Thursday, May 31, 2012

Harmony for All

The evening shift has its own vibe. At 3 PM I can walk into absolute chaos with staff spinning in their own individual orbits:  nurses, secretaries, X-ray techs, lab techs, and let's not forget docs.  I hate walking into chaos, people wound as tight as rubber bands.  I like calm.  No panic until it's time to panic.  Breathe in, breathe out.

My first official act is to GET THE DAY SHIFT OUT.  Currently, my colleagues are great people whose only fault is the mistaken notion that they cannot leave for the day with a single task undone. Often it has been such a busy day that after a full shift of fu*kery, there is not a single other thing you can do except leave.  Quietly.  And pour yourself a glass of wine when you get home.

I'm not really complaining.  Every nurse who has walked this planet has, at some point,  wanted to strangle with their own stethoscopes nurses who are so lazy that they waltz out the door in the middle of a shit storm, waiting with their coats on, purse on the shoulder, and car keys in hand.  Being on the  report-receiving end of a train-wreck with a shit ton of unfinished business just doesn't make anybody's day.  Report not given to the floor nurse, charts not filled out, pain meds 2 hours overdue, no labs drawn, antibiotics not started and patients not updated for hours.  Crazy busy happens, but when the nurse is chatting with EMT's and hasn't taken one of 10 people in the waiting room in two hours or is online shopping, that is unforgivable.  Shame on you.  That goes double for nurses who sit back reading the paper while directing the ER tech to do all the work.

Like I said, calm.  Let's just all be one in the moment.  Breathe in.  Breathe out.  Ommmmmmmmm............

Wednesday, May 30, 2012

This....or That

Allow me to assist you in navigating the murky waters of the emergency department.  We will bend over backwards to give you the best possible care.  Truthfully, though, you need to be mindful that the best care may not be exactly what you want or what your friends think you should have; you may not necessarily have it Your Way just because you ask for it or demand it.  Know that we are reasonable people and put on happy, smiley faces but don't do well when people are unreasonable or taking advantage.  Rudeness doesn't help either, and we spend an inordinate amount of time squirrel wrangling.  Or haggling.

What the patient wants:  narcotics
What the patient expects: to call and ask to speak to Dr. No-narcs, thus ascertaining whether or not he should come in or wait for another day.  Better yet, ask to speak to Dr. Santa Claus to ask a question, or ask to speak to any doctor for advice.
What actually occurs:  No name shall pass my ruby red lips.  I stonewall, hedge, hinder, thwart, oppose, hamper, block, resist, oppose or impede any efforts on the patient's behalf to get the information.  Over my cold, dead body.  I'm really good at rebuffs, too.

What the patient wants: weekend off
What the patient expects: that we will write a work excuse for an injury that occurred two weeks ago and wasn't even worthy of 1/2 day off then.
What actually occurs:  come in for an exam.  It's been two weeks, at most you will get a note giving the day of your visit.

What the patient wants: an ER visit that takes 10 minutes because she has to pick up her kids
What the patient expects: that her oh-so-minor complaint such as poison ivy deserves top priority and to be attended to ahead of chest pain, abdominal pain and head injuries because it "only takes a few seconds" to examine, treat, and write her a prescription.
What actually occurs:  I waste 10 minutes of my life that I will never get back triaging and then explaining that her ass will be in the waiting room about an hour, so she leaves in a huff without being seen.

What the patient wants: whatever Dr. Google, Dr. Oz, or Dr. As Seen on TV prescribes
What the patient expects: magic cure
What actually occurs:  the mindless fuck doodles informed health care consumer argues with the ER doc for 10 minutes of his/her life that he/she will never get back about how antibiotics DO work for viruses every time.

What the patient wants:  improving his odds of early demise from worsening obesity, diabetes, COPD and heart disease after a lifetime of non-compliance
What the patient expects: that there is a magic bullet that will extend his dismal life expectancy
What actually occurs:  There is not a whole hell of a lot we can fix in one ER visit.

What the patient wants: me to drop everything and call the pharmacy right away with your prescription for foot fungus
What the patient expects: to pick up it up in under 5 minutes so she won't be inconvenienced
What actually happens: you have been a rude pain in my ass from the moment you hit the door, so I phone in your prescription at 5:05 PM, leaving it on the recorded line.  The pharmacist picks those messages up every hour on the hour.  Buh-bye.

