CRNA and Cellulitis

In my youth, about the time that dinosaurs roamed the earth, I had a tendency to be intimidated if I had health care types for patients. Docs and nurses are not the best patients. For myself or my family, I don't (unless I am wearing scrubs) come right out and say I am a nurse with about 1000 years experience simply because it can be intimidating.

Case in point; my husband was admitted last year for a cellulitis in his hand. Since he was being discharged with the need to have IV antibiotics at home he required an IV change (yeah, that one: the one I had put in 2 days earlier). I gave the young nurse 2 tries, then I (nicely) bullied her into fetching me a warming pack and put the damn thing in myself. I really tried to stay out of her way but my husband is a hard stick; I was just looking out for him, not judging the nurse.

So a guy came in over the weekend with a pretty nasty infection; he would require IV antibiotics for a couple of doses, but could come to the ER for his medicine; hey, we're a full service ER.

As I looked over his arms for a suitable spot to place his IV, his wife helpfully shrieked, "You can't put it in that arm, that's the one with the infection!".

Um, ok. Gee ma'am, don't know what I would have done without that useless bit of information. I quickly intuited that she was some sort of health care person and she wanted me to know it.

In my experience, the degree of effort expended by an individual to inform me in some roundabout way that they are in health care:

a. is inversely proportional to their level of experience or years of practice

b. has no relation to the level of acuity said individual practices

c. is a clue that they are either a student or an LNA

or

d. just want me to know that while they may not be a kick-ass ER nurse like me, they are indeed a kick-ass school nurse, office nurse, camp nurse, etc.

Second case in point: the aforementioned unhelpful wife, once I had decided on my target vein and was moving in for the kill, asked, "will you put in a butterfly since he has to come back tomorrow? They are so much smaller".

This tells me that unhelpful wife is an idiot since a butterfly, while small and perhaps really useful for short term use (ie, minutes) under direct supervision is inappropriate for longer term use. People who exhibit health seeking behaviors such as migraneurs who capriciously use the ER for their chronic pain condition will often ask for a butterfly. I usually don't make an issue out of it, but explain that those are METAL needles which are not good for extended use. Then I promise to use a baby needle, usually inserting something like a 20 gauge. This is a good size stick and certainly not a baby sized needle unless the baby is a full grown adult. Which they are.

I decide to ignore unhelpful wife and address my comments to the patient who was being very quiet. I explained that the site I had chosen in the middle of his arm would not be as compromising to his lifestyle as one in the hand or the crook of his elbow.

"Oh, he knows all about it, he's a CRNA"

Ah. A nurse anesthetist. Cool. Scary damn specialty, though. Too much chemistry and opportunities for it all to go horribly, tragically wrong.

Mr. CRNA looked up at me and mused, "How am I going to work tomorrow?"

"Well, I'm pretty sure you have sick time; use it".

"Oh, he never takes any sick time", said unhelpful wife.

"Well, think about it, do you really want to go into the OR with this raging cellulitis? Hmmm? Is that a good idea?" I asked, hanging his bag of IV antibiotic.

"Guess not".

Unhelpful wife accurately intuited that I had lost interest in her and chose to regale me with tales of her horrible experiences in ER's. This not only bores me, but in most cases, this sort of discussion is about as tactful as telling me about the time you farted in church. It tells me a lot more about the kind of person you are than "scaring" me into believing you are an astute health care consumer or that you have any native intelligence at all.

To his credit, the CRNA patient was cool. Maybe he knew he was kind of screwed with that albatross of a wife.

"So, what what do you do for work?", I asked unhelpful wife, "are you a CRNA as well?". I knew she wanted me to ask. Really.

"Well, I work in dermatology".

"Wow, really, you're a dermatologist; that's great" I gushed, knowing damn well she was not. It is less than full disclosure, sort of like me saying I'm in MEDICINE; I work in the medical FIELD, but to say I work in medicine might lead one to believe that I was a physician. You can see my point, I'm sure.

Unhelpful wife squirmed noticibly and replied, "Oh no, I work in a dermatology OFFICE".

I moved in for the kill; "Oh, so what do you do there?"

"I'm a med tech, but I run the appointment desk".

Uh huh. Thought so.

July 4th Patient Parade Notes

With the 4th of July being my weekend to work, I was naturally despondent that most of my family were partying up at the lake.

