It had snowed 2 days before.  Not much, just a couple of inches of fluffy, sugary white stuff.

For days, her little footprints were still clearly visible.  Into the woods behind my house.  Headed half way to my neighbors house to check on his dog.  The flattened area where she rolled.  She loved to roll in snow.

The steady cold weather ensured that those footprints would remain undisturbed for weeks.  Looking at them crushed me and always brought another round of weeping.

When the temperature climbed to  just above freezing, the gradual melt made the prints bigger, then bigger still, until it was  large patches of grass with little snow.   She loved to roll in that, too.  I could somehow still see footprints.

My heart is broken into a million tiny pieces still.  But I can more often think of her without tears.

 I miss her.

  

It was the shoes

The purpose of a triage interview is to gain pertinent information about the patient as quickly and efficiently as possible.   It is best to let the person triaging direct the questions.  It saves a lot time.  It helps when it is actually not painful.

In truth, it is acutely painful at times.

While I was watching the Wizard of Oz recently, it occurred to me that explaining how the triage interview works can be compared to the tale of how Dorothy comes to be present in Oz.  I leave out the Tin Man and the Cowardly lion due to time constraints.


Me: "Why are you here?"

Patient: "Well, there I was, living with Auntie EM and Uncle Henry, and Miss Gulch was mean to Toto**... so I ran away, and.."

Me: "Why are you here TODAY?"

Patient: "Well, because Miss Gulch was taking Toto away, and  I decided to run away from home.  I met this man, a fortune teller, who told me there was a  tornado..."

Me: "What are the SYMPTOMS that caused you to come to the ER today?"

Patient: "After I went up in the the tornado I landed on a wicked witch, then the munchkins told me to follow the Yellow Brick Road...

Me: "Excuse me..."

 Patient:  (keeps talking)... with Toto and the scarecrow, and we were headed to Emerald City because..."

Me: "I'm going to stop you there.  If you could use one word to describe to me the complaint that brings you here today?"

Patient: "Well not really, it's complicated, its about way more than one thing..."

Me: "STOP.  One symptom, impulse or concern.  Just one"

"Oh.  Headache.  But...."

Me:  () Actually, I don't say anything.  The thought bubbles have stolen my speech.

**In my scenario, Toto is an emotional support iguana because Dorothy says he is.  In my opinion he is poorly trained.

ER nurses are really good at IV's.  Patients who profess to have "bad veins, being a really hard stick" and ask for someone "very experienced with difficult veins" are frequently not all that difficult....if you know where to look.    It begs the question, "how do you get good at starting difficult IV's if you don't do it often enough to get good at it?"  Often patients who will pick their IV spot have done so repeatedly, so "that one good vein"  is no longer a viable option.  

Here's what doesn't help:  Snarky and stupid  comments, superior attitudes, and straight up  challenging.  I'll let you decide which is which.  

1.  "Oh, good luck with that"

2.  The last nurse who tried an IV stuck me 15 times (bullshit.  There isn't a nurse on the planet who would do that many sticks.  Most are 3 and done, I'm 2 and done myself).

3.  I can't have any IV's in my hand.  "Why?"  I don't like them there

4.  I'm left handed, suck my thumb, text with that hand, etc, etc, etc.  

5.  It just always hurts if you put it there.

6.  I can only have a butterfly, and a really small one,  

7.   I've never had an IV there before

8.  You get one try.

9.  Trying to explain things to a 10 month old
10. Telling kids "it's not going to hurt".  I never lie.  It will hurt.  I say "pinch", not beesting like many of my cohorts.

I tell the ones who demand the best that I'm better than average with 40 + years of experience.
I tell them I only try an IV if I'm confident.  That is most of the time.
For those who tell me "I usually get blood drawn in this vein", (AKA choosing your IV site) I will always try there first.  Even if I think it's not going to work.  Even if I am dead certain it's not going to work.   You can blame yourself for that, having painted me into a corner.   I have forgotten more places to try IV's than you will ever dream of, even if you are an IV drug user.  And that's saying a lot.

The current trend of using ultrasound for IV's has hit a frenzy in my ER.  There are a few docs who are good at it, really good.  Now we have training available for RN's and paramedics who want to learn, but I will definitely not be one of them.   I have found that with so many people wanting to use the ultrasound and practice this shiny new skill, it has taken the art out of it.  IV starts will go the way of the dinosaur.  As will I, I suppose.  As will I.