....and to all, a good night

Christmas rerun while I wait for my Christmas Eve Chinese food.  

It all started on Christmas night.

It was pretty quiet; we were hanging out in the waiting room watching a very boring movie and chatting when I noticed that the ancient, chipped Nativity set on the small table next to me seemed somehow incomplete.

"Hey", I said to nobody in particular, " did this Nativity come with a Baby Jesus?".

Ellen sat bolt upright. "What?! You gotta be kidding me. I put that out myself! Maybe it fell on the floor?"

We searched around, but it was nowhere to be found. "It's really gone! Who would do that? Who would steal the Baby Jesus? Who would be that low?", said Ellen.

"Well, maybe someone just took it for a joke; you know, like those lawn ornament thingies?", suggested Mary.

"You mean garden gnomes; people would pose them in vacation spots and took pictures? Then they sent the people pictures of their gnomes on vacation?", I said.

"Yes, just like that. Maybe someone took Jesus on vacation", offered Mary.

“Why not?" I said, "to quote my daughter K: 'I like to think of Jesus as wearin’ a Tuxedo T-shirt, ‘cause it says,‘I want to be formal, but I’m here to party too.’"


"That is just terrible. I'm very upset about this", said Ellen in a huff.

I just think it is kind of ironic that someone took the very symbol of one of the most holy days of the Christian calendar from a religious hospital. But that wasn't the end of it, which brings me around to the Christmas decoration sweep over the weekend. Not only was the Baby Jesus MIA, but so was the Mary figurine.

Now Ellen is nearly apoplectic.

"Oh, more crime; what kind of person steals pieces of a Nativity scene. REALLY! People will stop at nothing these days, it is so sad."

“Dear Tiny Jesus, in your golden fleece diapers, with your curled-up, balled-up little fists pawin’ at the air…”

But wait! There's more. During the Christmas cleanup it was discovered that the nativity scene was also missing a farm animal.

Where has Donkey gone? Is he on vacation as well?

Donkey: Oh, man! Where do I begin? First there was the time the farmer traded me for some magic beans. I ain't never gotten over that. Then this fool went off and had a party, and they all starting trying to pin a tail on me. Then they all got drunk, and started hitting me with sticks, yelling "Piñata! Piñata!" What the hell is a piñata, anyway?

This news nearly puts poor Ellen over the edge until Chris from the lab offered an explanation.

"Oh, that. The head broke off, so since I couldn't find the head, I threw the rest of it away".

It is with some effort that I restrain myself from any comments regarding the business end of a donkey. And we have not as yet received any vacation photos, just saying.

Still, I was a little surprised at the lack of quality of the entire sorry set anyway, it should have been long retired. No manger, just a bunch of wise men, a donkey and the holy family sitting on a TV table in the waiting room. Not even in a place of honor.

When I actually put up a nativity set in my house when my kids were small, it went on top of the piano (which I also no longer have). It was the highlight of the Christmas decorating routine, with my kids placing the figures in various positions which were rearranged on a daily basis.

You may recall that my mother was scandalized when the baby Jesus was found to occupy a position on top of the manger when I was a kid, however, that was normal for my family. Often, the scene was embellished with one of the many dozens of Fisher-Price doll people, as well as Match Box cars, Transformers, plastic toy soldiers, boats, china animals, and a fence from one of the 50-pack plastic farm animal sets, many of which also joined the fun. The 3 wise men were plenty crowded; it was quite a party in there. My mother just shook her head.

My daughter drew the line at the plastic He-Man and other Masters of the Universe that my son J would add. "That's not 'propriate", she would say.

"He's guarding Jesus", J would explain.

Usually, though, at the end of the day Jesus was on the roof, but He-Man was at his post protecting him, and all was right with the world.

Next year I'm gonna bring in that He-Man in case Jesus returns. Just sayin'.

Well, ok...

That last post was so I could add one more than last year.

But I just wanted to add to my post of a couple of days ago in which my family member experienced the joys of the season in the ER.  She has been admitted to the hospital and doing pretty well.  The family looks to me to be critical, but she has been receiving excellent care.

On the way in to the hospital a couple of days later to visit I encountered a locked door.  I'm not all that familiar with the hospital anymore.  It has been over 40 years since I knew my way around, and it has changed drastically.

Along with the locked door, I encountered a confused older woman with a cane who inquired as to where the main entrance might be.

(I assume I must have some kind of light radiating from me that indicates I am a health care professional and stand at the ready to render assistance).

"I think it's up the hill there", I pointed.  "I came in this door the other day".

"Well, it took me a long time to get here, I'm not going to be able to get up that hill", she looked mildly distressed, glancing around and waiting for someone to save her.

Sigh.  "I'm going to try this door right down this ramp.  I'll come down with you, then check to see it there door is open".

We walked down the incline, and I deposited her on a bench, huffing.  As I clearly saw people walking out the door, I called back to inquire if she wanted me to get her a wheelchair.

"Yes, if you can get someone to push it".

Sigh.  That would be me.

I settled her into the wheelchair and we entered the building.  There was no reception area, only a bank of elevators.   I asked her which floor she would be visiting on.

She looked blank.  "I don't know".

Sigh.  Sigh.  I espied a telephone on a table nearby, and pushed her next to it.  "OK, pick up that phone, dial "o", and ask, the operator will direct you".

Brief conversation ensued.  "X Building, 9th floor", she said with satisfaction, clearly in no rush to find someone other than myself to take her there.  Good thing I was headed to the same building, except I was only going to the 7th.  But first she had to drop the stack of papers she was carrying.  She wasn't going to pick it up.  I couldn't leave it.

So,  I took her in the wheelchair up the elevator  to the 9th.  "I am ok from here", she said as I neared a wheelchair stall around the corner from the nurses station.  "Thank you, and I'll be sure to pay it forward"

"I'm sure someone will be very grateful, have a nice day".

Later, as I was headed to my car in the parking lot, another older, confused appearing woman stopped me.  "Do you know where the main entrance is?"

Sigh.  Sigh.  Sigh.

Hey! Look what I got!

All is calm

A family member had an ER experience.  Although she had a medical issue,  her room was located in the area where they house the psych patients.  5 security guards in the immediate vicinity.  Text to Mr. EDNurseasauras:

“Guy 2 beds down is talking about how he rat poisoned his family’s thanksgiving dinner, not enough to kill them.  Just to let them know that he could.  A few minutes ago they were each claiming to be a nurse.  Further clarified, one of them was a CNA a few years ago.  The other one has spent a lot of time in mental health institutions, which he considers fully qualifies as nursing education.”

Sigh.  Just another day at the office.

...and now for something completely different.

One of my favorite security guards accompanied me to my car.  After being accosted in the parking lot late at night last year, the older guys always ask me if I want an escort.  As I was parked in East Bum, I accepted.

Steve was having a laugh at one of the nasty frequent flyer drunks.  He was being his usual nasty, liquor-fueled courageous self, standing at the door of his room, making demands, hurling curses.  After being repeatedly told to get back into the room by Steve (and since the rest of us were completely ignoring him) he pulled down his pants and exposed himself.

