Wednesday, November 30, 2011

those warm family get togethers

On the holidays we all feel this sort of obligation to get together with the family even if we only see them once a year, even if we can't really stand them. It is what families are supposed to do. It is what we have been brought up to do.

We are supposed to tolerate perverted Uncle Ralph on Thanksgiving or your drunk nephew Bob. The rest of the year, you wouldn't have anything to do with them, but on Thanksgiving you feel a little warm spot in your heart for them, they are family after all....

So it all starts well, the relatives arrive one by one to a festively decorated home. Hugs and kisses all around. Refreshments are offered. Everyone settles down to catch up on who has been arrested, whose teenage daughter is pregnant, who died.

Then you run out of conversation. Some people have had a few cocktails. They start getting louder. Grandma looks annoyed. Son starts getting mad at Dad. Son pops dad in the mouth and they wrestle on the floor. Obnoxious Uncle Ralph says the wrong thing and gets popped in the eye by nephew. The warm family get togethers breaks up as various family members retire to lick their wounds, vowing they will never get together with these fools again.

Dad heads to the ER where it is discovered son has broken his jaw. He is sent home with instructions to only drink liquids till he sees an oral surgeon tomorrow. Drunk Uncle Ralph has an orbital fracture. I love the holidays....

uncle, I say, uncle...

Uncle. I surrender. I give up. I am waving the white flag.

I have come to the conclusion that I, madness the nurse, cannot possibly be the nurse that my employer wants me to be. So I've decided that I won't even try.

Here is what my employer wants me to do as a nurse:

1) Always have a shit eating grin on my face.

2) When someone calls me a "fucking bitch" and threatens me, "de-escalate" the situation by trying to understand the patients point of view.

3) Do not judge anybody - happily give narcotics to that drug seeker. Welcome that frequent flyer with a "hey Bob, what can we do for you today?".

4) Never question the doctor - THEY ARE THE DOCTOR and you're not, remember that. If the doctor chooses to order 50 tests on every person, give dilaudid to heroin Harry, that is their perogative. Your job is to carry out that order, no questions asked.

5) Be okay with the fact that some of your coworkers cannot carry their share of the load and you are going to have to pick up the slack. "We"re a team".

6) Be okay with working short in a high acuity, inner city ER that doesn't have the option to close the door, or refuse patients. Your employer is trying to save money by running lean..

7) Remember to fill in the 500 blanks required on every chart for every patient you see. Expect a nastygram if you don't.

8) Accept the daily change in the electronic charting that you do and be okay with changes in things like blood administration, which used to have maybe 4 or 5 boxes to fill in, now has about 20. "We're just trying to make things better and safer".

9) Be okay with the inefficient flow of patients to inpatient rooms. Understand that housekeeping has to have at least 2 hours to clean a room and that the nurses upstairs are way busier than you are.

10) Do not complain...about anything. You knew what you were getting into when you got this job, so stop whining.

I am officially throwing the towel in.

Monday, November 28, 2011

the best thing since sliced bread

I have mentioned this before, but it bears repeating... It is the greatest invention since sliced bread. The state prescription drug monitoring program. All pharmacies in the state are required to report dispensing of any controlled drugs to this registry. It can then be accessed by any physician or pharmacist. We use it a lot in our ER.

When someone comes in with chronic pain requesting narcotics, it is almost always used. The information is always interesting. I had a patient who was prescribed 360 Vicodin tablets at one time. I kid you not. That is the kind of ridiculousness that goes on in this country. Then we wonder why we have a prescription drug problem.

This information allows a doc to directly confront a drug seeking patient with how many scripts they have received over the last couple of months and from how many doctors. I mean what can a drug seeker say? Its right there in black and white.

