One of my most annoying pet peeves is individuals who wear pajamas out in public. Nothing quite says "I don't give a crap" more than donning fuzzy pajama bottoms and going out to the market, the pharmacy, Chile's....unless said individuals find it necessary to also don fuzzy slippers. Apparently the rules of polite society don't apply anymore.

I am equally annoyed when seemingly able bodied individuals come the the ER in pj's. If you drive to the ER, and also come in with a coffee from Dunks, you will be deserving of my scorn. Apparently, America's sick and stupid run on Dunkins also.

Of course, there are exceptions to this rule. I am perfectly willing to be accommodating to people with actual emergencies; chest pain, cutting off a finger in the snow blower (why they were snow blowing in pj's is a story for another time), children under age 9. Generally the elderly, anyone who arrives by ambulance...you get the picture.

I assume that anyone without major hemorrhage or an actual emergency who arrives in jammies and slippers is just being dramatic. Or an idiot. Or both.

So it was with a significant amount of effort to prevent the eyes from rolling right out of my head that I triaged an ENTIRE FAMILY of 5 wearing pajamas at 9 PM on a Friday night.

The emergency?

"There was a bat in the house....I think".

Nobody could say for certain; and nope, it didn't bite anyone. But good old family provider thought it was good idea to go to the ER for rabies prophylaxis. Immediately.

Post-exposure rabies prophylaxis is not terribly complicated, but it requires a LOT of calculations. For starters, everyone gets a 1 CC dose of rabies vaccine. This is the easiest part, and actually kind of fun to mix 'cause it produces a reeealy pretty magenta solution.

OK, enough of the fun part. Next, the patient also gets rabies immune globulin which is weight based; the more you weigh, the more shots you get.

Now, nurses really don't like to give a ton of shots, so the calculations involve squeezing as much of the medicine in as few shots as possible. If you are a big person, say, 250 lbs., let's figure this out together, and

YOU BE THE NURSE
The does is 20 IU's (international units) per kilogram. At 250 lbs., the patients weight is 113 kg. The total dose is 2260 IU.
Since the immune globulin comes 150 IU/ml and there are 300 IU per ampule, you will need you will get a grand total of 7.5 ampules of immune globulin.

Now, that is a total of 15 ml's to be divided into less than 3 mls per shot.
So, a 250 pound individual gets 5 shots of immune globulin and one shot of rabies vaccine on the first day. They have to come back three more times for more of the vaccine as well.

Wasn't that fun? And clear as mud?

But wait! Naturally, there is an app for that!

I don't have it, so using a standard calculator the old fashioned way is the only option. I still laughed my butt off when I read the description for the u-Rabid XL application for calculating rabies IG doses and followup scheduling:

"uRabid XL is the fastest & easiest way to calculate the Rabies Immune Globulin dose & Rabies Vaccine schedule.

Using standard US dosage calculation just enter the patients weight to determine the correct dose and use the division tool to calculate how many injections to give!

The bottom half of the program provides the standard Rabies Vaccine schedule for all return visits.

No calculators, no calendars - No hassle! uRabid will finally take all the guesswork out of injection administration for patients exposed to the deadly rabies virus"

It was a LOT of shots for 5 people, and we didn't have enough IG to accommodate both overweight parents and their pudgy children. The parents decided they didn't want it anyway when they found out how many shots were involved. I guess they probably went out to dinner and a movie in their jammies.

Crap Notes

I don't know why hospitals feel compelled to put bulletin boards in bathrooms designated for use by nurses. That is just EXACTLY what I want to do when I run in for a moment's relievment before ascites sets in: look at a bunch of messy notes, memos, bulletins, threats and various and sundry missives begging for donations.

Let's take a quick-look tour of said bulletin board, shall we? I will lock the door for my privacy.

Here is a poster that has been up for 2 months now advertising a fundraiser for Haiti. The event date is sometime in May. We will be "dancing the night away" to some band called The Casuals, and there will be a cash bar, raffles and fun, fun, fun. Hmm. Nope, don't plan to attend as it is run by Darlings of the Mother Ship with whom I have no contact. I am boycotting anyway since Administration refused to reimburse in any way nurses who have volunteered for humanitarian missions. Sherry was deployed to Haiti for two weeks, was home for a week, then went on her annual trip to Guyana (at her own expense). Not that she expected any financial remuneration, but you would think a catholic hospital would be more charitable; the party line here is, I guess, charity does emphatically not begin at home. However, any employee who wished could give up some of their earned time to help out. Mmmmm kay?