"There you go!  How do you like that?  Huh?  Huh?  Take that!"  He waggled his hips pointedly for good measure.

Everyone within earshot froze in place and stared....for about 4 seconds.  Then life went merrily on, as usual.  Nothing to see here.

The police were called.

"What do you want to do with him?", the officer asked.

Steve: "I wanted to tell him to just put him in a trebuchet and fucking launch him across the city".

Me: "Fetchez la vache!!"*








*you either get that quote and are laughing your butt off, or you don't.  

Saving fil

One of my favorite PA's is Fil.  It rhymes with Phil.  He's a good guy, careful, doesn't get rattled.  He's very funny in a dry, Sonoran Desert kind of way.  He is also one of the few providers who not only reads ALL the notes, but scrutinizes the medications and past medical history.  He sees me heading out to triage, and rubs his hands in gleeful anticipation.  Well, for him gleeful is a silent nod or raising his eyebrows.

"How's the storm out there?"  Meaning the waiting room.  "What kind of trouble are we getting into today?"

I do all I can to get a reaction out of Fil.  It makes my day.  

Fil appreciates when my triage contains nothing but a rambling quote.

Fil: "So I enjoyed your triage note.  I think you were trying to say she was crazy".

Me: "Yep".

I had a patient who is well known for her bat-shit craziness and over the top hysterics.  In the dead of winter, she managed to get a fish hook stuck in her thumb.

She, as usual, plunged into hysterics, begging the registration clerk to see a doctor  right away because of the horrible pain and serious nature of her injury.

Apparently her cat jumped up on the table while she was sorting and organizing her fishing gear.  Fluffy absconded with a triple hook lure, the hook embedded in the patient's hand when she tried to take it away.

I kept the triage note brief, eschewing punctuation.

"Fishing lure embedded in thumb while trying to catch a cat"

Coffee spewed.  Mission accomplished.

I just know

Auntie is my fav charge nurse on the 3-11 shift.  I've known her for years, we work well together.  She says really great things about me on my annual evaluation.

 Auntie usually has something to say if I show my face for part of any other shift other than evenings. "I need you on my shift, you aren't going to work days now are you?  I think we have a contract", she jokes....kind of.

I always reassure her that it is a special case, a swap for kid's school play, doctor's appointment, whatever.

I agreed to work an unprecedented 7-3 shift in its entirety for one of the junior older nurses (meaning about 10 years younger than me).  For a rarely offered TNCC class.

Actual text exchange with Auntie after she perused the schedule for the following week:

"I see a D next to your name on the 10th.  I believe that goes against our contract" Frowny face emoji)

"I'm working for LA so she could do TNCC.  I did much soul searching, agreed to do it, and hoped you wouldn't see it" (laughing so hard I'm crying emoji)

"lol I'm watching you" (monocle emoji x 5).

Oh, I know you are.

Dear Nurse-to be......

I recently took care of a high school student, mom confided that she wanted to be a nurse.  I was curious what attracted her to nursing.  She replied (monotone, and without eye contact):

"I want to be a  nurse because I want to help people"

I love that response, but it's a knee-jerker.

So did I.  I still do. So did we all.

If I knew then what I know now, I would say nurse candidates should be prepared for a different mind set.

Along with the mushy feels, having a sharp, inquiring mind, excellent critical thinking skills and an ability to problem solve is essential.  Nurse Nancy expectations is a good start only.

I wanted to be a pediatric nurse.  It seemed cool, helping sick kids.  When I decided that I was, like,  7.  I wanted to be an LPN.  I liked the caps.

My parents wanted me to go to a 4 year college and be an RN, but I never thought I had the right stuff  academically.  Also, they didn't really have the money to waste on an average, unmotivated student who would probably drop out when there were a couple of genius siblings coming along. As the family was stretched kind of thin in spite of the earnings from my lucrative after-school baby sitting and pharmacy clerking, we compromised on a 3 year diploma program.   I applied too late for the fall class after my high school graduation (ok, I procrastinated), but was immediately accepted for the following year.  I took a six week nurse's aide course and did that at a busy city hospital for the year.  Well, 11 months.  I worked as a lifeguard for the next summer, it being in my DNA to sleep until 9:30 and be on the beach all day.

The three year diploma program  prepared me very well.  In my senior year  I was,  prophetically, voted most likely to be an ER nurse.

Which I did, about a year after I graduated, and I did work in pedi.   In the last 40 plus years, I have worked in myriad other areas in addition to the ER. In the medical tent at sports events in my town.  Giving flu shots.  Lots of teaching.   CPR, EMT's teaching first aid classes.

I burned out on teaching, but I still like the helping people part.  I have become a bit more discriminating about the kind of help I provide because I am so inundated with tasks.  I am really, really tired of the constant concierge demands.  People are so grabby.  Cab vouchers and gourmet meals do not exist in my realm.  The drunks and constant psychiatric holds are tedious.  We generally run out of turkey sammiches by 7 PM, and I refuse to make toast.  Too many steps.

I never, not once, sought a degree in hospitality.  My degree is is a BSN....bachelor of SCIENCE.

I use science every day.  I dig it.  I like  how chemistry works, the human body is amazing. I like puzzles and problem solving.  Human illness and injury present endless opportunities to figure out what makes them tick...or stop ticking.

Math is important, without solid math skills there would be medication errors galore.  People would die. We convert pounds to kilos to ensure safe weight-based dosing.  We figure stuff out like how to convert mcg/kg/min and how fast to run drips.

Thanks to relentless drilling from grade one, I can effectively utilize vocabulary and  grammar to create coherent documentation.

I freaking love technology.  I love computers, machines, gadgets, monitors, pumps, you name it.  I'm always willing to learn new programs.  I have fun figuring out work-arounds and trouble shooting.  Vents are fun.  New central monitoring system?  New med pumps?  Sign me up.

Am I a people person?  Not so much.  I like people less than I used to.  It's not natural for me to put myself out there,  unless a sense of humor (mandatory for a nurse) is deployed as an ice-breaker.  I don a nurse-persona when interacting with patients.  I've said it before:  I am a good actress.  More importantly, I am good at what I do.

Is it necessary to have empathy?  Absolutely.  But know that little pieces of your self (or soul) will be chipped away.  Small bits of your humanity will be left by the wayside like breadcrumbs.  I don't know for sure if these bits die, or will someday be reassembled.   Maybe time simply blurs the painful memories.  Its kind of like a hard candy shell forms, born of frustration, anger, and because of people who don't do your job constantly telling you how to do it.  But mostly because of the hopeless cases, each drug addict you can't help, every sad, neglected, and pathetic elder alone with no family, every senseless death. You will weep buckets.  It will change how you view illness, life, and death.  And when you think you can't take another day, you will weep when someone survives against all odds...or someone says thank you for caring, and means it sincerely.  You will bask in the glow of that save, that thank you, that hug,  for days, weeks,   You will come to know that is why you put up with so much bad.  That one good thing that keeps you coming back.

