Friday, December 16, 2016

Why we're depressed

I brought a patient in from triage and gave her to one of the Kids on the medical side.  "This woman is the prototype  for Debbie Downer and Eeyore".

"Tell me".

"Every question leads to a tale of sorrow and woe.  Ask her any question.  Anything.  It will be the worst thing that has ever happened to anyone.  Ask about allergies?  I get a list of 20, and I had to hear about Every.  Single.  Reaction.  Each reaction lead to another set of complications.  Each complication to a debilitating condition.  Each condition to an endless series of Unfortunate Events.  And then there was a fire in which all of her oxycodone was burnt up.  It took me 39 minutes to triage her.  I feel like all the joy has been sucked out of me and all the fairies are dead. "

"So you're saying I'll never smile again.  Damn"

Thursday, November 17, 2016

Most days the ER is chock full of frail elders accompanied by family members whose mission is never, ever to let their  mom or dad die.  Nobody wants to say goodbye to a parent.

Even if it means doing unspeakable things to keep them alive.

To be clear, "alive" is not the same as "living".  Something everyone should think about.

So it was cool to have 91 year old ex nurse as a patient with all of her marbles, a sense of humor, and a cool daughter who was happy to let me be her mom's nurse.

Over 70 years ago (SEVENTY!) she went entered "nurses training" as it was called.  Now, nurses are "educated".  Think about that while you and ponder why endless courses in nursing theory is absolutely relevant to caring for patients.

There were some surprising similarities in our history.

 "I worked as a secretary for a couple of years, then got bored.  If I had gone straight out of high school,  I would have been finished with my training in time to serve in the War in some way, but it was over before I finished."

My plan was to finish nursing school and join the military (Navy was my preference), and go to Vietnam.  The war ended in my first year of school.

"I worked in a Veteran's hospital for awhile.  Those guys worked really hard to get themselves on track.  It wasn't easy".

I worked in a rehab right out of school.  Then I married a Vietnam veteran

"Of course when we were in school, it was the students who staffed the night shift.  There was no way they could have functioned without students.  God I hated night shift"

Me too.  As a student I worked as an aide at night, or "sat" as a private duty.  I could study or read while rich geriatric patients slept.  The night nurses were all young and mostly new grads.  They were cool.  They warned the students when the dreaded night supe was near.  She was mean.

"The only thing I never, ever wanted to do was work in maternity.  All those screaming women, vaginas and crying babies, no thanks"

My sentiments exactly.

I helped her up to the commode.  When she was ready, I rearranged her things that so that she could get back into bed. "Wait, I have to put on these godawful granny panties".  Note that they were granny panties, not Depends.  I loved her.

Of course many of these older adults are quite funny. I had another 90-year-old who, after being transported for being lethargic (note: she had already been given her nighttime medicines including sleeping pills)  suddenly awoke and demanded food. "What is there to eat around here?" She asked .

Me:  "well I can go and look and see what there is in there kitchenette. I might be able to find you some pudding".

Granny:  "Pudding??! Pudding is not a friggin  meal!"

Run for it, Marty!

One of our docs is deadly slow.  He has one speed.  He cannot be rushed.  He cannot be compelled to move at any other pace than that which he sets for himself.  There is no emergency that cannot be handled at a steady rate.  I have never heard him raise his voice, become rattled, sweat, bark at staff, or handle any issue without careful thought and consideration.

We do a lot of protocols when its busy anyway, even more when Dr. Glacier on.  Although you gotta love him, he is brilliant, loves to teach (be it medicine related or any one of millions of interesting factoids).  His lack of speed is not the most admirable quality when the patients are piling up.  The other docs kind of resent this practice and have a tendency not to pick up charts as quickly when one of their number is seen as not pulling their weight.  Thus resulting in a lot of waiting as the charts are racked.

Auntie is particularly annoyed by this.  As the resource/charge she becomes frustrated when departmental flow is at a standstill and dispositions grind to a halt.

Auntie directed yet another ambulance to park their haul to a hallway bed for the third time in 10 minutes.

"If he moved any slower he'd be moving backwards!", she fumed.

Which is what makes time travel possible.

Wednesday, November 16, 2016

Help me. Please.