Tuesday, May 29, 2012

I'll Load You Right Up

(Another) maladjusted, non-working, non-contributing, suck-the-life-right-out-of-me repeat offender for various complaints of pain and anxiety was "rushed" to the ER by an apparent new friend, breathless with concern.  This was apparently her first performance for the new friend; we had seen this same one dozens of times, the very familiar "unresponsive" in the car act, followed by miraculous consciousness and hyperventilation.  And pain.  Yawn.

After demanding a wheelchair, assistance, a Go Directly to a Treatment Room hall pass, and yelling for "somebody to fu*king do something" for his new friend's chronic and life threatening panic attack and narcotic-needing pain condition he said:

"This is an emergency!  She can't breath!  She needs.....Spazepam!"

No shit.  Let me just pull the pin on that Ativan grenade and let it fly, then everyone will feel allllllllll better.

Monday, May 21, 2012

RIP, Paper ER Records....We Will Miss You

After months of hype, our ER will join the rest of the world in the 21st century and initiate electronic health records.  Let the spinning begin.

 It is an already out-dated program, cumbersome, not user-friendly, and fits awkwardly with our existing systems...when it works. The roll-out date is soon. Very soon.  I agreed to be the super-user for our building, mainly because it is my 4th ER to have worked at when the electronic records have been the new is better not to rely on anyone else's wits but my own when it comes to computers.

I would say we are probably the last health care facility in the free world to finally put this into practice. As with any New Thing, the first thing people want to know is:  how will this affect me, personally?
Well, the simple answer is that electronic health records in my universe will not do two things: it will not lessen my work load or decrease my current responsibilities and it will not mean I have lots and lots of free time to spend with patients. Triage, which I can normally accomplish in under 3 or 4 minutes, will now take about 20 minutes.  There goes your door-to-doc time.  Of course the new plan is to put patients immediately into a treatment rooms, fill 'em up with unregistered patients, add lots of confusion about who is where and then have no place to put a cardiac patient.  But hey, overall that should really help those all-important patient satisfaction scores.  Naturally, electronic records should mean a lot less paper work, right?  Wrong.  We will have approximately 1/2 metric fu*k ton more when all is said and done.

There is much fear and loathing, wailing, and gnashing of teeth.  Ellen is beside herself.  New Cathy is ready to go work at Burger World.

I took another stupid phone call from one of the Suits about an aspect of my job that she could never, ever do.
Suit: "Are you excited?  Go live will be here before you know it!"
Me: (dead pan) "Beside myself.  What a joyous occasion".
Suit:  " I know, right?  Hey, we have something for you!  It's a t-shirt that says SUPER-USER!  Isn't that awesome?  I got you a large, is that OK?  You can wear it the first day so everyone knows who you are!"
Me:  "Oh.  Cool."

Really?  A t-shirt that says super-user?  That is so....wrong.  On several levels.
1.  I don't wear t-shirts.
2.  I would never wear one to work even if I did wear them.
3.  There are about 6 people who work here on the evening shift.  They all know who I am
4.  Think very carefully about the connotations of labeling anyone a super-user.  That would also apply to 2/3 of our frequent fliers seeking narcotics.

Monday, May 14, 2012

Smoke Signals

This man walks into the ER (classic start of a bad joke, why should today be any different).  He noticed that some thick, black smoke was pouring out of one the the chimneys in our very old building as he was passing by a couple of hours ago.  He was on his way to an appointment and just didn't have time to stop but, hey, nice of you to check in with us on your way home to make sure we were not burned to a crisp in the interim.  He suggested we might want to have our maintenance guy check it out.

Ellen gets nervous about these things and wondered if we should call maintenance now, on the off-shift and also off-site, or if I thought it could wait until the following day. Or if she should call the fire department.  I'm the nurse in charge which I guess also makes me in charge of everything else.  Besides, six months earlier there was a back-up of thick smoke that cleared out the building and left an odor for days.

Me:  Yeah, put a call in.  What the heck is a little overtime when we might be fully engulfed in flames in a little while?

Ellen: Wouldn't we have a lot of black smoke if there was a problem in the boiler room?

Me: Well it's a catholic hospital so white smoke means that a new pope has been elected.  Black smoke would mean they haven't made a decision.  Although  I'm pretty sure the old pope has to be dead first but I don't really keep up with that type of thing.

