Livin' the Dream

Often I  find it necessary to take two deep breaths and force a cordial expression on my face even when I have just had a vacation.  I am seeing way too many of the same faces again and again for absolutely silly reasons, merrily abusing the system. There are just too many taking the a free ride with their "hurray for me, f*ck you" attitudes.  Yes they have a primary care; they just don't want to be inconvenienced.

One of the free-riders is the wife of a narcotic seeking douche bag who is now living with his mother.   Or in jail or some sh*t.  She has an alliterative, cutesy name so I will just call her Betty Buttz.  Betty comes in to the ER regularly enough for me to know all her information and her kids by name for just stupid reasons at LEAST twice a week.  She can be counted on to come in on Thursday or Friday with nebulous injury or pain and is seeking a work note, AKA "Get Out of Jail Free Card" for the weekend.  She works maybe 8 hours per week at the most at a $1 store.  If she has a medical issue such as sore throat, rash or dental pain (often) she can be counted on for two or three additional visits for changes in antibiotics and additional "Get Out of Jail Free Cards for Condition XX, Not Magically Better".  She also regularly asks for refills for "stress and anxiety" medications.  She doesn't ever get them, but that doesn't prevent Betty from asking.

Betty's birth control poster children are also seen frequently.  They are easily the most klutzy, uncoordinated kids on the planet as mom's answer to every bump, bruise, ache and pain is to squeeze her fat free-care ass into her car and transport the kids to the ER.  I think the school office is wall-papered with her kid's "Get Out of Gym Free" notices.  These kids are obese and could use a little physical education.  Last time one of the kids had a 3 or 4 day old knee boo-boo I refused to give out another pair of  crutches because I know I have personally given out at least 2 sets to everyone in the family.  Unless they are using them to hold up the walls of their double-wide, they can reuse a pair.

As if these bi-and tri-weekly visits didn't suck enough empathy out of me, Betty Buttz has started to accompany Crayzee Cutter Friend as a mouthpiece / advocate for her regular field trips to the ER for her self-inflicted suture-requiring transfer-to-tertiary-care-psych-eval.  Crayzee Cutter Friend's medical history, multiple allergies and psych meds are also well known to me.  Betty Buttz is always helpful during Crayzee Cutter Friend's visits by routinely updating her Facebook status and texting their numerous friends and family who also never accompany her to the ER.

Crayzee Cutter Friend predictably gets a ride by Big Taxi with the Flashy Lights (again) to a complimentary psych evaluation (again) so Betty is pretty much at loose ends for the rest of the night (again).

"Where are the kids today, Betty?" I asked conversationally, like I cared.  Probably off playing in dumpsters and inhaling toxic fumes judging from their usual choice of activities.

"With their father".

"Isn't it nice you have an evening out?", I observed brightly.

Betty took the opportunity, as long as she was there, to get herself checked out in the ER (again).

Call a Toe Truck Please

Ms. Toe Fetish was in for her 3rd visit of the week for a toe infection; she had been seen about 5 other times in the past year for problems with every part of her body from the ankles down.  See, she has this thing about messing with her feet, picks at them, cuts skin, monkeys with them in weird ways.  She was all drama and har har about how disgusting it was, and how much it hurt, and how much "trouble" she was going to be in for not following pretty much any of her discharge instructions.
"It hurts really bad, it looks gross.  I can't bear to look at it"

For all her penchant for picking at her peds, I don't think she had washed it since last time she was in the ER, nor had she cleaned and dress it as instructed.  Her foot was filthy, and I mean disgustingly filthy.  I'm talking walk in mud, then step in an oil spill, then run through newly cut grass that smells like seaweed.   How much trouble is it to actually soak you foot in a basin of water?  She had on the same flaky old black nail polish on as well.  Ack.

She was also told to wear actual shoes, which she also did not do. She did, however, have plenty of time to take photos of it and send it to her friends.  Double ack.

"Is it the same doctor?  If it is he's going to yell at me, haha.  I hope it's not the same doctor (who by the way, didn't give her any narcotics).  Oh good, it isn't the same doctor.  Am I going to get a needle?  I'm really scared of needles.  Did I mention that this is really the most pain I've ever had in my life?  If most people say their worst pain is 10/10, then my pain has to be at least a 15 and maybe even 20/10" (also note she had about 6 piercings and 2 full sleeves of tattoos).

Really?  I had a sick baby to transfer so I sat her fat ass in the waiting room along with another lady who "just took Phenergan and it makes me sleepy so I need to have my microscopic laceration seen as soon as possible because I drove myself", which guaranteed that it would be at least 90 minutes, sorry.

