Cautionary Tale

It's fine to help your kids with their science projects, but that doesn't mean  doing it for them. 

Mom cut herself with  a pair of scissors while cutting a twig so the 12 year old wouldn't.  Why she needed to use the scissors in the first place was beyond me since the project entailed creating a primitive tool.  I don't think primitive people used scissors to fashion tools.

As she received 5 sutures mom commented: "We better get an A on this project".

WTF?  I never got a lot of  help on my projects from my parents except to cart it to and from school.  Unless it involved power tools, then I wasn't allowed to use the chain saw.  Lame Styrofoam solar systems or exploding volcanoes were otherwise my responsibility. 

Once I had to do a working digestive system.  I traced my little brother's outline on a piece of plywood, then filled in the esophagus, stomach, intestines etcetera. My dad drew a profile (face only) of Lucy (Peanuts Lucy, not I Love Lucy...although THAT would have been interesting).  My little brother was upset that I put Lucy on his body but he got over it.  I got some plastic tubing that I stapled  gingerly on the plywood being careful not to poke holes in it.  Thus I was able to demonstrate the fascinating journey of food, using Kool-Aid, through the body from start to finish.  Everyone thought it was gross, but that's fourth grade for you.  I got an A on the project. "We" didn't get an A.

Got Flu for You

 It's official: "Go directly to the ER at the first sign of flu" season is upon us.

One guy wasn't feeling great, "felt warm" (um, his thermometer didn't work), kinda tired, and had a sore arm because he had a flu shot yesterday.  Perfectly healthy guy.  Came from work.  Home with common sense generic remedies.  I think the CDC should start keeping statistics on ManFlu.

I did three flu swabs today, and not a single one was positive.  Nobody was sick enough for the ER, trust me.

One mother of a 6 year old called first to make sure we did flu tests and we could give her kid Tamiflu if needed.  Yes to the test, no to the Tamiflu.  We don't stock it, and the pharmacies are closed now.  Call your pediatrician for flu guidelines, no I can't say whether we will or will not give it to your kid anyway.  The advice she ignored.  The kid wasn't really sick other than a low grade fever.  He was otherwise healthy. But he did have a birthday in a few days and mom's goal was that she wanted him healthy for the party.

Negative flu test.  No Tamiflu.  Cancel the party.

Being Nosy

A three year old little girl was brought in by mom.  "She stuck something up her nose"

Tonight's foreign body was a little piece of plastic that came out with relative ease.  I always have some fun with this kind of thing.  Sometimes the parents know what the object might be, sometimes not.  . 

Here are a few examples of the responses I have gotten when I asked the kiddo WHAT was up nose:
"An eraser!"
"Kleenex!"
"A Barbie shoe!"
"Playdoh!"
"A cat treat!"
"A flower!  I was smelling it and it just stuck there!"
"Nothing!  Just boogers!"

I trust you have seen the image of the little girl who suffered for years with recurrent sinus problems who, it turns out, had a safety pin lodged up there in her sinus cavity.  Google "girl with safety pin in nose" to see it, I'm too lazy to post a link.  It's an impressive example of the kinds of shenanigans kids can get up to when you turn your back on them for like, 2 seconds.  When I was a school nurse one of my favorite kindergarten teachers brought two adorable little 5 year olds fresh from the playground.

Mrs. J: "Lacey, tell Mrs. EdN why we came to see her today"
Lacey: "I put a pebble up my nose!"
Me: (coughing to hide a laugh) "Lacey, how come you put a pebble in your nose?"
Lacey: "'Cause it was little!"
Mrs. J: "Now, Gina, will you please tell Mrs. EdN why we came to see her?"
Gina: "I put a pebble up my nose too!  I was showing Mrs. J. how Lacey did it!"
Me: (really, really trying not to laugh but really, really not succeeding) "Oh, I understand.  So the pebbles are still stuck up your nose?"
Lacey: "No, mine came out!"
Gina: "Mine fell out when I sneezed!"
Me: "Well that's good.  Let me just look and make sure, then I'll call your moms.  No more anything up the nose though, right girls?"
Lacey and Gina: (in little sing-song voices) "Noooooooo!!
Mrs. J: "And why don't we want to put anything up our nose?"
Lacey and Gina: "Because it's BAAAAAAAAD!!!"

Definitely everything we need to know we learned in kindergarten, sometimes the hard way.

The Long and Short

Whenever a patient says, "...to make a long story short", I know I should probably get a snack and settle in becuase it will be anything but short.