Ellen:  I don't understand.

Me:  I'll go check the boiler room; you call maintenance.

Ya gotta love Ellen.  She is so earnest; she always means well and would do anything for anybody.  She has at least 10 "get well" or "Happy Birthday", cards going around.  New people are powerless to  escape the Spanish Inquisition when it comes to Ellen's Vital Records:  Life Events, Spouse's name, Children, Pets (and their names), and especially Birthdays.  Everybody gets something; a cake, brownies, raspberry bars, or our favorite, Whoopie Pies.  And hers are goooooooooooood.   But I digress.

On another night I had a problem with a strong odor of smoke.  Cigarette smoke.  It was coming from somewhere......close.  REEEally close.  From inside the building.  From....Holy Shit!  That asshat was smoking.... in the bathroom?

Old Drunk: "Nope, I wasn't smoking"

Riiiiiiight.  "Sir, you cannot smoke in here.  If you do it again, I will call the police and have you escorted out"

I had to open up the ambulance bay doors to get the smell out.  It is bad enough that people reek of cigarettes in triage while they claim to smoke "2 or 3 cigs a day"; sometimes at the end of the day all I can smell is stale cigarette smoke.  It is so disgusting.

I am a reformed smoker.  I last smoked 33 years ago, my final pack of cigs hitting the trash bucket at the same time as my first positive home pregnancy test.  It was tough to do, no doubt about it.  I just don't get that people with kids think that they are not exposing them to the dangers of third-hand smoke by merely smoking outside. The chemical residue clings to clothing, skin, hair, furniture, and builds up in the car.  If you are "only smoking outside", you are exposing your family unnecessarily to harmful toxins.

OK.  Off my soap box.

Sunday, May 13, 2012

No Filters

I have had people call 911 from the waiting room on many occasions, usually by disgruntled individuals with relatively non-urgent complaints who felt that their problem deserved attention ahead of minor complaints such as chest pain.  Mostly by people who were not as sick as they thought they were.  Some who thought, erroneously, that they would be magically whisked into the back door and immediately ensconsed in a comfy bed, or taken to another hospital.  Never, ever have I had an 11 year old female do it for attention.

(Heard on police scanner):  "Got a 911 hang up from XXX st., the ER.  Came from a phone in the waiting room".

Me:  "WTF"??

Saturday, May 12, 2012

Lady, Lady, Lady

Lady is still up to her old tricks; frequent visits (mostly during the day), speed-dialing the patient services rep to complain about some imaginary slight, or for perhaps calling attention to her obesity, poor eating habits and lack of diabetic control cause-effect.

She had some abdominal surgery a while back, but at Ginormous University Hospital in another state.  Naturally, because she is a poor healer she had some wound dehiscence.  Said hole in her belly has been plugged up on a daily basis by the home care nurse.

The thing about home care is that the patient must, oddly, be at home to receive a service.  Lady's  home care nurse, understanding what a deep personal relationship we have with Lady, gave us a heads up that we might hear from her.  She didn't happen to be home at the time of his visit and she would only be able to stop back at her house late in the afternoon.  It depended on his other scheduled visits.

Of course she called to inquire if she should come right down for us to handle her emergent wet-dry dressing change.  She didn't know about the call from the home care nurse.

Lady: "Yeah, I'm having some issues with my home care nurse.  She's beginning to be a real pain in my ass.  She said that just because I missed her visit by 7 minutes she couldn't come back because she had to go way out to Booneysville and it would take her out of her way.  That is unacceptable, I was out buying groceries so I could have healthy food for my diabetes, and groceries don't buy themselves.  Should I come in and have you change it?"

Me: "No, Lady, your home care nurse is the one you see every day who knows about your wound and how best to do the dressing.  What exactly did she say?  Maybe that she would TRY to come by and that she would call you?"

Lady: "Uh, um.....well, she's really beginning to bother me.  She might be able to come back but she didn't say when"

Me: "It is the weekend, any issues you are having with her will have to be dealt with on Monday.  In the meantime, she is your nurse.  I suggest you wait until you hear from her.  She did say she would try to get back to you, but to be fair, you were not home when you agreed to be there.  That's not her fault, is it?  And if she had to go to Booneysville waiting around for you when she didn't know when you would be there isn't fair to her or her other patients"

Lady: "Well, so you're saying I shouldn't come in?"

