Dear Narcotic Seeker, an Open Letter...

I see you have had a number of visits for your Holy Trinity of Chronic Complaints (dental pain, back pain, migraine).  I make no apology for placing you in the waiting room.  Just so you know, the medical professionals upon whom you depend for your endless supply of prescriptions for Percocet are busy with actual emergencies today.  Two happen to be busy trying very hard not to die, one before we can get a helicopter here to transport her to Big City Hospital. 

Ellen, our secretary to whom you give the same information every time you come in, is busy trying to assist the professional staff by making phone calls and other duties since the nurses are up to their assholes in alligators.  It is inappropriate for you to lie on the floor in the waiting room and moan for a blanket. Frankly, we just don't care what you do or how much you act like a total douche; however, you are a distraction for Ellen, and you are making the small children and your fellow douchetards in the waiting area uncomfortable. 

If you sit in the chair like a grown-up and behave yourself, you might be seen by the doctor in the next two hours.  You might get one Percocet if you are a good little narc-seeker; however, telling me "Kiss my ass!" is not going to endear you to anyone.
With Disgust,
EDNurseasauras

When Stupid is Not a Concealed Weapon

New Cathy and I worked last weekend and I think we might have seen about 10 patients total, which amounts to DEADLY slow shifts. Wednesday, Thursday same thing. I managed to read about half of "1984", which I can't remember having read in high school but know that I did; I picked out lighting for my new kitchen and did most of my schoolwork for the week. And was bored out of my gourd, having to resort to watching a rerun of a ridiculous singing version of Gray's Anatomy; we saw in total 5 patients in 8 hours. All that quiet we have more than made up for in my last few shifts; it has been pants crappingly busy with actual REALLY SICK people.

I like to work with the Talker, he doesn't hurry people, which is why they love him.  He has no urgency to to boot them out the door no matter what the complaint.  This goes equally for dental paineurs (they get antibiotics only if they have more than one visit for same), antibiotic-seeking mothers whose kids have had a temp of 99 degrees for 10  minutes, back pain (chronic), and not-magically-better boo boos and viral illness after 12 hours. 

Of course this can backfire when it is really busy.  He largely ignores Bobo's mandate that all patients be seen within 20 minutes.  Sometimes it is as much as an hour.  Or more.  It gets complicated because the Talker doesn't automatically get xrays or order labs simply because the patient expects it; it is definitely not "Have it Your Way" ER when he is on.  If it will not affect how he will treat the complaint, he is all about not exposing patients to radiation or paying tons of money for lab work.  Have a UTI?  We dip it, he treats with antibiotics.  The common sense approach rules.

There were about 7 patients sitting in the waiting room; Ellen was buzzing around, dealing with a lot of non-emergent whining "how long is the wait".  This really bothers her because she hates to ask us when we are busy, and is just not hard-wired to be firm with the idiots.  Generally she is stuck in the middle where she never wants to be.

At 9:30 PM I looked over the charts in the rack:
Cough x 1 week in an 8 year old.  Not worse, just not better.

"Asthma attack" in a tween girl (drama, drama, drama).  Not wheezing, not coughing, not short of breath, sats 100% on room, lungs clear. Take a number honey, and get off your fucking cell phone.

Vomiting x 2 in a 20 year old frequent flier female who has been seen 8 times for "menstrual cramps" and always gets vicodin.  WTF.  Does not look sick and is drinking an iced coffee

Laceration in an 18 year old male.  Microscopic.  Will not require stitches.

"Flu-like symptoms"; nausea, no vomiting, no fever, no cough, no other symptoms except "I don't feel good".  History of fibromyalgia.

Dental pain, first visit for same; accompained by 23 year old boyfriend who has had innumerable visits for same

Dental pain, 10 visits between the us and the Mother Ship.  Known to have altered a presctiption in the past.

Of the patients in rooms and getting workups, two were being admitted with all the bullshit that entailed.  At least they would be gone by 11 PM.  One is getting antibiotics for cellulitis and is ready to leave.  One is awaiting disposition for a UTI.  Two kids with earaches waiting to be seen.  The Talker usually doesn't prescribe antibiotics for all earaches automatically. 

He spent 20 minutes in a circular argument patiently explaining to a woman who was strongly advocting for her 24 year old daughter for antibiotics for yet another viral illness.
"But we had them last time"
"She is not better so she needs them"
"If she doesn't have antibiotics how is she going to get better"
"But she had them last time and got better"
"She is sick, so she needs antibiotics"
"Couldn't you just give her some samples"
"She needs antibiotics because she is sick and not getting better"
"We will just come back tomorrow and get them"
You can't win any of these arguments when people are stupid

It may be time to start looking around for a new job.  At least in a regular ER, most of this time-wasting crap and parade of idiots would go to the fast-track.  Where I never want to work. 

Blast from the Past

I was flipping through the channels just now and came across an episode of "Marcus Welby, MD". This show is a time capsule of stuff that happened in the 1970's when I went to school.  Get a load of those caps and white uniforms!  Of course, the nursing stereotypes were pretty extreme.

