Planning

The 93 year old cardiac arrest rolled in without  advanced airway or IV access.  No drugs.  Asystole.  CPR was halfheartedly in progress.  The young man who had found her on the floor was living in the house, a friend of the patient's great grandson.  The patient was supposed to be DNR.  Why, then, was she in our ER?  The young man called 911 in a panic, and could not produce the DNR or any documentation. Since none of the actual family members were at home, CPR was initiated by EMS.  She was pronounced dead moments after her arrival in the ER since she had an advanced directive on file and the family member called us.  Good; we didn't have go all out on the Poor Dear, and the end of life wishes not to be kept alive by artificial means were (sort of) followed. 

Note to self and others: discuss end of life plans.  Have one in place.  Keep the DNR handy.  If there is a terminal illness, understand what to do if the family member dies at home.  This was a case of good intentions, just a tad short on follow through.

It fascinates me that although death is inevitable, so few families are prepared for it.  We don't often discuss it.  Terminal illness aside, it seems as if by ignoring the Reaper, he will ignore us. 

I can't stress this enough.  Everyone deserves to be treated with dignity, yet there is little dignity  when an elder loved one dies in an ER, worse still when it isn't their wish to be kept alive with heroic measures.   I would hate to have my last image of a loved one lying lifeless in an ER. 

Squirrel Count

I love Gil.  Some of the other nurses thinks he orders too many tests, but I don't.  He likes taking good care of patients, likes to educate, and always has something interesting to share.  Having worked with him for about 2 1/2 years we've come to know him will.  He used to be a little hyper, but he's over it.  We talked about that the other day. 
Gil: "I remember when I first started here, I was kind of ramped up.  At least you guys know when I need a time out".
Me: "Yeah, the first few months were....challenging at times.  Not that you weren't likable, that wasn't the problem.  And it wasn't a time out you needed:  a couple of times I just wanted to slap the shit out of you.  Calm.  I like calm and focus.  Breath in, breath out.  This is not Chicken Little ER".
Gil: "Always some bumps in the road with new docs, huh?"
Me: "Mmmmmhmmmmmmmmm".

Loe the guy, but he's a squirrel feeder.

"If you feed the squirrels, they will keep coming back".  This refers to narcotic seeking individuals.  Gil's solution is to give them, say, 2 Percocet to go and no prescription.  He may think he has shut off the squirrels, but he is still giving them acorns even if it's one at a time.  Besides, it just makes us nurses have to sign them out, put them in a little envelope, and write "one tablet every 4-6 hours as needed for the severe, excruciating and debilitating pain that has brought you to the ER like 20 times this year.  This is all you get, don't ask for more".  Well, not the last part.  Anyway, Gil just keeps on feeding those squirrels.  Last night's squirrel count as follows:

Case 1:
Complaint: Butt pain
Goal:  Narcotics
Plan: Home with narcotics
Female with a bruised butt from a fall down the stairs presenting with 20/10 pain on a scale where 10 is the max.  So bad she took Tylenol about 20 minutes before arriving. She was observed on camera as she walked normally to the door where she then proceded to mmmmmmmmmmmooooooooooovvvvvvvvvvvveeee iinnnnnnnnnnnnnnnnnnn sssssssssssssllllooooooooooooooooooooowwwwwwwwwwww mmmmmmmmmmmmmooooooootion.  Really.  It was like a 78 RPM record being played at 33 RPM.  And if you don't have any idea what I am talking about, ask your......grandfather.  After she got what she came in for, her gait was back to speed as observed on our trusty Spy Cam. I would be so sad if that stopped working.  Very entertaining.

Case 2:
Complaint: Back pain
Goal: Narcotics
Plan: Home with narcotics
Another young female who had been treated for sciatica and dental pain in 4 visits to the ER this month and had received Percocet for each of those visits.

Case 3:
Complaint: Acute knee pain.  I had to get her out of the car 'cause she couldn't walk
Goal: Pain relief, rule out fracture, and not to have to use crutches
Plan: Home with narcotic pain 'script and crutches.
This one was a middle aged woman who thought karma was working against her as she had said just yesterday that she would never use a walker.  Hah.  People make plans, the universe laughs.  We were completely out of knee immobilizers so I wrapped an ace bandage and gave her crutches.  I worked with her for 20 minutes but at the end of the session she said, "I'm not going to use them anyway".  Observed via Spy Cam walking normally in parking lot with the crutch tips pointing to Heaven.