I love the front desk clerks.  They are really good about alerting the triage nurse about which patients have checked in with chest pain, shortness of breath, or who "just don't look good".  They are also really good at pegging the drama queens such a those who drape themselves over the desk panting and moaning.   The clerks have a supply of surgical masks to offer the rudely coughing public as well as Lysol wipes.  I don't really blame them for wanting these patients out of their work area expeditiously.  I don't want them in my work area, either.

They are also really good at deflecting the Perpetual Complainers.  I never mind when they tell people "I'll have the nurse speak to you".  But mostly they can handle things quite well.

They see all, and know many of the repeat offenders who cause problems.  They quietly alert our Security team that they may want to "stand by", just to have a presence.  Or the police.

But once in awhile someone is manning the desk who has little experience or is just a tad clueless.  Or both.

Eva.  Sigh.

Eva will interrupt ongoing triage assessments, EKG's and private conversations for anything, no matter how mundane.  Chest pain?  Yes, interrupt me.  Shortness of breath?  Absolutely interrupt me.  Can I get a blanket/water/cab voucher for the lady in the wheelchair?  Hell no.  Not now, dear.

The other day Eva froze solid when I asked her to call a help alert and security for a patient who was "unconscious and not breathing" in a car.  "And call out back for some Narcan", I called as I went out to save another life.

Help didn't come for a couple of minutes.  Waiting.  No help alert.  Just me and the cyanotic  unresponsive patient and the female in the back seat who was helpfully filming the entire experience on her cell phone. As I held open his airway the driver of the car, who claimed he just found him unresponsive and didn't know him, helpfully urged me to "just get him out of the damned car, bitch!"  Security was busy putting yet another out of control, dangerous psychotic patient in four-point restraints.  "Narcan!" I hollered to my co-worker who was pushing a stretcher up the incline.    I recognized the patient from a previous appointment with death 3 days before, also miraculously saved by interventional Narcan.

Eva and I had a little discussion about what was meant by a help alert, and NARCAN.

"I just thought you meant I should call back and get you some help. I didn't know I was supposed to tell them someone had stopped breathing.  And I asked for someone named something-Ann, but. They didn't know what I was talking about because Ann doesn't come in til later".

Sigh.  On the plus side the patient lived, his Appointment with the Reaper postponed. For now.

Tuesday, November 15, 2016

The cost of doing business across unit lines

Another Friday afternoon, another adolescent  psych patient who had made controversial statements in school and was promptly sent to the ER for evaluation.  Friday's are a bad time to come to the ER for a psychiatric evaluation.  It was likely that this young patient would be spending the weekend in the boring ER, eating pudding with a cardboard spoon, watching boring TV, and not allowed to use the cell phone.  I am of the opinion that school counselors should not be allowed to see students on Friday afternoons.  My independent anecdotal study points to Friday afternoon as prime time for making regrettable statements resulting in ER visits.

The ER is a bad place for kids on weekends as we are overflowing with acting out professional psych patients, intoxicated individuals who have fallen off bar stools, and plain dangerous people.  It is not all that safe for staff.  So quiet adolescents get quite an education and maybe not so much attention.

I sent the tech in to get vital signs on this kid, a skinny 15 year old.  The tech seemed unconcerned that the BP was 66/28.  She shrugged, "I took it three times, so...."

I went in search of the appropriately sized cuff.  Nothing.  Not a single correctly sized cuff in the entire department.  I trudged up to pedi to beg for one.

Anne is the night charge on pedi and is known to be territorial.  I get that she needs to keep track of pedi belongings, but sheesh.  She came within inches of requesting a criminal background check for me to "borrow" the necessary hospital equipmet to properly care for a patient would have been on her unit had they the staff to do the necessary safety 1:1 psych watch.

I returned to the ER with the BP cuff, now 15 minutes past my quitting time, and gave report to one the kids on nights.  I handed her the cuff and asked if she would please go in and take the BP that I was quite sure wasn't in the toilet.

"Anne gave this to me.  I had to fill out an application and give her one of my kidneys, my cell phone number, and promise my first born child.  She asked which nurse would be taking over care of the patient, including last name.  I am trusting that this will be returned to pedi undamaged".

Then, trusting soul that I am, I brought it back myself.  The day nurses can give up one of their kidneys.  Or kids.