After you've done the job for awhile, you will not be the same person.  Do you have the stuff, dear high school student?  I hope you do.  But know that the stakes are high.  The potential for doing for others?  The sky is the limit.  So is the potential for harm, not only to your patients, but to yourself.  It's not easy.  I'm not sure anything that important should be.

Progression of Manbaby, an anecdotal study

Within one 5 hour shift, I had the entire spectrum of Manbaby stages:   infantile, toddler, school age, adolescent and grown-ass adult.    It is interesting to observe the progression.

1.  The infant was 11 months old.  A third child with a "really high temp, and going up and up" in spite of basically a topical spritz of Tylenol at 99.5 degrees.  No other symptoms, yet the parent was beside herself, screaming on her phone about the catastrophic medical emergency for which she nearly called 911.  I had to tell her to put the phone away and tend to the already walking
child, who looked like a rose, as he attempted to climb up an IV pole.

2.  The toddler with a head bump, no loss of consciousness, no visible injury.  He screamed and screamed as the mother loudly explained every second of the terrifying vital signs I was doing.  She helpfully conveyed fear with every word instead of distracting with the phone, a song, or book.  She demanded a pediatric neurologist to be called immediately as she rocked the shrieking child, smoothed his hair and kissed him repeatedly.  Feed the frenzy.

3.  Young school age kid (on the cusp between toddler and school age) with a simple forehead laceration.  Parents demanded plastics in triage (they don't take call here, and don't answer our calls) and asked when they would see a pediatric neurologist (never.  What is with the pedi neurologist demands?  Some Dateline episode I missed?).  Insisted on over-explaining everything to the kid, offering information he didn't need to have, talking incessantly about needles.   I put topical  numbing medicine on, much wailing and gnashing of teeth from both parents, hand holding, repeating over and over "it's not going to hurt", (it probably will.  I don't lie to the kids.  It stings).  The kid was too absorbed in an iPad game to notice.  5 minutes later, I heard blood curdling screams, a harbinger of good times to come.  Dad had used hand sanitizer on the kid and he had a paper cut.

We had to wrap the kid in a, "Bat Man cape" (arms in pillow case then burritoed in a sheet) and 2 people to hold him down for sutures.  More blood curdling screams.  Dad repeatedly saying "I know it hurts, daddy's here", drowning out our usual successful diversionary banter, while mom sobbed and rocked in the corner, wailing "it's almost over".  No attempts at diversion.

3.  School age kid, (age 11) hopping on two feet, with a knee injury sustained about 3 minutes prior     to arrival.  Hopping.  Two feet.  Mom immediately commandeered a wheelchair, of course, and harangued the registrar until I finished with the tiresome chest pain patient.  Within 5 minutes asked for blankets, pillows, juice, "some kind of splint", ice, pain medication, and for the orthopedic to be standing by to care for her precious little guy because "nothing is too good for my son".  She, too, smoothed his hair and told him how it was all going to be ok, don't be afraid, mommy's here.

4.  Adolescent male.  Age 16.  He's been here before as evidenced by mom's chummy "we know our way around" banter and checklist of what makes her special lil' guy better with his cyclic vomiting.  A liter of fluid and some zofran, and could we please get started on that because I have another kid at home whose plans were cancelled because of the patient's visit to the ER, and younger bro is NOT happy.  Mommy made sure to let me know that baby boy doesn't like needles, and could we please use the smallest size, and this arm, and not to try unless I'm sure, and he has persnickety veins, and could we draw the blood at the same time so he doesn't get too anxious.  Although I found a vein immediately I spent a good 10 minutes pretending to find one while Mommy cooed and cuddled.  Gag.  The kid didn't vomit once in the ER. Demanded juice and crackers after about 20 minutes and wanted to go home soon after that so they could get on with their evening plans.  I didn't hurry as I had other things to attend to.  This was a textbook example of novice Manbaby.  I suspect many, many issues at home.

5.  The  55 year old came in with his mother for....oh, never mind.  It makes me want to vomit.  I've covered Manbaby, both the gloriously single and the married kind complete with Mommywife in the past.

This is really a recipe for creating steel reinforced apron strings.  I don't care if it's not politically correct

11 years

Hard to believe that this is the 11th anniversary of this blog.
That I'm still working at the bedside.  That I still have something to say.

That people still read anything I write.

Boggles the mind.  Or Bloggles.

Don't know how much more I have left to say, but sometimes inspiration strikes.

So many of the blogs I loved back in the day are no longer around.  Madness.  Nurse K.  GuitargirlRN, to name a few favorites.

I wonder what all of them are up to, if they are still working in the ER.

If you are out there still, stop by and say hi!  Miss you all!  

Lake-sword autocracy vs. autonomous collective

My ER did some remodeling and created a locked area  for dedicated psych hold beds.  Now, because the patients have a nice, warm, safe, cushy bed with a TV, they wait much longer for a commitment bed.  'Cause, you know, they are in a safe place.  I refuse to work there.  The days holding routinely number in double digits. Weeks.

Two of our old psych rooms were turned into medical rooms.  There was no increase in staff to reflect the increased acuity.  The assistants are routinely taken off the floor to watch the suicidals which are now in overflow hallway beds with the drunks, and the beds are always filled.  We have more psych patients than before.  Many.

Sometimes it gets loud there, in the hallway, what with people trying to walk, steer stretchers, move X-ray machines, stuff like that.  There are 10 computers at that end of the ER.  It is loud.  Phones are constantly ringing, alarms always dinging. There is no privacy for the patients, and no privacy for us.  People are always hanging on the desk asking for things.  You can barely hear yourself think.

Often, the patients talk to each other, complain to each other, and get each other all ramped up and agitated.

One night was particularly wretched.  The patients were heckling, actually heckling, security, nurses, docs, anyone who walked the gauntlet of hallway dwellers.

Security and the assistants were beside themselves trying to keep things calm, but they had a job of it.

After a couple of hours I went out to dwell in triage, happy to get away from the cacophony.

One of my zone mates had PTSD from the events of the remainder of the shift.  She was wild-eyed, her usually flawless bob sticking out all over from many frustrated passes.

"It was awful.  It was really hard trying to take care of actual sick people, they just wouldn't shut up, they kept at it and at it.  "Nurse! Nurse!  I need, water, I need food, this sucks, I want to see my lawyer".  They were all trying to outdo each other in the asshole department.  Then they started to organize themselves.  They had a list of demands!  They were there so long they established their own form of government and elected a representative.   Possibly a king!”

Happy I am closer to retirement with each passing day.

Supreme executive power derives from a mandate from the masses, not some farcical aquatic ceremony.

In which we are screaming, but nobody can hear us

Our admins were absolutely skewered on the latest round of employee satisfaction scores.  For added fun, this year we were also given an opportunity to evaluate our director.  Some of the comments were shared during a staff meeting.  Meetings are administrative crack.  If it's not working, by all means, have a meeting or 12. The bosses appeared shamefaced, bewildered, confused.  

"Absent"
"Drowning, send lifeboats"

"Administrative puppet"

"Not an advocate for nurses"

"We have a director??"
"In your opinion, is there anything we do RIGHT?"

