The Games Have Begun

Hey! Anybody still there?

Summer was gone in a flash; why is that? It seems like just yesterday I took a day trip to the lake with Tina, enjoying a nice warm day, some kayaking and a cold beer or two. Ahh, the good old days.

I found this photo in my camera; David, are you noticing?

My brother and I used to have a

competition to see who could get the best sunset photo. Even though he is a better photographer than I am, this is clearly a contender. I would have liked to get up to the lake one more time for some leaf peeping, but it didn't happen. Too bad. I did get up there last year in October with two friends from nursing school. The temp went down to the mid-30's at night; we had not heat and no water, but we had a great time and some nice views.

Fall always makes me feel like taking a big, deep breath and square my shoulders in preparation for the onslaught of the winter edition of the Sick and the Stupid. Mostly because the sick stay home while the stupid go to the ER. Somehow doesn't seem right,now, does it? This winter flu season is already off to a rip-roaring start and promises even more New! and Improved! Sicker and More Stupid! individuals crusading to the ER in search of the Holy Grail.............instant gratification!

Now, we are staring down the barrel of winter; the kayak is in the barn and I barely come up for air since I am ALWAYS studying. Micro blows, thanks for asking.

We have had lots and lots and lots of individuals present with flu-like symptoms, it is a cornucopia of influenza We have given up mining for flu and just treat them for it anyway, but in most cases there is nothing to really go mining anyhow. Cough, no fever. Fever and vomiting, no cough. Sore throat. Many are simply diagnosed with viral illness, better kept at home with
Tylenol, rest and fluids. Somehow, though, these folks who drag themselves to the ER because they are so sick hear the word "virus" and take it as an open invitation to go to work. Or to send their kids to school so they can go to work.

Please, people. If you are coughing relentlessly you may as well stay home; your co-workers don't appreciate your attendance. Seriously. Nor do other parents appreciate having your ill children in school. Giving them Tylenol, sticking them on the bus and boogeying off to your oh-so-important job is not only so awful for your kids it makes you look like a complete jerk; kids ALWAYS rat you out to either the teacher or the school nurse that mommy gave them Tylenol for their temperature. Always. Having been a school nurse and knowing this trick I always asked the kids; usually they knew how high their fever is when they left home. I made it a point to convey this information to the parents when I called them.

Yeah, I know. Everybody is talking about the flu, or blogging about it. Or talking about blogging about it. Let me tell you, it is only going to get worse before it gets better. I will try really hard not to roll my eyes relentlessly because my mom told me they would stick that way.

People are panicked about the H1N1. "Last year", I complained to Dr. Cindy Lou, "this was just the flu. This year it is the Four Horsemen of the Apocalypse. And we haven't even started to see a lot of REALLY sick people. The doctor's offices are dumping all their patients here, and I'm sure it is going on all over. What's going to happen when we all get sick?".

And we will, we will. Some of our patient population is, to put it mildly, a bit challenged with the social graces. In other words, coughs and sneezes are not covered, but left to fly freely throughout the atmosphere; I have seen someone place USED KLEENEX on the registration desk; hand sanitizer? what is that? And the kids? don't get me started.

One of our unit secretaries Melissa, is pregnant with twins; around 22 weeks. When patients come in to our ER, she is one of the first to greet them. In other words, she is flu fodder. Being pregnant, she is, along with children, one of the high risk populations. She is nervous because her OB does not yet have the H1N1 to distribute until this week.

"Melissa, don't even talk to them unless they are wearing a mask!", I told her. "Just back up and point to the triage area, yell to one of us (nurses) and we'll take care of it. No sense putting yourself in the line of fire unnecessarily"

That is when I had the bright idea to create The Altar.

A little table containing a few face masks...............no, not this one.

more like this.

I added a big bottle of hand sanitizer and a sign that read:

IF YOU HAVE

COUGH, FEVER

OR

FLU-LIKE ILLNESS

PLEASE WEAR A MASK

TO PREVENT THE

SPREAD OF INFECTION

The "thank you" got cut off of my document. My boss thought that it was great that I was showing some initiative for "projects" (calm down, it won't happen again until after I finish with this synchro season, graduate from school and go to Alaska....in other words, don't hold your breath). Melissa was thrilled, and very relieved. And for the most part, people are pretty good about taking the masks. Of course some need to be educated about: the need to wear the mask over the nose AND mouth; that they are ineffective in the pocket or on the head when worn as a hat; and for Pete's sake, please leave some for the contagious people who are coming in after you, just because it's in a little basket doesn't mean it's appropriate for you to take a handful. Yikes.