Without me. That included Mr. Ednurseasauras and Tina, my daughter K and her boyfriend, Rockstar, my mom, two of my brothers and their two kids apiece, a random niece of my youngest brother who is a firefighter and my hero (an who, like me is a lowly public servant destined to work weekends for the rest of our lives) and about 1/2 ton of legal fireworks. A good time was had by all, except perhaps for Tina who hid under the house for most of the fireworks display, and K's new kitten, whom Tina apparently wanted to eat. I can't blame the dog, the cat is about the size of a chipmunk, and probably good eatin'. It is, after all, the Other white meat.

My weekend partner and second nurse is New Cathy, who replaced Dan. She was an even trade from the Mother Ship for Dan, whom I liked but others didn't warm to; he liked to play with his iPhone, but was a good nurse and I had fun working with him. He worked at the Mother Ship for about 3 months, bitching the entire time because it is disorganized and lacks leadership, then moved on to greener pastures. I have said there are no Utopias in emergency nursing, but anyway, good luck to Dan. New Cathy is great to work with and enjoys patient care. The Mother Ship cannot have her back.

July 4th is a funny holiday. Sometimes it's busy, sometimes not. I'm 3/4 of the way done with a four-day stretch, Friday through Monday. The first two days were pretty quiet, seeing only 18 or 19 patients for the entire day; that doesn't exactly pay the rent when you consider that we need to see a lot more than that. Probably double that considering many of our patients use our ER as a free-care clinic, and some days as a public toilet. The usual complainers, worriers, and nothing-better-to-do's who frequent our delightful establishment on mundane weekends apparently had other plans, were on vacation, or visiting other ER's.

There are several overnight summer camps who like to use our facility as much as we like to have them; for them, it is 17 miles closer than the Mother Ship, and for us, lots of lovely, polite young campers and counselors. Also they have insurance, not that that is really an issue but it is a refreshing change.

One day last week I kept track of how many of our patients had no insurance, private insurance, or Medicare and/or Medicaid which reimburses at a ridiculous $.30 on the dollar:

Out of 30 patients for the day, 7 had private insurance 4 had Medicare, 1 had Healthy Kids and 6 had Medicaid. That translates to 23% of patients whose treatment would be reimbursed at an inflated rate in order to make up for the 40% who have free care (ie., no insurance and no intention of paying) and the 36% whose treatment would be reimbursed at pennies on the dollar. Also, 4 other kids were eligible for Healthy Kids, but the parents "hadn't gotten around to it" yet. Which is really asinine, considering it is free and the social workers will pretty much do the paperwork for you if you have less than a 5th grade reading level.

Yesterday business picked up; it was a day for bringing families together in the ER for mundane reasons. Just a few observations here; all of the mothers were smokers as evidenced by the reek of tobacco, had artificial nails, didn't work, and requested such items as free sample of drugs, money for the vending machines, coloring books, crayons, stickers, took several pairs of gloves to make balloons, and had the nerve to ask for syringes to make squirtguns. The unruly kids trashed the waiting room, triage room, exam rooms while the oblivious parents chatted on their cell phones. White trash tornado.

On rare occasions we have patients who are interesting. One really nice young guy came in with a red banadana around his knee; he had sliced himself a tasty gash with a freshly sharpened chain saw; a running chain saw. I have seen some pretty chewed up flesh in my time from these dangerous things, but somehow he managed a clean laceration; it must have come in contact with his flesh for a milisecond, luckily for him.

New Cathy and I were working with Dr. Cripes (cause he says it all the time) who is fast but thorough, decisive and funny as hell. He usually has a running dialog going, but you have to really listen to hear the funny bits because they come out so quickly. Witty guy. Fun to work with, plus he lets us play with his iPad when he isn't using it; I LOVE that thing.

"Whatcha got?" he asked as I wandered into the treatment area from triage.

"Chain saw massacree", I replied. "It's gnarly but neat".

"Carving ribs, was he?". Cripes is so droll, isn't he?

"Nah, carving up the neighbor who borrowed his rake last fall. He didn't return it", I grinned.

Cripes chuckled. "You let him sit in the waiting room?".