I wish all docs used it. If they saw in print the prescription drug problem perhaps they would rethink their own prescribing habits. Cause guess what? At the core of this prescription drug addiction epidemic is the doctor. Its time for them to take a good look in the mirror.

the blood curdling scream

Ah yes...Its time to give report on your patient. You have a room number. The patient can finally get to a more comfortable bed. If only it were that easy...sometimes it seems the floor nurses have made a science out of how to delay getting an ER patient. So here it is..the top ten strategies employed to delay taking report:

1) Nobody home: No one answers the all.

2) Limbo move: Put you on eternal hold.

3) The switcheroo: Different nurses answer the phone and transfer you to other areas where the nurse taking report supposedly is. You end up back at the desk eventually.

4) The stunner: The HUC "accidentally" hangs up on you.

5) Housekeeping reverse play: Housekeeping has not arrived, just started, cleaning the room.

6) The CTD* defense: One of the patients on the unit is crashing and all of the nurses are involved, no one is available. (* circling the drain)

7) The dodge: The nurse "just transferred a patient", "just got another patient", they will "call you back".

8) The surprise play: As you are giving report, the nurse puts you on hold to talk to the charge nurse about whether this patient is appropriate for their unit.

9) The delay: The nurse is on break, at lunch or dinner and the buddy is way too busy to take report.

10) The shift changer: It is an hour before, or an hour after shift change. The nurses are all in report, they are doing their first assessments, the patient will go to the oncoming nurse after shift change, etc etc.

If you hear a blood curdling scream echoing through the halls of the hospital its probably an ER nurse who can't give report...

Saturday, November 26, 2011

from feast to famine

It was the day from hell. We knew it was coming. The last couple of days had been average. It's a holiday weekend. It was not a matter of if we would be pounded, but when. And of course who is in charge of this chaos? You guessed it.

When I took over charge things looked dire. They got worse. Everybody was running their ass off. The ER was full, the waiting room was full. The wait was 3 hours. The natives were restless.

At one point an irate patient came up to the window. They had taken an ambulance in for a very minor problem. They were triaged and put in the lobby. Two hours later they still hadn't gone back. They yelled at me and left. Moral of the story: If you take an ambulance in for a minor problem, you're going to the lobby like everyone else.

Here's the deal - the chaos went on for about 9 hours, to the point where we called in an extra doc and nurse. Two hours later the lobby was empty and so was the ER. I actually got to leave early.

That is ER in a nutshell. You go from bursting at the seams to empty all in the course of a 12 hour shift

Friday, November 25, 2011

everybody poops

I hate poop. I hate black poop. I hate GI bleed black poop. I hate the smell of GI bleed black poop. I hate it when GI bleed black poop is a continuous problem if you get my drift. I hate it when GI bleed black poop is so bad it gets on the floor. I hate it when the GI bleed black poop is so bad that I have to send the patient upstairs with a pants full or they will never get out of the ER.

I love coffee grounds. They really do work to take away bad smells. I love that there are upstairs with inpatient units in hospitals where patients eventually go. I love the feeling of relief that I feel when the whole GI bleed poop experience has come to an end. I love when I walk out the door of the hospital on a day with lots of GI bleed poop. The end.

Thursday, November 24, 2011

grandma got run over by a reindeer

Well, I hope she didn't, its a little too early for that. No doubt grandmas and grandpas galore were brought in by sons and daughters to be checked out today as they are every holiday. Its the time when families spend the most time with the elderly: on the holiday. Thats when they notice grandma sure is more confused, grandpa can't walk like he used to. Off they go, over the road and through the woods to the ER.

Or maybe grandpa and grandma really can't live on their own anymore. Family doesn't know what to do. When any situation arises where you don't know what to do, dash through the snow on a one horse open sleigh to the ER. They'll know what to do..oh yeah. We may have to put grandma or grandma away in a manger if there is no room at the inn, like what happened with you know who...but that turned out ok.