Mr. Yada: "Well it all started 2 weeks ago......blah blah fever 1 0 days ago....blah blah.....urinary/prostate problem....saw my primary care...blah blah yada yada....testicles hurt.....mumble snort.....pain when I urinate.....yada yada blabity blabity blabity yada...."

He went on for 10 minutes in spite of my attempts to pry the Reader's Digest abridged version out of him.

Me: "So, sir, to summarize, you have had intermittent fever for 10 days, testicular pain and swelling for 5 days, and urinary symptoms for 4 days?  Is that correct?"

Mr. Yada: " Um....yes, I would say that sums it up nicely.  How did you do that?"

Me: "Active listening and a scary ability to condense".

Opiate Entrepreneur (def):

(n) individual with an unreasonable number of  ER visits for bogus medical complaints, frequently involving improbable, nonsensical, or fictitious injuries causing severe unrealistic pain who seeks narcotics for the purpose of resale. See also: squirrel. 

This is nothing new except they are more aggressive and are more likely to get what they want thanks to hospital mandates on patient satisfaction.  This is behavior what turns ER nurses cynical and suspicious.  The docs see these people ocasionally; the nurses work every day and can usually recall at least a couple of their visits.  Today I had 6 of them within 2 hours.  What they had in common:

1.  More than 12 visits each for pain-related complaints
2.  No job.
3.  No insurance
4.  No ID
5.  No credibility
6.  No intention to pay anything for the visit.
7.  They left empty handed

Just...No

I am not really a girly girl, but I do like to get my nails done every couple of weeks and indulge in a pedicure every 5 or 6 weeks; maybe more often in the warmer months. Hey, I deserve it. I walk my dog every day and spend 8 hours on my feet at minimum. You only get two feet.

 I have been going to my present salon for nearly 7 years.  I am not all that fussy about who does them because they all know what they are doing.  Plus they can always fit me in the same day, which is good.

There is a  TV in the salon; it is always on.  When I first started going there, it was constant music videos, the owners favoirites being concerts of the Eagles, Celine Dion, Tina Turner, ABBA, and, oddly, J Lo.  I have heard all of these many times.  When they got a bigger TV it was movies for awhile.  Now, it is daytime talk shows and soaps, CNN, reruns of The Golden Girls and other boring stuff depending on what time of day I hit the salon.  It is generally quiet and calm, low conversation and the staff not overly chatty.  Just the way I like it.

Today I stepped into a Bizarro World; a new nail tech flirted shamelessly with one of the male technicians.  One woman shrieked into her cell phone incessantly (you know how I love that).  A whiny woman complained about the smell of acetone (seriously??  WTF did you expect in a nail salon, moron?).  Worse still was a man and wife duo getting pedicures and talking about the benefits of cosmetic surgery while "The Replacement Killers" movie was on TV. So NOT relaxing.

What's the world coming to? Next time it will probably be "Kill Bill", with the odor of acetone replaced with Old Spice.  If this turns into a men's nail salon, I'm outa here.

If He Could Only Go Back in Time

It has been at least three months since I have had to work with Bobo and I can't say I've missed the little twerp in the slightest.  Since he is the antithesis of team player he is always such a pleasure to work with.  Especially annoying is that he is still like a rabid squirrel on the 20 minute or less door-to-doc time. 

Most of the time the patients see the physician within the allotted (and heavily marketed) time frame.  Mostly the delay lies in the minor detail of the registration process as it is unwieldy and takes a ton of time.  There used to be two registration clerks, but  the Brain Trust that is administration actually cut secretarial hours after 3 PM so now there is only one until 7 PM when outpatient services close.  Brilliant.  This has resulted in ridiculous waits for the appointment-making and insurance-having outpatients as well as walk-in routine blood draws.  On 3-11 it can get pretty busy since both the ER and outpatient department business picks up.  It doesn't help that a couple of the secretaries are deadly sloooooow.  Thorough, but slow.  There is apparently no way for the Suits to speed up this process although I know it is MUCH faster at Pseudocity Hospital.  Probably faster at any hospital  that has a vision of rapid registration as a simple but effective means of improving satisfaction scores. But that would just make sense, what do I know.

