Darwinism...

......the process by which, via natural selection, unfit specimens remove themselves from the gene pool

A few candidates who are genetically hanging by a thread for your entertainment.  There will be a quiz at the conclusion of this presentation:

A.  40 year old man came in complaining of "really bad burns".  He had been at a local bonfire/pep rally or some crap, and was tending to the fire.  He had some 1st and 2nd degree burns on his right hand and arm, and the backs of both legs.

Me: "How did this happen?"
Guy: "I threw some gasoline on the fire"
Me: (blurted before I could stop myself), "WHY??"

Did I mention that he had three or four kids under the age of 12 with him?  Um, yeah.

B.  33 year old who used heroin for the first time.  At work. That's all I have to say about that.

C.  42 year old who had a couple of beers at lunch and went back to work.  As a roofer. Using a nail gun, he buried a couple of inches metal into his proximal femur. THIS CLOSE to his femoral artery

D.  36 year old nearly removed his own knee cap with a chain saw.  He admitted to taking a "butt load" of oxy's daily for his chronic pain condition for which he is disabled.  Let me also mention he weighed over 300 pounds and had stopped at Burger World (as evidenced by paper sack he was toting) and had a blood pressure of Patent Pending/100.  A more cynical person than I might wonder how in hell he imagined using a chain saw in his debilitated condition was a good decision. 

Which of the following statements is true: (I told you there would be a quiz)

1.  They are all men
2.  They have all made galactically stupid decisions
3.  Antibiotics cure viruses.

A.  1 & 2 only
B.  All of the above
C.  1 & 3.
D.  None of the above

On Falling

I was asked to cover a couple of hours for Kerry on a day off so she could go to a meeting, or buy chickens or something; sure!  2 hours=1/2 of a princess shift.

I took care of only one (one!  ONE!) patient for 2 hours and 20 minutes.  Young.  No job, no insurance and had applied for Medicaid when she found out she was pregnant; I don't know why she wasn't already on it since she had only one arm, a congenital condition.  She seemed like someone who had, or would soon be, falling through the cracks. 

She didn't know what to do: she was by herself and scared.  She had just had a "screening" ultrasound at a free clinic during her first pre-natal visit; her baby had stopped growing and had no heartbeat, she said.  She did not know what to do next since she wasn't bleeding or cramping.  The clinic kicked her to the curb with some phone numbers.  She was worried about the cost.

We did the usual blood tests and an ultrasound that confirmed fetal demise at about 8 weeks gestation.  Twins.  I arranged an appointment for her that very afternoon with the OB to discuss her options.  She elected not to keep it because she had to get home so her boyfriend could get to school.  I tried very hard to get her to change her mind

"I guess everything happens for a reason", she said.  "It would have been almost impossible with one baby, let alone two".

I made two phone calls to her over the weekend which went unanswered.  She didn't call either.

The next sound you hear will be someone falling through the cracks.

Planning

The 93 year old cardiac arrest rolled in without  advanced airway or IV access.  No drugs.  Asystole.  CPR was halfheartedly in progress.  The young man who had found her on the floor was living in the house, a friend of the patient's great grandson.  The patient was supposed to be DNR.  Why, then, was she in our ER?  The young man called 911 in a panic, and could not produce the DNR or any documentation. Since none of the actual family members were at home, CPR was initiated by EMS.  She was pronounced dead moments after her arrival in the ER since she had an advanced directive on file and the family member called us.  Good; we didn't have go all out on the Poor Dear, and the end of life wishes not to be kept alive by artificial means were (sort of) followed. 

Note to self and others: discuss end of life plans.  Have one in place.  Keep the DNR handy.  If there is a terminal illness, understand what to do if the family member dies at home.  This was a case of good intentions, just a tad short on follow through.

It fascinates me that although death is inevitable, so few families are prepared for it.  We don't often discuss it.  Terminal illness aside, it seems as if by ignoring the Reaper, he will ignore us. 

I can't stress this enough.  Everyone deserves to be treated with dignity, yet there is little dignity  when an elder loved one dies in an ER, worse still when it isn't their wish to be kept alive with heroic measures.   I would hate to have my last image of a loved one lying lifeless in an ER. 

Squirrel Count

I love Gil.  Some of the other nurses thinks he orders too many tests, but I don't.  He likes taking good care of patients, likes to educate, and always has something interesting to share.  Having worked with him for about 2 1/2 years we've come to know him will.  He used to be a little hyper, but he's over it.  We talked about that the other day. 
Gil: "I remember when I first started here, I was kind of ramped up.  At least you guys know when I need a time out".
Me: "Yeah, the first few months were....challenging at times.  Not that you weren't likable, that wasn't the problem.  And it wasn't a time out you needed:  a couple of times I just wanted to slap the shit out of you.  Calm.  I like calm and focus.  Breath in, breath out.  This is not Chicken Little ER".
Gil: "Always some bumps in the road with new docs, huh?"
Me: "Mmmmmhmmmmmmmmm".

