Wednesday, February 29, 2012

living on the edge of diasaster

This isn't something I think about much. Nurses live on the edge of potential disaster every hour of every day that we work. You just never know when something can go wrong. You can do the very best that you can and sometimes things go wrong anyway.

You are reminded that every little thing you do routinely is so important. Giving meds you have given a hundred times. Doing procedures you do every day. One slip and the potential harm can be devastating.

We as nurses don't think about this much. I suppose we can't. If we thought of all the what ifs, it would drive us crazy and we wouldn't be able to do our job.

I am amazed at all the risks we are willing to take every day in our care of patients. Its really pretty remarkable. We put our licenses on the line daily to do the job. I don't think we recognize what an amazing thing that is. I don't think people in the world realize what medical personnel risk every day. They risk making a mistake that could harm someone, but we come back day after day anyway.

Its pretty cool really.

you rat faced imbecile

When the tide turns in the ER, it can be an ugly thing. You know the patient is kind of a wacko, but you go along with all their aches and pains in an effort to just get the visit over with in the least stressful way possible for everyone concerned. So everything is honky-dorry and you are the patients new best friend, la dee dah. You are the most wonderful nurse who ever lived. And then it happens......something does not go the way the patients way and BOOM!!! New patient....a transformation from sweet, polite, best friends to THE PATIENT FROM HELL!!! The transformation is instantaneous and usually involves shouting, dramatic announcements: I"M LEAVING!!! Okay....hey I thought we were friends...

A patient comes in with some kind of cellulitis/fungus ( there's fungus amongus) thing on their feet. Oh by the way I have carbuncles (abscess like things that drain nasty goop) on my head, and I have an open sore with VRE (organism resistant to some antibiotics) on my derriere. Oh and by the way, I tip the scales at 350. The patients takes their shoes off and the bottom of her feet are black. And I am thinking to myself ICK!!! (You know that feeling you get when you are emptying a commode full of doo-doo). It just sends a shiver up my spine. In the end, said patient was going to be admitted and everything was copacetic. So, being the nice nurse that I am, I offer the patient something to eat (she's gotta keep her strength up after all). She chows down and in comes Miss Resident to do a history and physical. Miss Resident says to pleasant patient "Hey dude, there you are chowing down on a sandwich. I thought you were hurlin' so much, you were blowin' chunks all day!" (Or something to that effect) "I guess you can blow this pop stand and make tracks back to yo' crib after all".

This is when pleasant patient turns a bright shade of red, steam comes out of their ears and shouts: "I knew you weren't going to admit me, you rat faced imbecile" (or something to that effect). "Chill out, fool, let me get with the ER doc" says Miss Resident. "I'm out" says pleasant patient. (Cue dramatic exit music). Moral of the story: When someone seems too polite, too sweet, thinks you are the best nurse who ever lived, calls you ma'am, be afraid be very afraid and look for THE TIDE TO TURN....

Tuesday, February 28, 2012

why the hell are you here in ten words or less

When I'm in triage, I don't want to hear your life story. I don't have time for it. I want your problem in ten words or less. Sorry, I don't want to hear the details. I will ask you a few simple questions and thats all I need to know.

So don't go into detail of every day of the last 2 weeks or how this all started, etc etc etc. Hit the highlights. I don't want to see a letter from some doctor explaining your back problem. A copy of your MRI really does me no good.

There is nothing more annoying than being busy and having you go on and on while I have 10 people waiting. Maybe I come off as rude, when I say, "What made you come today SPECIFICALLY?"
You want so badly to tell your story and I want so badly to not to hear it.

These days your story is but one of the things I am supposed to do in triage. I have a myriad of other questions around pain and weight and height and superbug infections and implanted devices and allergies and meds and last period and blah blah blah.

So just get to the point. Make my job easier.

Sunday, February 26, 2012

red flags in the ER

its like deja vu today...

