ok. OK. OK!!! Enough!

My ER, all 6 beds of it is a Level I Drama center.
For the last 2 shifts I have experienced more Drama than I care to. I really hate it, frankly.

IT IS NOT OK:
To sob at the top of your voice because you have a headache. Doesn't all that angst simply make it worse? And while we're at it

IT IS NOT OK:
To lie to me and tell me that your mummy is coming to get you afer you have received narcotics for your chronic complaint when she is, in fact, in Florida. Where she undoubtedly moved to get away from you. You are 42; grow the fuck up.

IT IS NOT Ok:
To like on the floor panting in front of the triage area moaning and telling me you can't move because you have an infection in your neck. I am not picking you up. You walked in, didn't you?

IT IS NOT OK:
To scream at age 38 when I start an IV. The gentleman in the room next door is silent even though his hand is broken in several places and he is missing part of a finger, not to mention the burns on the same arm from an industrial accident. I really wish I could tell you about how brave he is and how stupid you appear, but HIPPA laws prevent me from mentioning it. I regret that the largest IV I have in the box is an 18 gauge.

IT IS NOT OK:
For you to make me triage you, for your 13th visit for dental pain in the last 12 months, AS WELL AS your two very young kids. I am not stupid, and using your two kids as a smoke screen with bogus "earaches" does not legitimize your visit. In fact, is is unconscionable not only that you are doing this but that you still have not applied for Health Kids. IT'S FREE, for crap's sake. Oh and by the way you smell like the bottom of an ashtray. That's REALLY not ok.

IT IS NOT OK:
For your inbred daughter to start to drive off while my co-worker is standing beside the car after we drag your Drama Queen ass out. It is bad enough that you are too lazy to get out of the car; it is cold out, and snowing, and we are not wearing jackets. There is no need to injure us as well. We don't get paid enough.

IT IS NOT OK:
That I have to deal with the Organ Bank for people that are deader than dirt. The family said "NO". You people are relentless; you are the Grim Reapers of health care and I would rather deal with funeral directors any day of the week. They are unfailingly pleasant and polite.

IT IS NOT OK:
That five Drama Tweens from the same school ski trip wasted our time with knee immobilizers and crutches with nothing injuries; not so much as a single swollen joint among them. Alas, they all have cell phones and the parents, too stupid to keep their little darlings home, are also too stupid to tell them to put the phones away in triage.

and finally,
IT IS OK:
That Sherry is going to Haiti for two weeks with 3 days notice with Remote Area Medical group (RAM). There are 10 nurses in our department; four of us have volunteered. Aside from Sherry, Mikki joined RNRN, and Cathy and I have signed on with Project Hope. Although I just got an email from Project Hope; they are pulling up anchor but are leaving a crew on the ground for some time I believe, the details were not yet worked out. So we'll see what happens, which one of us gets the call and which will answer.

Project Hope was why I became a nurse in the first place. The S.S. HOPE, started in 1958, was the first peace time hospital ship. When I heard about what it was, I was 6; I really wanted to be a nurse and take care of sick kids on that hospital ship. Half of that plan came true anyway. By the early 70's, my plan was to go to nursing school and learn to be an ER nurse. I wanted to go to Viet Nam, but the war ended when I was in my 2nd year. After graduation I still thought that the Navy was a good plan, but my boyfriend (now husband of 32 years) talked me out of it. In the late 80's I wanted to join the National Guard; but my kids were too little and again Mr. Ednurseasauras talked me out of it.

Which is kind of why I waited 3 weeks to tell him about volunteering with Project Hope. He took it pretty well, being as understanding as he could be about my motivation, but as always, supportive.

Guess I'll wait to tell my mother if/when I am called to serve....

What Goes Wrong Without the 6 Rights

I am blown away by a news story I just saw; several teachers at a school-based H1N1 flu clinic were given INSULIN instead of the flu vaccine they expected.
WHAT.
THE.
F**K???!!
The school system is apparently investigating; no students received insulin thankfully, however the superintendent has sent out a pre-emptive letters to parents.

This is not rocket science; this is not a terrorist attack; this is unlikely faulty packaging. This is human error, and I imagine someone's head will be served on a platter because they failed to follow the rules of engagement of medication administration. These are taught practically Day 1 of nursing school, the "Rule of the 6 Rights": the right drug, the right dose, the right route, the right time, the right patient and the right reason. It is vitally important to get the right DRUG, for Pete's sake read the label.

It is reported that no teachers suffered any lasting damage which is fortunate. I imagine that there will be a few inservices in that school in the wake of this calamity.