Loe the guy, but he's a squirrel feeder.

"If you feed the squirrels, they will keep coming back".  This refers to narcotic seeking individuals.  Gil's solution is to give them, say, 2 Percocet to go and no prescription.  He may think he has shut off the squirrels, but he is still giving them acorns even if it's one at a time.  Besides, it just makes us nurses have to sign them out, put them in a little envelope, and write "one tablet every 4-6 hours as needed for the severe, excruciating and debilitating pain that has brought you to the ER like 20 times this year.  This is all you get, don't ask for more".  Well, not the last part.  Anyway, Gil just keeps on feeding those squirrels.  Last night's squirrel count as follows:

Case 1:
Complaint: Butt pain
Goal:  Narcotics
Plan: Home with narcotics
Female with a bruised butt from a fall down the stairs presenting with 20/10 pain on a scale where 10 is the max.  So bad she took Tylenol about 20 minutes before arriving. She was observed on camera as she walked normally to the door where she then proceded to mmmmmmmmmmmooooooooooovvvvvvvvvvvveeee iinnnnnnnnnnnnnnnnnnn sssssssssssssllllooooooooooooooooooooowwwwwwwwwwww mmmmmmmmmmmmmooooooootion.  Really.  It was like a 78 RPM record being played at 33 RPM.  And if you don't have any idea what I am talking about, ask your......grandfather.  After she got what she came in for, her gait was back to speed as observed on our trusty Spy Cam. I would be so sad if that stopped working.  Very entertaining.

Case 2:
Complaint: Back pain
Goal: Narcotics
Plan: Home with narcotics
Another young female who had been treated for sciatica and dental pain in 4 visits to the ER this month and had received Percocet for each of those visits.

Case 3:
Complaint: Acute knee pain.  I had to get her out of the car 'cause she couldn't walk
Goal: Pain relief, rule out fracture, and not to have to use crutches
Plan: Home with narcotic pain 'script and crutches.
This one was a middle aged woman who thought karma was working against her as she had said just yesterday that she would never use a walker.  Hah.  People make plans, the universe laughs.  We were completely out of knee immobilizers so I wrapped an ace bandage and gave her crutches.  I worked with her for 20 minutes but at the end of the session she said, "I'm not going to use them anyway".  Observed via Spy Cam walking normally in parking lot with the crutch tips pointing to Heaven.

Case 4:
Complaint: Man-cold with sore throat.  Oh, and back pain.
Goal: Narcotics and work note.
Plan:  Home with Tramadol and work note.
Don't get me started on man-cold.  It is the season for most men to become a quivering puddle of sniffling, whining, hacking, helpless, miserableness.  "I don't feeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeel goooooooooooood!"  Percocet for a cold and sore throat of 4 hours??  Seriously?  Are you fu*king out of your mind? 

Here's an aside: a friend of mine who works in Endoscopy (AKA, the Bum-Lookup nurse) says that thanks to Michael Jackson's doctor, they are required to tell patent's that they will not be getting Propofol.  Thank you.

Get Off the Phone

I may put on a happy face in triage, but when things get ugly I can take it right back off.  Nothing ticks me off more than people who just can't put down the fu**ing cell phone. So sorry to interrupt your oh-so-important text messaging so that I may triage YOUR emergent ER visit for say, dental pain or rash.  Fever of 99.4 ("My normal temperature is 97.5, so that is BURNING UP  for me!")

 Me: "Hi, what can we do for you today?"
Loser: (continues with phone texting activities and doesn't respond)
I waited exactly 7 seconds.
Me: "Excuse me".  I walked out of triage.  I was really busy, so I made her wait awhile.
When I eventually went back in, I said "Are we all done updating the Facebook status?"
If they are too stupid to know they are rude, it is unlikely they will notice if I am....annoyed.

I do not sit in a triage room eagerly awaiting your visit.  I have other patients upon which to do EKG's, clean wounds, and start interventions along with myriad other technical, secretarial and janitorial tasks (beds don't make themselves, and I certainly don't mind emptying trash and linen when it is overflowing).  There may even be one or two patients with ACTUAL EMERGENCIES for whom it may be necessary to transfer out in a hurry.

I shouldn't have to tell people to shut off their damn phone, but common courtesy is non-existent.  Hell, MANNERS are non-existent.  Parents certainly aren't teaching the basics at home, and teachers are too busy just trying to get the little shits to sit in their seats without damaging their fragile self-esteem.  Don't get me started on HATS.  The last time I was at a public event where the National Anthem was played, the announcer actually told men to remove their hats.  Pathetic.

I never never encourage people to answer their cell phone in my presence in fact I just don't even acknowledge their moronic ring tone.  Like the Rocky theme.  If it is a teen or a kid playing a video game I tell them to put it away.

What happened to respectful human interaction?

Gone by the wayside:
1.  Saying please, thank you, and excuse me.
2.  Waiting your turn.
3.  Making eye contact 
4.  Teaching kids to have respect
5.  Taking responsibility for your actions

Thus ends today's rant.