Thursday, October 27, 2016

On evaluations and raises

I continue to work about four hours a month per diem back at Ye Olde Medde Center.  They would like me to work more, but….no.  It is different now.  Most of the same people, but with just enough….differentness to make it not a place to really want to call home.  And not to be too literal, but the place was torn down and rebuilt.  Just saying.  So I continue to fill in quite casually for staff meetings, an occasional sick call, or cover a couple of hours so someone can have an evening or afternoon off.  Hey, it's urgent care, not too much stress, 911 is on speed dial and nurses don't even have to call the mother ship anymore.  The provider does that.  Mostly I just like to stay connected with some of the old team and get gossip about the mother ship.  The galactically inefficiently run mother ship.

Sherry had my annual review ready on my most recent short shift.  Insert eye roll.

Ah, the review.  Invented by corporate clipboards to say as much nothing as possible on a random performance grid based on nothing that has anything to do with the actual ability to perform the job.  Made up by people who can't DO your job.  For a 2 cent raise if you're lucky.

 I just don't play the game anymore.  Setting personal goals, peer reviews, doing my own evaluation….I just say no to any of it.  You're the boss, you get paid the big bucks, YOU do my evaluation.  I really don't need this job, and you can stick the 2 cent raise.   My only goal is to make it to retirement in way less than 4 years, alive and in good health.

This requisite "discussion" of my job performance was pure theater:

Sherry: "Well, your review is excellent as usual, but I'm sorry to say there are no raises this year"
Me: (feigning surprise, horror, incredulity) "Seriously?  Even with all the recent layoffs of upper and middle management?!".
Sherry: (feigning administrator persona)  "No, sorry.  Across the board, no raises"
Me: "Strong motivation for improving morale, wonder why more institutions haven't thought of it.  Not even a pizza party?"
Sherry: (shifts in her seat and changes subject) "So, I have nothing but good things to say, but need one or two things from you.  Do you have any goals, educationally or professionally?"
Me: (pretending to think it over): "Nope"
Sherry: "You don't make it easy".
Me: (grinning) "You are a terrible manager, you take way too many vacations, and you let people push you around.  You are an outstanding clinical nurse, I hope they make the Kool-Aid delicious for you".
Sherry: (defeated) "OK.  I'm just going to write that you "contribute to keep staff up to date regarding ER trends"

What a laugh.  I keep them updated, alright.

As an urgent care, the Medde Center no longer sees the horror.  No gunshot victims, no stabbings, no SIDS babies.  No dangerous psychiatric patients or drunks.  Yet they appear to enjoy living vicariously through me for same, and beg for stories when I spend time there.  And I guess consider themselves lucky not to have to deal with any of it even though it really is pretty boring there, not even an interesting SVT to fix from time to time.  Not like the old days when it was an ER and they came actually brought ambulances with codes that sometimes survived, and traumas that needed helicopters.  Good times.

The annual  reviews at Pseudocity....that was different.  I put a scant amount of effort into my review there as it is a job I need, although I still say no to goals.  And we did get raises this year.  I thought it was an across the board 3%, but discovered accidentally that it was not.  Lazy Nurse announced a 2% raise.  I wisely kept silent, although the Karma Monitor in my brain was loudly applauding and whistling.

Monday, June 20, 2016

Take a breath


If you can say the following sentence:

"OMG I am so short of breath it's been going on for days I just haven't had the time to contact my doctor about it so I decided now would be a good time but I had to get my kids a snack after I picked them up at school and on the way over and an iced coffee in case it was going to be a long wait JARRED GET OFF THAT CHAIR AND HOLD ON TO YOUR SISTER,  DARREL PUT YOUR SHOES BACK ON TOYA DON'T PUT YOUR FRENCH FRIES ON THE FLOOR and then I forgot my my phone charger do you have one because the kids used up all my battery how long is this going to take?"

you are not short of breath.

Thank you.

Friday, April 22, 2016

Ambulance patch of the day

"……72 year old patient with history of Ebola….".  

I exchanged a dubious look with my partner.

"Wait for it",  I said.

"Correction.  Pt has a history of ecoli".

I love those guys.

Friday, April 15, 2016

New girl in town

There have been a lot of nurses hired in the last couple of years who have the same first initial.  Frankly, I have found it difficult to keep all the kids straight.  Maura, Mary, Merry, Maisie, Mac, Myra.    But they are a good bunch of ER nurses, smart and young they are.  We dinosaurs are still in the fight, but less prevalent on the off shifts which I prefer to work as the others have gone on to work  day shift.  So it's me and the "kids", 20 somethings to 40.  

