ode to the med room

What would nurses do without the med room? It is a place of refuge.

If you feel like you are going to lose it, you go to the med room. If you have to blow off steam you take a co worker into the med room and let er rip. You can gossip in the med room. You can make fun of patients in the med room. You can cry if you want to in the med room.

I talk to myself in the med room. I ask myself what I am doing in this God forsaken place? I call the patients idiots. I take a few deep breaths if a doc or coworker pissed me off.

Espescially in an ER, the med room is like the eye of a hurricane. It is a calm and peaceful place in the middle of a whirlwind. No docs, no techs, no management. The only people with reason to be in there are nurses. Its like our own secret clubhouse and it requires a secret code.

I for one, couldn't live without it.

gaming the system

She presents with "back pain". Sitting in the triage chair she says just to check her vitals to see if she is okay. Vitals are of course, normal. She asks if there was something wrong with her heart, the vitals would catch it right? Ponders deeply whether she should be seen.

I can't make that decision, you have to decide. States she will go to the waiting room to think about it. Comes to the desk and asks to use the phone to call for a med cab home. Med cab company calls and is told patient was never actually seen in the ER. They won't come.

Guess what? She wants to be seen. Big surpise huh? She decided this could be her heart, she has had an irregular rate in the past. EKG done in triage = normal. Big shocker that.

You have just witnessed the most expensive cab ride you will ever hear of - about $2,000. All of it will be billed to you - the taxpayer.

waiter there's a fly in my soup

Random thoughts at the end of January...

It seems crack addicts have sensitive palettes. The other day our cuisine just was unacceptable to said addict. Their light lit up immediately upon presentation of the entree. "I don't eat any of this stuff!". Geez, I thought scratching and conniving daily for that high, you would eat just about anything. But no, our friend wanted us to order specific items. Ala carte as it were...but alas, the kitchen was closed. Our poor friend was forced to gag down the entree presented....

When you go with a friend to the ER, why not be seen yourself for that pesky chronic complaint? That sore knee that has been bothering you for six months....hey you got the time right? After all the last doctor you saw was in jail...

Why not come to the ER for a second opinion on your tummy ache? Your own doctor is not telling you what you want to hear, so maybe the ER doc will unravel your complex condition. Also, if you been to 3-4 other ERs and are not happy with their service, come to ours, because we probably have the miracle cure you have been looking for...

We so appreciate it when you tell us when asked if you have a doctor, you say, "no I come here for my care". It makes us feel special that you chose our institution to meet your health care needs.....hey money is money and we'll take it any way we can get it.

When you know that you are going through alcohol withdrawl, grace our doorstep. We would be happy to stave off those shakes with a healthy dose of lorazepam. We will probably even start an IV and given the vitamins you are lacking. We'll make you feel good so you can go out and do it all over again.

Attn: ER staff will now be required to literally kiss the ass of every patient

The message has been heard LOUD and CLEAR by hospitals that REIMBURSEMENT WILL BE BASED ON PATIENT SATISFACTION in regard to medicare and this will drive the future of reimbursement.

All of this is now trickling down to those of us who actually do the work of caring for the patients. Its a WHATEVER THE PATIENTS WANTS WE ARE GOING TO DO, PERIOD, END OF CONVERSATION AND YOU WILL ALL GO ALONG WITH IT OR ELSE.

First thing that happened with this: Changing nurse uniform color so patients will be able to "identify" the nurse better. I don't even want to get into it, but suffice it to say that the hospital had already decided what color they wanted but made a phony attempt at making the nurses believe we had a choice of which color by vote. We now get at least one email daily about things like "don't forget to order your uniforms in a timely manner, so you will be ready". Duh, I really think we can figure this out on our own. Here's the thing: There is another group of employees in the ER who wear the new color and so do xray techs. No doubt all the litle old ladies and crackheads and drunks will be awful confused.

Next "initiative": Every room willl have a greaseboard in which the doc, nurse, EMT, etc will place their name. Ah yeah...I can see the docs doing this...the docs will expect us to do this. Forget it, put your own damn name up there. This has been tried before. Didn't work.

I can't wait for the next "initiative". No doubt there is a committee meeting about it. Maybe it will be required that the ER staff should kiss the ass of everybody who comes in. After all, this stuff is so much more important that the ACTUAL PATIENT CARE.