So to recap, patients are triaged promptly but often fall down the rabbit hole of registration.  That gets Bobo's tighty whities in a wad.  He used to say is was because the nurses were taking too long to triage.  WTF?  I wasn't taking that lying down, so  I began adding the time "triage competed" boldly next to the triage time.  In most cases it was less than 5 minutes.  He probably noticed that I only did this when he was working, and that I had instigated the other nurses to do the same.  Thus endeth the discussion of how long nurses take to triage.  But did it do anything to speed up registration?  Um, no.  I learned to make copies of complicated med lists for the above average patient who came equipped with such because we must HAND WRITE med lists or we get dinged, another stupid time waster.

Some of the other docs fail to write down the times of their first interaction with the patient and leave it to the nurses. It is usually a guess as we are also responsible for noting the following in addition to triage time:  time to room, time physician sees patient, time of labs, xrays, EKG's and discharges in addition to the obvious like meds given, IV starts, vital signs, pain scale, blah, blah, blah.   I've mentioned that Bobo obsessively writes his own times down, and gets testy if we fail to write down time to room.   I think he gets a prize for having the fastest door-to-doc times, even if it means going out to triage and seeing the patient first if the nurses are in the middle of something he can't drag us away from.  I have occasionally found him in triage if we are especially busy, so that his time-to-patient  is earlier than the triage time.  I don't think he has realized that this doesn't help his numbers at all as "door" time is calculated as "triage" time; the system won't calculate a minus.  It also doesn't take into consideration that there is sometimes as much as a 20 minute wait for triage.   

Last night I thought Bobo would have a stroke.  There were sick and complicated patients, multiple admissions and transfers, endless phone calls ("You have asked me to make 3 phone calls, start 2 IV's, and splint a kid; which would you like me to do first?"), the death of an end stage liver patient who's family was in denial which entailed even more calls and tied up a room for 3 hours (with the ER wake/viewing), and one nurse-accompanied transfer necessitating calling our boss in to cover for an hour. 

Notice to all the non-urgents in the waiting room who expected rapid service: due to circumstances and Actual Emergencies beyond our control, 20 minute door-to-doc is suspended for the evening.

You Might Be Having a Bad Day If.....

....you are burned by falling "into" a bonfire.  While you are wearing spiked heals and drinking tequila
....you get into a car accident while enroute to the ER.  With a tick bite.
....you are fake-vomiting into the toilet (ie, sound effects and  spitting). Then your brand new I phone falls in.
...."you just can't get hold of" your doctor and you need an emergent narcotic refill.  He is here in the ER and  says he fired you a year ago.
....your friend pierced your navel for you after you were forbidden to have it done.  You are not 18 for another week and we need parental permission to treat you for that infection. 
...you come into the ER for back pain so bad you needed to be out of work today and will need to be out for the weekend.  I did not triage you. But you did wait on me at the drive-up window at Dunkin' Donuts about an hour ago.  Nice to see you again.
...your dog is startled by a cat and bolts, you pulled off your feet, and your head hits a rock.  You are 71 and have a fractured skull.

Which one is the worst Bad Day?

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

.......was a 32 year old male who just wanted to ask a question about whether or not he should be seen, thus incurring an ER charge.  His 5 day old tattoo was looking a little red and swollen even though he had scrupulously treated it as directed by his tattoo artist with A&D ointment. 

Here is a teachable moment: as always, if you are already in my ER and "just want an opinion if I should be seen", the answer is, with few exceptions, yes.  Liability.  Even if it is for a stupid reason.  This was not a stupid reason, and he did have an infection.  Antibiotics.

Interesting conversation overheard between the patient and Cripes:
Tattoo guy: "Yeah, I have some tattoos so I know how they should be treated.  The place I go is really clean and uses all sterile stuff.  I've never gotten an infection before"
Cripes: "Well, it's good you came in"
Tattoo guy: "I have been getting a few tattoos over the last couple of years.  I used get piercings when I was younger but I've found that tattoos are more socially acceptable than piercings, more main-stream, ya know?  You're more likely to find business people with tats, see.  I work a lot with the public"
Cripes: "Oh, what do you do?"
Tattoo guy: "Auto salvage.  And I have quite a car collection.  Are you a car guy, Doc?  What do you drive?"
Cripes: "Oh, I have a Tundra"
Tattoo guy: "I have a 1945 Blah, a 1957 Blah Blah, a sweet 1960 Blah Blah Blah a..." (he listed about 6 more classic cars). 

I don't know, like, or care about cars.  Someone talks about cars or golf and I start doing the multiplication tables in my head or fake a seizure.  Booooooooooooooooooooooring.  But I did think the guy's take on the social implications of piercings....insightful.

