Around Town (Part 1)

I live in a pretty small town; I also work in a pretty small town, however, there is a miles-wide socioeconomic gulf between both of these villages. My work town is an old mill-town; we will call it Milltown, for the purposes of fun and entertainment. It is on the lower end of the social order, a poorer town with all of the problems that one would expect. It is also the more interesting of the two, and I tend to spend more time there than in my own town.

I know many of the police officers as they are mandated to "check up" on us in the evening, being an establishment of mostly women. The majority of our docs are male, as is our Brazilian housekeeper, but our only security team is 911. We have video surveillance, but more on that another time.

I also know the EMT's and paramedics from Milltown, as well as surrounding towns. These are always good people to know. They are mostly hard working and care about the patients, as well as being mindful of our limitations in my small facility. For instance, most will not bring us cardiac, stroke, major trauma, head injury and the like for lack of CT scanner and other diagnostic tools or the ability to definitively care for them. The paramedics from my town are lazy, though, and at night they tend to bring inappropriate but stable patients to us. They know better than to bring alcohol intoxication and suicidal patients to us (although they do walk in) because we have no facility to watch them, keep them (and us) safe, or a social worker to arrange appropriate admission. Of course at night they do anyway; a couple of them, as I said, are lazy. There are exceptions that we gladly accept from any town EMS, though; they have had several "hot potato" cases and major trauma involving a child that have been brought to us because they are 1. without an airway or 2. so badly injured they need to be airlifted to the Big Time Hospital. Conveniently, the landing zone is our back yard. We don't panic, we are all well trained, or have spent time in trauma centers. We do the job we are trained to do despite the limitations to the best of our ability. In several of these worst case scenarios the patients have survived and done well. We all pat ourselves on the back for a positive outcome.

There are lots and lots of people that routinely use the Milltown Medical Hut and Boat Rental. Some have insurance; many do not. It will be interesting to see what the Obamessiah's health mandate will provide for all of us in the coming months.

Today's Last Patient of the Night

Why is it that patients with generalized crotchital complaints come to the ER right before closing time? Discuss. I will get a snack.

I recounted this patient with the acquired pants circus. Tonight, I will tell you about another kind of circus.

Diana, Cathy, Beth, Dr. Cindy Lou, and I were finishing up a deadly slow night and hoped to deadbolt castle gates and release the crocodiles into the moat, when, of course, the final patient of the night ambles in. With broken crotchery.

I watched on the video camera as two people strolled in at 10:45 PM (remember, we close at 11 PM). Helen, our secretary/receptionist/social director/den mother/worry wart had already directed them into triage. Helen is a bit older than middle aged, remembers everybody's birthday, anniversary, kids, spouses and pets names, asks after everyone's events, vacations, days off and remembers what those plans were. She feeds and fusses over us if we nurses are too busy to eat, tosses rooms for us, shuttles labs, and we would be hard pressed to function without her. She would give you the shirt off her back and buy you a Coke with her last dollar if you asked for it. We love her and protect her as much as possible, and I don't allow her to be exposed to rude people and idiots in general.

So I was right on top of this one, and whispered "What is it?" as I passed her in the hallway.

Helen laughed nervously and whispered,"I don't know, they said it was 'personal'".

Ok. I opened the conversation by asking my standard "What can we do for you today?". There was a teenage boy sitting in the hot seat who appeared calm, cool and collected as he slouched. Mom, on the other hand, was pretty ramped up. Perhaps too much coffee.

"Well, he has been walking around like he has a load in his pants all night, and I called his pediatrician and they said to come right down and get it checked out because I really didn't think it should wait until tomorrow they said something about epi-, epi, uh something but it didn't sound good so we came right away".

Take a breath, lady. "Um what exactly is the problem?"

"He has pain in his....well, down in.....I don't know how else to call it: he has pain in his ball sack". Except she drew it out like "baaaawwwwwl sack"

I am mentally pinching my lips and reciting, don't say scrotum, don't say scrotum.

"So when did the pain start, and is it on one side or both?"

The kid shrugged and said "about 5 o'clock I think".

Mom disagreed, "no, I think it was more around 6 or 6:30, remember, we had the pizza and you didn't have it then and after we talked about baseball and you were on the phone for awhile about that assignment.."


I managed to get a word in to ask about injury and urinary problems, no longer addressing my questions to mom. Mom, however, was determined to have the last word.

"He swears to God he isn't having sex, that would be another whole set of problems wouldn't it, but hell you can't watch them every minute and he doesn't have a girlfriend, as least he says he doesn't, and he is not whacking off...."

"Um, I think we can go ahead over to Helen to get him registered and then Dr Cindy Lou can see him as soon as...."