Dave the drunk and Cathy the crackhead

You know what I get tired of? People bringing Dave the drunk or Cathy the crackhead to the ER. Their life is down the toilet and the family or friend doesn't know what to do with them. They are afraid for the persons safety. Hey I get that. You care about them.

Here's the thing: THERE IS NOTHING WE CAN DO FOR THEM IN THE ER. The doc will run some tests to make sure they are physically OK. THey may give them one of those stupid banana bags. They will give them a number to call about treatment. Thats about it.

Nobody is going to fix them in the ER. The magic treatment fairy is not going to appear and scoop them up. Very few hospitals these days have inpatient chemical dependency treatment. That ended years ago.

I can't tell you how many times I have triaged Dave the drunk and Cathy the crackhead accompanied by worried family. Dave and Cathy just sit there and say little, if anything. Family does all the talking. Tales of how Dave or Cathy are not taking care of themselves, ruining their lives, the lives of those around them. Its sad.

Family is always disappointed when Dave or Cathy are not admitted. They expected us to save them. The thing is ERs are not in the saving drunk or dope addict business. Please don't bring them.

the modern day ER

Hospitals these days seem to serve 2 groups of people. The elderly with complex medical problems and histories, and the poor who come to ER for their medical care.

What happened to everybody else? Are they going to urgent care? Are they going to their own doctors? Are they just not seeking care because they don't have insurance?

Honestly this is what hospitals have become. They are turning into places where those admitted are really sick. Often they have a long list of medical problems which make their current problem more complex.

Maybe the people in the middle have figured out that if they come in for some minor problem, they will sit for hours and have decided they can wait to see their own doctor.

The poor people seem to be willing to wait. Are they are used to waiting? They will sit for hours with their sore throats or tummy aches waiting to be seen. Then they come back next month for some other minor difficulty.

Makes me wonder if hospitals will become high tech nursing homes keeping old people alive. Makes me think that ERs will always be the place where the poor seek care. In Washington state this last year they tried to limit the amount of times someone on medicaid could be seen in ER for a nonacute complaint to three times. After three times, they would be charged like a hundred dollars or something. It was overturned by the court.

We are fooling ourselves when we think we can limit healthcare costs. They will only keep going up.

emergency department no-no's

from the archives

Emergency department no-no's:

1) Don't fall and come in by ambulance and have a baggie of crack in your sock that the doctor finds when he examines you. At age 65 no less. Then keep coming out of your room yelling that we have no right to take your property.

2) Don't come in with your girlfriend (the patient) and then go out to the ER entrance and try the door on a car that is sitting there and get in and look around for something to steal. Then go back in your girlfriends room like nothing happened.You see my dear moron, we have cameras at the entrance, so smile you are BUSTED!

3) Don't come in with your boyfriend and both of you ask to be seen for the same thing: chronic back pain. Then expect both of you to get a supply of Vicodin. I don't think so.

4) Don't go in the bathroom and down a bottle of jack daniels before you are admitted to mental health.

5) Don't come in after being banned from 3 local hospitals because you were sexually aggressive and threatened to kill the staff, then set your sights on our hospital.

6) Don't adjust your own IV pump to cause yourself another medical problem so you can be admitted.

7) Don't call us on the phone and ask if we do c-sections there because you are "tired of carrying this baby".

8) Don't pack some hospital sheets and towels into a patient belongings bag and try to leave with them. EWWWW!

9) Don't come in for something related to your pregnancy and then steal the fetal heart monitor that we used to hear your baby's heartbeat.

10) Don't tie up your dog at the emergency entrance and then come in to be seen.

the crappie floppers

There are a lot of what I would, if I were being generous, call "ineffective copers" in the world. These are the people who can't tolerate a punture wound without doing a crappie flop in front of triage.

They run to the ER at the drop of a hat and as they cross our threshold revert to behavior similar to that of a 2 year old. Here's the thing, they fill thousands of ER beds across the country. The public thinks ERs are full of people who are really sick or injured. Wrong. They are filled with these kind of people.

These are the people with "chronic pain". They will keep coming back until someone labels them with some kind of syndrome or dubious condition to try and get rid of them.
They have achieved their goal. Now they have finally have a title for themselves. They can tell everybody: see, I told you I had something wrong with me. Even drug companies are taking advantage of the thousands of ineffective copers by developing drugs for them.

Instead of dealing with their underlying depression and emotional problems, they become their diagnosis, it becomes their identity. Their lives revolve around it. They suck their family into it.