Here is another: Bring Your Child to Work Day sometime in April. (Grandchildren also welcome!!). This is not imply that the little darlings get to stay with mummy or daddy (or Granny and Gramps). Nope, the kids will be herded to the cafeteria and fed hot chocolate, given coloring books and stickers and probably be made to join hands in a circle to sing Kum Ba Ya. Then an exciting tour of "materials management, food services, the front lobby and out patient services area" will ensue, followed by a free lunch. This effectively keeps the younguns out of the very clinical areas in which we are attempting to interest them. If mum or dad is a nurse, sorry, you don't get to see them performing amazing feats of nursing care. I am not sure how this fiesta would promote careers in health care, but if my kids were young I would have signed them up tout de suite. I did everything in my power to discourage health care careers with both K and J, and have thus far been successful. I had a bit of a scare when K decided on a career in social work knowing that population sucks the life right out of you. Fortunately, she decided that while the practice of social work was distasteful, the study of sociology was sublime. So she majored in that, and minored in English. Ah, I would love to minor in English, but it is just not possible with my BSN program. No minors allowed, haha.

There are several memos on the bulletin board for CPR, ACLS, PALS and the like. One of them has listed all the personnel who require such certifications and the expiration dates; I notice that the name of the woman who died last year is on the list. Talk about expired.

There are more notes to "join this, read this". Oh, here is one for CPI class. Now, this is Crisis Prevention Institute, which "trains human service professionals in ways to safely manage disruptive and assaultive behavior". Here's how I handle it: 911. These classes used to teach about one hours worth of self defense maneuvers, surely enough to keep you REALLY safe until the wheezing, overweight and geriatric security guard shuffles on in with his walker. Urgh. This is a mandated course so that the bean counters can check off one of those distasteful little chores, likely mandated to them by JCAHO, Homeland Security or the ASPCA. Violence in health care is pervasive, haven't you heard that 75% of nurses have experienced workplace violence. If that isn't a ringing endorsement for recruitment. I have been pushing administration for years to let us have tasers. I know that there is pepper spray in a foam available, but how about if it was more like Silly String? That would be awesome.

A flyer for the Northeast symposium for ER nurses has the usual offerings of panels, discussions, lectures and vendors. But act now and you can get on a romantic dinner cruise on Lake Champlain on Maid of the Mist, or whatever. Nah. Heard there was a monster in there.



OK, one more. I love this. It is for the Sunshine fund. Gotta love the Sunshine fund. Lee runs the Sunshine fund with all the attention to detail that was not evident in any of the banking scandals of 2009; with an iron fist. I don't think that $36 a year is unreasonable, and look at the perks. Fruit baskets and flowers. For all occasions! It does specify the conditions for which one might receive an honorarium. Ahem. Hospitalization (inpatient) of employee, spouse, or child. Death of employee, spouse, child or parent of employee. Birth of a child of an employee. Graduation of employee from an institute of higher learning, either graduate or undergraduate. Although my boss got a party when she finished her Master's degree. If I ever get mine, screw the fruit basket and just send me a gift certificate for a massage. There are some situations that aren't covered, for example, our housekeeper attained US citizenship and he got a nice fruit basket. And one of the ladies in the lab got remarried. Wonder why the newly divorced don't get fruit baskets? Shit, I'm beginning to sound like Andy Rooney. I hate Andy Rooney. So last year Mr. Ednurseasauras was hospitalized with a nasty infection in his hand (due to a near fatal goring with a tree branch when he was hiking Mt. Washington). About 2 weeks later, I got an envelope containing a $50 gift certificate to a very nice restaurant along with a profuse apology from Lee for not having acted immediately to acknowledge my husbands pain and suffering. Lee prides herself on flawless accounting, diligent collection of funds, and instantaneous provision of tokens of sympathy and congratulations. Mr. Ednursesauras had knee surgery 3 months later, and the fruit basket was in my kitchen when we returned from the Big City. I wrote a lovely thank you note and requested to be passed over if anymore of my family (or myself) became ill so as not to be asked to pay double the following year. So far, so good. Enjoyed the fruit, too.

Around Town (Part 1)

I live in a pretty small town; I also work in a pretty small town, however, there is a miles-wide socioeconomic gulf between both of these villages. My work town is an old mill-town; we will call it Milltown, for the purposes of fun and entertainment. It is on the lower end of the social order, a poorer town with all of the problems that one would expect. It is also the more interesting of the two, and I tend to spend more time there than in my own town.