PS  Aren't you dying to know what kind of tattoo he had?

It was a a horse.  Ya know, like on those sports cars?

Found on the Bathroom Bulletin Board

My religious hospital is always having some kind of fund raiser, asking for money, donations of time, collecting for Christmas baskets and back-to-school-backpacks, food pantries, the Lenten diaper drive, soliciting for nine different kinds of cancer, Sister Mary Clarence's beer fund, inner city victory gardens, windmills over Holland, employees with acute need, orphans in third world countries, etc, etc, etc.  It is something every single week, literally.  For a non-profit, they seem to want to squeeze every last penny out of the people who work there.  I pick my battles and one or two things a year.  I prefer to choose my own charities mostly.

So as I perused the Potty Notes, I came across this interesting nugget:

"Collecting Items for the Homless (sic)"

sweatshirts
toiletries
sleeping bags
tents
socks
hats
shirts
sweatpants
blankets
crockpots

Crockpots? Ooooooooooooookay!

Keep Honking, I'm Reloading

Many of the Really Sick walk in. That is what we are there for, we are the closest help for evaluation/treatment/stabilization and transfer to a tertiary care facility.  Sometimes, people who somehow manage to get themselves into a car will subsequently have difficulty getting out, due either to confusion or firmly held beliefs about when it is and is not appropriate to call 911. This is a behaviour peculiar to many an older adult, but is rampant among the Old Yankee population.  A penny saved is a penny earned; if I can breath, I can walk; if it ain't cut off, it's only a flesh wound. 

Sometimes family members will simply request a wheelchair.  Sometimes they will come in and calmly request assistance, and we will trudge into the parking lot regardless of rain, snow, sleet or dark of night.  But when there are only two of us nurses to tote that barge and lift that bale it can be a strain on the back; we are not superhuman.  And we are none of us spring chicks.  The youngest of us is 42.  The eldest is......well, me, with three of my colleagues within a couple of years.  Lab and xray on the evening shift?  Same boat.  The docs?  Again, same boat.  Gil already has a couple of stents, and though younger, Bobo is downright fragile.

 We used to have an elderly post stroke lady who could barely walk who would to beeeeeeeeeeeep her car horn incessantly so we could come out and drag inside her equally mobility-challenged and even older husband by wheelchair for a catheter change.  That was a treat.  I think that was Second in Commands doing: "Sure, just beep the horn!  We have curb service!".  Not.  I think he died or is in a nursing home. 

When patients comes into the ambulance bay laying on the horn, though, we pay attention.  Recent treks to the parking lot for assistance include:
"She's having a seizure"
"My husband has severe pain"
"My mother is short of breath"
"My daughter can't move her leg"

As for the above, none of them were exactly as advertised, and turned out to be more of a panic situation than anything life threatening.  Seizure?  Tremors in a Parkinson's patient who was either under-dosed or had missed their Sinemet.  Severe pain?  OK, that one was kidney stone, painful and scary;  way more painful in men than women.  Or more common anyway.  Short of breath?  COPD, always short of breath and still smokes.  Daughter who couldn't move her leg?  Soccer playing teenage girl.  Drama, drama, drama.  I usually make a bet that the teen will be on her cell phone within 5 minutes, and that at the conclusion of the visit she will hop up from her death bed and miraculously walk.  Nobody will take my bet anymore because I am always right.  The mechanism of injury is never commensurate with the level of disability portrayed.  Also, they are uniformly poor actresses.

People in an absolute panic get pissed when ER nurses don't exhibit the same level of panic.  They think that by remaining calm and in control we are complacent and uncaring.  Really?  Do do you think anything will get accomplished if I am jumping up and down screaming?  Seriously?  I will get out the Dope Slap machine and set it to stun if necessary.

And, although I operate on the principle that it is not time to panic until it's time to panic, once in a while someone will get my adrenaline pumping.

BEEEEEEEEEEEEEEEEEEEEEEEP!  BEEEEEEP!  BEEEEEP!  BEEEEEEEEEEEEEEEP!!!!

New Cathy and I beheld an enormous SUV, engine still running, stopped diagonally across our ambulance bay and blocking the parking lot entrance because it was attached to a large trailer.  The trailer was partially  in the street. The 70ish man in the driver's seat was pale and sweaty and breathing rapidly.  Wow, I thought.  He's having the Big One.  "Sir, what's  wrong?  Are you having pain?  Are you diabetic?"

"Call.  The police.  Secure.  The guns."