They suck the life out of the ER staff. They unnecessarily fill beds that seriously ill people could be in. They spend millions of health care dollars a year on their syndromes and conditions. They are part of the reason your health insurance is so high.

ER staff should get combat pay

The thing about working in the ER is you will deal with all kinds of people. Some you won't want to deal with.

Like gangbangers, criminals, sex offenders, mean drunks, people who choose not to take baths or use deodorant. Whether you like it or not, all these people get sick and injured too.

I have taken care of people who, frankly, scared me. Sometimes you just get this sense that people are dangerous. That's when you do whats necessary and don't spend a lot of time in the room. You keep the curtain open and security nearby.

This is the part where you wonder why people who work in ERs don't get more money. Where else do you deal with not only "regular" patients, but all the people the rest of society avoids, moves away from, etc. This is where the danger comes in. Where there is danger, there should be more pay. Kind of like the military, when you are in a war of conflict area, you get hazardous duty pay. Thats what we should get in ER.

DING! DING! DING!

There is a game we play in the ER. Its called the ER charge nurse bed game.

You are charge, the phone rings. There are 2 chest pains in the lobby and an ambulance on the way. You have 5 minutes to come up with 3 beds...GO!!!

Go directly to docs area, with a stern look on your face, ask docs who can go to the hall. Docs say nobody can move. You move their patients anyway! You come up with the beds! DING DING DING You score 25 points.

You are charge, the phone rings. There is a critical 3 minutes out. All the beds are full, including the stab rooms! GO!!! You do a 2 patient room switch and the ambulance rolls in just as a bed goes into the stab room! DING DING DING You score 25 points.

There are fifteen patients waiting in the lobby. The natives are restless. The triage staff is threatening mutiny. You are waiting for beds for 4 admits. GO!!! ou quickly called the supervisor, threaten to go on divert to ambulances. She comes up with the beds. DING DING DING You score 50 points.

Final score: 100 points. You win: $16.00 extra ($2/hr) for being the charge nurse for 8 hours. You stop and pick up some cheap wine on the way home.

Thank you for playing the ER charge nurse bed game.

please don't pee in the wastebasket

Today sucked. Of course. Its a monday. Its winter. There is vomiting and diarrhea and coughing and a lot of gnashing of teeth going on. People are depressed and tearful and bloated and dizzy and weak.

It was the kind of day in which one of my patients chose to pee into the wastebasket. That was a lot of fun. The thing is some made it into the basket and some didn't...

It was busy through to about 7 pm and then triage cleared out and there were empty rooms and we got a breather for a little bit. Mr pee-in-the-basket man finally went up after waiting 3 hours for a room. He was actually able to put urine in a urinal before he left and I thought to myself: "he's trainable". And life was good.

Another typically crazy day in the ER, in which I questioned my own sanity at least 3 times during the day. Then life went on and I got to go home on time.

We interupt this blog...

***PUBIC SERVICE ANNOUNCEMENT***

Attention all citizens:

The following are not emergencies:

1) bug bites - unless it have swollen to the size of a baseball

2) the fact that you cannot control your teenage daughter or son

3) you are fatigued or can't sleep

4) you want your son, daughter, brother, sister, etc. to get chemical dependency treatment

5) the condom broke

6) you are hungover

7) G tube not working

8) the cut is less than 1"

9) any kind of medication refill

10) menstrual cramps

Thank you,

your neighborhood ER

I love unions

You know what I am damn tired of? Nurses bashing unions. Specifically nursing unions. Here's my advice: If you don't like unions, go work in a non union hospital. They exist in every city. You can move to a non union, right to work state. Good luck with that.

Nurses in this country fought long and hard to get the wages and benefits that we all earn. Nursing contracts set precedents for non union nurses wages. In other words all nurses reap the benefits of union contracts, its just that some don't pay the dues.

Shut up. I hear all of you anti-union people yelling unions promote mediocrity, blah blah blah. Do you honestly think that there wouldn't be a certain amount of mediocre nurses even if there weren't unions? Its part of the workplace sweetheart. They exist in every job, whether there is a union or not.

Shut up again. People can be fired who work in union hospitals, the difference being there is a STEP process to it in which the employer has to prove a reason for firing. To those of you who think that you couldn't be fired at the drop of a hat just because they don't like you in a non union hospital, you are a fool.