Mom still hasn't taken a breath or my hint to shut it down and continues, " what do you think it might be, will you do tests or xrays or what? I was thinking it could be nothing but didn't want to take a chance; I called my brother and he said it was probably blue balls, I don't know what that is but it sounds really painful and bad, do you think it could be something like that?"

I coughed into my hand a few times to hide my laughter and directed them to the registration desk. "I'll take the young man into a room, right around the corner when you're done", I sang, and whisked him into a treatment room. I directed him to undress and closed the door.

My audience awaited. Cindy Lou asked, "Ok, what is it?" Within a minute she was already on the phone with the Mother Ship to arrange for an ultrasound of his Baaaaaawl sack since we only have ultrasound during the day. They were out the door in 10 minutes.

I restrained myself giving mom a copy of "Adult Words for Body Parts". Wonder if she still calls it a winkie.

Today's Last Patient of the Night

She had experienced chest and arm pain since early AM and strolled in at 10:50 PM (we close our doors at 11, but must stick around until the last patient leaves). Her medical problems included fibromyalgia (eyeroll) and Lyme disease. Her allergy list had 30 medications.

My doc asked her what about her pain had changed at that hour of the night that had not bestirred her to come to the ER earlier in the day: "I didn't want to go to bed with it". Uh huh.

In rapid succesion she was put on the monitor, given oxygen, an EKG, an IV, aspirin and nitro. (now 10:57).

Brian, my doc, is a take charge, no bullshit, straight shooting, decisive, action oriented ex Navy Seal who does not suffer fools. He is also committed to Getting Out of Work on Time at all costs. He can be funny as hell, too. At this hour of the night, though, he is all business.

"Don't even run that blood; she's headed downtown (to our Mother Ship) right now. I'm not dicking around with this for an hour when she needs to be admitted anyway".

Cool. He notifies the attending at the downtown ER, we call the local ambulance and she is out the door in 24 minutes.

This was not just an attempt to get her out so we could go home (well, part of it was, but not completely). We would have had to wait until the labs came back before we could entertain the idea of sending her to be admitted. This involves way more bullshit than it is worth sometimes. Since nearly all of our docs also work at the Mother Ship, when on the receiving end they tend to be most obliging with this sort of fast-tracked transfer, knowing that the majority of the patient's diagnostic workup needs to completed. Hey, they have all been there. And most will do anything to avoid the crap that is inherent in a direct admission, particularly in the middle of the night.

Direct admissions (from the ER to a hospital bed on a floor somewhere)are a pain in the ass. It takes hours, literally. Here is a recent timeline, from time of decision to admit to getting the patient our of the department:

8:01 PM Patient x needs admission to tememetry unit. Patient agrees
8:02 PM Call to beep hospitalist
8:22 PM Hospitalist returns call, speaks to ER doc, agrees to accept.
8:27 PM Call to hospital admission office notifying them we need a bed. All pertinent information is conveyed. The admissions office must speak first to the nursing supervisor.
9:00 PM 2nd call to admission office: nursing supervisor hasn't gotten back to admissions. I urge them to beep her for an answer.
9:16 PM 3rd call to admissions office: nursing supervisor is "busy".
9:17 PM In frustration I beep the supervisor 911 myself and bitch. She promises to get back to me in 10 minutes
9:30 PM Still waiting. Patient is tired, uncomfortable, hungry because we have no food, and impatient and is thinking her own bed is looking better. She is dissuaded from leaving.
9:40 PM Finally admissions calls and assigns a bed
9:40:14 PM Call to regional ambulance for transport. Standard response is "30-40 minutes". It is generally closer to an hour. I call rival ambulance service to inquire if their response time is quicker, using the information to play one against the other. It is generally effective and I am promised an ambulance in 20 minutes.
10:15 PM Ambulance dispatchers are liars. Call to dispatch to inquire as to whether or not they have fallen down a rabbit hole; "Just down the street!" they say. Yeah, right.
10:20 PM Ambulance arrives. The paperwork is exchanged, the ritual fiddling and diddling is accomplished and the patient is out the door at:
10:32 PM It takes about 20 minutes to get to the Mother Ship. 10 minutes to get to the room and into a bed, and the patient still has not been examined by the hospitalist. This occurs THREE HOURS after the decision to admit the patient has been made. Shameful.

This is why our Last Patient of the Night got a Fast Rail pass to the ER. It would have been 3 AM before she would have gotten out of our department.

Working at an ER that closes has given me a new appreciation for the dirty looks I get at Stop and Shop when I run in for one thing; I tend to go to the all-night WalMart instead, even though it is out of my way.

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.