I know many of the police officers as they are mandated to "check up" on us in the evening, being an establishment of mostly women. The majority of our docs are male, as is our Brazilian housekeeper, but our only security team is 911. We have video surveillance, but more on that another time.

I also know the EMT's and paramedics from Milltown, as well as surrounding towns. These are always good people to know. They are mostly hard working and care about the patients, as well as being mindful of our limitations in my small facility. For instance, most will not bring us cardiac, stroke, major trauma, head injury and the like for lack of CT scanner and other diagnostic tools or the ability to definitively care for them. The paramedics from my town are lazy, though, and at night they tend to bring inappropriate but stable patients to us. They know better than to bring alcohol intoxication and suicidal patients to us (although they do walk in) because we have no facility to watch them, keep them (and us) safe, or a social worker to arrange appropriate admission. Of course at night they do anyway; a couple of them, as I said, are lazy. There are exceptions that we gladly accept from any town EMS, though; they have had several "hot potato" cases and major trauma involving a child that have been brought to us because they are 1. without an airway or 2. so badly injured they need to be airlifted to the Big Time Hospital. Conveniently, the landing zone is our back yard. We don't panic, we are all well trained, or have spent time in trauma centers. We do the job we are trained to do despite the limitations to the best of our ability. In several of these worst case scenarios the patients have survived and done well. We all pat ourselves on the back for a positive outcome.

There are lots and lots of people that routinely use the Milltown Medical Hut and Boat Rental. Some have insurance; many do not. It will be interesting to see what the Obamessiah's health mandate will provide for all of us in the coming months.

Today's Last Patient of the Night

Why is it that patients with generalized crotchital complaints come to the ER right before closing time? Discuss. I will get a snack.

I recounted this patient with the acquired pants circus. Tonight, I will tell you about another kind of circus.

Diana, Cathy, Beth, Dr. Cindy Lou, and I were finishing up a deadly slow night and hoped to deadbolt castle gates and release the crocodiles into the moat, when, of course, the final patient of the night ambles in. With broken crotchery.

I watched on the video camera as two people strolled in at 10:45 PM (remember, we close at 11 PM). Helen, our secretary/receptionist/social director/den mother/worry wart had already directed them into triage. Helen is a bit older than middle aged, remembers everybody's birthday, anniversary, kids, spouses and pets names, asks after everyone's events, vacations, days off and remembers what those plans were. She feeds and fusses over us if we nurses are too busy to eat, tosses rooms for us, shuttles labs, and we would be hard pressed to function without her. She would give you the shirt off her back and buy you a Coke with her last dollar if you asked for it. We love her and protect her as much as possible, and I don't allow her to be exposed to rude people and idiots in general.

So I was right on top of this one, and whispered "What is it?" as I passed her in the hallway.

Helen laughed nervously and whispered,"I don't know, they said it was 'personal'".

Ok. I opened the conversation by asking my standard "What can we do for you today?". There was a teenage boy sitting in the hot seat who appeared calm, cool and collected as he slouched. Mom, on the other hand, was pretty ramped up. Perhaps too much coffee.

"Well, he has been walking around like he has a load in his pants all night, and I called his pediatrician and they said to come right down and get it checked out because I really didn't think it should wait until tomorrow they said something about epi-, epi, uh something but it didn't sound good so we came right away".

Take a breath, lady. "Um what exactly is the problem?"

"He has pain in his....well, down in.....I don't know how else to call it: he has pain in his ball sack". Except she drew it out like "baaaawwwwwl sack"

I am mentally pinching my lips and reciting, don't say scrotum, don't say scrotum.

"So when did the pain start, and is it on one side or both?"

The kid shrugged and said "about 5 o'clock I think".

Mom disagreed, "no, I think it was more around 6 or 6:30, remember, we had the pizza and you didn't have it then and after we talked about baseball and you were on the phone for awhile about that assignment.."


I managed to get a word in to ask about injury and urinary problems, no longer addressing my questions to mom. Mom, however, was determined to have the last word.

"He swears to God he isn't having sex, that would be another whole set of problems wouldn't it, but hell you can't watch them every minute and he doesn't have a girlfriend, as least he says he doesn't, and he is not whacking off...."

"Um, I think we can go ahead over to Helen to get him registered and then Dr Cindy Lou can see him as soon as...."