WTF?  Guns?

I reached in, put the car in park and turned off the engine lest we be run over.  New Cathy and I hauled him into the wheelchair (he could, fortunately, briefly stand).  All the while he muttered, "Secure.  The guns.  I.  Have a.  License.  Legal.  Need to.  Lock.  Them.  Up". 

He was diabetic, had a cardiac history, and was dehydrated having driven most of the day from some gun show.  He wasn't having the Big One that day, but he was admitted anyway. 

The guns?  All legal.  The local police came over to move the SUV and secure the weapons, locking them up at the station.  BEEEEEEEEEEEEEEEEEEEEEEEEEEP!!!!

Just a Thought

I pass by a local church daily on my way to work.  For days and days parishoners with heavy equipment worked on extending their parking lot by excavating a hill.  After endless grading and preparation, it was ready for asphalt.

I envisioned a sign for the project:
"Jesus Paves".

Darwinism...

......the process by which, via natural selection, unfit specimens remove themselves from the gene pool

A few candidates who are genetically hanging by a thread for your entertainment.  There will be a quiz at the conclusion of this presentation:

A.  40 year old man came in complaining of "really bad burns".  He had been at a local bonfire/pep rally or some crap, and was tending to the fire.  He had some 1st and 2nd degree burns on his right hand and arm, and the backs of both legs.

Me: "How did this happen?"
Guy: "I threw some gasoline on the fire"
Me: (blurted before I could stop myself), "WHY??"

Did I mention that he had three or four kids under the age of 12 with him?  Um, yeah.

B.  33 year old who used heroin for the first time.  At work. That's all I have to say about that.

C.  42 year old who had a couple of beers at lunch and went back to work.  As a roofer. Using a nail gun, he buried a couple of inches metal into his proximal femur. THIS CLOSE to his femoral artery

D.  36 year old nearly removed his own knee cap with a chain saw.  He admitted to taking a "butt load" of oxy's daily for his chronic pain condition for which he is disabled.  Let me also mention he weighed over 300 pounds and had stopped at Burger World (as evidenced by paper sack he was toting) and had a blood pressure of Patent Pending/100.  A more cynical person than I might wonder how in hell he imagined using a chain saw in his debilitated condition was a good decision. 

Which of the following statements is true: (I told you there would be a quiz)

1.  They are all men
2.  They have all made galactically stupid decisions
3.  Antibiotics cure viruses.

A.  1 & 2 only
B.  All of the above
C.  1 & 3.
D.  None of the above

On Falling

I was asked to cover a couple of hours for Kerry on a day off so she could go to a meeting, or buy chickens or something; sure!  2 hours=1/2 of a princess shift.

I took care of only one (one!  ONE!) patient for 2 hours and 20 minutes.  Young.  No job, no insurance and had applied for Medicaid when she found out she was pregnant; I don't know why she wasn't already on it since she had only one arm, a congenital condition.  She seemed like someone who had, or would soon be, falling through the cracks. 

She didn't know what to do: she was by herself and scared.  She had just had a "screening" ultrasound at a free clinic during her first pre-natal visit; her baby had stopped growing and had no heartbeat, she said.  She did not know what to do next since she wasn't bleeding or cramping.  The clinic kicked her to the curb with some phone numbers.  She was worried about the cost.

We did the usual blood tests and an ultrasound that confirmed fetal demise at about 8 weeks gestation.  Twins.  I arranged an appointment for her that very afternoon with the OB to discuss her options.  She elected not to keep it because she had to get home so her boyfriend could get to school.  I tried very hard to get her to change her mind

"I guess everything happens for a reason", she said.  "It would have been almost impossible with one baby, let alone two".

I made two phone calls to her over the weekend which went unanswered.  She didn't call either.

The next sound you hear will be someone falling through the cracks.

Planning

The 93 year old cardiac arrest rolled in without  advanced airway or IV access.  No drugs.  Asystole.  CPR was halfheartedly in progress.  The young man who had found her on the floor was living in the house, a friend of the patient's great grandson.  The patient was supposed to be DNR.  Why, then, was she in our ER?  The young man called 911 in a panic, and could not produce the DNR or any documentation. Since none of the actual family members were at home, CPR was initiated by EMS.  She was pronounced dead moments after her arrival in the ER since she had an advanced directive on file and the family member called us.  Good; we didn't have go all out on the Poor Dear, and the end of life wishes not to be kept alive by artificial means were (sort of) followed. 