"Nope", I assured him, "he refused a wheelchair. He missed the femoral artery, though if he had hit it, I would have insisted. Just to be thorough. Besides, Helen likes to keep her registration desk free from pesky bodily fluids". Today Helen was harboring blueberry cupcakes somewhere, with little American flags. They looked yummy, too.

After Cripes injected lidocaine into the young mans knee and went off to examine ather patient (to give the lidocaine time to work) the young man was trying to take a photo of his laceration with his cell. The first two were in shadows.

"Here, let me adjust the light", I offered. "It really needs some perspective, I think", as I got a ruler out and placed it next to his knee.

"Yeah, that's great; much better shot. You're really into this, aren't you, sick like me!" he mused.

Busted. "Oh sure, that's why I love my job so much. We'll take another picture after it's fixed, OK?", I said.

15 staples later, another photo-op and a nice dressing and he was on his way. I just love things that we can fix.

One man came in and was immediately whisked into a treatment room; he had been experiencing weakness, lightheadedness, palpitations and chest tightness as he lay on the living room floor. For two hours. His EKG and all other tests were normal.

"He's wound tighter than a drum; if you poke him he would probably vibrate like a tuning fork. Can I give him some Ativan? And maybe some for his wife, every time I walk into the room she scurries into the corner", I asked Cripes as the man lay rigidly on the stretcher.

"Sure; I'm going to give him a 'script for some anyway. Man, he is anxious", said Cripes.

This patient, being a typical Type A personality was:
a. dentist
b. college professor
c. bike mechanic
d. engineer
e. landscaper

If you guessed anything other than choice D, you are wrong.

Mary, Diana, and Helen were very unbusy toward 8:30 PM. I thought it would be nice to put the July 4th Boston Esplanade concert on the TV, but they were engrossed in Extreme Makeover. Move that Bus indeed. "I just want to see how it ends" begged Diana, who is our lab tech. She is fast, fast, fast. We are spoiled when she works because our lab results are done at lightening speed.

"Music haters!" I accused. I really didn't care, I had other stuff to do. I do like Toby Keith, though.

The Milltown fireworks, we anticipated, would be visible just over the tops of the trees across the park adjacent to our ER. About 9:20 PM Mary and Diana had commandeered wheelchairs, popped corn and were settling in for the show. New Cathy and I finished up with another camper with a broken finger and, since we had no more patients, thought we might get to see the show.

Nope. The floodgates opened; the parking lot started filling up before the first shell was fired. Non-urinating 8 year old; fractured wrist; firework cinder in the eye (no corneal abrasion, but she got Vicodin for it) and the idiot who let a pack of firecrackers explode in his hands.

Fireworks + alcohol= stupid.

He had mostly 1st and 2nd degree burns; I gave him a big tub of water and some face cloths so he could bath his burns to his face and hands. Also to wash off the aloe that he stupidly put on.

Within moments his "bathing" had saturated my entire treatment room. Really, he was splish-splashing like it was a giant bird bath. Soon he had abandoned the tub of water (and the saturated side of the room) and proceeded to saturate the other side of the room by running the sink at top (and continuous) speed.

"Dude, please. You are saturating equipment and other things that should remain dry, and now we can't use it. Please (just grow the fuck up)be more considerate; I will give you something for pain as soon as Dr. Cripes has had a chance to look at you".

After two injections of Dilaudid, a handful of Vicodin to take home, and 50 gallons of water covering every surface of my treatment room AND two bathrooms, he left. Hopefully to think about what he had done and how not to repeat it.

Finally, at 10:50 another bonehead comes in for a non-healing wound he has had for 2 weeks. It wouldn't have been so bad but the idiot had called at 7:30, presumably to make an appointment or try for "call-ahead" seating, like Chile's. Yikes.

The poor lady with the wrist fracture was splinted, given pain meds and sent on her way to follow up with ortho.

New Cathy and I scurried around for 10 minutes putting things back together, leaving witty notes for the day shift (which is notorious for leaving tattle-tale type notes and reminders for evenings- I thought I would return the favor).

Hope all of my friends had a great 4th, especially Anne and Debbie who watched the Boston fireworks from Debbie's new apartment overlooking the Charles River. Hate you, mean it! Oh, and Happy Belated Birthday to you, Ps2ue!

Happy 4th of July to us. Wonder if Cumby's has any Coffee Heathbar ice cream? Nah, I'll just have a beer.