That explains why the director has been out and about in the department, "visible" more in the last 2 days than at any time in the last 12 month 5 years.  She was not out of her rat hole office to help.   She was certainly not dressed for patient care, in her sharp little booties and lab coat.  Why do admins wear lab coats if they never do anything to get dirty, such as:

start an IV, surely you remember how.

answer some call lights.  

deliver a couple of meal trays, get some blankets, walk someone to the bathroom.

Instead, we have to take time away from our task to make inane conversation about HOW ANOTHER AWARD MADE UP BY ADMINS WOULD MAKE US FEEL MORE VALUED.  

SOO looking forward to next year's roast.  Doubt they will make this an annual event, though.  

So

There are days I love my job, some when I hate what being an ER nurse has become.  I would love it if I could still do nursing 1970's style.  20 uninterrupted minutes for each of my patients at a time, helping them understand all their meds, treatments, and an in-depth plan that we will work out together for the length of their stay, complete with meal times, snacks, back rubs, bed baths, etc.  It would be lovely to chat with them about their family,  jobs,  previous experience in hospitals, belief systems, hobbies, how they love to take long walks on moonlit beaches.  For the most part, though, it is a race against time, and I waste a good bit of  it apologizing for what isn't being done rapidly enough to suit them.  Priorities?  Constantly changing.  Minute to minute, actually.  A nurse's priorities are manipulated by everyone EXCEPT nurses.

Although I don't work in Massachusetts, several friends and family have asked my opinion on their proposed upcoming ballot question regarding  nurse:patient staffing  ratios.  Let me walk you through my thought process on that issue, and share this exhausted bedside nurse's perspective.

My tale begins shortly after receiving nurse to nurse report from the off-going day shift.  I was responsible for four patients in the critical care zone (strokes, heart attacks, trauma) one more than is prescribed, although there is no mandate here.  It is assumed that if one nurse is busy with something truly critical, the other will pick up the "slack".  I hit the ground running.

There are three providers, all of whom have promised patients that "the nurse will be right in".  As you can imagine, I can't be in four places at once.

(In real time, now) I am answering the call light of one of my patients who is demanding instantaneous service who has to go to the bathroom.  I can simply take off the cardiac monitor leads and disconnect the IV as he is ambulatory.

I return to my desk and computer, where I must log in and acknowledge all orders and do all of my charting.  At my work station,  I find the family members of 2 elderly patients standing at my desk.  One wants water and warm blankets for their father, the other has a mother who needs to go to the bathroom "right now".  Neither of those patients are mine.  I explain that I or their nurse will attend to them as soon as possible.  The emergent toileter relative argues that the need is immediate, so I have to take care of that patient (belonging to my zone partner who is busy with a combative suicidal overdose) before I even begin to attend to the needs of my own patients.  It is a weak, dizzy, and demented nursing home patient, and the relative is useless (as they usually are), so I hunt down another equally busy nurse to assist with transfer of the patient from the bed to the commode, which I also have to hunt down.  In addition, she is caked with stool that has to be cleaned before returning her to bed.  Naturally, the relative also wants water, warm blankets and a turkey sandwich which I ignore for now place low on the priority list of tasks.  My ambulatory patient, now back in bed,  is also now ringing for meds and to have the IV restarted.

It has been 25 minutes since three physicians have promised things to patients that I have yet to provide.

Back to my desk to print med orders for 3 of my patients.  This is a policy, also a safety issue.   I must take the printed sheets to the bedside for confirmation of identifiers and allergies.  Every med.  Every patient.  Every time.  Antibiotics and anti emetics for 2 of them.  IV fluids and pain meds for one.  Before I get the orders printed I am interrupted once again by emergent-toileter-relative-who-is-not-my-patient at my desk to demand the warm blankets and water.  I say shortly that I will send in her nurse.  I hate when people stand at my desk, it's just rude.    Unless your relative is coding, standing at the desk is like jumping the queue.  Use the fucking call light.

Here is a short list of what I must do now:
Wait behind 2 other nurses to get meds out of the Pyxis, one of which is an orientee and is being coached by her preceptor so even the commonly used meds take awhile to find.  After a couple of minutes it is my turn.  I must input my password, use my fingerprint ID, find the patient name, then pull saline, tubing, antibiotic, second tubing for the antibiotic, small admixture bag with adapter, and anti nausea meds for both patients which entails knowing what they are called in the Pyxis.  A one liter bag of saline I know is listed under "Sodium chloride", with a drop down list for how big a bag you want.  I have to hit the screen on average about 4-5 times for EVERY ITEM  I need after typing in some key letters, then wait for the door or drawer to open, then the individual lid containing only the desired medicine.  I pull out what was ordered, close the lid and drawer.  Fortunately the antibiotic and anti emetic is exactly the same for both patients and this ain't my first rodeo, so I have what I need relatively quickly.  I also get the pain med and more IV fluid for the ambulatory patient.  One of the newer nurses has a question about how to administer a medication that she has never used, so I instruct her on how it's done.  Remember that.  I am taking time out of patient care to provide information to a less seasoned nurse.  This will always be a priority for me, you cannot burn the newbs, lives literally depend on it.  I grab a couple of syringes and blunt needles to draw up the anti- emetics and drop one "set" of meds by my computer, taking my orders into the other patient's room.

35 minutes have elapsed.  Nobody has what was ordered yet.

The first patient complains about the wait, I apologize insincerely, eyeball the monitor and general condition of the patient, (note that he doesn't look that uncomfortable) while simultaneously  mixing the antibiotic.  I confirm identifiers (name, DOB) and allergies.  I hang the IV fluids.  I inject the anti emetic over 2 minutes, and during this time I assess the patient:  skin color, and temperature, vital signs, pain level, get a quick and dirty on the onset of illness.  I try to make eye contact and sound sincere but I'm pretty business-like.  There is already an IV pump in the room and I spike the antibiotic that I have already mixed, hang it, priming the tubing and feeding it through the pump.  I set the pump for one hour.  I make sure the patient has a call light and have one foot out the door to run to my next task.  The family wants to know how soon admission to comfy floor bed will happen (hours) and what time is dinner (you have abdominal pain.  Never).

47 minutes elapsed.  I repeat the procedures on the 2nd patient, but must find an available pump first which takes a few minutes. I have to retrieve a visitor from the waiting room, as all must be escorted in our ER (topic for another day).  Emergent-toileter-relative-who-is-not-my-patient glares at me from her helicoptering position at the door.  I am moving too fast to flag down.

I am back at my desk now about 57 minutes in and I haven't even laid eyes on the 4th patient.  I have done nothing but toilet a patient who isn't mine, clean up shit, give meds and fluids.  I have done nothing, really, to educate my patients or make them more comfortable, or even make them feel like I care about their problems.  Tasks, tasks, tasks.

 I discover that CT has called, along with ultrasound, for the shortness of breath and leg swelling which is patient number 4.  I explain that the doc wanted to wait on the lab test before sending for the CT.  I hunt down the physician to see if it's ok to send to to ultrasound.  First I check to see if the patient has a patent IV: yep.  Quick assessment, check the monitor and VS, then disconnect and transport the patient myself to ultrasound because there is never anyone available to transport since our last transporter, the 4th this year, quit after 2 months on the job.