Me: "No, I said wait to hear from her.  If she can't reschedule your visit, have her call ME"

Lady: "Oh.  So she can tell you how to do the dressing"

Me : "Yes" (actually because I know she will not be calling me which means you will not come in by that big white taxi with the flashing red lights for a dressing change that doesn't need to be done)

Come Monday, two things happened; Lady fired the home care nurse, and the home care nurse stopped by to thank me.

Friday, May 11, 2012

Nurses...Advocating. Leading. Caring.

This statement has apparently been adopted by the American Nurses Association, which I didn't know until I Googled it.  I did this because I KNOW my hospital didn't come up with it on their own.  It appeared as a caption on a list of "Nurses' Week Activities" in a previous post, with all of the crappy offerings letting nurses at this facility know just how valued we are. Massive eye roll here.

Not a fan of Nurses Week, never have been.    It's a Healthcare Hallmark Holiday.  Like Grandparents Day, or National Potato Chip Day, or any one of hundreds of silly recognition days.  

Just out of curiosity I checked around the web to see what kind of floral or gift offerings exist specifically for Nurses Week.  I came up with coffee mugs filled with Hershey Kisses, as well as snack baskets filled with M&M's, Kit Kats, Snickers, cookies and other bad stuff.  These are apparently interchangeable as Teacher's Week gifts.  A few contained "healthy" stuff like commercially prepared granola bars, cheddar cheese popcorn, etc.  Yikes.

I get that food, candy, and coffee (hence the candy filled mugs) are the first things on the list when it comes to "treats" for nurses.  But I envisioned that our twisted marketing department had their own perspective on "Nurse Feeding" and came up with this:

Keeping nurses full of fatty, high calorie and/or sugary foods will contribute to obesity and other health problems.  The benefits, while minimal both short- and long- term for nurses, will be increased for the corporation patient satisfaction scores: 
1.   Long term health issues guarantees a steady stream of nurses as patients due to the increase in diabetes, obesity, cardiac disease. Revenues will be markedly increased.
2.  Patients, with careful marketing, can be lead to view RNoUS (RN's of Unusual Size) as more empathetic, and thus perceived as more caring.  Satisfaction scores will be increased exponentially.

I would be happy with a salad, thanks.  And because I can never find anything I need to do my job, my constant running about insures that my activity  level remains high.  Hey!  Maybe we could get some coupons for decent footwear...

Tuesday, May 8, 2012

Nurses Week

It is Nurses Week.  Time to roll out a day by day schedule to honor the wonderful nurses:

Sundaes on Sunday, all shifts all units:  note that our unit did not get them, being off-shift and off-site.  Apparently none of the oh-so-important 9-5'ers considered us worthy of ice cream.

Appetizers in the Lobby:  an Invitation-Only event singling out advanced practice nurses, nurses with professional certification, or nurses who have completed the clinical ladder "Jumping Through Hoops in Order to Get a 20 cent Raise If You Are At the Top of The Pay Scale" paperwork.  Way to exclude 95% of the nurses, dear employer, as if our profession isn't divisive enough as it is.

Bagels: only for the home care people.  Didn't say if cream cheese was included, or if it was BYO.

Nursing Grand Rounds:  Always a boring affair, not worth the drive.  Usually some doctor hijacks the meeting.  No food either.

Mini Mall in the Lobby:  Big whoop.  I am assuming that since it is in the lobby, it is also open to the public. Wonderful opportunity to spend money on ourselves, during our scheduled breaks of course, if there is enough staff to take them.  If so then there will be smoothies, candy offerings and soft pretzels.  For purchase in the cafeteria.  So much pampering.  I can hardly stand it.

Midnight Breakfast:   For the night shift, between 12 and 2 AM.  In my experience and years of working nights, this is the busiest time.  Except from 6-7, when it would be more convenient for the Suits who claim to be coming in to serve breakfast.  Most likely the same Suits who said we would be getting Sundaes, so be sure to bring a snack, kids

Hourly Raffles and Free Giveaways:  Most likely free swag from drug reps and cheap crap like key chains and water bottles with the company logo so we can be walking advertisements.  Nice.  It would be considered a sincere  gesture if they raffled off a day off with pay, or a massage, or even a donation to a charity of our choice.

Finally, Bagels:  from 6-8 AM on Saturday morning.  I suspect they will be leftovers from home care several days previously.  Frankly I would prefer Pop Tarts.