I will never understand why nurses don't support things that better us. We would rather whine about bad conditions than do something about it. The nurses who formed unions DID something about it. You reap the benefits of their work, so shut the hell up.

the nursing exodus

There is a nursing shortage coming. Its not coming because of an increasing number of patients. It coming because nurses are going to start leaving hospitals. Its inevitable. Its already happening.

The conflict between dealing with an increasingly demanding and difficult patient population and hospitals emphasis on patient satisfaction will drive the exodus. We are expected to kiss the butt of every patient who comes in the door. We are expected to understand the stress patients are going through and "de-escalate" situations and put up with verbal, and sometimes physical abuse, as "part of the job".

Young nurses are going to get out. They already are. Almost every new nurse I know is going back to school in order to get out of the hospital. They don't want to work in an environment like this. I say more power to them. I would do the same if in their shoes. I would advise new nurses to look at the wide variety of options available to nurses. Don't settle for the hospital environment. It is physically, mentally and emotionally exhausting and nurses who work there should be making twice what they do for the stress they are under.

So, young nurses stay out of the hospital. You may be tempted to work there because it pays the best. Its not worth it. Its too hard and getting harder. Be an NP, CRNA, nurse clinician. Those jobs pay the same, or more, as a hospital and you will have a lot more control over your practice. I say this as a nurse who has worked in a hospital for many years. If I had it to do over, I wouldn't have stayed.

Dear Mr/Mrs CEO....

Why is it that CEOs these days feel the need to be touchy/feely?

The CEO of our hospital sends all the employees an email every week. Often times it will include something personal about them or their families. The last CEO would give us these bits of history about the hospital. He would also tell us how "the money shit is behind this month - not good".

Dear Mr/Mrs CEO:

Please do not send out any further emails. I wish you luck with your family, but I really don't want to hear about them or your personal life. I'm just not interested. Perhaps that makes me a cold bitch, oh well...

I could care less about the history of the hospital. I really don't need to know the monthly financial picture and whether the money is up or down.

Here's the thing, I'm just trying to get through another crazy day in the emergency room with my sanity intact. Just do your job and leave me out of the rest of it.

Sincerely,

Madness the nurse

the stupidest person on earth

Stupidest thing I have seen in the ER:

Father and daughter present after MVA fender bender. Of course
Dad has the usual bullshit back pain, blah blah blah complaint. He insists that daughter be seen even though she HAS NO COMPLAINTS. She has no pain, nothing. You heard me right.

This is the point we have come to with MVAs in this country. These personal injury lawyers advertising on TV have caused this kind of foolishness.
My question does it violate any regulations, EMTALA regulations to refuse to see his daughter in this situation? By the way, daughter was 17 years old.

it doesn't add up

a full moon

too many chronic pain patients

ER dr feelgood

a very cranky madness

welcome to the ER money pit

Can I ask a question? Why is it that when someone comes from urgent care, another hospital, clinic, another ER and has already had lab tests, EKGs, etc., they have to be done all over again? This even happens if the place they come from is part of the same corporation and the labs are on the computer.

Apparently we don't believe THAT OTHER HOSPITAL OR WHOEVER. They have deficient equipment that is probably giving the wrong results. So we better do this shit all over again JUST TO BE SURE.

Another question: Why does someone transferring from another hospital to this hospital have to be seen in the emergency room? They have been worked up at the other hospital. Often they are coming for tests unavailable at the other hospital. Our docs would say that the tests they come for would make a difference in where they are put in the hospital. My question:
So lets say, on the million to one off chance that a completely different diagnosis is found than the one that was suspected on presentation to our ER,why can't the tests be done inpatient and if need be, transfer them to the proper floor? The patient will be more comfortable in an inpatient bed, the ER won't have to use up that bed for a patient that should have been a DIRECT ADMIT. Say it with me boys and girls, D-I-R-E-C-T A-D-M-I-T.

One last question: When did it become the job of the ER to diagnose disease? I ask this because of the increasing use of things like MRIs and CT angios. MRIs have become commonplace in the ER. Mostly we are doing head MRIs. Someone will come in with a neuro symptom. THEIR CT HEAD IS NORMAL. You have ruled out head bleed, stroke, gigantic tumor. Then for some reason,
an MRI is ordered. Shouldn't the procedure be that if you
you have RULED OUT emergent conditions a) it can be done outpatient b) if you are that concerned admit them.

