a big belly wound (remember Scultetus binders?).  There was nothing she couldn't get from the kitchen staff if she thought it would entice a finicky eater to take nourishment.  For all her brusque and bossy affect she was a hell of a nurse; you would want her to take care of your family.  I learned a hell of lot from her. 

Just a "nursing assistant"?  Oh, HELL no.

Wednesday, September 21, 2011

From Out of the Blue

Sherry was curious about a little kid she had sent to the Big City Kid's Hospital with a forearm fracture from a few nights ago.  We rarely get any follow up on people we transfer to other places unless we call them, or they have some kind of complaint or lost a slipper or some shit.

The parents, who were very, very anxious, were thrilled with the excellent care at Big City Kid's where he had a closed reduction under sedation.  It was a long night, but he did well.  They were also grateful for the care he had received at our facility.  He was, however, almost out of pain medicine.  Long story short, Cripes, who had seen the kid the other night was willing to write a 'script for the same pain medicine to tide the kid over for another day or two. 

Dad came in to pick up the prescription and had this to say.

"Thank you for taking such good care of us the other night.  You can't know everyone's story and what's gone on in their past.  I just wanted you to know that how you treat people really does make a difference.  Fifteen years ago, I had a son who didn't make it.  I walked the halls at Big City Kid's.  You remember the people, the doctor's and nurses, who reached out and tried to make a connection, a kind word.  Some encouragement.  Or helped us prepare for the worst.  How you treat people matters.  I was back walking the halls like I have for the last fifteen years.  Thank you for caring about us".

I never cry at work.  This made me cry.

Monday, September 19, 2011

Stop Bugging Me

"I think I have  a bug in my ear", said the guy in triage.  "I was mowing my lawn and brushed against a rose bush and it feels like something is in my ear canal.  I didn't dare poke it with a Q tip"

Good plan.  Every time I get someone with a complaint like this, I think of the old Night Gallery episode hosted by that creepy guy Rod Serling.  Some guy gets and earwig planted in his ear which then proceeds to munch its way through the brain (being unable to reverse direction), reducing the poor bastard to a shrieking mass of agony until it crawls out the other side.  Whereupon the doctor informs him that it was, in fact, a female....which had laid eggs. Shudder.  All of which is myth.

OK, I'm being dramatic.

So the guy wasn't having any particular difficulty while I was triaging.  As I a walked him to registration, he freaked and started screaming.


I grabbed him by the t-shirt and dragged him into the nearest treatment room.  Kate went to grab some lidocaine to immobilize whatever was in his ear.  Suddenly, the guy stopped screaming and  froze.

"It stopped". 

No shit.  "Let me see if I can see anything", I told him.  As I pushed back his longish hair, I saw it: a GIANT Japanese beetle sitting in his outer ear.  "Don't move for a second", I said.  Trying not to either panic the guy or lose sight of the bug I reached for a glove or 4x4 gauze on the counter behind me.  In the nanoecond I took to glance behind me, the beetle...was gone.

"Did you see anything?  Is there anything there?  Is it a bee?  Did you get it?"

Shit.  No, wait!  There it is up on the very tip of his little, pointy elfen ear!

WHACK!  I smacked the flap of his ear with my hand.  Yes, I struck my patient.  A first for me.

The beetle crawled on the floor unconcerned.  I scooped it up with a wad of 4x4's.

"Oh, thankyouthankyouthankyou!  You saved my life!"

Gil wandered in and wanted to know what all the shouting was about.

"This brave nurse saved my life!  She got a beetle out of my ear, I thought I would go crazy!  She's a genius"

Gil:  "Oh, that's great!  Did you use lidocaine?"

Me: "Nope.  I just told it to go to the light, so it did"

Gil: "Hahaha!"

Saturday, September 17, 2011

Two More Reasons to have a Crappy Attitude

1.  Mandatory flu shots, or wear a mask from December 1 to the end of March for every employee whether they work in a clinical area or not (note: the docs are not employed by the hospital).  It's not that I object to getting a flu shot per se,  I simply have a problem with authority.

2. My co-workers have decided to do the schedule through MID JANUARY, so as to get their holiday requests in.    I can't stand it.  I am boycotting the schedule until Halloween.

Friday, September 16, 2011


I got a phone call from one of the adult overnight dormitory staff at Wicked Expensive Alternative Prep School around 9:00 PM.  He wanted to know if it was appropriate to bring one of the boys for dental pain.