I return to my desk once again.  One of the physicians wants to know if meds were given:  yes, not charted.  She thought so, was just wondering if there had been any response.  No idea.  Haven't been in the room, but haven't heard any puking and they asked about dinner, so all good from my perspective.

All of this has taken place in about 1 hour and 10 minutes into my shift.  I have charted nothing, my zone partner is nowhere to be found, and my boss wants to know if any of my patients have orders for admission to the floor and can be transported (nope) or discharged (hell no),  or can be moved out of a room for an ambulance arriving with chest pains.  That means that now any remaining  tasks care to be provided to any other patients will be put on hold while I take the next 20 minutes with this new patient.  Move family of patient in ultrasound to hallway amidst grumbles, move in new stretcher, accept ambulance report, then triage/assess/undress/EKG/place on monitor/start IV and draw labs on the chest pain patient who is from a nursing home.  This patient turns out to be an elderly 90 year old, non-verbal and demented, also combative, and therefore non-participatory in his care.  He has  2,000 meds and has never been at our facility, so they all have to be entered into the computer.  I say screw it, and merely attach the list to the chart with a sticky note to the provider that I will get to the meds when I can (our pharmacist who loves to do that shit).   It is Friday afternoon and nursing homes are well known for the tactic of sending their difficult patients to the ER at this time with vague complaints or  "chest pain".  My 20 minute intake takes about 45 minutes to an hour due to incontinence, possible fever and sepsis, while dodging swinging fists and verbal abuse.

I feel I have been a bad zone partner and not been able to help with the combative overdose, but fortunately the paramedic (bless him) has been in with her the whole time.  Her other 2 patients are fortunately awaiting admission, so need little in terms of assessment and treatment at this time (except for the soul-sucking emergent-toileter whose family member continues to glare and ask for stupid things like jello).  I carry on.  In the meantime, two of my patients are on the call bell "just" wanting updates on their admission progress (hours, you are stalled in the ER as there are no available beds on the floors), "just" some warm blankets, "just a quick question",  and at 4:15 in the afternoon to inquire if a sleeping pill will be ordered when they are admitted.  Dunno, and right now I don't care.  Not my job and not up to me, ask the hospitalist.

Less than 2 hours into my shift and I have had limited contact with my patients.  This doesn't feel good for any of us.  Its "adequate" at best.  To me it was crappy care.

Our administrative clip board commandos walked out at the end of the day knowing the department was about to implode, but leaving us with "adequate staffing".

"Adequate staffing" did not add additional personnel for the additional 12 patients in hallway beds.  There were two LNA's, one of whom was designated to sit and watch the suicidal patients in the overflow hallway beds.  The other was being ridden like a cheap pony.  There was one paramedic who was occupied.  The EKG department calls it a day at 4 PM and we have to do our own.  Just one less resource and an additional task.

If we had 4 extra nurses we would have been golden, even with non-stop ambulances and an overcrowded waiting room (5 hour wait).

With 3,  it would have meant a world of difference.

One or two even would have helped.  An extra paramedic.  A couple of LNA's.  Our secretaries were thoroughly in the weeds.

At this point I completely understood why Massachusetts nurses put this on the ballot, born of utter frustration.  More nurses, better care.

Hospital executives don't care and won't spend the money on nursing unless compelled to do so.

If I lived in Massachusetts I would vote yes.

On not receiving coffee, chocolates

Working the evening and overnight shifts in the ER is a lot like being the unfavored child.

The darlings of the day shift enjoy things like adequate staffing.  A call out for the day shift?  Immediate urgent ping to all staff!  Come in and work for double time!  Crazy busy!  Boarding 6!

They have a charge nurse and a manager on the floor in addition to the department nurse director.   None of them take patients.   Day staff enjoys perks like breaks, and many free drug-rep sponsored lunches.  Baked goods, candy, treats all arrive on day shift.  Recipients of various "awards" (photo ops) devised by clipboard commandoes are all day shift divas.  They have transport volunteers so they never have to lift a finger to transport their patients.  The urgent care part of the ER opens at 9 AM, so they stack potentials in the waiting room starting about an hour prior, then fill those beds up all at once.  Heaven forbid they see urgent care patients.

Which brings me to Nurses' Week, the favored Hallmark holiday for administrators with plenty of time on their hands.  This year, there were no shitty water bottles.  No umbrellas, pens, or other 35 cent items for mass distribution.  No "lottery" for a beach basket with everything a person needs to have a fun day by the ocean.  No wine basket.  No reiki in the break room.

There was a giant cake, courtesy of our buds at the local ambulance service.  Very delicious.

Some of the docs were cool, springing for  pizzas, a favorite meal from a local chicken place, ice cream with all the fixings,  much appreciated and  meant more to those of us working the off-shifts than the formal annual pomp and ceremony photo-op "gathering" for nurses week.  A selection of ice cream (chocolate and vanilla, from what I heard) and some sprinkles to announce the Big Kahuna's pick for the nurse of the year award, who was a non-clinical administrative Quality darling.  Everyone knows Quality is Satan.   The sundae bar soiree was held in the middle of the afternoon in the hospital cafe.  Bear in mind most staff work 12 hour shifts.  Floor nurses are busy with patients, meds, and discharges in addition to the mid-afternoon admission rush.  These guys hardly get a pee break and rarely get to lunch, let alone leave the floor en masse to listen to know- nothing admins make speeches.   I boycott these "celebrations" on principle, and ya'll can stick your ice cream buffet.

You want happy employees?  Send us some damn help on the off-shifts.

Head smacking moment

I spent a loooong shift at the old stomping grounds Medde Center with some of my old crew.  Good times, like, I mean, before The Apocalypse.

But it's urgent care.  I complain about how hard it is at Pseudocity,  how busy it is, and how punishing it is on my aging body.  However, I have come to the conclusion that I would rather poke hot, sharp, steel needles in both of my eyes than go back to a steady diet of stupid and have finally figured out why.

At Pseudocity, we do see the same patients.  Rash.  Boo Boos.  Back pain.  Sore throat.  Colds.  Lots of silly nonsense sometimes.  However, those patients are low priority and often sit in the waiting room for a long time.  They won't be seen sooner than chest pains or strokes.  They eventually get seen, but they are kind of out of sight and out of mind.  Sometimes they get bored and leave.  They can actually see the chaos that trumps their non-urgent complaint which tends to put things in perspective for most people with even minimally functioning common sense.  But at the MEdde Center, they are promptly registered, roomed and triaged.  On days when there are two providers, they are in and out.  Actual urgent care, and it can be a little faster paced and somewhat fun.  But when they are already roomed, they are RIGHT THERE in your face.  There is no privacy, and sitting at the computer, making phone calls and conducting business is seen as ignoring their low priority problem and they don't like it.

Today, only one provider and she was slow.  I should say methodical, actually, because she's always been careful and conscientious, but that does slow the process.  When patients wait in a tiny room for about an hour, they get testy and threaten to leave.  Here are the three that stand out.