I have been a school nurse; it is a tough job as you operate as a stranger in a strange land. The priority is the kids' health, but the job is really what everyone else thinks it should be. School nurses are asked to teach health classes; educate teachers; act as a resource for anyone in the school from the teachers, the custodians, the cafeteria ladies as well as parents. School nurses are mandated to be the immunization police, do health screenings such as hearing, vision, height and weight, scoliosis as well as the follow up and try to get responses back from parents who really could give a crap. Then there are field trips, meds and of course the everyday parade of booboos and broken bones from PE (for you non-school nurses, that's gym, not a pulmonary embolism). School nurses are asked to sit in on, and give commentary in team meetings that involve kids with disabilities, health issues, and anything that impacts learning. I could write a book about it; I did it for almost 10 years.

I feel bad for the school nurse who made this mistake, and that's what it is. Makes ya think. School systems tend to cut and run at the first sign of bad press; it's the modern equivalent of human sacrifice.

Annoying People

This young woman complained of back pain, having fallen on ice 2 days before. Her pain was 10/10 even despite the one dose of Tylenol she had taken the night before. I asked the usual questions about her significant medical history, allergies and medications. With a woman of childbearing age we ask the date of the last menstrual period, particularly if there is a possibility of needing any xrays. Her response to this question was, "oh, I don't know. A couple of months ago. I don't want any xrays, I'm really scared of them". For some reason, I begin to smell a rat; there is something just not right. However, I failed to ask the important follow up: "is there any possibility you might be pregnant?". Hey, we were busy and I did the best I could; it was some time before she got into a treatment room.

Gil, my doc of the day seemed to be in the room for a long time. He is very thorough. I had a minute to pull up a couple of past visits: only three for 2009. Not drug seeking behavior. I noticed she was seen for a possible miscarriage in July.

As I was reading this, Gil came out of the room. "Did you know she was pregnant?", he asked. "Nope. She didn't mention it, in fact she said her LMP (last menstrual period) was a couple of months ago".

"She didn't say anything to me either", Gil shook his head. "I inquired when I examined her gravid belly".

I am hearing dissonant clash of very loud warning bells now. "You know, in 30 some-odd years I have never had a gone-to-ground pregnant woman whose first words after a fall are NOT 'I'm pregnant'. Yet this one doesn't disclose it to either you or me, and hedges on the LMP by saying she's afraid of xrays and doesn't say why? I have her old record up, maybe you should have a look".

A look at a visit months ago revealed an ultrasound for a possible miscarriage; some higher math determined what the young woman didn't tell us: she was about 32 weeks pregnant.

Now I get it; it's about her, not the baby. At first I thought that this was scamming for narcotics, perhaps to sell, but she was asking for pain medicine. The fetal heart beat was fine; she had no signs of labor. Did she have an obstetrician? Nope. It had been at least 3 months (if she was being honest) since she had any prenatal care; probably none at all since her ER visit months ago. Our plan was to send her to the mother ship.

Gil didn't trust that she would show up at the downtown ER; I didn't trust her as far as I could throw her with an IV in her hand. She would go by ambulance. Must we always save people from themselves?

Her charming female companion burst out of the room, and in a voice that would melt paint off the walls demanded to know who was going to bring her home. "I had to borrow my brother in law's car because her's is crap; I can't wait around for her all day and she is freaking out about how to get home. How will she get back here?"

"Well, she could take a cab, or perhaps another family member could pick her up; that is her problem. And keep your voice down, you're disturbing others".

She was nearly apoplectic with rage, but I stared her down while she appeared to swallow her tongue. "She won't go then", charming compantion said sulkily.

"No problem, she can sign herself out AMA (Against Medical Advice). If you have any influence with her, I suggest you talk her into it. She's had a fall, basically no pre-natal care and her baby is at risk. There is an obstetrician waiting to see her. Up to you. She can talk to social services when she gets down there about comping her a cab, I don't do that here. Let me know what you decide", I said dismissively.

She went. The baby was fine. She got excellent free care even though she had little interest in the baby and no insurance. We already have socialized medicine. People who are paying for health insurance, following the rules, and working damn hard are getting the shaft. This one not only gets excellent free care but expects door to door service. Sheesh.

Some people just bring out the worst in me, more so as I get older. I am letting my annoyance show, which will likely get me into trouble. I have zero tolerance for complete idiocy and listening to bullshit, and it's not just at work. Last night at skating practice I was pretty rude myself to one completely annoying teammate; not that she didn't have it coming. She travels in her own orbit, says stupid things and never bloody shuts up. Urrgh. I have given up trying to be nice to her and can't wait for the end of the season so I will never have to see her again. Most of the time I just want to slap the ears off her head. Urrrrrhhhhgggghhhh. The point is until recently I never would have let the verbal zingers fly. Best get a handle on that.