Red flags in the ER:

1) You say you have "chemical sensitivities".
2) You have more than 2 allergies.
3) You have fibromyalgia, chronic fatigue syndrome, some kind of syndrome no one has ever heard of.
3) You bring your MRI or CT with you, usually of your back, stating you can't get into see the doctor for a "couple of weeks".
4) You say you just moved here from out of town.
5) You bring a suitcase with you.
6) You brought something in a bag that you want to show me.
7) You can't tolerate the "pain" of an automatic blood pressure cuff.
8) You're allergic to haldol or thorazine.
9) You are 40 and your mother is accompanying you
10) You say another emergency room "don't know what they're doin'".
11) Your medical problem started in 1930.
12) You say "yes ma'am a lot.
13) Your relative is taking notes.
14) The medics want me to come outside of your room to give me report.
15) You are taking more than 3 psych meds.
16) Your wife, daughter, husband, son, etc. speaks for you.
17) We have to bring a cart to get you out of the car but somehow you got yourself into it at home.
18) You are eating a big mac on arrival to the ER.
19) Your relative calls ahead to say you are coming.
20) Your first question at the triage desk is: How long is the wait?

Friday, February 24, 2012

the chickens come home to roost

Every ER nurse hates it. The overtreatment of patients. Someone comes in with a virus and instead of sending them on their merry way to tough it out at home, an IV is started, an antiemetic is given,lab tests, sometimes even narcotics are ordered. Its stupid. Unnecessary. When nurses ask why we are are told, this is what the patients expect and our goal is their happiness.

Really this is just a racket. You can take a simple virus and run up hundreds, if not thousands of dollars, increasing the level of care and therefore, the level of reimbursement to the doctor. This is how ER docs make a lot of money these days.

In Washington state, the state government has decided they will no longer pay for medically unnecessary ER visits for medicaid patients starting April 1st. Of course, ER docs are very unhappy about this because the gig is up. They will no longer be reimbursed for all this unnecessary shit. THey will tell you that this is about control of thier practice, EMTALA etc., but its all bullshit. Their unhappiness is about the bottom line: MONEY. These people are a significant part of every ER's business. They will no longer be able to upcode and get more money.

So whats an unhappy ER doc to do? Take that cough (see Whitecoat)and make it pneumonia. Take that upset stomach and make it an ulcer. In other words, take this stupidity to a higher level to justify even more unnecessary tests and care. Coming to you ER soon.

And whats an unhappy medicaid patient to do when they can't use the ER as their clinic? It won't be long til every person with a cold has chest pain or shortness of breath. Every stomachache is having black stools. They will play the system even more than they do now.

In the end, it will probably cost more money. It will be abandanoned. Here's the thing, these politicians still think they can fix a collapsing system with bandaids. Its just another nail in the coffin of American health care as we know it.

Thursday, February 23, 2012

keystone kops running the ship

In the never ending keystone koppery that goes on at work, about half of the "care boards" have been put up. These are eraseable boards for each room. The nurse, doc and tech are supposed to put our names on it. It also has a section listing such things as EKG, labs, xrays, admit - ordered/done.

We are supposed to keep this up to date so the patient will be "more informed about what is going on". Here's the thing: The boards have been placed away from the patient in the room and the letters on the board are so small that I had a hard time reading it 2 feet away. Perhaps we need to issue binoculars to each patient so they can read their "care boards".

In another scathingly brilliant move, in order to place the boards the clothing hook was removed. Now there is no place to hang a coat or anything else. Brilliant.

Tuesday, February 21, 2012

2:30 pm: complete chaos

There are times in an ER when you lose control. When I say lose control I mean the entire ER is in a state of complete chaos. That happened at about 2:30 PM today. It was total chaos.

In comes a respiratory arrest, followed about 20 seconds later by another patient in cardiac arrest. Meanwhile the ER is already very busy. Those two threw us over the edge into the chaotic abyss. Two intubations going on at once with CPR in progress and everything else that goes along with an arrest.

It was that kind of day. At one point I had a man who has about a 90% chance of having TB and did I have a mask on at the beginning of his visit? Of course not. At the same time one of my other patients who happens to be 99 years old has a BP in the 70's, is in renal failure and is septic. The other patient is a frequent flier dialysis patient who is in with his usual chest pain. All this is going on while the two arrests are being dealt with. The guy from dialysis is an anxious man with emphysema who has the patience of a two year old. They decide to admit him and the charge nurse decides to have someone take him to his room upstairs while I call report. When I call report they tell me they can't take him after all, so soon as he gets there he will be heading back to us.