Case 4:
Complaint: Man-cold with sore throat.  Oh, and back pain.
Goal: Narcotics and work note.
Plan:  Home with Tramadol and work note.
Don't get me started on man-cold.  It is the season for most men to become a quivering puddle of sniffling, whining, hacking, helpless, miserableness.  "I don't feeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeel goooooooooooood!"  Percocet for a cold and sore throat of 4 hours??  Seriously?  Are you fu*king out of your mind? 

Here's an aside: a friend of mine who works in Endoscopy (AKA, the Bum-Lookup nurse) says that thanks to Michael Jackson's doctor, they are required to tell patent's that they will not be getting Propofol.  Thank you.

Get Off the Phone

I may put on a happy face in triage, but when things get ugly I can take it right back off.  Nothing ticks me off more than people who just can't put down the fu**ing cell phone. So sorry to interrupt your oh-so-important text messaging so that I may triage YOUR emergent ER visit for say, dental pain or rash.  Fever of 99.4 ("My normal temperature is 97.5, so that is BURNING UP  for me!")

 Me: "Hi, what can we do for you today?"
Loser: (continues with phone texting activities and doesn't respond)
I waited exactly 7 seconds.
Me: "Excuse me".  I walked out of triage.  I was really busy, so I made her wait awhile.
When I eventually went back in, I said "Are we all done updating the Facebook status?"
If they are too stupid to know they are rude, it is unlikely they will notice if I am....annoyed.

I do not sit in a triage room eagerly awaiting your visit.  I have other patients upon which to do EKG's, clean wounds, and start interventions along with myriad other technical, secretarial and janitorial tasks (beds don't make themselves, and I certainly don't mind emptying trash and linen when it is overflowing).  There may even be one or two patients with ACTUAL EMERGENCIES for whom it may be necessary to transfer out in a hurry.

I shouldn't have to tell people to shut off their damn phone, but common courtesy is non-existent.  Hell, MANNERS are non-existent.  Parents certainly aren't teaching the basics at home, and teachers are too busy just trying to get the little shits to sit in their seats without damaging their fragile self-esteem.  Don't get me started on HATS.  The last time I was at a public event where the National Anthem was played, the announcer actually told men to remove their hats.  Pathetic.

I never never encourage people to answer their cell phone in my presence in fact I just don't even acknowledge their moronic ring tone.  Like the Rocky theme.  If it is a teen or a kid playing a video game I tell them to put it away.

What happened to respectful human interaction?

Gone by the wayside:
1.  Saying please, thank you, and excuse me.
2.  Waiting your turn.
3.  Making eye contact 
4.  Teaching kids to have respect
5.  Taking responsibility for your actions

Thus ends today's rant.

Feed Me

You have 35 (WTF!) visits to our ER alone this year for migraine, I have no doubt that this is drug seeking.

Gil: "Well, I know he's here a lot.  I'm suggesting that he make his own appointment at Up State Big Hospital, and keep a log of his migraine activity.   I think he  really does have  migraines"

Me: "That makes one of you".  

We nurses know who has had at least one visit per week, sometimes multiple visits in one day.  We know all of your little dramas, which lies you have told, and when you park your car around back after telling us your ride will be "right along".  

 I dutifully prepare your dose of the "d" medicine after ascertaining that your usual cadre of medication allergies was unchanged.  Toradol.  Tramadol.  Codeine.  Phenergan.  Imitrex.  Fioricet.

Within seconds of the administration of your meds, your photophobia has resolved.  You are a magically a different person and you try to engage me in a conversation about the Patriot's.  I get it; you really are just normal, friendly  guy. 

I'm sure you are.  But I don't give you anything to work with.  I'm sorry to be in a hurry to wrap this up as I have a vomiting 80 year old with an anxious family to deal with, as well as an infant with an uneducated single mother in need of teaching.  You understand.  Neither you nor the doctor has any interest in addressing your addiction, we are rubber-stamping this visit and leaving it for the next person to handle.  You have gotten what you wanted, so really, my time is better spent on caring for someone who actually wants help.  Sorry, but that's the way it is.  If you actually asked for help I would go the distance for you, and I mean that sincerely.  But until you have burned all the bridges and hit rock bottom, there is little I can do.  And it makes me feel like an ass each time you come in and play your little game. 
Feeding squirrels.  If you keep feeding them, they will surely return.  What happens when the acorns run out?

