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.

Who?

The staff-reduction-cost-saving measure is to have only one nurse in triage when there isn't enough staff for the rest of the department.  Truthfully, we could actually use 2 nurses and a dedicated tech most of the time.  We routinely run at about 114% capacity with a 4 hour wait.

My third shift in a row being alone for 87% of my shift was a steady stream of complaints such as rash, febrile kids, and chest pain.  With a couple of weak and dizzy and a rapid a-fib or two along with frequent flyer depression/suicidals.  We use a language line for the non-English speakers which always takes about 4 times longer to triage.  With a paucity of techs most shifts, or because they have been pulled to sit on suicide watches, I have to do my own EKG's.  The line of patients waiting to be triaged just kept getting longer.  

One patient was a name dropper.  Sigh.  That doesn't do anything to make me change my triage process.

Name dropper pt: "My neighbor is Nurse X, do you know her?  She's the head of all the nurses?"

Nurse X is a clinical leader on one of the med-surg floors.  I know who she is.  Definitely not head of all nurses.

I cocked my head as if considering, gave him a quizzical look.  "Mmmm, nope.  I don't know her".

Name Dropper: (disappointed) "Are you sure, she has a really big, important job".

Me; (knowing whatever I say next will be reported back to the neighbor, and not giving a rat's ass)
"Sorry, no.  People that far up the food chain as you say never come down here.  We frighten them".

Name Dropper had chest pain intermittently for about a week, and after a strenuous workout at the gym resulting in chest pain, consulted the neighbor.

I start the usual protocol, EKG, labs, xray, knowing that there won't be a bed for a few hours.  At least unless the diagnostics indicate a heart attack or whatnot.

I got some pushback for the cardiac protocol, he let me do the EKG, but wasn't sure if the labs and xray were really necessary "because I don't have insurance".

I waste little time, offer that the consequence for not doing so could result in death, and have pretty much moved on to my next impossible list of tasks.  Name Dropper decides to consult with Very Important floor nurse before moving ahead.

Me:  "Ok, well let me know what you decide, you can have a seat in the waiting room while you make your phone call".

Got an email from my manager a couple of days later.  "Nurse X doesn't understand why you told her neighbor that you didn't know her".

Response:  "More importantly, does she know me?"

On practice

I don't routinely do port access.  I once had a bad experience in which a frequent flyer gastroparesis patient, who was also fond of drinking alcohol and was just, in general, a gross individual, sat bolt upright to vomit (spit into a vomit sack) just as I was pushing the needle in.   Scarred me for life.  Seriously, I have port PTSD.

I CAN do it.  I CHOOSE not to.

So when my patient asked me if I was good at ports, I had to tell the truth.  "It's not my best skill", and hit up my zone mate to do it for the second time that day.  I was willing to try it because it looked like an easy one.  She wasn't willing to let me practice.  I was fine with that.

We call it nursing "practice", but when it comes to patients, nobody really wants us to actually PRACTICE on them.

You don't always get the best wherever you go.  You might expect it, but it is a statistical improbability that you will always get it.   Not the best meal, not the best mechanic, not the best teacher.  Not the best hospital. Not the best doctor.  Not the best nurse.  Sometimes you get adequate or mediocre but working on it, or just enthusiastic and learning.   Sometimes you get adequate or mediocre... and just happy to get by.  Even the best role models can't do miracles with the material they have to work with.  The nurse/doctor/lawyer who graduated dead last in the class and passed the boards or the bar is STILL a nurse/doctor/lawyer.

Think about it.

Every nurse on the planet has practiced on patients. Every.  Single.  One.   First patient, first injection, first IV, first code.  First birth.  First death.  First everything.  You don't get better at something unless you do it repeatedly, over and over and over until there is a comfort level.

That said, nobody in health care these days is working in an environment in which actual practice, with the goal of improvement, is encouraged.  Speaking from that place, we all know that perfection is expected from patients and mandated by administration, office dwellers,  and keepers of clipboard minutiae. These folks sequester themselves in their spic and span patient-free ivory towers with the sole purpose of writing how-to's, decision trees, step-by-step procedures, and check- off lists.  All of which serve to create distance from fall-out, (or create a fall guy) when things go off the rails and something untoward occurs. Their work is never done, for there will always be some scenario that was not considered.  Also, shit happens.

Practice does not necessarily make one perfect.  That is impossible.  Practice might make one competent, or safe, or prove that more practice is necessary.  It might even prove that the teacher is not right for the job.  There is lots to learn, but the biggest lesson is that no amount of preparation guarantees perfection.

Nothing is perfect in health care.  That is the only absolute.