One of my most annoying pet peeves is individuals who wear pajamas out in public. Nothing quite says "I don't give a crap" more than donning fuzzy pajama bottoms and going out to the market, the pharmacy, Chile's....unless said individuals find it necessary to also don fuzzy slippers. Apparently the rules of polite society don't apply anymore.

I am equally annoyed when seemingly able bodied individuals come the the ER in pj's. If you drive to the ER, and also come in with a coffee from Dunks, you will be deserving of my scorn. Apparently, America's sick and stupid run on Dunkins also.

Of course, there are exceptions to this rule. I am perfectly willing to be accommodating to people with actual emergencies; chest pain, cutting off a finger in the snow blower (why they were snow blowing in pj's is a story for another time), children under age 9. Generally the elderly, anyone who arrives by ambulance...you get the picture.

I assume that anyone without major hemorrhage or an actual emergency who arrives in jammies and slippers is just being dramatic. Or an idiot. Or both.

So it was with a significant amount of effort to prevent the eyes from rolling right out of my head that I triaged an ENTIRE FAMILY of 5 wearing pajamas at 9 PM on a Friday night.

The emergency?

"There was a bat in the house....I think".

Nobody could say for certain; and nope, it didn't bite anyone. But good old family provider thought it was good idea to go to the ER for rabies prophylaxis. Immediately.

Post-exposure rabies prophylaxis is not terribly complicated, but it requires a LOT of calculations. For starters, everyone gets a 1 CC dose of rabies vaccine. This is the easiest part, and actually kind of fun to mix 'cause it produces a reeealy pretty magenta solution.

OK, enough of the fun part. Next, the patient also gets rabies immune globulin which is weight based; the more you weigh, the more shots you get.

Now, nurses really don't like to give a ton of shots, so the calculations involve squeezing as much of the medicine in as few shots as possible. If you are a big person, say, 250 lbs., let's figure this out together, and

YOU BE THE NURSE
The does is 20 IU's (international units) per kilogram. At 250 lbs., the patients weight is 113 kg. The total dose is 2260 IU.
Since the immune globulin comes 150 IU/ml and there are 300 IU per ampule, you will need you will get a grand total of 7.5 ampules of immune globulin.

Now, that is a total of 15 ml's to be divided into less than 3 mls per shot.
So, a 250 pound individual gets 5 shots of immune globulin and one shot of rabies vaccine on the first day. They have to come back three more times for more of the vaccine as well.

Wasn't that fun? And clear as mud?

But wait! Naturally, there is an app for that!

I don't have it, so using a standard calculator the old fashioned way is the only option. I still laughed my butt off when I read the description for the u-Rabid XL application for calculating rabies IG doses and followup scheduling:

"uRabid XL is the fastest & easiest way to calculate the Rabies Immune Globulin dose & Rabies Vaccine schedule.

Using standard US dosage calculation just enter the patients weight to determine the correct dose and use the division tool to calculate how many injections to give!

The bottom half of the program provides the standard Rabies Vaccine schedule for all return visits.

No calculators, no calendars - No hassle! uRabid will finally take all the guesswork out of injection administration for patients exposed to the deadly rabies virus"

It was a LOT of shots for 5 people, and we didn't have enough IG to accommodate both overweight parents and their pudgy children. The parents decided they didn't want it anyway when they found out how many shots were involved. I guess they probably went out to dinner and a movie in their jammies.

Crap Notes

I don't know why hospitals feel compelled to put bulletin boards in bathrooms designated for use by nurses. That is just EXACTLY what I want to do when I run in for a moment's relievment before ascites sets in: look at a bunch of messy notes, memos, bulletins, threats and various and sundry missives begging for donations.

Let's take a quick-look tour of said bulletin board, shall we? I will lock the door for my privacy.

Here is a poster that has been up for 2 months now advertising a fundraiser for Haiti. The event date is sometime in May. We will be "dancing the night away" to some band called The Casuals, and there will be a cash bar, raffles and fun, fun, fun. Hmm. Nope, don't plan to attend as it is run by Darlings of the Mother Ship with whom I have no contact. I am boycotting anyway since Administration refused to reimburse in any way nurses who have volunteered for humanitarian missions. Sherry was deployed to Haiti for two weeks, was home for a week, then went on her annual trip to Guyana (at her own expense). Not that she expected any financial remuneration, but you would think a catholic hospital would be more charitable; the party line here is, I guess, charity does emphatically not begin at home. However, any employee who wished could give up some of their earned time to help out. Mmmmm kay?