When Ms. Toe Fetish was eventually seen (Phenergan lady left in a huff; it doesn't help to cop an attitude with the staff) she had the inevitable injection in her toe.  She went on for some time about that, actually getting up off of her bed of exquisite pain and opening the door to the room so we could hear her predict how painful it was going to be later.  "Yeah, this is really going to hurt later, huh?", "I can almost feel how bad this is going to be when the shot wears off", "This hurt before the shot, it is going to be twice as painful when it wears off I'll bet".

She proceeded to ignore the actual discharge instructions and reinvent them.

"Now, I should come right back if it hurts and to have the dressing changed tomorrow, right?"

Sherry: "Oh, no.  You don't have to come back, there's no need.  Just soak it, wear shoes, put a bandaid on tomorrow and have your own doctor see it.  Remember that soap and water are you friends, please take this complimentary basin home".  Like it says in the instructions that we have so nicely written out for you at a 6th grade reading level.  Sherry always sounds so nice when she gives people the hard truth.

Nursing Manglement

Nursing: a career in which the more education one receives, the less likely one is to actually know how to do the job.

I thought when I got my degree I would "get" why nurses in management were such dicks to non-management nurses, the nurses who are on the front lines and caring for patients, the nurses who get dumped on with ever-increasing paper work and bullish*t.

Guess what.  My expensive high quality education has ill-prepared me for insightful revelations into the though processes of management: I don't get it.

There seems to be several types of nursing management that I have had the dubious pleasure to work with:

1.  Did the job for a long time.  Can't do it now, but respects nurses who do; does whatever possible to make  the job run more smoothly.

My most-favorite boss/leadership mentor of all time was my manager in a big ER where I was a clinical leader.  She gave me the best advice ever: listen.  Sometimes it's the only thing you can do.  The second best piece of advice was one she often used, offer "What can I do to help?" She did actual nursing for some portion of almost every day, even if it was only holding a kid long enough for someone to stick an IV in.  This is a nurse who not only had all my respect, but someone whose respect I wanted in return.

2.  Has limited clinical experience. Has lots of education.  Couldn't do the job terribly well and now can't do the job at all.  Ineffective.
At one hospital, some upper management brainiac decided to promote the horrible ICU nurse manager and make her ER nurse manager as well.  Great idea.   All the ICU nurses hated her.  She didn't know a balloon pump from a water balloon.  She never worked a single shift in the ER and had no understanding of how ER nurses work.  Or how our department was run.  In fact that small hospital was the only place she had ever worked from the time she passed her boards.  Miserable human being, she was eventually canned because 10 people quit, including me.

3. RN with an MBA.
If you are going to run with the big dogs, and all that.  Yes, she dealt effectively with upper management so probably didn't spend much time with bullsh*t nursing theory classes, of which I swear I will never take another the rest of my life.  What good is nursing theory when it ill prepares a manager to deal with other managers?  This boss said every day she could not do our job clinically, although she was lavish with praise for jobs well done, as well as a bang-up customer service rep.  However, the only time I ever actually saw her was if there was a problem.  She was great for committees.  Have a suggestion or an idea?  "Great!  Get a committee together and let me know what you come up with!"  Shared governance really just means "let's have a meeting or 10 about that.  Then, management will do whatever they wanted to do anyway".

4.  The hands-on clinical leader vs. the hands-off clinical leader.
This type of boss may or may not have the education.  They are really good at either doing the job OR sitting on his/her ass and delegating.  Being a clinical leader is definitely the type of job that can be characterized as "Lead, Follow, or Get the Hell Out of My Way".  Clinical nurses can tell in about 5 minutes which ones are lazy and which ones support the nurses they work with by actually helping; some examples are supporting their staff by yelling at the floors to take patients, or bullying the nursing supervisors to get off their asses and have THEM yell at the floors to take patients.  They have little tolerance for lazy nurses and just don't put up with nurses who insist on riding the LNA's like My Little Ponies while they put their feet up and update their Facebook status.  My favorites love to put out fires; my least favorites run through the ward screaming "FIRE!" while it just gets hotter and the flames spread.

The Dreaded

A 25 year old female came in with her husband.  She was 26 weeks pregnant with her first child and had been ill with a viral illness for 3 days.  She had not felt her baby move for 12 hours.  Go directly to the nearest ER if you are too scared to monitor this yourself at home per OB on-call; we are too busy in labor and delivery.

Ah, geeze.  Why do they come to my ER with no ultrasound available at night?  I. Do. NOT. Like. Pregnancy. Related. Stuff.......Seriously, it gives me agita.

"OK.  I am going to listen to your baby's heartbeat.  This is not my best skill because I don't do it all the time, so PLEASE don't be scared if I don't find it right away, mmmm-kay?"