Mom still hasn't taken a breath or my hint to shut it down and continues, " what do you think it might be, will you do tests or xrays or what? I was thinking it could be nothing but didn't want to take a chance; I called my brother and he said it was probably blue balls, I don't know what that is but it sounds really painful and bad, do you think it could be something like that?"

I coughed into my hand a few times to hide my laughter and directed them to the registration desk. "I'll take the young man into a room, right around the corner when you're done", I sang, and whisked him into a treatment room. I directed him to undress and closed the door.

My audience awaited. Cindy Lou asked, "Ok, what is it?" Within a minute she was already on the phone with the Mother Ship to arrange for an ultrasound of his Baaaaaawl sack since we only have ultrasound during the day. They were out the door in 10 minutes.

I restrained myself giving mom a copy of "Adult Words for Body Parts". Wonder if she still calls it a winkie.

Today's Last Patient of the Night

She had experienced chest and arm pain since early AM and strolled in at 10:50 PM (we close our doors at 11, but must stick around until the last patient leaves). Her medical problems included fibromyalgia (eyeroll) and Lyme disease. Her allergy list had 30 medications.

My doc asked her what about her pain had changed at that hour of the night that had not bestirred her to come to the ER earlier in the day: "I didn't want to go to bed with it". Uh huh.

In rapid succesion she was put on the monitor, given oxygen, an EKG, an IV, aspirin and nitro. (now 10:57).

Brian, my doc, is a take charge, no bullshit, straight shooting, decisive, action oriented ex Navy Seal who does not suffer fools. He is also committed to Getting Out of Work on Time at all costs. He can be funny as hell, too. At this hour of the night, though, he is all business.

"Don't even run that blood; she's headed downtown (to our Mother Ship) right now. I'm not dicking around with this for an hour when she needs to be admitted anyway".

Cool. He notifies the attending at the downtown ER, we call the local ambulance and she is out the door in 24 minutes.

This was not just an attempt to get her out so we could go home (well, part of it was, but not completely). We would have had to wait until the labs came back before we could entertain the idea of sending her to be admitted. This involves way more bullshit than it is worth sometimes. Since nearly all of our docs also work at the Mother Ship, when on the receiving end they tend to be most obliging with this sort of fast-tracked transfer, knowing that the majority of the patient's diagnostic workup needs to completed. Hey, they have all been there. And most will do anything to avoid the crap that is inherent in a direct admission, particularly in the middle of the night.

Direct admissions (from the ER to a hospital bed on a floor somewhere)are a pain in the ass. It takes hours, literally. Here is a recent timeline, from time of decision to admit to getting the patient our of the department:

8:01 PM Patient x needs admission to tememetry unit. Patient agrees
8:02 PM Call to beep hospitalist
8:22 PM Hospitalist returns call, speaks to ER doc, agrees to accept.
8:27 PM Call to hospital admission office notifying them we need a bed. All pertinent information is conveyed. The admissions office must speak first to the nursing supervisor.
9:00 PM 2nd call to admission office: nursing supervisor hasn't gotten back to admissions. I urge them to beep her for an answer.
9:16 PM 3rd call to admissions office: nursing supervisor is "busy".
9:17 PM In frustration I beep the supervisor 911 myself and bitch. She promises to get back to me in 10 minutes
9:30 PM Still waiting. Patient is tired, uncomfortable, hungry because we have no food, and impatient and is thinking her own bed is looking better. She is dissuaded from leaving.
9:40 PM Finally admissions calls and assigns a bed
9:40:14 PM Call to regional ambulance for transport. Standard response is "30-40 minutes". It is generally closer to an hour. I call rival ambulance service to inquire if their response time is quicker, using the information to play one against the other. It is generally effective and I am promised an ambulance in 20 minutes.
10:15 PM Ambulance dispatchers are liars. Call to dispatch to inquire as to whether or not they have fallen down a rabbit hole; "Just down the street!" they say. Yeah, right.
10:20 PM Ambulance arrives. The paperwork is exchanged, the ritual fiddling and diddling is accomplished and the patient is out the door at:
10:32 PM It takes about 20 minutes to get to the Mother Ship. 10 minutes to get to the room and into a bed, and the patient still has not been examined by the hospitalist. This occurs THREE HOURS after the decision to admit the patient has been made. Shameful.

This is why our Last Patient of the Night got a Fast Rail pass to the ER. It would have been 3 AM before she would have gotten out of our department.

Working at an ER that closes has given me a new appreciation for the dirty looks I get at Stop and Shop when I run in for one thing; I tend to go to the all-night WalMart instead, even though it is out of my way.