So bring all ye elderly, yea bring them to your local ER breathern. We will give them a warm blanket and footies, a box lunch. We will sing joy to the world and we will hark the herald when angels sing. We will rock with them around the politically correct christmas tree, deck the halls, and then hope for a silent night. Amen

Wednesday, November 23, 2011

the dreaded black friday

So I am off Thanksgiving - nice right? Yup. Here's the thing, being off the holiday, you always pay the price. I work friday, saturday and sunday this weekend. This is one of those weekends that you dread as an ER nurse. Friday after Thanksgving is guaranteed to be ugly. Everybody is off work, out shopping, doctors office closed or at least closing early. Its a recipe for disaster.

Anyway, Happy Thanksgiving to you all!

Dancing Turkey Animations provided by

Tuesday, November 22, 2011

when charge phone meets toilet

As the charge nurse you take all the calls noboby else wants.

Like when somebody calls who eloped and wants test results and the doctor to call in a pain script. Ah..I think not.

Or the guy whose wife six weeks ago came in and had an xray and now six months later has some questions about the results of the xray.

Or the call about a patient being transferred from a small town that no one knows about. They are coming in after having been worked up in another ER. They were supposed to be a direct admit to a floor, however no arrangements were made. Of course where are they coming. Yup right to us. Turns out in the end they had come to the wrong hospital, but were having an MI and went to the CV lab.

Or the family who wants to come down to the ER right now to talk about the death of their loved one 2 days ago and get some questions answered.

Or the local pharmacy calling about a patient presenting with 2 different prescriptions for pain pills from 2 different hospitals and what should they do.

Or the patient calling to complain about something that happened in the ER 3 days ago that they are not happy about.

All of these kind of calls happen when the place is going nuts, of course. One time when I worked charge, I had the charge phone in my pocket and I turned around to flush the toilet and the phone did a perfect swan dive into the toilet. Of course it wasn't reachable. Hey it was an accident! It could've happened to anybody! At least thats what I told them....

Monday, November 21, 2011

wasting away again in frequent flyerville

Frequent flyers. We all hate them. Doctors, nurses, techs... When we see them on the triage board, we collectively groan. Sometimes we disappear. Sometimes we flip a coin, do rock-paper-scissors to see who will taken them. They are the bane of our existence.

Here's the thing, they are not getting the help they need when they come to the emergency room. They are handled in one of two ways:

1) They are quickly discharged. Its a been there, done that situation for the doc.
2) They are worked up by the OCD/CYA docs, wasting everyones time.

I would venture to guess that the vast majority of these people are on medicaid or have no insurance at all. The reimbursement for their bills are nonexistent or very low. They cost the hospital money.

If you added up all the frequent flyers in our ER, I think it would come to at least 10-15%. Lots of people. Lets say we have 60,000 visits a year - thats 6-9,000 unnecessary, money wasting visits. In this day and age of hospitals just trying to make ends meet, its really ridiculous.

It seems like most ERs just ignore the problem. Like mine does. We let it go on and on. Some ERs hire case managers who work with these people. They try to hook them up with community resources, direct them somewhere else, try to figure out what they really need so they can stop coming to the ER. Does it work? I have seen articles saying that it does.

Does your ER use them? What do you think about how well they work?

Case management in any area of medicine has a huge future. It has been proven to save money. Its an alternative for nurses who don't want to do bedside nursing anymore

Sunday, November 20, 2011

madness' alter ego: beadnurse

If you need a gift for Christmas. I make jewelry.

the antidote to a bad shift

If you ever feel down and out after a shift, go to this site and it will cheer you up: ZDOGGMD

Friday, November 18, 2011

I become a sniper

Okay, this is the last straw. It seems that my ER has plans to eventually have a billboard with time to see a doctor like you see in other states. Apparently there will be some kind of link to this billboard from triage.

Here's my response: Once it goes into place, I plan to keep people in the lobby as long as I can. Unless you are dying you ain't going back. Its either that or I get a rifle and take out the sign..

Interesting thing about this picture: apparently there are some ER wait times that you can't trust. Some people be lyin' and shit.