Wonderful. Then the nephrologist comes in and decides that he can be discharged, writes orders but can't talk to our ED doc who is in desperately trying to intubate one of the arrests. So we start making arrangements to send the guy back to the nursing home. I mention to the ED doc, when he is done intubating, something about this guy going home and he blows up. He says that the guy isn't going anywhere, he's going to be admitted. And get that nerphrologist on the phone right now.....OK so now he is back being admitted again. Then the patient says he wants to be transferred to the VA where he normally gets his care....OK somebody shoot me before I completely lose it.

Oh by the way did I mention that at 3 pm I assume the coveted position of charge nurse? So in the midst of all this shit, I dive in. Did I also mention that we have been down two nurses on days? Eventually, after a couple of hours, during which we wentr on divert for ambulances, the ER settles down and as the evening winds down it actually calms down enough to have some empty beds.

This is the time when you sit back and wonder why you do this shit? Why do you kill yourself working these twelve hour shifts? One of my co-workers told the story of being in such a zombie like state of exhaustion one night this week on the way home that she drove away from the gas pump with the nozzle in her gas tank and took the hose down....Why do we do it? I don't know. I'm just trying to make it to retirement. I think I'll start a calendar like they do in jail or during a war....

Sunday, February 19, 2012

you ain't who you say you are

Some drug seekers are really stupid. They don't realize that we have access to other hospitals records these days. They are very easy to get.

Within our corporate system, which has at least 5 hospitals, your records as at our fingertips. We also can get records from other hospitals in the city, with your permission of course, on the computer. If you got nothing to hide, why would you say no to this?

So when I go to arrive you and I find two of you on the computer, my antenna goes up. Same name, same address, same brithdate, different social security number. Then, Mr. patient I ask you your social and you give me the one that has no previous records. Out to the waiting room with you.

I mention this to registration. It seems the other record - you part 2 - has all of your previous records on it. You fail to mention all of these visits at the other hospital of course.

So you gave me a bogus social security number. Oh whats this....I go to the waiting room and you are no where to be found..where'd you go? You left us. Darn.

Saturday, February 18, 2012

there's no peace in the bathroom anymore**

There's not even any peace in the toilet where I work. There is a giant bulletin board in there posted with changes to things around work.

A recent highlight:
Once again, committees have met. Protocols have been changed. Approvals have been sought...
The hospital is CHANGING TO A NEW ADULT DIAPER, a product near and dear to every nurses heart. This one will be new and improved according to the poster. Yeah, I say! Who doesn't want a new and improved adult diaper..but that isn't all says the poster, let us give you the physiology behind why this is an improved diaper.

I don't want to know the physiology behind why this diaper holds more urine, contains it better. Just supply me with the damn thing and I will ooh and aah at the appropriate time.

This is what is happening in hospitals these days. EVERYTHING that changes, no matter how small, has become a BIG DEAL that requires paragraphs of explanation. I get the feeling that people who make these little decisions feel the need to justify the change or their jobs so they come up with these elaborate explanations for the change.

I long for the old days when it went like this:

Attn: nursing staff
Re: adults diapers

We will be using a new kind of adult diaper. It will be in the same place.

Thats it. Thats all you have to tell us. No physiology. No quiz.

**This picture is of women modeling the latest in adult diapers at a fashion show in Japan.

Thursday, February 16, 2012

shabby chic it ain't

My morale is in the toilet.

I work in an ER that is falling apart, shabby, embarassing really. Every year they try to get money for a new ER. This year we were told - BEST CHANCE YET - yeah, this is our year. Not. Again refused.

Our ER is too small for the amount of patients we get. It is inefficient. It is congested. The way it is set up makes the environment more stressful.

Every other ER in our "corporation" has been remodeled. Makes me wonder what is going on. Why would you want an area that admits at least 30% of patients to be in this kind of shape?

I wonder if it is because we are in the inner city, in the ghetto, lots of uninsured patients, or patients on medicaid or medicare with its low reimbursement.

Anyway, why should the employees care if the mangement doesn't? Maybe I should move on.

Sunday, February 12, 2012


Hospitals these days are in the middle of a nationwide campaign to do what I like to call PUTTING LIPSTICK ON A PIG.

Across the country hospitals are scrambling to stay afloat with decreased reimbursement. Hospitals have become conglomerates - corporate entities, another way of trying to stay afloat. It is no longer practical to have a stand alone hospital or clinic. They are in competition for patients.