Here is another: Bring Your Child to Work Day sometime in April. (Grandchildren also welcome!!). This is not imply that the little darlings get to stay with mummy or daddy (or Granny and Gramps). Nope, the kids will be herded to the cafeteria and fed hot chocolate, given coloring books and stickers and probably be made to join hands in a circle to sing Kum Ba Ya. Then an exciting tour of "materials management, food services, the front lobby and out patient services area" will ensue, followed by a free lunch. This effectively keeps the younguns out of the very clinical areas in which we are attempting to interest them. If mum or dad is a nurse, sorry, you don't get to see them performing amazing feats of nursing care. I am not sure how this fiesta would promote careers in health care, but if my kids were young I would have signed them up tout de suite. I did everything in my power to discourage health care careers with both K and J, and have thus far been successful. I had a bit of a scare when K decided on a career in social work knowing that population sucks the life right out of you. Fortunately, she decided that while the practice of social work was distasteful, the study of sociology was sublime. So she majored in that, and minored in English. Ah, I would love to minor in English, but it is just not possible with my BSN program. No minors allowed, haha.

There are several memos on the bulletin board for CPR, ACLS, PALS and the like. One of them has listed all the personnel who require such certifications and the expiration dates; I notice that the name of the woman who died last year is on the list. Talk about expired.

There are more notes to "join this, read this". Oh, here is one for CPI class. Now, this is Crisis Prevention Institute, which "trains human service professionals in ways to safely manage disruptive and assaultive behavior". Here's how I handle it: 911. These classes used to teach about one hours worth of self defense maneuvers, surely enough to keep you REALLY safe until the wheezing, overweight and geriatric security guard shuffles on in with his walker. Urgh. This is a mandated course so that the bean counters can check off one of those distasteful little chores, likely mandated to them by JCAHO, Homeland Security or the ASPCA. Violence in health care is pervasive, haven't you heard that 75% of nurses have experienced workplace violence. If that isn't a ringing endorsement for recruitment. I have been pushing administration for years to let us have tasers. I know that there is pepper spray in a foam available, but how about if it was more like Silly String? That would be awesome.

A flyer for the Northeast symposium for ER nurses has the usual offerings of panels, discussions, lectures and vendors. But act now and you can get on a romantic dinner cruise on Lake Champlain on Maid of the Mist, or whatever. Nah. Heard there was a monster in there.



OK, one more. I love this. It is for the Sunshine fund. Gotta love the Sunshine fund. Lee runs the Sunshine fund with all the attention to detail that was not evident in any of the banking scandals of 2009; with an iron fist. I don't think that $36 a year is unreasonable, and look at the perks. Fruit baskets and flowers. For all occasions! It does specify the conditions for which one might receive an honorarium. Ahem. Hospitalization (inpatient) of employee, spouse, or child. Death of employee, spouse, child or parent of employee. Birth of a child of an employee. Graduation of employee from an institute of higher learning, either graduate or undergraduate. Although my boss got a party when she finished her Master's degree. If I ever get mine, screw the fruit basket and just send me a gift certificate for a massage. There are some situations that aren't covered, for example, our housekeeper attained US citizenship and he got a nice fruit basket. And one of the ladies in the lab got remarried. Wonder why the newly divorced don't get fruit baskets? Shit, I'm beginning to sound like Andy Rooney. I hate Andy Rooney. So last year Mr. Ednurseasauras was hospitalized with a nasty infection in his hand (due to a near fatal goring with a tree branch when he was hiking Mt. Washington). About 2 weeks later, I got an envelope containing a $50 gift certificate to a very nice restaurant along with a profuse apology from Lee for not having acted immediately to acknowledge my husbands pain and suffering. Lee prides herself on flawless accounting, diligent collection of funds, and instantaneous provision of tokens of sympathy and congratulations. Mr. Ednursesauras had knee surgery 3 months later, and the fruit basket was in my kitchen when we returned from the Big City. I wrote a lovely thank you note and requested to be passed over if anymore of my family (or myself) became ill so as not to be asked to pay double the following year. So far, so good. Enjoyed the fruit, too.

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.