Thursday, November 17, 2011

the land of make believe

I work in the land of make believe. In this land all of the nurses are perfect. We never call in sick. We have a sweet smile and a kind word for every patient, even that drunk guy who shit and peed himself. Intead of reacting angrily to being called a "fuckin' bitch", we de-escalate the crap out of that person for an hour if we have to. Cause thats the kind of nurses that we are...

We think all of the doctors are perfect. We don't mind if OCD doc orders 50 unnecessary tests, you just never know what evil lurks after all. We understand her concerns about liability. Who wouldn't? And if candy man doc orders dilaudid q 5 min, we give it with glee and push it in rapidly just like the drug seekers want us to. They are in pain after all...

We understand why the nurse upstairs is in an isolation room, busy, at dinner, on the phone, in the bathroom, and we wait patiently for her to call us back. Housekeeping is our best friend and we don't mind if it takes 2 hours to clean that "stat clean". Once again we will use our "de-escalation" skills to talk the family down. Thats what we do..

When the lobby is full and back pain Barney has come up to the desk for the 10th time in the last half hour, we will sympathize and offer him a cart in back of triage, who cares if there are already 8 carts lined up back there? There is always room for one more..

Last but most certainly not least, we don't mind going 6 or 8 hours without a break. Our patients need us and if it means missing a meal to take care of them, well - do you think florence nightengale every got a break? I don't think so...

Our ER is perfect. The nurses are perfect, it goes without saying our docs are perfect. Our care is perfect. We follow all the rules. We do everything they tell us to do. We never complain. We love everybody and want everyone to be happy...

How was your day?

Tuesday, November 15, 2011

grandpa's day to die

Grandpa went down in the kitchen. Somehow mentally disabled son was able to call 911. Medics shocked grandpa and got back a rhythm and intubated grandpa. They come to ER and we are waiting to start the hypothermia protocol that lowers the body temperature post cardiac arrest and preserves brain function.

Before we could get started, son who lives in another state is called about how much they want done with Grandpa being that he is 89. Son says that he is power of attorney and makes medical decisions for grandpa. Grandpa has a living will/DNR order. Meanwhile daughter arrives and says she also is power of attorney.. She says that grandpa said plainly he did not want extraordinary measures done.

Doctor explains situation to long distance son and son says he wants to go and get living will document to see exactly what it says. He will fax it to doctor. Doctor says he doesn't need paper, that talking with both son and daughter will be sufficient.

Son wants guarantees about grandpas situation and hems and haws for twenty minutes trying to postpone the decision while doctor patiently explains everything. Son insists he needs to look at the document, saying "don't stop anything for 15 minutes while I look for it". Son will call us back. Son is transferred to grandpas room and talks with sister and they finally decide to not do any more major interventions with grandpa and to remove the breathing tube.

I am listening to all of this at the desk. Grandpa isn't my patient. It is painful to listen to. To listen to son try to make a decision. It is frustrating also because grandpa had already decided what he wanted, but we still have to listen to the family. Meanwhile grandpa sits there waiting while children decide whether to end his life.

You would think that when someone has a do not resuscitate order, that everything would be clear. Its not. I have seen more than a few times, a family override mom or dads decision, and go forward with aggressive interventions anyway. We have to listen to them. The hospital isn't going to put itself in a position legally where they go against the families wishes. Most people also don't realize that DNR paperwork has to be redone yearly.

What happened to grandpa? He was breathing (not real well) on his own and he was groaning loudly when he went up to a room. I really felt for what the family was going to have to go through in the next few hours. I also wondered what would happen to mentally disabled son who lived with grandpa and now is left without someone to take care of him.

Sunday, November 13, 2011

you'd never know she's a junkie

There are 22 million people addicted to drugs in America. What amazes me is the range of people addicted to drugs. From the most sophisticated, educated person to the junkie on the street, addiction hits every strata of society.