1.  Leg boo boo, 30 minutes in:  "I have groceries in the car, how much longer will I have to wait?  Everything is melting".

2.  7 year old with recess wrist injury: (given a fun sling by the school nurse), 35 minutes in and pending X-ray which she doesn't need and everyone knows it "Does she really need to wait? She's moving it just fine now she's been here so long.  Do you have any crayons?".

3.  54 year old with atraumatic neck pain for a week: (yelled from the doorway) "I've been here for two hours (one, actually), and I"m in terrible pain! (note: did not take any OTC analgesics, use ice or heat, or  call her own doctor) "Next time I'm going to Mega Hospital, and I'm writing a bad review on Google".

Bye Felicia.  You can threaten to leave all you want, I'm not gonna beg you to stay.

So, back to  my epiphany.   Right now the prospect of a permanent urgent care job is not enticing.   The constancy and sheer boredom of routine office-type complaints and entitled attitudes would turn my brain to mush.  I'm not saying the job is without challenges, but there simply is not enough challenge for me.  I've fought to regain my critical care skills, it is not time to put them on the shelf forever.  

Paintol, the musical

This wasn't my patient, but I giggled about it for about an hour.

During a time of extremely high volume recently one of my colleagues was triaging an irritated and impatient young woman with an minimal (not urgent) complaints.  Her list of chronic illnesses (fibro, back pain, anxiety, migraines, etc.) was reviewed, as well as numerous meds and seemingly dozens of allergies. She added to the list:

"...and I also have pain___", mutters something unintelligible .

"Excuse me, I din't quite catch that, could you repeat it?"

Looks more annoyed.  Says a bit louder, "PAIN___"

"I'm sorry, I'm just not getting that"

Now pissed.  "Paintol!  Paintol!!  "I HAVE PAINTOL!! Are you deaf?"

Apparently has a tolerance for pain and has made it into some kind of syndrome.

It is not a thing.

#Istillhatepeople

Having had the privilege of the previous car paying for my coffee at the drive through Dunks, I immediately retuned to favor and paid for the car behind me.

As I drove off, I felt all warm and fuzzy, my crackly edges warming just a little.

Until I approached the town square. He had a yield sign, I had the right of way.  He plowed right through it without even slowing.  I gave the 15 second horn blast, just to gently remind him he was in the wrong.  He flipped me the bird.   Then hit the biggest pothole in town.

Karma.

Proof that it has a sense of humor, and occasionally works in reverse.

More, and more, and more names

Didn't think there was going to be a ton of opportunities to do this, but there are an astounding number of people who think it is OK to condemn their children to a life-long sentence of instructing the world how to spell and/or pronounce their stupidly spelled name.

Thanks to all of the disciples in my circle who are now alert to this phenomenon and provide me with ever more outlandish names.

Lisle (Lyle)

MeKinnah

Eryck

Bryannah

Alyjah (Elijah)

Paislee

Arndrea (Andrea)

Cleao

Skyla

Blissany

Cessylia

Sigh.

Soylent Green is People!

I hate to keep harping on it, but there can be no doubt as to why we are a nation of obese morons.
Yesterday I had the following actual patients:

Vomiting for 3 days,
New onset atrial fib
General weakness and chest pain
Flu-like symptoms
Diarrhea
Abdominal pain (2 patients)
Detox from alcohol and vomiting

All of which had the same overarching concern, having  NOT EATEN A SINGLE THING ALL DAY, and wanting food, wonderful hospital food before zofran, diltiazem, or ruling out a heart attack.

 Many patients comment on how awful the food is in the hospital, but sheesh, they can't wait to stuff it in their mouths.   Mostly it's the specific diet food trays that seem to be lacking in imagination and  is why patients ignore the healthy food choices and send their family scurrying for buckets of Kentucky Fried Chicken.

The cardiac and diabetic patients get Pale Trays.  There are restrictions on both, but without any discernible distinction of the food on either.  They consist of:

Some kind of chicken, probably baked.  It is boneless, skinless and....pale.  So, so pale.  Perhaps with a sprinkling of dried green stuff.  Could be parsley, could be green plastic shavings  from tiny plastic green toy army men, who knows.  The chicken is accompanied by some kind of pale starch, possible canned potatoes of some description.  Maybe some kind of fruit cocktail, which is also pale, but comes with a cherry, providing a bit of color in a wee plastic container, or some yellowish colored canned fruit.  The pale cherry,  the color of which does not appear in nature, sits on top.  And some vanilla pudding.  The latter two will be sugar free.

The  psuicidal psych patients are only allowed "finger foods".  They don't get disposable plastic utensils, they get cardboard spoons that can't be fashioned into a weapon.  So it's burgers and fries, pizza, chicken fingers, sandwiches.  But the burgers ALWAYS COME WITH A SIDE OF RED ONION.  Which smell bad when left about in the ER.  Red onions should be banned from the ER.

Regardless of how bad the food is, ER patients will complain about being hungry above all else.  If the chest pain is 5, the hunger level will be 10.

Pet peeve.  Aside from the disgusting stench of people who smoke 3 packs a day and leave their stink in my cubicle of a triage room, I also have issues with the food odors.  Sacks of burgers and fries often accompany patients to the ER, it being just too difficult to pass a fast food joint when loved ones have chest pain or abdominal pain.  Or other similar emergency.  That counter you just placed your feast on is where the urine samples go.  Yep, there, in front of the vomit sacks.  Sure, just put that right down there.  And your greasy French fry finger can go right here in my oximeter.  I'll just disinfect it.

Urp.

How to class up your delivery and get VIP service in the ER

Repost, because it made me laugh.

Polite society has certainly gone the way of the hoop skirt.  Pardon my sainted bloomers, but the ability to express oneself in a reasonably polite and courteous manner, keep civil when one's opinion differs, or engage in respectful dissent is non-existent.  Many people unapologetically present their problems thus: "I have a pain in my ass" instead of "low back pain" without shame.  Descent into name calling and profanity to make their point is the new norm.  You can't reason with people, and it isn't just because they are dumber than a bag of hammers.  It is strictly ignorance because THEY THINK NOTHING IS WRONG WITH THE WAY THEY SPEAK.  Don't get me started on how they talk to their kids.

Hospitals have scripting and behavioral expectations for staff, why should we not hold patients to a higher standard?  How about a little accountability for unacceptable language, profanity, and inappropriate expressions?

I offer a guide for alternative language; scripting for patients if you will.

Instead of: "Why do you have to ask so many fu*king questions?
You might try: Forgive my impatience, my good woman.  Would you kindly assist me in understanding why you need to know what medicines I take and how it is relevant to any treatment I might receive for my chronic, debilitating, and narcotic-requiring back problem?  I would like to be an active participant in my care.

Instead of: "I have a mother-fu*king toothache, my pain is through the roof.  I can't afford no fu*ing dentist.  Just hook me up with pain pills, bitch"
You might try: "Alas, dear lady,  I am irretrievably guilty of neglecting my dental health and am suffering from yet another exacerbation of uncontrollable pain.   I can imagine that it seems inconceivable that I have allowed this situation to deteriorate to this degree. I regret that my current financial situation severely curtails my ability to offer adequate  monetary compensation to a dental professional as I would be unable to purchase cigarettes, liquor, or marijuana.  Would it be at all possible to provide me with some additional narcotic pain relievers?"

