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.