Sure, come on down.  No, we don't have a dentist "on call".  No, I have not idea what treatment he will get. Yes, he will be fully evaluated by the physician.  No, I can't tell you how long the visit will be.  Yes, we have some medicines available for patients to use until the pharmacy is open.  Yes, in most cases we can call in a prescription provided you use a pharmacy that has an overnight answering machine.  No, I do not have the power to order the pharmacist to open the store for you.  Just get off the phone and get the kid here, huh?

Wicked Expensive Alternative Prep School has kids from all over the country and a large contingent of international students.  There is a nurse who lives there, but I guess they give her a night off every once in a while.  I think that along with the usual college prep courses, the kids are encouraged to pursue other interests not usually found at regular schools.  Like, if they wanted to learn unicycling or something, or pottery, or start a social networking site or learn to juggle.  Whatever, good for them to encourage independence and exploration.  They are big on tapping into the genius of the faculty for ideas and guidance for their students' pursuits.  I guess they figure the parents are paying enough money for the expertise, if they want to learn tie dyeing or candle making, fine.

Not impressed with the dorm guy, though.  He forgot all the kid's paperwork that included parental permission to treat him.  He wanted to know if we had someone on staff who could speak Mandarin (??).  The very sweet young man spoke perfect English and oh, by the way, was KOREAN.

Does anyone but me find it disturbing that when he finished the registration process, the dorm guy wanted to know "where we put the Chinese kid?"

Thursday, September 15, 2011

Bored I Guess

For years and years I worked at least two and often three jobs at the same time, but at at least one was always in the ER. I have had lots of different experiences.  I've worked in schools, as a camp nurse, in home care, employee health, a travel clinic, a same day surgery unit, pediatrics, telemetry, and med surg.  I have worked in large medical centers and community hospitals.  I been a staff nurse, charge nurse, supervisor, director.  I have done independent QA audits, worked for an agency. I have worked days, evenings, nights, weekends and holidays.  I have worked from within walking distance to my job or traveled over and hour.  I have worked with individuals who have become lifelong friends and others whose names I can't remember.  I have been both student and a teacher.  Sometimes I have felt unsure of myself and terrified, but have grown enough as a nurse to feel comfortable and competent, smart enough to know that I don't know everything.  I have done a lot, seen a lot, learned a lot.

I  have been restless and not altogether happy with my job lately.  For the last 3 years, it has been my only job.  It is close to home and I work with a small group of nice, accommodating people in a small ER.

I have been thinking that maybe it is too small.  I feel as though I am losing my skills as an ER nurse.  Few codes, trauma as rare as hen's teeth.  I am SO TIRED of the constant parade of drug seekers and the pressure to just make everyone happy, even if what they want isn't what they need.  Want antibiotics for a virus?  Sure!  An Xray for your three week old ankle injury that you insist must be broken?  No problem!  Dilaudid for your migraine of 10 minutes?  Absolutely!  Why do you need doctors with experience and expertise when you have WebMD?  All we ask in return is positive customer satisfaction scores.

I have never felt less valued as a professional nurse anywhere.  It's not my boss, she's great. It's the organization we work for.  Our director talks a good game, but there is no visible support for the activities of nursing.  There is a part-time research nurse, nobody really knows what she does and I have never seen her.  Committees?  The same dull people with the same dull ideas. 

I have a really crappy attitude and no real goals since finishing school.  For the first time in a long time I have no concrete plans to move on, move up, or move out.  Maybe it is because I am working only one job in a small town, I don't know.  I am in a real rut.  I have to work about 10 more years until I can retire and that pisses me off.  I can't see myself doing what I'm doing for another 10 years.

I keep telling myself I am lucky to have a job.

Sunday, September 11, 2011

My Children of 9/11

10 years ago I was working as a school nurse for the sixth graders' annual 5 day Nature Camp trip.  This was always a fun experience for all, and highly anticipated by those of us fortunate enough to go.  The week was carnival time for faculty, a "Get Out of Jail Free" pass or a Wonka Golden Ticket.  It was five days of  not sitting in a classroom.  The kids were our responsibility for three meals and overnight, but otherwise they were herded like sheep from activity to activity and supervised by the camp staff for purposes of learning and soaking up the nature.  Compared to school, it was a free for all.  There was plenty I could have done instead of going; the first couple of weeks of school were always busy.  Lots of consultations with parents and doctors, meetings with teachers, health plans for some of the more fragile kids.  I had already spent two weeks prior to the first day of school preparing for the trip as well as for the kids in my school with health needs.