Bobo, our medical director and somewhat socially challenged on his best days has actually paid out of his own pocket for some nurses day gift (I think his wife is a nurse).  In the past we have received lunch bags, t shirts, and coffee mugs.  But slogans like "Nurses Call the Shots",  "Love a Nurse PRN", "Nurses Rock" and other silliness goes right to the bottom of the charity bag for me.  Let me say that I truly appreciate that he has taken the time and effort to do this.  I really do. But I actually hate that more than the company logo.

At my nursing school graduation 35 years ago, one speaker exhorted us as newly minted nurses never to condone slogans that exploit us as men and women in health care, perpetuate stereotypes, and fail to present nurses as professionals.  Big boobs, thigh highs and stilettos, giant know what I'm talking about.  I have a few Emergency Nurses Association coffee mugs from a former boss that are tasteful, but other than that I say NO to silly slogans.

The only Nurses Week recognition I'm looking for is just a little sincere appreciation for the job I do from my employer.  Sincerity is not one of their strong points, so hopefully my boss will come through with the ice cream.

Saturday, May 5, 2012

May 5 Hijinks

So this massive full moon on May 5 has certainly brought out some interesting specimens.

A 13 year old skater-chick came in who had fallen 4 hours previously.  Her douche-tard father CALLED 911 to get the phone number of the ER to see if we were open.  "Dad....that was really stupid.  You could have just Googled the phone number from your phone".   Couldn't have been his natural child as she had an abundance of native intelligence.

The usual Friday / Saturday night morphine-seeking migraine came in at her usual hour before closing.

Me: "Jeez, she's here every weekend.  Doesn't she have something better to do on a Saturday night?  Couldn't she just go to a movie if she's bored?"
Kate:  "Why not just have a fu*king Margarita and call it a night?"
Me: "Cinco de Migraine is celebrated with morphine apparently".
Gil:  "She's been overusing, I've seen her the last 4 out of 6 weekends"
Me: "That's only because you were off two of those weekends"
Gil: "Well, she can have her neurologist write a letter.  She's shut off"

From the "Your Doctor Lied to You to Get You to Come to the ER" files:
Woman: "Yeah, I called my doctor and was told to come in to get my liver checked, hee hee"
Me: "Why?"
Woman: "I took a few too many Tylenol, and she said it might damage my liver, so I should have some blood drawn (snicker)"
She had taken 25 tablets of Tylenol, 500 mg each 26 hours previously.  No, you don't get your blood checked and then get to go home, you are now at serious risk for liver failure and / or death.  Guess what?  Tylenol overdose is not funny.  You get admitted to the ICU with a 1:1 suicide watch.  I wish people would understand that just because you can buy something over the counter, or is "natural", or "organic" does NOT mean it is harmless. The antidote for Tylenol overdose is drinking a butt-load of liquid that smells like rotten eggs without puking, and pray that your liver makes it through.  The medic that transferred my patient noted "she was really sad" on the way to her hospital bed.  "Well, I was pretty clear that this was a very serious thing; when she came in she was all giggly and acting like it was no big deal".    
I have seen this lady several times because she is also diabetic (on oral meds) and occasionally runs out of, fails to take or forgets to take, doesn't pick up her prescription, etc, etc then comes in with nausea and DKA, haha isn't that so silly of me.  I think she really stepped in it this time.

A 52 year old man came in with toothache for 2 months and stated he had a "Dental Emergency".
Emergency?  Nope.  Dumber than a bag of hammers.

A 20-something female in excess of 300 pounds came in with nasal congestion.  "Any medications?" I asked.  "Only pre-natal vitamins", she replied.  Oh.  So you're pregnant, I...oh, never mind.  WTF, Gil?  You want me to find the fetal heart rate?  Yeah, not my best skill in the best of circumstances I would rather put an IV in an infant, but the patient was understanding.  Yes, I did find it.  Eventually.

"Cholera" was the diagnosis for an individual who had come in with an ankle injury.  Ooops.  Slight coding error.

On the subject of "My Doctor Told Me....Go to the ER":
I just don't really care.  Tell me the reason why you called your doctor, and give me the abridged version. I don't have time to listen to "Well, it all started in 1997, on a lovely spring day, I think it was a Wednesday".  I will interrupt and ask pointed questions.  I'm good at that.