We Do This To Ourselves

So with New Cathy gone, I have had a few days of working with SIC (Second in Command). She's not too bad to work with as long as we are busy. I have figured out that I am somehow threatening to her, or that my experience makes her feel inadequate. The sum total of her ER experience lies within our small 6 room facility. That doesn't make her a bad ER nurse, she is actually a very good nurse and I have never knowingly said or done anything to make her think that I felt she was incompetent, but people can be so weird. Having worked in larger, busier ER's where nurses have more autonomy and/or standing orders, (and flow rather depends on it) I sometimes chafe at waiting to get things started when I know that they are going to be required anyway. I appreciate that we all come from different backgrounds, so maybe she is finally getting comfortable enough to let her guard down instead of always being on the attack. Anyway, we were working with Bobo, who is still, apparently on his meds and willing to have a laugh or two.

Bobo had the misfortune of having to deliver (for the first time since his residency) a baby several months ago at our treat 'n transfer station and Taco stand. Luckily, he was working with Mikki who has some OB experience and the midwife showed up to "coach" over his shoulder. Mom and baby did fine, but Sherry and Bobo were shaken up since nothing strikes fear into the hearts of ER personnel like the sight of a gravid female in active labor. At Your Cervix, I know this is your thing so hats off to you.

You can maybe understand why the 39 week pregnant female who "just wanted a labor check" (we don't do this) was not an especially welcome patient, especially since she didn't want to have to drive to the Big House downtown. You should know that, especially anxiety provoking for us, she was Gravida 10, Para 7.*

And no ma'am, she didn't call her OB. WTF.


Some creaky, squeaky memory deep in my brain from about 40 years ago whispered that with that number of pregnancies and deliveries, she was the most fearsome and feared of all OB patients, the Grand Multip

She was having inconsistent contractions; or maybe they were Braxton Hicks. No rupture of membranes. No history of precipitous delivery. She just "didn't want to go all the way downtown to be told just go home, you're not in labor".

As if.

As she was using the toilet she remarked, "Gee, I almost feel like I have to push".

"No you don't!", I shot back. Saying it makes it true, right?

Finding a fetal heart rate is not my strongest skill set, but I managed. This was followed by quick check by Bobo who insisted on sending her downtown in an amb'lance even though she was only 2-3 cm.

I know, I know. Why?


L.I.A.B.I.L.I.T.Y. The bottom-most rung of the bottom line.


Rather irksome in an otherwise successful turf was the bored and superior-sounding L&D nurse to whom I gave report. She had no idea that we are in the sticks without so much as a baby warmer which is why the hot-potato treatment.


When I was younger and inexperienced, I might have been made to feel badly. Now, I just recognize this kind of behavior for what it is; the "Eat your young" mentality rears its ugly head. We all have our strengths and weaknesses, comfort levels, and skills; it is important to remember that. Different specialty and critical care areas require different knowledge and education. In the ER, we have lots of knowledge and a variety of skills; we know a little bit about some things and cover every age from cradle to grave. That doesn't make me an expert on everything, but it does give me enough knowledge to have a healthy respect for what is most dangerous, and, most importantly, what I don't know.

In fact, that is kind of the point, isn't it? Every patient we see in the ER, every patient we triage we think, "What is the worst case scenario here?". Then we go about ruling it out, right?

Chest pain: having a big MI, or costochondritis?

Shortness of breath: pneumonia, PE, or anxiety?

Rectal bleeding: a big GI bleed, or hemmorhoids?

Rash: poison ivy or necrotizing fasciits (flesh eating disease, so called)

This is why most people go to the ER in the first place, they think of the worst thing it could be(or have determined that they have it, thanks to the magic of the internet) and count on us to rule it out. We often don't have to hunt Zebra,** the patient has conveniently done it for us.
But it's nice when we can help minimize their fears and allay their anxiety.

We certainly would never tolerate anyone who made the patients feel stupid, no matter how trivial the complaint may seem at first glance. That is one reason why it is sometimes so difficult to calm people with non-urgent complaints who can't understand why they are being made to wait. We don't make them feel stupid. It would be really nice if the culture of nursing was such that we go out of our way to extend the same courtesy to our colleagues.




*10 pregnancies, 7 births. This would be her 8th child.
**Zebra hunt: "If you hear hoof beats think horses and not zebras". A rephrase of Occam's Razor: All other things being equal, the simplest answer is usually the best.

Winter, sigh.

New Cathy is off on a cruise somewhere warm; how dare she leave me to the cold, arctic north. Mr. Ednurseasauras has been in Arizona with the guys (OK, Vegas too..but he doesn't drink, gamble or do any of the stuff that normal people do in Vegas). Before he left, he spent 20 minutes teaching me how to use the snowblower in case of a Nor'easter while he is gone. It is a brand new snowblower. Let the record show that I have now used it more than he has. With another storm dumping more of the cursed white stuff yesterday, I am glad he is back and ready to resume snowblowing responsibilities. And that I didn't screw up the snowblower by putting in gas from a small container intended for the leaf blower.

There is so much snow we are having trouble getting rid of it in some areas. Last Friday I told Jane, my boss, that the pile of now in our parking lot had completely covered up the handicapped parking signs by the patient entrance. I thought that this was a problem because people without handicapped placards were parking there indiscriminantly, even people who come in 3 times a week and KNOW that they shouldn't park there. That leaves the little old ladies to park in Hip Fracture territory, and wouldn't that suck if one of them fell. She said she would put in a work order to have the signs unburied.