Note to self and others: discuss end of life plans.  Have one in place.  Keep the DNR handy.  If there is a terminal illness, understand what to do if the family member dies at home.  This was a case of good intentions, just a tad short on follow through.

It fascinates me that although death is inevitable, so few families are prepared for it.  We don't often discuss it.  Terminal illness aside, it seems as if by ignoring the Reaper, he will ignore us. 

I can't stress this enough.  Everyone deserves to be treated with dignity, yet there is little dignity  when an elder loved one dies in an ER, worse still when it isn't their wish to be kept alive with heroic measures.   I would hate to have my last image of a loved one lying lifeless in an ER. 

Squirrel Count

I love Gil.  Some of the other nurses thinks he orders too many tests, but I don't.  He likes taking good care of patients, likes to educate, and always has something interesting to share.  Having worked with him for about 2 1/2 years we've come to know him will.  He used to be a little hyper, but he's over it.  We talked about that the other day. 
Gil: "I remember when I first started here, I was kind of ramped up.  At least you guys know when I need a time out".
Me: "Yeah, the first few months were....challenging at times.  Not that you weren't likable, that wasn't the problem.  And it wasn't a time out you needed:  a couple of times I just wanted to slap the shit out of you.  Calm.  I like calm and focus.  Breath in, breath out.  This is not Chicken Little ER".
Gil: "Always some bumps in the road with new docs, huh?"
Me: "Mmmmmhmmmmmmmmm".

Loe the guy, but he's a squirrel feeder.

"If you feed the squirrels, they will keep coming back".  This refers to narcotic seeking individuals.  Gil's solution is to give them, say, 2 Percocet to go and no prescription.  He may think he has shut off the squirrels, but he is still giving them acorns even if it's one at a time.  Besides, it just makes us nurses have to sign them out, put them in a little envelope, and write "one tablet every 4-6 hours as needed for the severe, excruciating and debilitating pain that has brought you to the ER like 20 times this year.  This is all you get, don't ask for more".  Well, not the last part.  Anyway, Gil just keeps on feeding those squirrels.  Last night's squirrel count as follows:

Case 1:
Complaint: Butt pain
Goal:  Narcotics
Plan: Home with narcotics
Female with a bruised butt from a fall down the stairs presenting with 20/10 pain on a scale where 10 is the max.  So bad she took Tylenol about 20 minutes before arriving. She was observed on camera as she walked normally to the door where she then proceded to mmmmmmmmmmmooooooooooovvvvvvvvvvvveeee iinnnnnnnnnnnnnnnnnnn sssssssssssssllllooooooooooooooooooooowwwwwwwwwwww mmmmmmmmmmmmmooooooootion.  Really.  It was like a 78 RPM record being played at 33 RPM.  And if you don't have any idea what I am talking about, ask your......grandfather.  After she got what she came in for, her gait was back to speed as observed on our trusty Spy Cam. I would be so sad if that stopped working.  Very entertaining.

Case 2:
Complaint: Back pain
Goal: Narcotics
Plan: Home with narcotics
Another young female who had been treated for sciatica and dental pain in 4 visits to the ER this month and had received Percocet for each of those visits.

Case 3:
Complaint: Acute knee pain.  I had to get her out of the car 'cause she couldn't walk
Goal: Pain relief, rule out fracture, and not to have to use crutches
Plan: Home with narcotic pain 'script and crutches.
This one was a middle aged woman who thought karma was working against her as she had said just yesterday that she would never use a walker.  Hah.  People make plans, the universe laughs.  We were completely out of knee immobilizers so I wrapped an ace bandage and gave her crutches.  I worked with her for 20 minutes but at the end of the session she said, "I'm not going to use them anyway".  Observed via Spy Cam walking normally in parking lot with the crutch tips pointing to Heaven.

Case 4:
Complaint: Man-cold with sore throat.  Oh, and back pain.
Goal: Narcotics and work note.
Plan:  Home with Tramadol and work note.
Don't get me started on man-cold.  It is the season for most men to become a quivering puddle of sniffling, whining, hacking, helpless, miserableness.  "I don't feeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeel goooooooooooood!"  Percocet for a cold and sore throat of 4 hours??  Seriously?  Are you fu*king out of your mind? 

Here's an aside: a friend of mine who works in Endoscopy (AKA, the Bum-Lookup nurse) says that thanks to Michael Jackson's doctor, they are required to tell patent's that they will not be getting Propofol.  Thank you.