EDNurseasauras goops up the wand, places Doppler on mom's belly and gets......

Beep!  Beep!  Beep!  Beep!  Beep!  I know with absolute certainty that it is neither the mother's pulse nor mine.

"There it is, your baby's heartbeat!", I say with relief.

Mom: "Oh, thank you, thank you, thank you! I was so scared!"

Me too, sweetie.  Me too.

Lunatic Fringe, I Know You're Out There

"Oh, I know her", Ellen whispered as the patient was ushered into a treatment room.  "I think she moved away, I hope she hasn't moved back.  She hasn't been here for YEARS, but she used to come in alllllllll the time for a bunch of things and it always had to do with pain everywhere.  She never shuts up.  And.  She looks awful"

More like 8 miles bad road.

"She is 3 years younger than me!", whispered Partner in Crime.  She was mid-50's and looked 70.  

It was Crayzee Dog Lady, allergic to 17 different meds including oxycontin, nsaids, several different anti-seizure meds, 3 different kinds of band-aids.  I gave up on an allergy bracelet.  Her med list was horrific.  CDL clearly relished her role as Medical Mystery and of course being Chronically Sicker Than Anyone Else on the Planet, having the World's Worst Case of Everything Puzzling Under the Sun.

To make a long story short, she wanted pain meds for her excruciating rib pain.  Seems her Emotional Companion Dog in Training, an enormous 8 month old Doberman over whom she had absolutely no control, had pulled her down.  See, this is the reason why you need to actually TRAIN dogs.

CDL had an x-ray (negative) and moaned and groaned in her room while we waited for records from her latest admission at another hospital.  When she wasn't in an out of her room informing us how sick she was and how much she seems to enjoy talking about herself and her maladies, her own favorite subject and bestest hobby.  She was eventually given a dose of Vicodin with the stipulation that she get a ride home.

"Oh, my friends are on their way from Walmart.  It shouldn't be long"

45 minutes later no sign of the friends.  "There must be a lot of traffic", she said.  Not on Sunday night.

"She's waiting for us to turn our backs so she can scarper out the door", I said.  We are wise to that.

"She probably takes about 1,000 mg of oxy's a day, but we're still liable if she hits someone", said Partner in Crime.

Eventually CDL stated she was going out to the car to let the dog out.  WTF.

"Don't drive", I called as she walked out the door.  I should have just let her leave.

She brought the dog in to the ER.  With all of her pain.  A ginormous doberman.  The American's With Disabilities Act has some specific guidelines for what is and is not considered a service dog.  An untrained doberman?  Not so much and do I have to balls to tell her to get out?  Nope.  Because that would be considered insensitive, right?  Would my employer back me up?  Hell no.

"You need to keep that door shut".  Banging, clanging, dog whining, CDL yelling "heel!  heel!"

Eventually three genetically challenged looking individuals arrive.  "You can take her home, right now".

One of the  more intelligent looking said ominously, "We have to talk to her".

I waited exactly 45 seconds then banged on the door.

The Three Amigos were standing around watching this woman with excruciating, severe, debilitating pain bent over and mopping up the floor.  The sheet was off the bed.  The dog was actually ON the bed, placidly watching the sideshow.

"Please tell me that dog did not have an accident in my treatment room", I said icily.

"Fluffy knocked over my soda can!  It was an accident!  He's just so busy!"

Me: "You all need to leave.  Right now.  I have to get my housekeeper to completely decontaminate this room"

CDL: "We haven't worked out the details of how to get......"

Me: "I mean it.  You all need to leave immediately, this is just plain rude.  Take the dog and all of you settle this outside.  This is not fair to the next patient who needs this room."

CDL: "But I....."

Me: "Go.  Now."

Off they went.  I felt badly for the poor little housekeeper who said there was soda everywhere.

This just frosts my a$$.  Legitimate service dogs are needed by individuals with disabilities.  Lovely well trained service dogs.  What happens to all these great service dogs if this kind of shit is allowed to go on because crazy people declare that their untrained mutts wearing tutu's and Laker's jackets are necessary for their emotional support?  I heard of one guy who's service animal was mauled by what was actually simply a pet that went unchallenged in a store.  Now he has an injured and emotionally destroyed and useless service dog because someone decided the rules did not apply.  Does this make any sense?

More Fun with Drug Seekers

Another busy night with the oh-so-wonderful Bobo was the usual  freak show.  We gave out 30 Percocet because certainly every single pain deserves to go home with at least four pills.  Right.  That was dental pain, chronic back pain, and various atraumatic aches and pains.  What a tool.  I had to get in his face and advocate for narcotics for a patient with a bad wrist fracture who really needed them; then she said she hated that stuff and wouldn't take anything stronger than ibuprofen unless she really, really couldn't stand it.  Sheesh.