Several months ago Susan was hired, with lots of experience.  She is around my age and has a similar haircut and glasses.  Lots of people have been getting us confused.  Which is disheartening since she outweighs me by a good 30 pounds.

One night at least 4 people in one hour, notably all the social workers with the psych patents, approached and started rattling off info about their oh-so-important revolving door suicidals and acting out teenagers.  "Nope", I said.  You want Susan.  I'm Regina".  Off they toddle to find her.  No, I don't know where she is.  With a medical patient most likely and not fixing a meal tray for your entitled douche bag who lacks coping skills.  

Marge is a social worker without any adult social skills, I have no idea how she keeps her job.  She barges in on any conversation and actively seeks out nurses in patient rooms in order to do some sort of emergent phone retrieval, take orders from a psychiatrist, or call report RIGHT NOW to the receiving psych facility.  Doesn't matter if you are in the middle of a code or mixing meds.  
She annoys the shit out of me.

Therefore, when she started to rattle of the latest  ridiculous needs demands for her critically ill attention seeking revolving door suicidal pt, I simply put my hand up in a "stop" gesture.

"Marge", I said. "I am Regina, you want Susan.  She is the other red-headed middle aged fat white woman wearing glasses on the floor tonight".

She spluttered, turned red, and walked away.  

Really it's not that hard. We have ID badges the size of dinner plates at chest level.  

Wednesday, March 9, 2016

Dear patient who went to the Urgent Care..

…because you have had chest pains for days and your doctor told you to go to the ER.

During your stopover the Urgent Care you had an EKG which was proclaimed "fine", whereupon you were instructed to go to the the actual ER (us) "for further testing".  You arrived by private motor conveyance, which by all accounts does not qualify as an ambulance thus indicating that you did not require advanced life support or monitoring.  I understand that this particular urgent care DID offer you an ambulance as a precaution, which you vehemently refused.

Just so we are clear, you are not, at present, having a heart attack, based on the EKG I completed in the triage area.  That is our policy.  An EKG done outside the hospital in a doctor's office or urgent care center we don't trust (pretty much all of them) gets an EKG.  Sorry, policy.  Also, the urgent care should know to tell you (but apparently doesn't) to leave all those little stickers on your chest.  This would be important in order to compare any subsequent EKG's.  But you took the time to take them off, so….moot point.

I fully understand that "chest pain is an emergency!", a fact that  has been ingrained into every cell in my body and seared on what is left of my soul for the last 40 years.  Please understand that head trauma, stroke, and hemorrhage are also emergencies, and the patients who are experiencing them have arrived in an ambulance through the back door in the last 15 minutes.  Please note the onset of their symptoms was not days and days ago.   There are also 4 other chest paineurs ahead of you, as well as several others who are experiencing other serious symptoms that also deserve immediate care.

I will listen politely to your ranting and threats to call my boss, but please refrain from haranguing my front desk clerk.  She is busy assisting other patients and has wasted enough of her time dealing with your nonsense.  Shortly,  I will be happy to check your vital signs again and reassess you.  While you sit in the waiting room until a bed is available in the ER, I will have your blood drawn for cardiac markers, and, following our protocol, and have alerted my resource that you are here.   However, you have arrived at a very busy time.   I can not create a bed where non exists.  I can assure you, based on the assessment of my physician, that you are not presently having a life-threatening emergency, and we will get to you as soon as we possibly can.

As an aside, no, I have no interest in speaking to your doctor, but I know that my charge nurse did.  He most certainly did not tell her to "get you in to a damn room right this minute".  The conversation between your doctor and the charge nurse went thus:

Doc: "Hi, I know that my patient Mr. X is there.  He is calling me from the waiting room, he's a bit of a pain.  Can I tell him that I called and spoke to you?"

Auntie: "Sure.  You can tell him there are 4 chest paineurs ahead of him, plus a trauma and a stroke.  He had a EKG, in fact 2 that are within normal limits.  He has labs pending.  It's gonna be awhile."

Doc: "I know you're busy and will get to him when you can.  Have a nice night, and I'll bring donuts next time I come in".

Auntie: "Sure, thanks for calling".