Cuts and Cutting Remarks

New Hampshire hospitals have been scrambling to come up with millions of dollars in budget shortfalls.  The state legislature in its infinite wisdom voted to cut Medicaid reimbursements along with many other cuts to state and local agencies and programs.  The impact to hospitals involves money that had been counted on during budget planning for the coming year, but now the rug has been pulled out from under. 

The state  taxes hospitals 5.5 percent on  patient revenues, but returns the amount of the tax in matching federal Medicaid funds so they effectively lost no money.  That's out now, and hospitals have been cutting jobs all summer, the latest round of layoffs occurring about a week ago. 

We lost a number of positions, none of which were clip board personnel or Suits in Charge of Stupid Shit, not surprisingly.  I get to keep my job.  But there were several LPN's who lost their jobs.  Just axed.  Some genius in the public relations department of another hospital, who also cut their LPN's, justified cutting them  since, "LPN's are really just glorified nursing assistants".  Really??  Talk about adding insult to injury.

I have never worked in a hospital that employs LPN's in the ER, but I have worked with my fair share in many other areas.  Some were good, some were great. 

The first one I ever worked with was Mrs. Maccaione.  I don't know if she had a first name, you either called her Mrs. Maccaione, or "Mac".  In 1973 she had to be in her mid-sixties.  Mac wore whites from the top of her starched cap to the polished perfection of her white Clinic shoes.  She was as broad around as she was tall, and at 5 feet was an imposing and intimidating poster child for Crusty Old World War II Nurse.  With her rolling bandy-legged gait and the whoosh! whoosh! of her pudgy thighs in their snow white support hose, she bore down on me and the other two nursing assistants like a ship under full sail; usually with guns a-blazing.   She was NO NONSENSE in the flesh.  She really did try and bounce quarters off of draw sheets.  Mac was well known for her scrutiny of top sheets for precise hospital corners.  Woe to you if you were caught resting a pillow under your chin to apply a pillow case.  You would hear about it in spades if your patients weren't  bathed in a timely manner or their immediate environment was not spotlessly clean.  We were scared to death of her.

In the early 1970's, day surgery was non-existent.  If you had a cholecystectomy or appendectomy, you were in the hospital for about a week.  A tonsilectomy?  Two nights.  Wisdom teeth?  That involved checking in to the hospital the night before your surgery and staying all day.  Sometimes patients went home, sometimes they could "elect" to stay another night, like if they were vomiting or whatever. 

Mac always greeted the patients and oriented them.  This was a job that needed to be DONE RIGHT.  She strode into the room and  stood at parade rest. 

"Good afternoon!  Welcome to Unit F.  I'm Mrs. Maccaione-call me Mac.  You are scheduled for _____surgery tomorrow at 0800 hours.  Today, you will be getting a visit from the anesthesiologist and having whatever testing may be deemed necessary, if any.  You will be signing a surgical consent if you have not already done so.  For today, you will be given a regular supper, served between 5 and 5:30 PM along with a light snack at approximately 8 PM. Visiting hours conclude at 8 PM, so plan accordingly.  At this time, the switchboard will not put through any incoming phone calls to the rooms.  Lights out in this unit is generally between 10 and 11 PM; you will be needing your rest.  At 12 midnight, you will be NPO: Latin, Nothing By Mouth until after your surgery.  You will be awakened at 5:45 AM to prepare you for your surgery.  Questions?"

This monologue was delivered  rapid-fire.  I'm sure most patients didn't dare ask questions of Mac. Most of the doctors were scared of her. 

But you should have seen her in action when it came to encouraging a fresh post-op and making them feel cared for.  Or getting another 6 feet of corridor out of a tired newly ambulatory patient with a big belly wound (remember Scultetus binders?).  There was nothing she couldn't get from the kitchen staff if she thought it would entice a finicky eater to take nourishment.  For all her brusque and bossy affect she was a hell of a nurse; you would want her to take care of your family.  I learned a hell of lot from her. 

Just a "nursing assistant"?  Oh, HELL no.