Health care services are now being operated like corporations. Corporations are in the busy of making money and now hospitals are in the business of making money. What is our product? Health care. Who is our customer? Patients. Who do we want to make happy? Patients. Happy patients will come back or recommend us to their friends.

How do you make patients happy in the mind of the corporate managers who are running hospitals these days? You do fluffy stuff. You make lobbies that look like hotels. You dress the staff in the same colors. You have the staff use things like "care boards", do bedside report in ER. You change patient meals to "room service". You have valet parking. You form committees that talk about how to make the patients happy.

All fine and good, except for one thing: If you do surveys you will find that what patients want most, and benefit from, is the human contact of a nurse. The nurse who has time to talk to the patient and learn what they need (care planning), how they are doing (assessment), who has the time to do the things that make the patient better (nursing care).

Instead of putting the resources into the human aspect of care (better nurse staffing), the thing that makes the difference in patient outcomes, the money goes to dress up the hospital in various ways.

Our health care system is failing. These changes won't help that. These attempts to PUT LIPSTICK ON A PIG, will only hasten its inevitable collapse.

Thursday, February 09, 2012

Say it ain't so...

One of my favorite all time bloggers is gone: Tex at Weird Nursing Tales. It sucks. He wrote a lot of funny songs, many of them about the ER and performed them in videos. For a selection go here: ER SING ALONGS.

Here's one of my favorites because I'm mentioned(!!)in it:

I'll miss you Tex.

the swatch police

Hours have been spent in comittees. Detailed studies have been done. Statistics have been compiled. Strategies have been mapped out. Thousands of dollars have been spent. Stop the presses. This may change health care as we know it. It seems PATIENTS WILL BE HAPPIER AND HEALTH CARE OUTCOMES WILL IMPROVE IF NURSES ALL WEAR THE SAME COLOR.

Yes people, this is key to patient satisfaction and improved hospital performance. Apparently it doesn't matter what color, just that all nurses wear the SAME color. Patients will be able to identify you as a nurse because you are all wearing the same color! Apparently there has been a lot of confusion among patients in hospitals about who in the hell is their nurse. This is gonna clear all of that up people.

Okay, so then I can expect once that magic date arrives and all of the nurses are suited up, patients will be happy, nice, respectful. No one will call me a f--king bitch anymore right? Right?

NOTE TO NURSING STAFF FROM MANAGEMENT: You must comply with the exact shade that we have chosen. Any "off" shade of that color will be considered a "violation of the uniform code" and you will be disciplined up to, and including, firing. Yes, for the first week, we will have members of management working undercover, swatch in hand, making sure all shades match. A sort of swatch police, if you will.

Thank God homeless drunk Dave, Crack head Carol, violent pscyh Patti and demented Dora, who probably were very confused about who their nurse is, will easily be able to identify them. Another advance for medicine.

NOTE TO SELF: Make an appt to get a neon green mohawk for first day of new uniform policy.

Wednesday, February 08, 2012

the bat shit crazy club

After many years in the ER, I have developed certain talents. I would say one that I have perfected is the ability to keep a straight face. You could tell me that you have are growing a second head or have a tuba up your behind, and I would tell you "okay, have a seat in the waiting room, we'll be with you shortly". There is little that you could tell me that would stun me. Heard it all, seen it all.

With that in mind, may I say that there are many bat shit crazy, freak-deaky people in this world,and eventually, they make their way down to the emergency room. I had one a couple of months ago. This dude seemed to be making a game out of how far he could go with all these bizarre facts about himself and his life. I'm not even going to get into it here because it is just too weird.

I thought what is this guy getting out of this? Telling me all this weird shit. Is he doing it for attention? For effect? Is he trying to freak me out? All I thought about him was that he was a fucking nut. I avoided him as much as I could.

I didn't discharge him, the charge nurse did. She said to me she hadn't know he couldn't hear. I said, couldn't hear? The man had been talking to me and hearing me just fine. It turns out when she went in to do the discharge, he starting using sign language like he couldn't hear. Bat shit crazy, just like I said. This world is a crazy place. There are more lunatics than you realize

Monday, February 06, 2012

the case of the missing gown

People will take anything. Sheets, pillows, towels, wash cloths, phones, phone cords, fetal dopplers, computers. You name it, if it is not nailed down, its gone.