Another common test: CT heart angio. An MI has been ruled out intially in ER by EKG, lab tests. This is not an emergent situation. Another example of if you are that concerned admit them, otherwise do it outpatient. It has got to the point where if your 4th cousin twice removed on you mothers side had high blood pressure, off to CT angio you go. I have NEVER seen anybody rushed to the CV lab or surgery from the results of a CT angio. In fact, the vast majority are normal.

Oh by the way, if you happen to come after 5 pm, CT angio is closed and our sophisticated technology will not be used in your case.

This is the kind of ridiculous shit that goes on in hospitals every day. Thousands of dollars in medical costs are run up unnecessarily. The bottom line on all of the above is one thing: M-O-N-E-Y.

5 rules of ER

Because I feel lazy tonight, I have shamelessly plagarized the following 5 rules of ER from ENW humor
.So what.
1) If it requires the ambulance team and entire truck crew of firefighters to transport you and safely place you on a hospital stretcher, it is time to go on a diet.

2)If you are well enough to complain about the wait, you are well enough to go home.

3)We know how many times you've been to an ER. We can usually tell if you are faking it during the first 5 seconds of talking to you. Do not lie to us. If you lie about one thing, we will have to assume you are lying about everything. You don't want that.

4)If you want something, be nice. I will go out of my way to piss off rude people.

5)Please don't bring in a "show and tell". If you have to fish it out of the toilet, it's really not necessary to bring it in, we will take your word. If you did fish something out of the toilet, you may not use my pen.

dear doctor: you know where you can put your banana bag?

You know what I hate? Banana bags. They are a stupid waste of my time. I mean really...we are concerned about a drunks nutritional deficiencies? Like this bag is gonna make all the difference..OK. And I'm sure this bag will prevent the dreaded Werners encephalopathy (I've been a nurse for a loooong time and I have never seen it) every alcoholic fears. Right. So let me go into that room with the piss soaked drunk and fight him for an IV. I live for this shit.

Please don't come into the ER if you fell off the wagon. Please don't come into the ER saying you have "alcohol poising". Your symptoms are that of a withdrawing drunk. Don't bring your relative in for treatment. Maybe you didn't hear, we don't do treatment in the ER. We will send you right back out the door with a phone number. Don't come in if you are hungover. I will probably have to miss the IV a couple of times and put in a #14 for your foolishness.

It is a lot easier to deal with a street drunk than it is with someone who still has a home and a family. The street drunk knows what they are and accepts it. They don't play stupid games.

ARE YOU SERIOUS?!

In triage today I found myself silently asking the following question patient after patient: ARE YOU SERIOUS?!! I mean really...you came here for that?

Constipation for 3 days, womitted once 3 hours ago, hungover, strep test, lots of boo boos and owies. If was a damn buffoon parade out there.

At one point, a psych patient ran past the back of triage and was tackled to floor by security. That was exciting....it was the most excitement we got believe me.

Come on down, Miss wah wah, I got a headache, you're the next contestant on the the biggest idiot show.

the OLD PERSON WORKUP

Is it my imagination or are old people multiplying? I swear half of our patients (if not more) are 80 and above these days. Its like an old people parade every day.

What are the most common complaint for those old hats among us? Weakness. Dizziness. Near syncope. In other words who the hell knows what is wrong with them. Maybe they are just old for cripes sake. Maybe you just feel weak and dizzy when you are that old and feel like fainting occasionally.

Old people seem to come in 3 categories: 1) the nice people who have kept their wits about them 2) the demented 3) the nervous Nellies.

I love the people who are nice of course. They are the type of person who hates bothering us. They are a delight. The demented are really okay too, except if they are mean or are yellers. Yellers are can drive you to drink after work. The nervous Nellies are the worst. They are 99.9% women. Why is it when women get old they seem to become nervous twits? Seriously. They drive you nuts. Usually nervous Nellies are accompanied by Overly Involved and Neurotic Daughter who appear at the room door q5" asking for something.

There is no telling what is wrong with weak, dizzy, near syncopal Ned/Nellie, of course, so they get the $10,000 OLD PERSON WORKUP. They get a CBC, Lytes, Troponin, UA, CXR, EKG, head CT. They are put on the monitor, usually have to start an IV. Often times have to be cathed. Nellie usually has to get on the commode q15".

In other words they are a whole helluva lot of work. If half the ER is full of Ned/Nellies, you run your butt off. Pretty soon, in the next 10 years, 90% of ER patients will be over 70. Then what?