How I wish I could tell you that.  But, that is my burden to bear.

Now, please just take a deep breath and have a seat.  Waiting sucks, but patient patients are a virtue.
Thanks for your kind attention to this matter.


Tuesday, March 8, 2016

Man Baby, a cautionary tale

My latest needy patient, the dreaded Man Baby, reminded me of one of Hood Nurse's epic posts from a few years ago.  It is both hilarious and sadly true.  I miss Hood Nurse's regular posts, she is a badass.  You should go and read this, right now.

So, my patient, fat and bald and a self-professed wimp.  A man baby of the first order.  Clearly he did not do much for himself even on those banner days in which he was fit as a fiddle.  This was a middle aged man who had arrived by ambulance after vomiting once with a "high fever" of 99.5.   Wow.
 "I don't feeeeeeeeel goooooood", he whined

FYI, whining tops  my list of "Things I Hate".

 Mommy-wife enabler accompanied him, soothing his brow, holding his vomit bag (for him to spit in, for Man Baby never vomited), asking for warm wet washcloths to moisten his lips, and requesting juice, (no), crackers (hell no), extra blankets, and of course "one more thing to ask the doctor".  Plus she was a helicoptering monitor-watcher.   "Why is that monitor alarm going off!?  Is his blood pressure ok??  What is that number?? What's wrong???"

Well.  Here is the short list:
Mancold, manflu, man-monia (unlikely).

 Or a rare fatal disease (also unlikely).

Absent anything being found really wrong, I'm liking the all encompassing manvirus as the culprit.


You will get better, or you will die.  Going way out on a limb here, being a stupid nurse and whatnot, but guessing today is not going to be the second date (the one to the right of the dash) on your gravestone.

He was given the panacea for all ills when it is not politically correct to kick patients to the curb within 10 minutes of arrival:  IV fluids and Zofran.  In a 12 hour shift I will personally execute these lifesaving orders about 10 times.  That is just one nurse.  There are lots of others who will be saving lives many times over this shift, one bag of normal saline and 4 mg Zofran at a time.

He was there for a couple of hours, moaning, watching TV, texting on his phone, sending the little woman scurrying for ginger ale and ice, and arranging his other chargeable electronics.  He was pretty busy.  Eventually he was given the good news that he did, in fact, have a virus.  Since he had not vomited, his vitals were completely normal and was drinking  ginger ale, there was nothing more to be done for him.  Also, once a patient who presents with vomiting has asked for a meal tray, his status automatically defaults to "discharge pending".

He was shocked.  "I don't think I can go home like this".

Trust me, read your instructions,  "you will get better.  Drink lots of fluids, rest, take tylenol for headache and fever, here is a script for some Zofran.   Now get out and man up "

Mommy-wife will take really good care of you, maybe order out some Chinese.

Monday, March 7, 2016

On perfecting the art of hiding

When I am working in the biggest pod in my department, the one shared by three nurses, the nurse/patient ratio is generally less clear-cut.  A nurse could have a single trauma or STEMI patient and be bogged down, or five psych hold patients who are being watched by techs….which would mostly be an easy assignment.   Or two drunks who are sleeping.  Or three stable chest pain rule-outs but with nightmare families.   Or one soul-sucker (now in  restraints)  throwing chairs against the wall and threatening to slice off our heads with a sword.  Whatever.  The point is that some days you are the dog, some days the hydrant.  And when it is your turn to be the hydrant, you hope your teammates will remember what it was like and pitch in accordingly.

As ER staffing is a cyclical thing, we currently have  a lot of Freshman ER nurses.  I am mostly impressed with how quickly many of them have assimilated on the off-shift hours.  They jump in where needed, ask great questions, and in general are a hard working  bunch.  But of course, there is always that one.  Newish ER Nurse has moved up the food chain to sophomore-headed-into-junior-year level in terms of experience and how long she has worked there.  Yet, during the times when it is truly crazy, Newish Nurse remains seated.  Or in hiding.  Not getting the teamwork thing.

She has been renamed "Lazy Nurse"

She can generally be counted on to have the lightest assignment regardless of what is going on in the department.  Among her evasive maneuvers for keeping her work load light:

Never taking an ambulance patch and just taking responsibility for it it.  She just walks in the other direction.