So why should I be surprised when my patient is heading out the door with a patient gown on underneath their shirt trailing in the wind? Apparently they needed some new pajamas. Maybe it was just too much trouble to take it off. My thought: How many people have worn that skanky gown and peed, pooped, vomitted on it?

My coworker suggested that I call the patient and leave a message asking for the return of the gown ASAP. If not, they will be billed for it. Hmmmm....

Saturday, February 04, 2012

mary the nurse masochist

There is somebody I work with who has labelled how nurses are sometimes treated by patients as bullying. He predicts that in the future nurses will force employers to deal with this. He thinks that the young nurses coming into the profession today won't put up with it like the older nurses have. I hope so.

I wonder why allow ourselves to keep being treated badly by patients? Sometimes I think that we convince ourselves that this person is under stress and normally they wouldn't be like that. We as a group tend to give people the benefit of the doubt, to forgive bad behavior.

Putting up with abuse is taught to us starting in nursing school and reinforced by our employers. We are taught to understand, empathize, to de-escalate. We are told that the patient is always right. We are told patient satisfaction is number one, even if it means taking verbal and sometimes physical abuse. When we object we are told, you knew what this job would be like when you got it. Maybe if you can't handle it, you should move on. In other words, WE are the problem, not the abuser.

We as a group allow ourselves to be treated like we are sub human. In what other job than ours would people allow themselves to be abused? What a strange profession we work in, that this goes on. What a strange group of people we are, to allow it to go on. Why don't we value ourselves more?

Thursday, February 02, 2012


Up here in the normally frozen tundra, we are in transilvanian state of mind. It is so foggy you can't see the skyline. There has been little snow. Everything is gray and dreary and it feels like there is no hope in sight. The ER is full of vomitters and diarrheaurs and coughers and such. So in an attempt to elevate my spirits, I looked up medical humor on the internet. Here are the results:

Stupid doctors orders:

Elevate patient's scrotum while lying in bed.

Please bathe patient. If nursing staff is too incompetent to do this, please inform me.

Apply Nystatin powder to groin and under weiner prn.

D/C orders from ER doc for 13yr old etoh pt. Under home d/c Rx: "Ass-kickin by parents PRN"

Nitropaste 1.5 inches to chest wall, q6h,
"TITRATE" to SBP> 90 by wiping off 1/4 inch at a time.

Keep bum covered, family request. I'm not kidding!

Humidified oxygen to liberate sputum.

Please, for the love of God, transfer pt to floor. Monitored bed not necessary.

ER acronyms:

BTSOOM - Beats The Sh*t Out Of Me

bugs in the rug - pubic lice

DILLIGAF - Do I Look Like I Give A F*ck

SOSFOLFOFNOF same old story frail old lady fell over, fractured neck of femur

BUNDY but unfortunately not dead yet

Ringo – (after Beatles drummer Ringo Starr) an expendable team member

BWS beached whale syndrome

Surgery report:

Pre-procedure: Suspected foreign object lodged in rectum. Radiology suggests may be golf ball.
Post-procedure: Foreign object removed from rectum. Sent to lab for analysis.
Lab report: Confirm foreign object is golf ball. Brand: Titleist.

the Amanda Trujillo case

A nurse advocates for her patient, as nurses are supposed to and gets fired. It is the story of Amanda Trujillo, a nurse in Arizona.

Here is her story in her own words:

My name is Amanda Trujillo. I’m a registered nurse of six years , specializing in cardiology, geriatrics, and end of life/palliative care. Back in April of this year I was caring for a dying patient whom I had discovered had no clue about what they were about to participate in when they agreed to get a major invasive surgery. When I properly educated the patient using the allowed materials by my employer they became upset that the physician never explained details of the surgery or what had to be done after the surgery (complex lifetime daily self care). The patient also had no idea that they had a choice about whether they had to get the surgery or not or that there were other options. They asked about hospice and comfort care and I educated the patient within my nursing license and the nursing code of ethics. The patient requested a case management consult to visit with hospice to explore this option further in order to make a better decision for their course of care. I documented extensively for the doctor to read the next day and I also passed the info on to the next nurse taking over, emphasizing the importance of speaking with the doctor about the gross misunderstanding they had about the surgery. The doctor became enraged, threw a well witnessed tantrum in the nursing station, refused to let the patient visit with hospice, and insisted I be fired and my license taken. He was successful on all counts.

More info at this website