Oh crap, I just remembered today was my brother Bob's birthday. HAPPY BIRTHDAY, BOB!

Donorcycles and Near Drowning

Spring never came, summer looked as if it might skip New England entirely and it has been raining for a month. At last, the sun is out and warm weather, it seems, has finally stuck the landing here in the Artic Tundra of the northeast. Every SUV has a dog's head sticking out of it, mine included. Tina, my dog, is happily chasing chipmunks in the woods. Yesterday, I'm not lying, there were two ducks sitting in a tree in my backyard bog. That was a first for me, so I had to Google "Do ducks perch in trees" just for laughs....guess I'm not the only one to wonder since there was quite an extensive amount of informtion to be had on ducks perching in trees. Mr. EDnurseasauras was not best pleased to be awakened to see this once in a lifetime sight, though. Oh, and the grass is green and my eyes are watering. Other sure signs of warm weather are yard sale signs; I saw a sign on a tree in one neighborhood advertising "Puppy's For Sale". Puppy's what? Being a stickler for spelling and grammar, that really annoyed me. The hot dog stand in town advertised with this hastily written sign, in magic marker on a poster board:

"Hot Dog $1.50 withacanofcoke" kind of squished in. Hurryupandeat.

Being the first actually really hot day means that all the pale skin that hasn't seen the light of day since Labor Day is going to get roasted. Pass the melanoma please.

Bikes, skateboards and other devices invented for challenging the fragility of the human body are being dusted off so that we who work in the ER have job security. We have lots of sutures and tetanus, and have stockpiled slings, casting material, splints, bandages and crutches.

And the sure sign of spring: motorcycles are back on the road for all of the seasonal drivers (Simplysweet, I'm talking 'bout chu...). Indeed, they are everywhere. In this Live Free and Die Stupid state, the mandatory use of helmets is not a law...more of a suggestion, actually. Of course, those of us who care for such idiots who choose not to wear protective headgear and wind up in my ER could tell you a few stories about ruined bodies, ruined lives and ruined families. Here's a small public service announcement for anyone who doesn't wear a brain bucket; some may believe it is just another means of thinning the herd, but scraping your brains off the highways and byways is someone's job. I guarantee it does not make anyone's day. Let me walk you through a couple of scenarios.

Patient A is traveling along the road on a bright sunny afternoon on his Harley, wearing jeans, a T shirt, and sneakers; he is not wearing a helmet. At a speed of 40 MPH, for whatever reason, he hits a patch of dirt, a rock in the road, swerves to avoid a squirrel and loses control of the bike. He is brought to the ER unconcious with a big bleed in his head. This turns out to be a really bad day for him because, despite our best efforts, he dies of his injuries.

Patient B, while riding his Harley on a lovely summer day also hits a patch of dirt, swerves to avoid a squirrel and loses control of his bike. He is brought to our ER concious and alert, but with a big crack in his helmet. That helmet saved his life. I don't know anyone who has sustained an injury without a helmet and survived who persists in riding without one. I am sure they are out there, though.

Another equally stupid idea is to let kids ride those ATV's. I don't know the law on this but it just doesn't seem to make sense to let a kid behind the wheel of something so heavy that he would be powerless to get it off if landed on him..........provided he was still alive. When you bring in your 9 year old covered in blood from an ATV crash telling me he has been riding since he was 4 merely signals me that you are an idiot and should be locked up.

Two separate but related incidents tended to bring out the sighing, eye rolling and lecturing old nurse in me.

We heard the radio call from MAC base on our scanner about a 3 year old who had fallen in the river not far from our facility

"We won't get that, will we?" asked Cathy, my Southern Girl coworker.

"Maybe. If the patient needs an airway we will, it he's coding we will, and if it was more of a swim than an actual near-drowing we will". I get out the warming blanket just in case.

Sure enough 20 minutes later we get the patient, a little cold (the river is frigid this time of year) and his mother who went in after him. His head went under for seconds before she brought him out spluttering and crying. An eyewitness said she was reading a magazine when the kid went in. So it turned out lucky, and thus the weak members of civilized societies propagate their kind. This was reinforced after I met the dad.

He appeared to be a combination of Colonel Sanders and Mark Twain, complete with beard and straw hat to go with his portly appearance. He had no trouble telling his kid, loudly, about all of his experiences in the ER.

("This one time, at band camp...")