Instead of: "I am sicker than anybody in this shit hole and I shouldn't have to wait for a room"
You might try: Please excuse me if I seem short-tempered, but might I respectfully request that my condition be re-assessed?  I understand that my man-cold is not especially urgent, but I do believe this  illness seems to have escalated in the 10 minutes I have been asked to repose in the anteroom"

Instead of: Any expressions such as  "Coochy pain",  "Kicked in the scrote",  "My girlfriend/boyfriend gave me some nasty-ass infection in my pu**y/dick".
You might try: I regret that I have a matter of some....delicacy to discuss.  Please forgive me if I offend you with any unacceptable slang, but...oh, I blush to say it...I have an injury/possible disease in my nether regions.  

Instead of: "I fired my doctor because he/she is the world's biggest douche bag.  He blew me off when I asked for an increase in my pain meds because he thinks I am full of shit".
You might try: I am currently between primary care providers, thank you.  We have come to an amicable parting of ways and I find myself in an unaccustomed awkward position.  Might I beg your indulgence in providing me with just a few of my usual analgesics just to tide me over until I have engaged another primary care provider?

Instead of: "What the hell am I waiting for?"
You might try: Excuse me, I completely understand that you are very busy caring for people much sicker than I am.  When you have a moment, might I trouble you for an update?

Instead of: "You are all a bunch of bitches/ c*ck suckers," etc.
You might try: I would just like to thank you so much for the excellent care you have provided me today.  I would love to let your administrators know how great my visit has been"

Let's raise the bar a little, people.

ER Nurses Guide to the Universe

I pretty much live in triage since I almost always work 3-11, a shift that attracts newer ER nurses as opposed to the dayshift dinosaurs.  There is a mandatory triage course but it requires AT LEAST two years of working independently in our ER, AND demonstrating the ability to consistently make good decisions.

Also an ability to separate the the truly sick from the truly non-sick, regardless of how much the patients/family members whine or demand a bed "right now", because their mother's brother in law is king of the hospital.  There is a lot of that kind of thing, name dropping and what-not.  Threatening to call your own doctor or chief of surgery has no bearing on the wait time if there is not an urgent need of care. And guess what?  I'm the gatekeeper, literally the one who decides how quickly you need to be seen.  As one of my favorite doctors says, every ER visit is relative.  It may be your worst illness or injury EVER (for YOU), but it may not be the worst thing in the ER AT THAT MOMENT. Needing to pick the kids up at the bus does not fast track the visit.

Sadly, there are those that will  employ underhanded means to get themselves to the head of the line.  High drama, embellishing symptoms, and outright lying to move up the visit food chain more quickly.  These are not the squeaky wheels who demand, scream, and threaten bodily harm, but the truth benders for whatever personal gain they might derive.  It's never a good idea.  It could compromise your care, perhaps even your life.  Or someone else's life, come to that.  So as a public service, may I suggest you not lie to your triage nurse.  Just don't.

Some top reasons for lying:

Embarrassment
Don't lie if you have medical issues but choose not to take your prescribed meds.  Yes, we will think you are a dumb ass, but if you are supposed to be on medication for your diabetes or hypertension, we will not waste valuable time and resources trying to figure it out.  We can just go to the damage control and/or treatment phase.  Cutting to the chase is always best, and allow us to move on to the next patient who needs help.

Don't lie about whether or not you've been drinking, or how much.  We automatically at least  double the amount you tell us, for example, if you say 2 beers, we know it's probably a six pack.  If we smell alcohol and you say you have not been drinking, we know your BAL is 260 at least.  If you say you don't drink heavily every day like we suspect, because you have the look of someone who drinks every day, we will be waiting for you to withdraw.  Hope you don't have a seizure.

Don't lie about your opioid use.  You've been here before.  We used Narcan on you yesterday.  Those track marks on your arm are not "years old".  Your antecubital MRSA "spider bite"  is a dead giveaway.

If your pain doctor has fired you for lying, we know.

"I just fell on it."    C'mon.

Laziness
There are far too many ER visits due to laziness.  Especially for people who aren't paying for it, but that's another whole issue.

Don't come to the ER because you didn't bother to contact your doctor for a refill of meds you use each and every day and tell us you "couldn't contact your doctor, been calling for days and my call has not been answered".

Please don't come because you "didn't have time" to call your pediatrician for a condition that your child has had all day or all weekend, such as an earache or sore throat, and it is now 9 PM.  Or got sent home from school at noon with a stomach ache, had lunch and a play date, and after dinner has a stomach ache.  Also consider that to us, a "high fever" of 100 is not a high fever.  If you haven't bothered to take the temperature because you are too lazy to buy a 1.00 thermometer and the child "feels warm" and you still didn't give any Tylenol, you will be waiting a long time.  Your child was not "lethargic" when he was jumping off the chairs in the waiting area.  He still isn't as he tears apart the triage office.  His "difficulty breathing" is real, though.  His nose is full of snot because you couldn't be bothered to wipe it away as you whiled away your time in the waiting area on your cell phone.

Your doctor is a douche if he told you "just go to the ER and tell them you need an MRI".  You won't get it, I promise, although it is not my responsibility to tell you that in triage.  You will have to wait a couple of hours and hear it from the provider.  It's above my pay grade.

It is really not cool to come to the ER if you are pregnant and say you are having vaginal bleeding so you can get a million dollar workup and picture of your baby.  Please go to the $1.00 store and purchase yourself a pregnancy test, and demonstrate some level of responsibility before you and your baby daddy sign up for all the freebies on the State Sponsored Breeding Program.

Denial

Nobody wants to believe they have a serious medical issues.    Heart attack.  Cancer.  Don't lie about how long you have had the symptoms.   Your significant  other knows and will rat you out.  Don't waste time that way.

If your doctor has put you on medication for your blood pressure, congestive heart failure and diabetes, please don't stop taking your medication.  You were already sick, the meds didn't make you sick.  None of these issues is going to get magically better.  In fact, you will get worse and probably die since you have refused to be admitted or follow a reasonable plan of care.

Here is a thought, on the issue of denial.  This is your son's third visit to the ER since the beginning of his pee wee sports program (usually football).  Might be a head bang, might be a leg or arm injury. Your kid is 12 and weighs about 50 pounds, his diagnosis is going to be "Not Suited for Contact Sports".  Think about it, and please  let him do something else, I beg you.  He is going to get killed and he knows it, he's trying to save his own life.

Also on the issue of denial, your teen daughter had a mild allergic reaction to some antidepressant weeks ago.  Bringing her in for the last 3 nights at the same time with "difficulty breathing", and "it's happening again", with normal vital signs, fake gasping and wheezing to be treated by Ativan is not actually a breathing  problem, madam.  Your kid is probably having other issues as evidenced by the meds she's on.  She is having anxiety and no amount of you trying to make it a medical issue, and thus "easily treatable" is going to make it so.  Start counseling immediately.  And for god's sake, call the school.