The common image in this country of a drug addict is someone who is a crack addict or heroin user who is living on the street looking for their next fix. Probably the majority of people have their own home and are working, managing to appear normal day to day. I have certainly seen many, many people who if you looked at them you would never suspect they are addicts. They are dressed well. They are clean. They are articulate but they are really no different than the junkie on the street. Can't live without the fix.

A lot of these people are addicted to prescription drugs. They find a doctor willing to supply them or they go to different doctors or hospitals talking people into writing them a script. They are often the most clever because they don't have to worry about food, shelter, money for drugs. They know that if they can talk a doctor into giving it to them, they can afford to get it. These are the people who can go on for years, seemingly normal, sometimes able to hide it from everybody.

Eventually it catches up with them because they are caught or it starts to interfere with their life. These are the people that the family brings in wondering what is wrong with them, only to find out they are on dope. These are the people dragged into ER by the family wanting us to do something, put them in treatment right now. Of course, we can't do that. Insurance these days doesn't often pay for inpatient treatment. Families are shocked by this. You mean I have to take them back home? I would almost think being a person who is educated, has a good job, a house in the suburbs would have a harder time gettin' off dope then the junkie on the street.

The junkie on the street has already lost everything. The suburban junkie can go on for years supplying themselves. Often the family will deny their problem. They will tell themselves that "people like us" aren't addicted to drugs. We're not like that crack addict. But guess what folks? Your junkie is no different than that crack addict. The difference is your junkie has an easier time getting the dope because they have money. The crack addict spends every day trying to get money for that fix. It will probably take longer for your addict to hit bottom. But when they do, it will be a long hard fall. I have seen doctors, lawyers, executives, nurse fall. Its true what they say: the bigger they are, the harder they fall.

Friday, November 11, 2011

today's triage facts and figures

Highest number of people waiting in the lobby to get in today: 22

Highest number of people in line at the triage window at one time: 10

Highest number of people in the ER at one time today: 52

Longest length of time someone waited: 3 hours

Most members of one family triaged today: 3

Longest time someone had a symptom they were being seen for: 2 years

Shortest time someone had a symptom they were being seen for: 1/2 hour

Percentage of people who didn't really need to be there: 90%

Dumbest reason to come to the ER: "I want to be seen for an std, I have no symptoms but something doesn't feel right".

Smartest reason to come to ER today: severe chest pain for 3 days

Amount of time left in the shift when I got dinner: 1 hour

Amount of times I felt like running screaming from the ER while working in triage: 12 - at least twice an hour

don't forget them

If you have a few extra dollars this veterans day, think about contributing to FISHER HOUSE. Here is their purpose in their own words:

"Because members of the military and their families are stationed worldwide and must often travel great distances for specialized medical care, Fisher House Foundation donates "comfort homes," built on the grounds of major military and VA medical centers. These homes enable family members to be close to a loved one at the most stressful times - during the hospitalization for an unexpected illness, disease, or injury."

Thursday, November 10, 2011

don't cry, histrionic Harold, don't cry

I was gnarly last week, I admit it. Working too much with too few days off. No time for recovery of sanity.

So its my last day before a few days off. The black cloud that was hovering over me is slowly lifting. Then HE comes in. Histrionic Harold.

Red flags:

1) Medics wanted to give me report outside the room

2) From the time he arrived and was transfered to the cart, he made this WOOOOOOOOOOOO!!! sound while sitting there with his eyes closed.

3) Daughter arrives and does not want to go into room with Dad.

4) He normally gets care at another hospital.

So we manage to get throught the first few minutes. I am entering stuff in the computer and He is rambling on about all of his medical history back to the Mayflower. And I let him ramble. Half listening. Not really caring what he is saying.

I didn't give him the call light. I'm no fool. At some point he requested to have the call light and I had to hand it over. Mistake.

Periodically throughout the visit I hear WOOOOOOOOOOOO!!!

At some point daughter leaves in disgust.