That was 2 storms ago. Now the snow pile is higher than the top of a full sized pick up truck. I worked a rare day shift today and was pretty surprised to find one of the building and grounds guys driving in. He came in laughing and wanting to know if we were smoking crack because those signs were gonna stay buried for a good, long time. He offered to drive back to the Big House to get some sawhorses and put some makeshift signs up. I can only imagine what kind of violations we would be racking up when someone with a placard complains.

The Lady on Elm Street

One of our least favorite frequent fliers individuals well known to our facility is a very large lady (over 400 pounds) for numerous non-emergent complaints. In fact, she utilizes the town ambulance service several times per week for her free taxi ride transport to the ER. On one less than joyous occasion, the ambulance stretcher malfunctioned, causing this plus sized lady to plummet to the ground. Never mind that two of the EMT's sustained injury. Now, when the ambulance is toned out to a medcal call at number x Elm Street, an entire batallion of responders is activated. Self preservation. In addition, if transport is required, there is call service who sends a bariatric stretcher. More self preservation, as well as shielding the town from a lawsuit.

Once her care is completed (usually some minor dressing change, an xray of a wrist, elbow, knee, ankle from fall, or abdominal pain that she suffers from chronically) she is ready to go home. On the return trip, she invariably asks for a taxi voucher. The local taxi service is reluctant to take her because she rarely wears more than a nightgown and robe, her fuzzy pink (or used to be pink) slippers that smell like pee, and she leaves the back seat of the cab a mess. Since the single cab company knows the address, there aren't many who are willing to risk their backs to heave her out of the cab. We don't have the authority to give the cabbie a whopping tip, but usually they deserve it; consider it combat pay.

Sounds like this lady is a pretty sad case, doesn't it? That because of her size we are reluctant to provide care? Consider her problems her own fault? Don't care that she has nobody to care for or about her?

Wrong.

So wrong.

We have all tried so hard with her; most of the doctor's have had caring heart to heart chats with her about how dangerous her weight is for her health, discussed options ad nauseum, services, alternatives, health promotion. The Talker has spent hours with her; Cindy Lu Hu has spent hours with her; Gil has spent hours with her; Cripes has spent hours with her; even Bobo has spent hours with her. Her response was to lodge a complaint against each and every one of them because they discussed her weight.


A.


Complaint.


How can you help someone manage their health by ignoring (forgive me) the elephant in the room? Can't be done.

Kerry got written up because she tried to arrange a home health aid. Why? It was none of her business what her home was like; never mind that she smells like a goat. Kerry did it out of concern for her well-being and she was repaid by getting a complaint. So has Sherry who has seen her as a home-care patient. So has Mikki. So has our boss, Jane. Jane had this little gem to share:

"I was putting ornaments on the Christmas Tree in the waiting room and I dropped one of them. It landed on the floor and shattererd. The Lady from Elm Street was sitting in the waiting room and said to her companion (with whom she had managed to get a ride for an outpatient blood draw), "Did you see that? She threw that at me! It's lucky we didn't get cut! I should complain"

I gave her a steely glance and said I hope you are kidding, in a deadly voice.
She backed down and said she was. "



I learned that there had been no less than 20 complaints over the last two years; she must have Patient Services on speed dial.

We all know how this will end.

She will have need of care for a life-threatening issue when she calls 911.

More likely, one day EMS will find her dead in her house.

Today's Last Patient of the Night.....

....was 22, had no insurance, had presented 16 times in the last 8 months for the Holy Trinity of Pain Complaints* and wanted oxycodone for menstrual cramps.

Um.

No.

*migraine, dental pain, back pain

When Spidey Sense Kicks In

The patient had presented with mid-lower back pain, more in the flank area, rated as maybe 4/10. He felt a little uncomfortable. His BP was a little high, heart rate in the 80's. Dr. CindyLou Hu pounded on the area but the patient said nah, that doesn't hurt, it feels like it is DEEP inside. Hmmm...

Back pain? or something worse?

Dr. CindyLou elected to do a CT instead of sending him home with pain meds. It showed a HUGE dissecting aortic aneurysm (click here to read about it). This would be a bad thing, but there are two types.

One type requires surgery like, yesterday; if it ruptures, it's all over. The other can be treated conservatively with medication. It was an overnight shift so CT's are read remotely by an on-call radiology service with whom the hospital contracts; I believe they exist in bunkers somewhere, perhaps in Antarctica, or in rainforests, possibly connected with the Dharma Project and sharing office space with Keebler Elves while alternating searches for Sasquatch and the Loch Ness Monster. Normally there is a little bit of a lag for readings (hey that happens during the day as well). Fortunately this guy had the NOT IMMEDIATELY FATAL type and was admitted to Higher Level of Care Medical Center where he did well.





As Dr. Cindy Lou and most nurses would say, sometimes you just gotta go with that gut feeling. Not all BAD THINGS slap you in the face and say they are a BAD THING; but experience helps, and sometimes the patient just can't say for sure what is going on beyond (and this includes parents regarding their kids), "there is something that just isn't right".





I once had a 38 year old with nausea who said he just didn't feel right; except he LOOKED like he was going to die, literally, right in front of me. An EKG confirmed that he was having the BIG ONE. Some nurses never develop that sixth sense that prods immediate action, but most do. Gotta trust that Spidey Sense.