Today's Last Patient of the Night

Every so often there is a patient who will haunt me forever; our Last Patient of the Night is one I will think about often.

He was small for a 4 year old, a beautiful blue eyed blond little boy. He was whimpering strangely in the arms of a woman whom I assumed was his mother, also blond and blue eyed. They were accompanied by two little girls, probably 8 to 10 years old. They were silent.

"He's an orphan", said the mom. "We're his host family for the holidays, and we have a folder of his medical records. He burned his finger tips when he touched the glass screen of the fireplace".

I took a look at the little boy's fingers; the 2nd, 3rd, and 4th fingers of his left hand had a blister on the pads where they had come into contact with the blistering heat. He was alternately putting his hand on the ice covered in a wet paper towel, and removing them and sobbing, clenching his fists with pain. These types of burns usually do fine, but are excruciatingly painful for the first few hours.

The mother went on, "He's from Latvia, and he's deaf. He's from a program where orphans spend time with families for the holidays; we would like to adopt him".

"We love him", the youngest of the little girls said simply.

Normally immune to such situations, my heart melted on the spot.

His records were, uselessly, in Latvian. We tried some numbing medicine on the burns, gave him some Tylenol with codeine and tried to make him comfortable. I got a sterile cup, filled it with room temperature saline and had him dip his little fingers in it. Immediately he stopped crying. After several seconds, he lifted his fingers out of the cup experimentally; his face crumpled with pain, and he howled like a wounded animal. I gestured to him to put his fingers back in the water and was rewarded with a surprised grin. He put his head on the mother's shoulder and sighed contentedly.

I really didn't want to pry, but I asked, "Does he have to go back to Latvia after the holidays?"

"Yes, and that's going to be so hard. He's such a precious boy; he never cries, well, at least until he hurt his fingers. I wonder, do you think it's because he's deaf?"

"It's an orphan thing", explained the older of the two little girls sagely. I was astonished at her insight.

"Does he sign at all?", I asked. I vaguely recalled that American Sign Language (ASL) is not universal; most countries have their own sign language and their own rules. From some deep, forgotten part of my brain I recalled some signs I had learned years and years ago when my friend Geri and I took 2 semesters of an evening school sign language course.

The little boy had started to shiver; I balled both my hands into fists with the thumbs sticking out between the index and middle fingers. Shaking my hands in front of my I said, "Cold".


No reaction from the little boy, but the mom was interested. "What's the sign for 'hot'?"

I just couldn't remember. I remembered "play", "mom", "girl and boy", "friend". The two little girls quickly picked up on the few signs I could remember. One final sign popped into the front of my brain; I made a motion as if to pull at the visor of a ball cap, followed by touching my lips with the fingertips of my hand and then touching my other hand with both palms up.

"Good boy". Such a good, sweet boy; this family was in love.

" I know how to say 'I love you'", offered the youngest little girl, as she extend her thumb, index and pinky finger and held her palm side out; "That's the most important sign of all".

They were ready to go home. The two little girls wordlessly gathered up their coats, the mom's purse and car keys. The oldest gently put the little boy's hat on his head and softly kissed his flushed, tear stained cheek. They went out into the snowy night.

My New Year's wish is the hope, with all of my heart, that this lovely family will be able to make the little guy a permanent part of their family. They all deserve a happily ever after ending.

New Year's Rockin' Eve

New Year's Eve was fairly steady. By 7 PM we had seen a number of patients, all of whom were pleasant, polite, in real need of emergency care and in general, a pleasure.

Usually on holidays, you get the extreme version of the Sick and the Stupid.

To recap, the Sick consist of any patients who should be in the ER; that would be lacerations that require suturing, chest pains, head injuries, fractures and the like. The Stupid are those patients who should emphatically NOT be in the ER for any reason; that includes rash for 3 weeks, any chronic pain, fever of 100 degrees as the chief complaint, ear wax, or any who has a doctor's appointment the same day but just doesn't feel like waiting.

As I said, on holidays it is the extreme version; REALLY sick or REALLY stupid. This I categorize as complaints that range from Illness to Idiocy. Same rules apply.

The gentleman who should have been in the ER like yesterday for blood sugars above 600 would qualify, as well as the man who nearly severed his thumb while decapitating Mr. Thomas Turkey, AKA, New Year's day dinner, with a hatchet. Nothing like fresh poultry I guess....hmm, what is that in my stuffing? Thumbthing wicked this way comes.... Honestly, who has turkey on New Years Day?