First he will go home. Then he will stay. Then he will go home. Finally a bed is ordered. I consider making a run for it out the door.

I actually maintain my patience remarkably well. One thing about the ER, eventually even the worst patients leave. Besides, I'm off for a few days starting the next day, so its all good

on the yellowbrick road to ER

Wednesday, November 09, 2011

scathingly brilliant medicare idea #1,678

Health care just keeps getting weirder and weirder.

Beginning in October 2012 Medicare will begin withholding 1% of its payments to hospitals to put into a fund that will amount to $850 million dollars in the first year. Based on patient satisfaction scores, this money will be doled out in bonuses to hospitals with the highest scores. The idea behind this being patients will get better care.

This obsession with patient satisfaction is already going on in a lot of places, some more than others. There is nothing wrong with wanting patients to be happy. A worthy goal.

What makes a patient happy? Feeling like somebody cares, relieving their pain, understanding what is going on, getting better.

Nurses care, otherwise we wouldn't be nurses. We want to spend time with patients, listen to them, support them. Here's the problem: We don't have time. We are short staffed. We are required to chart a thousand things on the computer. Call light not answered in a timely manner because there aren't enough nurses, because they are trying to complete all the charting requirements = unhappy patients = bad satisfaction scores = less money for hospitals.

Nurses relieve pain. We want to relieve pain. However, there are a lot of drug seekers in the world. Sometimes they don't get what they want. They get mad. Mad drug seeker patient = low satisfaction score = less money for hospitals.

Nurses want the patients to understand what is going on. They want to be able to take the whirlwind of doctors, results, etc. and break it down in a language the patient can understand. Sometimes we can't do that: short staffed, busy charting. Confused patients = low satisfaction scores = less money for hospitals.

Patients want to get better. Of course they do. Nurses want them to get better too. Sometimes nurses are too busy or somebody deteriorates, there is short staffing and all the tasks that patients require to get better can't be accomplished. Patient having to stay longer or develops complications because nurse not able to give required care = low satisfaction scores = less money for hospitals.

Better patient satisfaction and improved care, great goals to have. Will there be improved nurse staffing to make that happen: NO. Are they realistic in todays health care system: NO.

Monday, November 07, 2011

virtual reality can be your friend

I love White Coats call room blog. Its a great source of interesting articles on ER medicine.

Today he references a new development in ER medicine called E-emergency services. These are emergency MD and nurse consultants available via internet to small hospitals. There is a camera in the patient room which can be controlled by the person at the other end of the internet to move around, zoom in on the patient. It allows the consultant to be a second set of eyes for assessment. They can make suggestions, answer questions. The heart monitor with all of the vital signs, cardiac rhythm can be viewed.
Xrays and CTs, ekgs can be reviewed. All the MD or nurse needs to do is press a button and they are instantly available.

The idea behind this is to provide better and similar care, to the extent possible,as a patient would get in a larger city. It can avoid unnecessary transfers and therefore, save money. By keeping patients in the local hospital, they can remain financially viable. It benefits the patient by being closer to family and follow up that they will actually use.

This is very interesting development, similar to the E-ICUs which do the same thing for ICUs. Now if we could only get a E-MD or E-NP service set up in which people could be seen "virtually" at their homes by computers for simple problems without having to come to the officer or the emergency department. Wouldn't that be great and cost saving? All of this is the future of medicine.

the tale of esmeralda and edward

Once upon a midnight dreary there was a not so fair maiden named Esmerelda who lived under a bridge. Only she wasn't a troll, and she didn't collect money so you could cross the bridge. It seemed that Esmerelda like to imbibe in local libations a little too much. So she ended up making her home under the bridge. Alas, no one would take her in anymore, not even her family.

Esmerelda had a beau, Edward, who like Esmerelda, was often in his cups. So the two joined lives and lived under the bridge. Everyday they took to the streets of their fair city, stationing themselves at various locations in order to beg for money from the local populace. Once they had a few coins, off they would go to the local tavern to imbibe in the grog.