These 6th graders had just moved on to the middle school, but I knew them well; they had been my responsibility for grades 3-5, with their health problems, adjustment issues and daily boo-boos. Although there was a camp nurse who distributed meds, my presence was pretty much redundant.  It was my guarantee of being there that sealed the deal for parents that their kids would be safe and well cared for.  Oh, I  checked peak flows and did asthma checks so as not to be awakened for nebs in the middle of the night for wheezy kids.  I located the kids who forgot to show up for meds.  I could tell by a look who needed special attention or a pep talk.  I managed the diabetics exclusively.  On occasion I made a trip to the ER for a few stitches (those kids always got treated to a burger or ice cream on the way back to camp but were sworn to secrecy).   I always had a few kids who had never left home for as much as a sleepover, kids who were on the verge of illness, or kids who were allergic to everything including clouds.  Every year there was one or two new kids who had moved to town and didn't have a single friend and arrived with some sort of medical issue.  I gave the really nervous parents my cell phone number since we usually left for the trip only 3 days into the school year and the mostly middle school faculty were new to the kids.  Up until that year, no one had ever called me although I did make a few calls home so they wouldn't worry too much.  Since the kids were forbidden to use the phone, it was always appreciated.

My own kids were nearly grown; my daughter was 21 and had already started her 3rd year of college the week before.  My son was starting his first year at a Boston area college the day after I returned.  It was going to be a busy week and weekend, but it was all under control.

On that day, September 11, 2001, the kids were settling into their second day of after-breakfast activities with their camp leaders.  The other 9 teachers and I had a precious 2 hours and 15 minutes until we were needed to chaperon free play time and then lunch for the kids.  We were enjoying the beautiful sunny day on the deck overlooking a sparkling blue lake.  It was summer still, but with that unmistakable crispness that meant fall would not be far behind.  I remember how we admired the color of the sky and the green of the surrounding mountains, dotted with just a touch of red and yellow of early-changing leaves and how pretty it was as the view was reflected in the lake.  Some teachers were milling around, reading the paper on the deck and enjoying a peaceful cup of coffee or just sitting and chatting.  Two of my good friends were 5th grade teachers.  We were making a plan to escape to Dunkin' Donuts for some adult time and maybe taking out a few sailboats later in the afternoon when the kids were with their learning groups.  Joe, a grade 4 teacher drove up in his car.

"Hey", said Joe, "Something really bad happened in New York at the World Trade Center.  A plane crash.    I'm going down to the rec room TV to check on it".

We quickly followed, collecting most of the other faculty en route.  I remembered that there had been a bomb attack maybe ten years earlier.  I thought about the logistics of evacuating those buildings and what a nightmare it must have been.  In my wildest dreams I could not have imagined the horror that was to come.

We sat riveted and in shock as the events of the day unfolded.  It was like a bad dream; many of the teachers had tears streaming down their faces.  One teacher was married to a National Guardsman, another to a federal agent; both wondered not if but when and where their husbands would be called to duty.

At some point, it occurred to us: "What do we tell the kids?".

I suggested that we tell them nothing.  There were 10 of us, how could we handle the emotional needs of 180 kids who might have a grandfather who works in one of the towers, or whose aunt lives in New York, or
whose cousin works for an airline or the fire department?

Joe agreed.  He suggested that we talk to the school principal; after all, it should ultimately be their decision.  We could be called home right away.  Parents would be calling the school and the camp.  We had to be prepared for an onslaught of parents driving the two hours to scoop up their kids and bring them home and who could blame them? 

Cathy was a 5th grade teacher who worried about the safety of us all.  With planes targeting the Pentagon and White House as well as the Twin Towers, who knew what could be next?  Was it safe to even be on the roads?

Two 6th grade teachers, Sally and Carl were the undisputed team leaders.  They thought the best plan was to keep things as normal as possible until we heard otherwise.   As a group we agreed, then scattered to meet up with our kids before lunch for 45 minutes of free time.

Joe went to find the camp director; Sally tried to contact the school principal and/or the superintendent's office.  Overloaded telephone systems and a serious lack of cell phone service prevented her from reaching anyone.  For the next several hours, in fact for the next three days, we were cut off from the world and on our own. 