Seriously dude, I do not care if you had a broken toe or a bee sting. Neither does your kid, and where were you when your wife was reading a magazine while your son decided to go for a swim in the Swift River? I really just hate in when people act like a parent for my benefit. I already know you're an idiot, just shut the hell up. Sheesh.

Two weeks later, in rush the Parents of the Year with the little swimmer. "I think he cut his finger off!", Mom shrieked. Dad, affable as ever helped the situation not one bit by trying to tell the kid how he cut his finger when he was 5; all while we are trying to get information about how the injury happened, etc.

The child was playing with a disposable razor. Yes. A. Disposable. Razor. The excuses this time included, "well, the cap was on, and he's played with them before. He likes to pretend he's shaving".

Oh, that's different. Perhaps you'd like to give him a knife to stick into an electrical outlet when he gets home? It should be OK if the knife has a wooden handle. Pour a little water on the floor too. And hey, instead of a sticker, please let him help himself to a fun Bic lighter; we have an array of colors to choose from.

Yikes. The finger wasn't cut off, only needed a few stitches. Ever helpful, Dad retained the focus on himself the entire time, not getting the hint when I suggested he could maybe talk to his son to keep him calm. Finally I had to say "Dude, pay attention to your kid, please! This isn't the time to share your diarrhea problem with the class!". Idiot.

Discharge instructions included (no lie) "Do not allow child to play with razors", and "Choose appropriate toys". Oh and expect a visit from social services at some point.

Now calling.....

"Smith?"

I called out in the waiting room for the next patient on the hitlist.

This had been preceded by a discussion about how to pronounce the patient's first name.

Dayseanne.

"Could it be, um, Daisy Anne?" my Southern girl coworker mused.

"Doubt it. It's a male".

"Day Shawn, maybe?" wondered Sherry.

"I won't take a chance, since he's 11. I'll go with the last name"

"Good call".

Turns out it was pronounced Day Sheen. The fact that he will be spelling if for the rest of his life is probably secondary to telling people how to pronounce it.

CPR Recert

Every year or two (depending on where I'm working and what the rules are) all nurses have to recertify CPR (more accurately BLS, basic life support). This is a something I have done every year since CPR was invented and it became illegal to allow people to die a natural and dignified death without pounding their chest and breaking a few ribs. Something to think about when you have decisions to make about familiy members, I can tell you.

Back in the early 70's, things were sometimes a little unclear as to who got CPR and who didn't, but we all learned it anyway. I worked as a nurses aide (now called LNA's or licensed nursing assistants) for a year out of high school before I went to nursing school, but that is a story for another day. Anyway I think the first CPR class I attended was in 1972 or '73. That's a helluva long time to be poundin' away on the dummy every year or so. It was a lot more complicated then, now it's pretty streamlined.

The first time a patient died on my watch was when I was a puppy nurse, out of school less than a year. I was the 3-11 charge nurse on a 40 bed rehab floor, although they were mostly chronics; brain injured individuals without much rehab potential and things like that. It was kind of a nursing home floor really. I was the only licensed individual, but oddly my 3 year diploma program which people are so condescending about prepared me for a leadership position 3 months out of school when the average ADN and BSN students were still in orientation. That's not a slam, just a statement of truth.

I was feeding an elderly woman, I'll never forget it, mashed potatoes. Some of it dropped onto her lap and I had lost the napkin. I stepped out of the room to the kitchenette across the hall and returned in about 20 seconds. She was gone, sitting bolt upright and holding onto her spoon as if she planned to continue using it. I did have to do post-mortem care with the policy book propped open on the bedside table. One of those life experiences I guess. But CPR? It was a rarity at that place.

I taught CPR for about 15 years later on and got pretty well burnt out doing it. I taught scouts, dental offices, teachers (they are the worst for performance anxiety), business offices, restaurants, EMS, and the usual hospital inhabitants of nurses, respiratory therapists, lab and xray, unit secretaries, EKG techs and doctors of course. Doctors were the worst because most of them a)sucked at it and b) just weren't interested in doing it right at all. I guess that was OK, during a code you would much rather have a doc who knew their ACLS (advanced cardiac life support) shit than BLS. Nurses and EMT's mostly did CPR anyway; Call me crazy, but I thought it was important for the docs to know proper technique so that they could evaluate CPR in progress for effectiveness since they are the ones running the codes.

