Reel it In

As reams of mandated, useless, and repetitive paperwork take more and more time away from patient care it becomes increasingly difficult to sit with patients and discuss their discharge plans. One of the best things about working in a smaller facility is that we generally have plenty of time to spend with patients doing the kind of teaching that is rapidly becoming a thing of the past. We do our best to provide detailed instructions and an opportunity to ask as many questions as needed.

Sometimes, though, it just doesn't matter because the public just lacks manners and common sense.

Me: (entering patient's room): I have your discharge instructions and I would like to go over them with you.

Patient: (speaking on cell phone) I have to go, the nurse is here with my discharge. What? No. How did that happen? (to me): Just a sec. (to cell phone): What are you talking about? No, I don't have any prescriptions yet......

Me: (Leaves the room and closes the door).

Patient: (10 minutes later, opens the door). I thought you were going to give my my papers, I've been waiting for 10 minutes.

Me: I was waiting for you to finish your phone call so that I could have your undivided attention (restrains an expletive as co-worker kicks me under the desk).

Smile!

I just love that we have video cameras that capture all the drama of what is happening around our ER. There are, in total, 11 separate views that include our 3 parking lots, entry way, and waiting room among others. Other than a bit of unfrosted glass to peer out of in our ambulance bay that is adjacent to the main parking area and a small window in triage, there is not a greater opportunity to observe incoming than what our cameras capture. I can sit comfortably at one of two chairs at the nurses desk, pull up the camera program on my computer and, with the mere push of a button, visualize up to eight separate views simultaneously. Most patients are unaware of this, so we frequently have some fun with it.

Occasionally I will see a severely debilitated, limping patient come in complaining of severe back pain. What a thrill to see (on camera) the very same patient miraculously straighten up and walk with a rapid and steady gait through the parking lot to a waiting vehicle with his magic prescription for narcotics. A Miracle!!!

Equally miraculous is the patient who arrived by ambulance with the knee injury; no fracture, but it could definitely be a ligamentous or cartilage injury. Good thing it felt so much better after application of knee immobilizer and careful crutch walking instructions that the patient was observed to have removed the brace and THROW IT AND THE CRUTCHES INTO THE BUSHES AND WALK NORMALLY!! I was so impressed with our physician's ability to heal with just a 'script for Tramadol!

We call the biggest bush "The Giving Tree" because we have found that sometimes the afflicted who have experienced a miracle healing will heave unto it their slings, wrist splints or ace bandages like those who are healed at Lourdes. HALLELUJAH!!!

Lots of times people who shouldn't be driving home because we have given them medication are caught in a lie observed getting into the driver's side of a car; we like to let them know that they are impaired, and since we have no way of alerting every driver on the road, they will not be allowed to drive. Or we call the police. Decide.

One night we had a couple of cars broken into with the theft of some items such as a GPS, backpack, and money (who leaves money in a car?). I was able to pull up video evidence for the police that resulted in the apprehension of some less than scrupulous individuals; and since one of the individuals was attending a meeting, SNAP! Gotcha piture purty lady, heh heh.

Mikki likes that we can see if the police are parked in our back parking lot (she is a 'fraidy cat) to ensure our safety as we walk out.

Ellen wants to be able to tell all of the patients without ID or insurance, "that's quite alright, simply look up into that corner while our camera captures your likeness for future reference".

Me? I just have my eyes glued to the screen to make sure that no cars pull in at 10:57 PM. Then I lock the door. Good night!

Groundhog Day

The only way the groundhog would have seen his shadow around here is if he started digging a week ago.

I can't find my car, let alone a groundhog hole.

But the good news is, he did not see his shadow, thus, spring is on the way.

Readers Guide to Triage

Triage is the part of the ER visit with which the general public seems to have the most difficulty.

When in triage, I usually greet patients by asking, "What can we do for you today?". I think it is so much more friendly than saying "Why are you here" (just sounds too confrontational), or "What brings you here today" (because the average asshole will say, my car, my mother-in-law, or a taxi. It is unfunny and unproductive and makes the patient look like an idiot, frankly).

By asking "What can we do for you", it is opportunity for me to collect information and to create a dialog about why the patient is in the ER, and and gives the patient an opportunity to state their expectations. We are in the business (and business it surely is, make no mistake about that) of helping people, but it does require a little bit of effort on the patient's part.

What is not helpful are the following responses:

1. "I don't know, you tell me"

2. "My doctor told me to come in" (also the school nurse, trainer, day care provider, home care nurse, my neighbor who is a nurse's aide. Oh, and my mother is also a big one)

3. "Kill me" (also I want to die, or simply lying on the floor moaning while texting all of your friends)

4. "I'm sick".

Each of these answers will earn at minimum a withering glance, such as the one Nurse Jackie is offering. I don' t even respond anymore, except to possibly say "Is there anything you'd like to add to that?"

Other less than helpful responses include:

5. "Well, it all started with _______ in 1998.....".
Please, just keep it to a single compalint if possible. Sore throat. Migraine. Shortness of breath. Chest pain. Cold symptoms. Vomiting. Very simply, I don't need to know every aspect of your medical history. And, you will just wind up repeating it to the doctor, who also really doesn't need to know you had a colonoscopy or a mammogram in the last 5 years. Sheesh. Plus being long winded in triage only delays your care.

6. "You have my records"
I might, but why should I look them up? It takes time away from other patients. If you don't have the ability (are short of breath, mentally debilitated, or require resuscitation) I might look them up. But, if you don't care to provide me with the information or it is too much of a chore, consider that may also be for me.

Things triage nurses never say, but are always thinking. If thought bubbles were visible, we would all be screwed:

7. It's not nearly as bad as you think. (Actually, I do say this quite often for things like lacerations especially for frightened kids. Especially if I'm pretty sure they won't need sutures)

8. You aren't as sick as you think you are. (Mostly for the Man-Cold; a blog in and of itself)

9. Did you call your doctor about this chronic/long time/insignificant issue?

10. If you already have percocet and oxycontin at home, what more did you think we could do for you?

11. You aren't really wheezing if you are consciously making the noise yourself in the back of your throat.

12. You are not unconscious if you are merely lying with your eyes closed

13. You have got to be on crack if you think I believe that you weigh only 250 pounds/smoke 3 cigarettes per day/have no money in your Coach bag next to your Iphone to buy an inhaler .

14. Did you think to try ice/Tylenol/ibuprofen?

15. You injured this a week ago, have been playing sports and going to school, it's not swollen and a bone isn't sticking out, but it's just "not better". Are you an idiot?

16. You have had an antibiotic for 24 hours and you are not all better. Are you an idiot?

17. You don't know any of your medications; don't you think that you should? (For this I usually offer a handy little plastic sleeve and a medication list card; people love giveaways)

Also: if I offer you a wheelchair it is because I am concerned about liability, not necessarily that you shouldn't be walking on it since clearly you have been walking around on it for days.

Today's Last Patient of the Night.....

was a 20 month old brought by mother for "vomiting".



Me: When did the vomiting start?

Mom: A half hour ago. He was with my ex. I think he might have gotten into some medicine.

Me: What makes you say that?

Mom: Well it was blue and green and had chunks in it. Nyquil is blue.

Me: Did you speak to the Dad to see if it was possible, or that he had been given any blue foods?

Mom: What?! There are no naturally occuring blue foods!

Me: Rainbow Goldfish? Skittles? May not be natural, but they come in green and blue.

Mom: Oh. I didn't think of that.



Note: the child had eaten a lot rainbow colored Goldfish crackers when mom checked.