During the lunch break the camp staff taken off and briefed by their director, who ordered them to keep things as normal as possible for our kids.  Some were unhappy about that, but we were insistent. They would stick to the program.

It was late afternoon before Sally was able to speak to anyone from school administration.  They agreed with our course of action; they had had a meeting with parent organizers and the consensus was that as long as we, the  faculty, were OK with staying, the kids would remain at camp; the only difference was that we would leave after breakfast on Friday and arrive home before 1 PM instead of 5 PM.  Teachers on all three buses would brief the kids on the way home. 

And so, as our country grieved for the lives lost, the threat to our freedom, and the near-destruction of our piece of mind, our kids learned and played.  They bonded with teachers and classmates as a group, communed with nature, and made memories.  They missed home a little, and school not so much.  They had the freedom to eat peanut butter and jelly instead of veggie burgers, and some enjoyed their sloth, showering and wearing clean clothes only when compelled to do so.  For three more days our students did  all the normal things they had a right to do as kids.  They did not have any access to TV's or newspapers; our only link with the outside world was a few moments of news casts several times per day and newspapers, which we kept hidden.  The kids were isolated, not having access to either.  We, their teachers, protected their innocence for just a few more days, shielded them from fear and from the rest of the world.

That Friday as I drove home, it seemed as though I had landed in another world; I had never seen so many flags flying from homes, schools, fire stations, police stations, public buildings.  Hand made signs and banners proclaimed that we as Americans were still strong, that nothing would break us.  There were pleas for vengeance and retribution. There were prayers for peace and for the families of the victims. 

For Baby Boomers like me, the assassination of President Kennedy was a tragedy that changed a generation.  For this generation, it is September 11, 2001.

But for our kids, our 180 students, our group of 11 year olds who had left home on a Monday and returned to a changed world on Friday, their experience was significantly different.  In their before and after world of 9/11, there was a big pause filled with childish things, a right of passage unmarred by those attacks in our own backyard.  The world stood still for most of us, but for these sixth graders life was as it should be.

I've often wondered how their  experience at Nature Camp may have shaped their future; perhaps in a completely different way from most kids their age as they played and learned with their classmates in isolation from the sadness of the rest of the country.

I cherish a note written by one of the parents to the 10 of us who were with their children during one of the darkest moments in history to thank us for what we had done to shield them from the horrors of reality:

"Our kids did not watch TV; they did not see the horrible images or the constant replay of planes striking the Twin Towers.  Thanks to you, our kids got to experience normalcy and innocence in a way that none of the other kids at school did, perhaps not anywhere in the country.   We are so fortunate to have such dedicated individuals who put the needs of our children first when there was so much uncertainty in the world.  Surely you feared for your own families, but never showed it to our kids.  Thanks to you, we had 180 of the happiest kids in America".

Thursday, September 8, 2011

In Terrorum

Ms. Annoying, one of our very frequent fliers, came in the other day having been MIA for about 4-5 months.  Her many, many visits were always an energetic pursuit for narcotics for one of the Holy Trinity of Chronic Pain ComplaintsTM (back pain, dental pain, migraine) but that was not why she had come in.  She was having some kind of allergic reaction and suspected a new antidepressant.   She has always been known for disruptive behavior and abusive language when she doesn't get what she wants.  This time she seemed pretty normal.  It seemed odd to me that she had no complaints of any type of pain, but people don't always disclose the "actual reason" for their visit in triage.

After an evaluation by the Mac, I went over her discharge instructions with her that included only a prescription for Prednisone.  Apropos of nothing she said: "I am totally off narcotics.  I was in rehab for three months".


I was floored.  "I'm happy for you.  That is such an accomplishment, it must have been very difficult"

She told me her story of three very intense months.  She had lost her children but found the strength to persevere.    She had been in the process of rebuilding her life one step at a time.  Good for her, I hope she can keep it up and I mean that sincerely. 

"I know I must have been a nightmare when I came in here before.  It is a terrible thing, addiction.  It consumes you, and that stuff is poison.  Nobody should put those drugs into their mouth unless they have cancer.  Tell all the doctor's; narcotics are the devil".

Well, of course they are when they are abused.  I am thinking that this might be an effective strategy in a religious hospital.  "I'm sorry, ma'am,  I regret that we cannot give you any percocet as they are Satan's handiwork.  Here is some ibuprofen".