She absolutely rides the medics and techs like a cheap ponies: IV starts, EKG's, transports, vital signs.  She gets them to do it all.

She never, ever volunteers for the next patient when it is her turn.  She remains silent when, as a group we are asked, "Who's up?"

There is always a selection of snack items and beverages in her work area which keeps her very busy.

Hiding in the med room.  On her cell phone.

Once the night medic was managing a septic patient all by herself until I jumped in to help her.  Not that she wasn't doing a great job, but where the fuck was the patient's nurse?  Lazy Nurse.  Nobody knows.  Having a nice chat with someone, or preparing a meal in the break room.

Lazy Nurse's laziness has not gone unnoticed.

Auntie, the clinical leader on shift, has started to keep score and actively seeks her out when she is "missing".  She has vowed that it would be "a very long time" before Newish ER Nurse would be having the triage assignment (which, by the way, is my second home) when many of the sophomore-junior nurses with at least a year in the department have progressed to being assigned there if is an experienced nurse to help out.  "She is just not motivated enough, not fast enough, and there would be a line out the door and down the block.   Disaster.  Nope".

Auntie is gunning for Lazy Nurse.  Shudder.  I wouldn't want to be in her shoes.

Tuesday, February 9, 2016

You know...

…it's bad enough that a female senior management member was wearing a backpack.

 I observed her  casually cruising the portable desserts in the cafeteria line on her way out after a long day of sitting in meetings, creating forms, and adding to the existing metric fuck ton of workload for clinical staff (although she lacks any ability to actually do any aspect of the job).  But it was what was on the backpack that just made me crazy:

All Who Wander Are Not Lost.


Monday, January 11, 2016

Rocket Man

EMS dropped off a LOL with late afternoon "weakness", the universal label for non-specific maladies  affecting frail elders who have been left to fend for themselves most of the day.  They are  found in their La-Z-boy recliners, where they have spent the afternoon sleeping, by family members returning home for the day in a state generally described as "confused", or "unresponsive".  Often they are "fatigued".  Usually they have numerous co-morbidities, a med list as long your arm, and have "not eaten all day".  Cue the turkey sandwich.

This particular day found me floating in the department without an assignment, helping out as necessary as Float Fairy (or Everybody's Bitch).  Floaters mostly do EKG's, triage ambulance patients, and transport patients to other departments or inpatient units.  Or start a lot of IV's.

The LOL was brought by paramedics I have known for a long time, who are experienced and known to be thorough.   As I had taken the radio patch,  I owned the patient until I could find the resource person to assign another nurse.  Every room in the department was full and we were on overflow hallway beds.  This is never good.

"OK to triage her in the hall?"  I asked.  Sure, no problem she's been stable enroute was the response.

Except she had a heart rate of 30.  THIRTY.  And hypotensive.

A monitored room was cleared immediately.

I thought the EKG looked tremendously weird.  I checked and rechecked my lead placement.  The elderly patient roused a bit.

She whispered, "Situs inverses".

Ah.  This is a very interesting condition in which the organs of the abdomen are backwards, and in this case a mirror image.  Cardio came right away.

I had done (and labeled correctly for posterity) an EKG done the right way, the reverse way, and another weird way that I can't even remember.

As I excitedly whirled to present the latest tracing to the taciturn cardio guy, I found that he had sidled right up next to me.  I hate a sidler, I really do.  My fist connected with his groin, and he doubled right over, being a small an somewhat frail individual as all brilliant people seem to be.

Ooof.  Had he been taller than me it would have been a glancing blow to the upper leg, but no.  I muttered an apology, he muttered "no worries", and we both continued on as if nothing happened.

Man, there are a lot of people I would pay to punch in the rockets, but he wasn't one of them.  I felt kinda bad.

After I laughed for about a half hour.

Saturday, January 9, 2016

Chicken Seizure Salad

BPOM told me:

 "I took that lady on the ambulance last Tuesday, we were called out for a unresponsive.  She was sitting in the car and said she thought she was going to have a seizure.  So, we transport her and on the way she started clucking like a chicken.  buck buck buck buck aback!!  Buck AAAch!!  BUCK AAAACK!!!!! While shaking her hands and arms.  After about 20 seconds of this, she stops, looks around calmly and asks, "What happened?"   "Well, you were clucking like a chicken".  "Oh, I had a seizure then.  I don't remember any of it".