Well it seems Esmerelda and Edward often didn't get along, especially after they left the tavern and staggered back to the bridge. Sometimes they took a grog to go and Edward would take Esmereldas grog and drink it himself, upsetting Esmerelda to no end. Well, one day Esmerelda had had enough of Edward. He had taken her grog one too many times. She went to a local stable and asked the stable boy to call a healer, telling him that she needed attention. While waiting for the healer, Edward happened along and began arguing with Esmerelda. When he arrived, the healer had to separate the two with the help of the stable boy. Esmerelda told the healer that, alas, she had chest pain and needed attention. The healer, knowing Esmerelda from past encounters, cast a suspicious eye in her direction. He believed her not. Much to his exasperation, he had no choice but to take Esmerelda on his horse to his home where he kept the magic beans that everybody sought. He had been employed by the local townspeople to heal any ailments they may have and dole out the magic beans. So off they went, the healer and Esmerelda, riding the short distance to his humble abode.

As usual when he arrived, there was a line of the townsfolk waiting to see him, moaning and groaning. They had come for the magic beans, as they did everyday. With a weary sigh, the healer took Esmerelda into the house, knowing she was wasting his time, for he knew there was nothing amiss with this less than fair lass. In fact as soon as he came in the door, he sent his assistant down the lane to inquire of madame Grenalda whether she had room for Esmerelda. Madame Grenalda, also employed by the townspeople, ran a local flop house where the locals could sleep off their overindulgence of the grog. Luckily, Grenalda, bless her heart, had space. After looking Esmerelda over, wasting his valueable time, he bade the assistant to get the wheelbarrel and cart Esmerelda down to Grenaldas. Off they went.

Grenalda, seeing who it was, nodded at Esmerelda saying, "Back so soon my lass? And without your beau today I see". "I am through with that cad! said a now fuming Esmerelda. "If I had a door he would not be gracin' it again!" Grenalda, rolled her eyes, having heard it all before....She told the assistant to take Esmerelda across the room and put her on the pile of rags to sleep it off. Esmerelda quickly fell asleep. A few hours later, she walked out of Grenaldas, feeling a bit jittery knowing she needed to secure a few coins for the grog before the jitters grew worse. In the distance, there was Edward, in his usual spot trying to secure a handout. With a sigh of resignation, Esmerelda walked down the lane to join him.

Saturday, November 05, 2011

ER karma gonna get you

OK today was eerily quiet. (yes I said it, the Q WORD!!) There was a time when we actually had 4 patients in the main ER.

It was like the world had come to and end and we were the only people left alive. When it is like that it makes ER staff edgy. You know something bad is coming. If it doesn't come today, it will come tomorrow. Its inevitable. It is ER karma. It is the universe balancing itself. Whatever. We will pay the price for this respite and we will pay for it big.

Because of this, I am dreading work tomorrow. Sundays are predictable. Get rid of the drunks sleeping it off from the night before. Then comes the LOLs falling out in church, goes on to daughter/son bringing elderly mom/dad in because its the weekend and thats when they see them. Then there are the lets go to the ER before the football game is on crowd. Then as afternoon turns to evening, its the I really don't feel good, I better go to ER before I have to go to work tomorrow crowd. Sunday nights are inevitably busy.

I can't wait.

Friday, November 04, 2011

Suicidal? You may end up in podunk, virginia

When are there too many psychs for one emergency department to handle at once? Is it five, ten? How about eleven? Thats right, apparently the world has gone nuts becuase that is how many we had yesterday evening. Its gotta be a record. Luckily they were calm, cool and collected psych patients. Nobody tried to ram their head against the wall.