I can't say as though all of this was the norm because I trained at a pretty progressive teaching hospital. Well, marginally more progressive than most I guess.  "Natural childbirth" was hip in 1975, and fathers were part of the birth team functioning as the labor coach.  But, only if the couple was married; no "baby daddies" allowed at that time.
 
This episode took place in 1975 and featured Gena Rowlands as a 36 year old professional woman, busy, successful and having it all except a baby; she had been struggling with infertility for years.  In real life she was probably 45 and looked it.

Upon declaring her about four weeks pregnant, the mother-to-be phones up the husband to tell him the ecstatic news.  The proud papa rushes over to old Marc's office with champagne, whereupon ALL THE DOCTORS, NURSES, HUSBAND AND PREGNANT WOMAN COMMENCE TO DRINK.  Yikes.

A group of pregnant women, Marcus Welby's nurse and a couple of nursing students take a tour of the "Maternity Ward".  First they get a look at the labor room, where "a nurse will help you time your contractions for the first stage of labor".  Guess L&D nurses didn't have much to do in those days, at least until it was time for delivery.

Next, the group of scared looking women, clad in white OR gowns and caps moves on to the delivery room "where you will be moved for your second phase of labor".  Scary damn place.  "This is the table where you'll bring your child into the world!" Nurse Lopez says brightly

"Where do we first get to see our baby, Miss Lopez?", asks a scared primip.

Nurse Lopez looks strained, takes a breath and says, "Well, maybe in here Susan...if you're awake in time.  You may be just under a local anesthetic if there are no complications.  Then, you'll hear your baby's very first cry right in here".  Camera pans to incubator, OR green-covered equipment, stirrups and scary shit as the young mother looks terrified.  "Something to look forward to, isn't it?", Nurse Lopez asks gently and unconvincingly.  The group is ushered out, no doubt to view other medieval implements of torture.

The rest of the show is pretty crayzee, but I don't have time to see it.  I'll DVR it for later.

Stubborn, all of them

I thought some of those tough old Yankee birds were a trial when I lived in Massachusetts; they were nothing compared to these stubborn NH Yankees.

I got a 70 something year old man by private car for "trouble breathing", who needed a wheelchair assist from the door.  He was gasping like guppy; his O2 sats were in the 60's.  According to his daughter he had been having increasing shortness of breath for about a week.  He wasn't eating or drinking, and couldn't get off the couch for the last couple of days.  His daughter said "He has emphysema and his inhalers aren't working.  He has refused to come to the hospital, and wouldn't let us call an ambulance; I had to call my brother to help me get him out of the house when he finally relented".

No shit.  He was frail and cachectic, a bearded, grizzled old guy.  He was not on home oxygen.  He did not have nebulizers.  And he continued to smoke (until a few days ago).

"He refused nebulizers and oxygen, well, he is a smoker so even if he didn't refuse it he would probably blow himself up or start a fire".

We managed to turn him around without intubating him, but it took awhile and he was pretty tired.  I assumed he would go to the ICU, but apparently the hospitalist didn't think it was necessary. WTF.  The doc was a stubborn as the patient

Our doc was Arnie,who only works with us one or two shifts per month; in four years I have probably worked with him maybe 7 or 8 times.  I appealed to Arnie that, c'mon, he needed a higher level of care than can be provided on the medical floor. "I think he'll be ok".

Yeah, right; time for an end-around.

I called the nursing supervisor and told her that even on 100%, he desatted to the 80's with minimal exertion and in my opinion, nurse to nurse, (code for the doc doesn't see it that way) he was not appropriate for the floor.  She agreed.  But, since nurses are considered idiots who can't make decisions at this joke of a hospital we had to play games;  nursing supervisors at this religious institution being all female don't have much influence. 

We decided to have the hospitalist see the patient in the ER but still keep him a direct admit. Cripes was the doc downtown and was also given the heads up.  His wife is a nurse and he is one of the few who actually thinks nurses have anything to contribute.

"He's going to the unit", said Cripes.  "Cripes, he's on a non-rebreather!"

Yep.

I took the shotgun approach to report and faxed it to everyone; the ER nurse I talked to.

"Oh yeah; he's going to the unit".

Like I sad.

This Could have been bad

Telephone caller: "Hi, would it be possible to get rabies shots there?"
Me: "For humans or animals?" (I wasn't being a wise ass, really)

A while later, a woman came in who stated that she had been bitten by a skunk; well, that got my interest.

The middle-aged woman had been raking in her back yard and didn't notice the mangy, dirty skunk until it was right beside her.  At that point, she was too afraid to move and scare it into spraying her.  Unbelievably, the skunk sort of rolled on her foot; then bit it.  It wandered off and then sprayed.

Not normal skunk behavior for sure, and it occurred at 4 PM when it was still daylight. 

Fortunately, the patient was wearing a heavy boot at the time; the skunk never broke the skin, luckily for her.  She skated off without getting rabies prophylaxis after our doc got some advice from the state Board of Health.

The skunk was not found according to police.