I had to retrieve Drama Mama from the parking lot.  She had been hit by a car, having been standing in front of it when it accelerated. Three hours prior to arrival.  She arrived by private car without swelling, bruising or a mark on her.  "I can't stand up!"

 I won't go into the booooooooring detail here, but let's just say the mechanism of injury, while consistent with the degree of 20/10 pain the patient stated she was experiencing, was not evident in the exam.  In other words, she had pain everywhere but not so much as a ding.  And then there was the healing abcess on her forearm and that history of IV drug use that she denied and said it was from a fish hook.  She was so high on the last 2 visits that forgot her own story.

It seems the Dilaudid train had left the station without her.  She had been getting daily wound checks/packing/IV antibiotics (of COURSE she was not sent home with an IV, duh!) and multiple doses of narcotics at each visit because of her histrionics. Bobo, to his credit, was not convinced with Drama Mama's appallingly sub-standard over-the-top acting.  Apparently yelling about your pain (between cell phone calls to yell to yell to friends and family about life-threatening pain) is considered to be the ultimate test of veracity.

Bobo: Don't put an IV in her
Me: Duh
Bobo: Just go ahead and give her 1mg of Dilaudid IM

Drama Mama got her shot; moaning, sobbing,crying (without tears of course) she managed to very calmly ask me what side she should roll over to and then EFFORTLESSLY proceed to do so.

Eight minutes later she was on the call bell yelling hysterically: "It's not working!  I need more medicine!"
Me: "It will take a little longer than eight minutes to work.  But I'll tell the doctor"

Bobo was informed, at the 10 minute mark when he was done with...whatever he was doing, that I had given the shot exactly 10 minutes previously and she was refusing an x-ray until she gets more medicine.

He told her nothing more and that she needed to give it 30 minutes.

Ding!  On the call bell again (which, but the way, she had to get out of bed to retrieve because I failed to give it to her bad nurse that I am).  "As long as I have to wait a half hour I might as well have an x-ray"

Me: "Peachy!"

She managed to get another 1/2 mg Dilaudid out of Bobo before even he got tired of her and kicked her to the curb.  Drama Mama walked excruciatingly slowly with her enabler/handler/boyfriend twice her age to the doorway, yelling at him the whole time to "hold me up!", accompanied by much moaning, sighing, wailing and gnashing of teeth.

End of story?

Nope.

She was in the next day as I came to work, same complaint except this time she had embellished her story and added theft of her daughter's back pack and some oxycontin's, and that she had tried to stop them from taking the vicodin we had prescribed the night before by standing in front of the vehicle.  Not realizing the lie that she was hit by the car BEFORE she came to the ER.

And we didn't prescribe any vicodin.

Which proves that time travel IS NOT possible!

Fifty Shades of Drunk

Patients frequently walk unknowingly into the ambulance bay door instead of the main ER door even though it has a big-a$$ sign on it that says AMBULANCE on it.  This is right in the middle of the department work area so immediately all eyes are upon thee. It is like walking directly onto a brightly lit  stage.  Spotlight!

A couple walked in center stage, and the woman, realizing that she was on stage immediately put her hand to her head.  She had apparently passed out cold when she went outside to smoke a cigarette while out to dinner with spouse and friends.  She fell into a puddle as it was raining.

"I think it might be an allergic reaction"

She "didn't have much to drink...maybe it was the lobster mac and cheese.  My father is allergic to lobster".

"Not much to drink", it transpires, consisted of  6 beers and 2 margaritas over the course of the evening.

The woman asked if we would be testing her for lobster allergy.  Um, no.  You need an allergist for that, it's not an emergency.  She also continued to tell us that she doesn't drink much (not since they invented the funnel, ba-dum chhhhhh!), has a respectable job, children, responsibilities, etc, etc.  She was not an alcoholic.

And thus the middle aged couple continued to speculate, while the woman was rehydrated, that the cause of her syncopal episode was allergy (possibly), dehydration (quite likely), encephalitis, meningitis (improbable), or heart related (ruled out).

There was NO WAY it could be related to alcohol related since she just didn't have that much to drink.

Defying Gravity

I worried about this guy.  IV drug user; hugely swollen and red arm, an abscess gone completely haywire, and it looked like it had been going on for awhile.  He was promptly triaged and placed in a room, the dirty used ace bandage unwrapped.  The smell was horrible.  He looked sick.

He left without being seen, scampering unnoticed out of the department after about 10 minutes on the premise of using the rest room.  Home number disconnected.  Police well-being check turned up an abandoned house.

Some people don't merely fall through the cracks: they plummet.  Perpetual free-fall.