So I was more or less prepared for trouble when one of the local regular customers strolled in. At least he waited until we had dinner. He is known for being rude, often aggressive and I have personally thrown him out at least once. He got into it with the doc in the past because the doc wouldn't write him a 'script for 120 Valium like the last doctor. WTF.

Tonight he complained of a rash, convinced it was bedbugs, or hives, or MRSA, or plague.

He is especially nasty to women, and we usually try to protect our secretaries from his bullshit because they are all really nice and don't deserve it; not that anyone does. On the other hand, he has had a run-in or two (and been thrown out) by my usual co-worker, AKA my "work husband", Dan; he is 6 foot 5 and takes no bullshit from anyone. Dan was already ramping up as soon as he caught sight of the guy so I went in to triage him. Must have been a good day for him because he gave me no trouble; asicd from failure to make eye contact, which drives me nuts.


As he passes by Dan, he mumbles to his friend "That's the guy gave me bullshit last time I was in here"; Dan rises to the occasion and returns fire, "Yep", he says, "I recall you told me to polish up my resume; I'm still here".

I cringe and resist the urge to dive! dive! dive! under the desk.

The man and his friend get all huffy so I took the higher ground. "Why don't you have a seat in the room, the doctor will be in to see you shortly; we all just need to be respectful of each other and you will get your problem taken care of" I offered.

They grumbled into the room, he got his 'script for prednisone and hydroxyzine for his itchy pseudobugs or MRSA or galloping crud, and went outside to smoke.

"His companion wants to check in too", said my doc of the eve.

Frig.

The 20 year old female claimed the guy as a family friend. Her complaint was abdominal cramping; she was 4 months pregnant, having discovered this fact after taking an ambulance ride downtown to our mother ship in the last couple of weeks for the exact same problem. No prenatal care. No insurance.

She had not followed up with an OB as instructed. I quickly deduced that she wanted pre-natal vitamins and an ultrasound...in other words a picture of her baby.

She was a little skittish. I entered the room to draw her blood, and she decided she felt really nervous and wanted to step outside for some fresh air.

OK.

"Just a few minutes, though, OK? If we need to send you downtown (for an ultrasound) we should get this show on the road"

I waited about 10 minutes and decided she needed a kick in the ass; I went out the door to discover her smoking a butt.

I coaxed her inside and prepared my various tubes and assembled equipment, and explained what I was going to do. She proceded to tell me what awful veins she had and how she was terrified of needles and how "sum nurse" dug around for her vein for over and hour trying to draw blood.

Uh huh. I love a challenge and nothing gives me more pleasure than a successful venipuncture on the first try; I rather pride myself on it, actually. I attribute my success to the countless pedi IV starts when I worked at Utopia Hospital.

But I digress. The young lady said, "I'm just really anxious about my baby, I am scared there might be something wrong with it".

"If you are really concerned about your baby, you should quit smoking immediately".

"Well, I've really cut down since I found out I was pregnant".

"Your baby doesn't know from cutting down. You are at risk for having a low birth weight baby. Do you know what that means?"

"Having a small baby? Wouldn't that be better for delivery?"

Arrgh. This kid is doomed.


As the festivities began to wind down we were hopeful that we might get out at 11PM, our usual closing time. I triaged a sore throat at 10:20 PM, then a febrile, inconsolable, wheezing 8 month old who was afebrile, sleeping and had no wheezing. But did have an ear infection and didn't wake up during the exam or when I put Oticaine in followed by a cotton ball.



At 10:40 PM local EMS was toned out for a lethargic 4 year old with special needs, not otherwise specified. We know most of the medically fragile kids in the area and the address we heard over the scanner was unfamiliar. Moments later, we heard that CPR was n progress.



"Should we stick around to see if they need to come here?" I wondered aloud.

"They know what time we close", offered the secretary.

"I know, but a pedi code is anxiety provoking, they won't be thinking about it in the field", I responded.

I asked our doc who was an ex Greatest EMT in the history of the world, before he went on to become World's Greatest Paramedic before he got kicked out of the Air Force Academy for being a big mouth, followed by the designation of Most Intellectual ED Doc in the Universe. But good to work with when we can keep him focused.



"Wait and see".



By 11:05 PM we had heard nothing. "We're closed" said our doc. I wasn't sure, but it was his call. Still, we knew he would sit in the parking lot for a few minutes.



Since we nurses and other lower life forms park out back in a lower parking lot, Lisa and I made our way down the back elevator, alarmed the building and went outside into gently falling snow. We had gone a half a dozen steps across the lot when we heard the siren. Lisa and I froze in our tracks. The ambulance approached, got closer and louder. I fumbled in my coat pocket for the key and tried to remember how to disarm the system to get back inside as I listened.



We held our breath. One block away. Outside our ER.

And continued toward the city.