I don't mind jumping through hoops as long as they are reasonable. I'm not a young woman anymore, and the knees just won't tolerate being on the floor slaving over a hot CPR dummy. The education team had kindly provided cushy mats to ease the stress. The child and infant mannequins were on tables for our convenience, also a plus. As far as I know we were all nurses, EMT's, paramedics. The last thing we want is someone who has never performed one minute of CPR in their lifetime on a living person nit picking the depth of compressions. You always know who they are because it goes something like this:

"You need to make a tighter seal" or "You need to compress faster" or "You didn't yell help" or "You forgot to blah blah blah blah".

Sigh. It was the same today, there is always one yutz in the pack who pecks away at every minuscule detail and holds up the entire line.

I'm happy to tell you she had nothing to nit-pick with me (smug expression).

I waited for my turn behind a new EMT, young, probably about 11 years old judging by the look of him; they get younger every year for some reason. The poor kid had to perform after he became completely unnerved by the young woman in front of him.

The very attractive young lady had on white capri's made out of some interestingly rather sheer material; unfortunately she was obviously wearing a thong (blue).

Picture this; if you have never seen CPR performed, go to Youtube and try to imagine what this poor young EMT had to witness. Think about this attractive young woman with her back to us, kneeling next to the mannequin in her see-through white capri's, pumping (yes, pumping) from the shoulders and bending at the waist. Up, down. Up, down. Up, down.

Are you getting a mental image? Good, because that was likely the only image in the EMT's head as he fumbled through his demonstration. He left rather quickly afterward.

So that's CPR for this year, now I'm all set.

Repeat Business

I think I've said it before.


My ER is quite a magnet for repeat business for dental pain, migraineurs and various other narcotic seekers. It's quite a business.

Some of our docs and a couple of the nurses work at other ER's and see the same people from time to time. It's funny how they kind of just walk out when a nurse who took the same complaint (word for word) looks at the chart and says "Hmmm. I know you were give a 'script for Pen VK and Vicodin last Friday evening at Mt. Seaside. Are you not taking them?"


One girl claimed her backpack was stolen. Which contained her prescription for Percocet. One guy said he lost his prescription (at least his fifth for 20 Vicodin in the last 2 months). Another claimed her 3 year old threw her Percocet in the toilet. And the old standby "I knocked them into the sink".

How refreshing would it be to have someone come in and say, "Look, I'm addicted to painkillers" instead of devising these ridiculous fairy tales. A young guy I remembered from 2 or 3 months ago came in and told the exact same story about how he saw the dentist, he has an abcess and was told to come to the ER for antibiotics (and pain pills) and blah blah it will cost him $700 to pull his tooth and he doesn't have the money. Same story exactly, I looked it up because I remembered he had an unusual name. Funny that this time he had a different last name. He was invited never to return.


We have an unusual group of co-dependent migraineurs. A couple of them take turns driving each other (we don't let 'em drive after they get their fix for obvious reasons). One doc gave a migraineur VALIUM for cripes sake along with 100 mg out of the usual 150 mg of Demerol they normally receive. Now they all want it.


Speaking of driving under the influence of mind altering drugs, one of the chronic migraineurs got her meds, got on the phone for her ride, and said she would wait outside on the bench as he would be right along. OK. We were busy, but I was suspicious. I know what she drives, too, and I checked the parking lot. Nope, no van. No patient on the bench either.


I popped into my bosses office which has an expansive view of the back parking lot where we employees park. Oh, look.....there is my patient 15 feet below me starting her van and driving away.


Oh, doctor, guess who just lied and drove home?
Wanna talk liability?


That's it, he says. She's not getting another narcotic from me, and let the record show that she was observed driving after she said she had a ride.


Three days later she came back, parked her van in the back and got............NOTHING.


This is not to be mean or vindictive. Do you want to put your loved ones, both on and off the road at risk with this nutbag driving with a boatload of narcotics onboard? Didn't think so. I sure don't.

One of our newer docs refuses to give Demerol. At all, which is kind of interesting. She might order morphine, with a Vistaril chaser (which stings like a mad bastard when you inject it I might add). One of the co-dependents now claims morphine as an allergy.


I will say that some of the other docs are interested in coming up with unified plan. We are all feeling like pushers.


Come to find out, without fanfare and without warning the hospital pharmacy had decided to take Demerol out of the formulary as of June 1 (basically a list of meds the hospital carries....we aren't CVS, you know).


Apparently one of the migraneurs was forewarned, and must have thought it meant that we were no longer stocking Demerol in our satellite ER only, because low and behold, there she was on June 1............at the downtown main ER. Hmmmmmm.