Of course, when the ER has that many psychs, the majority of which will be admitted, its trouble. There are not going to be that many beds or staff for all those patients. Then what? Then they are transferred to other hospitals in the city or suburbs. If we are full, chances are their has been some change in barometric pressure in the country, and they may be full too. What then? Then you go outstate to hospitals in smaller cities. Those cities may be 100-200 miles away.

So picture this: You are on a 72 hour hold. You are going to be admitted whether you like it or not. In a situation like this, you will be admitted anywhere we can get you a bed. That may be 150 miles away. Away from where you live, work, your family is.

That is the modern mental health care system in a nutshell in this country. If you ever need help again, think you will come back?

Tuesday, November 01, 2011

new blog

I have started a new blog for shits and giggles.

Here's the link:


Its political, so if you don't like politics don't go their girlfriend.

wonder where your nurse is?

Dear Jane/John Q. Public ER patient:

Wonder where your nurse is?

That's me over at the desk. I am filling in hundreds of blanks on the computer. I am doing the charting on the computer around your visit.

I'm sure you understand I have to chart things about what is wrong with you, the meds I give you etc. What you don't understand is that there is WAY more to the story than that.

When you come in to triage, I am charting what is wrong with you yes.. oh but that is just the beginning. Your complaint is a miniscule part of what I do in triage.

In triage I am charting:

your complaint
your allergies and your reaction to them
you height and weight
your level of pain and describing exactly what kind of pain you have
whether you have flu symptoms
whether you have had TB
whether you have had MRSA, VRE, etc
whether you have any implanted devices and what they are
your last tetanus short
our acuity - I choose from 1-5 as to how sick you are
your last period
whether you need an interpeter
how you got here
are you ambulatory, in a wheelchair?
who brought you

When I assess you in your room:

Your complaint
a head to toe assessment
a screening of: verbal or physical violence, your risk for suicide, do you have money for food, are there any barriers to your understanding of your care
your meds, their dose, how often you take them, when did you last take them

during your visit:

Depending on your acuity, your vital signs every 15 min to 1 hour
all meds I give you
your level of pain and a description of it
your IV
your IV solution start and stop times
any medication infusion start and stop time
tests you have and when you went and came back
anything that happens to you during your visit
something about your family

specific charting:

conscious sedation checklist and education and charting every 15 minutes for 1 hour after
a long checklist of neurological symptoms, if you are having a stroke, a head bleed about every 15-30 minutes
if you are restrained, I chart a long checklist every 15 minutes
a complex blood administration checklist
specific charting around trauma
any intake and output you have
post cardiac arrest hypothermia protocol and all that goes with it
a strip of your cardiac rhythm
an assessment of your skin condition
any social worker visits
any mental health clinician visits
any MD specialist visit
your c collar and backboard info, wound irrigation and bandage
all bruises and scrapes

If you are critical:

rapid sequence intubation charting
size of endotracheal tube, where it is, ventilation settings
bipap and its settting
your infusions and any changes I make in them
your NG tube
your foley
use of rapid infuser, fluid warmer, bair hugger, chest tubes, central lines,
CVP lines, arterial lines, etc.
blood, platelet, plasma infusion
critical lab results
other stuff I can't remember

At discharge

your understanding of instructions
whether you understand what your medication is for and possible side effects
your level of pain
where are you going
how you will get there
if you had narcs who will take you home

On admission:

your condition at transfer
your medication infusions at transfer
your level of pain at transfer
your IVs at transfer
where your belongings are
is your family here
who is transferring you
do you have monitor, 02 at transfer

I am reading the 5-10 emails I get daily about policy and procedure changes,
hospital events, emails from VP of nursing, CEO, manager, other nurses.

I am answering calls from lab, xray, MRI, CT, other departments, your family members and friends, etc.

I am trying to read the 10 education things I get quarterly that I am supposed to complete on work time.

So if you feel like we don't see each other much during your visit, this is why. Healthcare's priority has gone from you to this.


your nurse

P.S. Your doctor other there, increasing in ERs, has a person who does their computer charting for them, just so you know...