You have an agenda

We are experts at determining who just wants narcotics.  Seriously.  There is no story we have not heard.  If you say your drugs were stolen we will expect that you have filed a police report.  Bringing a note from your doctor, copies of scans, and empty prescription bottles is laughable to us.  Bringing your kids with you is a rookie move.  Further, if your chief complaint is one of the Holy Trinity of pain complaints (back pain, dental pain, migraine) you are already suspect.  FYI, we are now RARELY prescribing narcotics for ANYTHING.  I'm sorry if your doctor told you to go to the ER.  Please put on your big boy pants and make an appointment.  And yes, dental care is EXPENSIVE , but you only get one set of permanent teeth.  Judging by the condition of yours you have not made it a priority, brushing and flossing being just soooooo tedious.

Work notes are handy to have when you have failed to go to work because you are sick.  Please understand that your work note will just say "seen in the ER today and OK to go to work", it will not explain why you have been out for a week.

One woman's chief complaint was "I'm really short of breath and I'm going to be homeless", and seeking a medical hotel admission which is basically someone to wait on her.  She then proceeded with concierge demands (sandwiches, juice, hot blankets, more pillows, phone charger).   She was kicked out eventually because there was no reason to admit her, although the social worker went to great lengths to help her with her situation.  The next day, she presented as suicidal in hopes of an inpatient psych admission.  Sorry, no beds for days.  What you will be getting is a 24 hour suicide  watch in the ER, paper plates, no food that cannot be eaten with your fingers as we don't allow utensils (so you aren't tempted to stab yourself in the jugular with a plastic fork).  Also, no TV, limited phone privileges, and a hard, uncomfortable ER cot.  Difference between a 4 star accommodation and a Motel 6.

Embellishment (to appear sicker, thus garnering a bed and hastening access)

An ambulance ride does not automatically guarantee you an immediate bed in the ER.

Don't call an ambulance if you don't need it.  This is the worst thing to do to your neighbors and community.  If your family members, all 15 of them, have preceded your arrival, please feel free to join them in the waiting room.  If your EMS providers patch in on the radio and tell us "well known to your facility", "normal vital signs", we will ask if you are appropriate for triage.  And out you go to join the queue.

Don't lie if you've been to another hospital and claim that you don't know why there are bruises on the arms and sticky residue from adhesive tape and monitor leads.  You didn't "just get blood drawn". That's three days worth at least, right there.  If you walk in on crutches that are about 10 years old and have tea towels on the arm pads, and claim that you "just got them",  your nonsense knee injury will be deemed bullshit and you will not be receiving the Percocet you claim is the only thing that works.

We have seen caregivers of every type and description bring their patients to the ER with everything from seizure to altered mental status to weakness to pulled out feeding tube.  Often these caregivers scarper at the first opportunity and are never seen again.  Some local nursing homes have been known to send a challenging patient or two to the ER on a Friday afternoon with "fever", which is non-existent on arrival.  When the patient is ready to back, they claim "their administration won't take the patient back because they are too disruptive/demented/violent".   We usually win the administrative sumo wrestling, our patient services rep is a more of a pit bull than your corporate clipboard.  The patient will return to your facility and you will have to deal with it on Monday, sorry.

Worst of all, DON'T EVER, EVER lie about chest pain.  If you are in the ER for chronic back pain, do not say you have chest pain to get seen quicker.  That is the ultimate dick move, and will not be treated kindly.  You will likely not die of the chronic back pain for which you have run out of pain meds, but somebody may while we attend to your nonsense.  And it will be well documented for your next visit for something potentially bad.

Karma.  It will get you.

Dobby is free

In the midst of the busiest of busy days ever, this little germ pops into the ER for  evaluation of
"I can't feel my toes".

As this was a person in her late 20's, I was not concerned about anything truly serious until I saw that she was wearing a post op shoe. (AKA, Ugly Shoes: sizes small, medium and large).

"What happened to your foot?"

"Well I broke it a couple of weeks ago, and that is fine.  I was shoveling out my car from the snow, though, and now I can't feel my toes.  The officer who helped me thought I should get it checked".

She apparently did so in the last 20 minutes while wearing a sock and the post op shoe.  On one of the coldest days.

"I see.  Is your sock wet?"

"yes, I didn't have time to change it".

"Ah.  Well, here is a pair of dry hospital fuzzy socks and a warm blanket.  Take off the post op shoe and the wet sock.  It is about a 3 hour wait".

Moron.

For the amusement of Fil, I documented the following:

"Ednurseasauras has given Emily a sock"

Tidbits from triage

Happy New Year!  Count down to retirement!  In 3 years, sigh.

Holiday weeks are either crazy busy or crazy slow.  This past week was the
Worst.  Week. Ever.

Limited office hours at overwhelmed primary care locations, urgent care and doc in the boxes just sending everybody with a pulse, stacks and stacks of people.  At no time was there any less tan 10 people awaiting triage and a four, five hour wait for care.  22 in the rack waiting to be seen by a doctor.  Thanks to protocols and docs trusting us nurses, the sickest were seen first and the kind-of-sick had EKG's, labs and X-rays in progress or completed.  It didn't exactly streamline things, but it was helpful to get stuff going.

Of course, when people are that sick in the waiting room, the squeaky wheels just make life more difficult.  Complaining about the wait.  Embellishing their symptoms (adding chest pain to the mix did not expedite their visit).  Fake vomiting didn't work either, there were no beds, just none.

I had one man voluble complaining that his 78 year old mother had been waiting 3 hours.
"Our doctor called about this!  It's ridiculous!  She's old and sick and needs to see a doctor right now!"

In response, the family member of another patient told him to sit down and be quiet.

"My mother is 85 and she's just as sick, and we've been waiting longer than that."

Hilarity ensued.  I called security and ducked back into my cubicle.

Drama alert.  I was told there was a woman who was in the bathroom and was screaming for a doctor right away.  A 17 year old was on the throne, moaning that her intestines were on fire, she couldn't get up, and wanted to have diarrhea and throw up at the same time.

I sent a couple of barf bags over the top and advised her that I would see her in triage when she was ready.

On the subject of "my doctor/urgent care/ called ahead":
We probably had 50 notifications on 3-11 shift alone.  Yeah, your doctor may have called.  Our doctors don't do what they say, they make their own decisions.   It changes nothing with the process of triage, and we are going to repeat most of the tests anyway, so there's that.  Also,
1.  I don't have a list of your medications.  You should
2.  My computer doesn't have the same information as your doctor.
3.  You are not getting an MRI today for your back pain.
4.  You may be admitted, or you may not.  Please leave your suitcase outside.

At five hours into my shift I elected to use the bathroom and eat some food.  Naturally, the next patient  gave me a snarky "Did you have a nice lunch?".

I responded pleasantly, "What kind of work do you do?"
He told me some office type occupation.
Me: "Oh, so you don't get lunch?"
Him: (haughtily) "I do, but I don't deal with life and death"
Me: (narrowing eyes and leaning forward slightly): "Exactly"

He was there for man-cold.  Enjoy your 5 hour wait.