Monday, July 30, 2012

I am the triage princess

Strange things happen when I am at the triage desk window. Its like I become something to be honored or revered...

People will kneel at the triage window and I have to assume it is in my honor, or that they are saying a little prayer for me.

This happens even more often: People will lean through the window and bow their heads. Stop it are embarassing me..

There are times when people will actually LAY in front of the triage window, prostating themselves before me. I quickly tell them to get up, that that kind of behavior is not necessary..

Sometimes this last one will take place WHILE I am triaging someone. They will sometimes kind of begin to "wilt", slipping to the floor as if they can't stay upright in my presence..

I know I am special, but this is ridiculous.


Saturday, July 28, 2012

memo to drug seekers

Dear drug seekers:

The following are drug seeker presentations that we see on a daily basis. In other words, don't need to be a lot more original.

1) "I lost/they were stolen/I forgot..". You lost your prescription, bottle of pain pills. You forgot them at your home 150 miles from here. Some dastardly dude stole your pain pills while you were napping.
2) "I am allergic to ibuprofen, tylenol, toradol, darvocet, ultram..." The only thing that works for you is that magic percocet.
3) "I can't get into my doctor until next week". That unempathetic doctor doesn't care about you.
4) "I used to have (back, neck, foot, etc) pain years ago and now it is flaring up so I don't have a doctor anymore".
5) "I am out in the car and I need help (probably a stetcher) because I am in so much pain". (Somehow I got into the car at home...)
6) "Let me get on my knees or lay down in triage to show you how much pain I am in".
7) "Let me be as polite as I can and call you yes maam and maybe you will think I am a nice guy" and not a drug seeker.
8) "I am so terribly sorry to bother you at all, I know you are so busy, but I couldn't stand it anymore".
9) "I just moved here from (fill in city) and don't have a doctor here/left all my pain meds back in (fill in city)".
10) "I went to (fill in ER) and they didn't do anything for me".
11) I have surgery scheduled at (fill in hospital) next week and I need something to tide me over til then".
12) "I am not looking for narcotics".
13) "Is Dr so and so working? He was so nice last time I was here".

Thursday, July 26, 2012

urban warfare

Here's the thing about working in the ER #2:

1) The day after I work 2-3 days in a row, is a recovery day. It is still on my mind. I am still a little hyped up. I am dead tired. In other words, nothing much will be accomplished on this day. This is the "coming down" day.

2) The day before I have to go back to work I am starting to think about work and kind of dread it, especially if I have to work a couple of days in a row. Life is so peaceful away from work. That peace is over. This is the "calm before the storm" day.

As I approach work in the car, I feel myself ramping up, steeling myself for the day ahead which will bring who knows what? This is the "preparing for urban warfare" time.

'Cause some days it really is kind of like a war zone.

Wednesday, July 25, 2012

Nurses are human too

Here's the thing about working in the ER:

1) It is hard to remember that even though we may think they are complete and total idiots, the people who come into the ER think they are having a crisis. For them its a crisis. To us, it is an idiotic reason to come and a waste of our time, but to them its something they felt they needed immediate help with.

2) The majority of people who come to the ER do not need to be there. However, they are going to keep coming. They ain't going away. Many are on medical assitance or don't have insurance and they think it is normal to run to the ER at a drop of a hat. Unfortunately, these are the people we take care of and will continue to take care of.

3) The frustration and anger that all of the ER staff feel about the following won't change. ITs around this: In room 1 you have someone who is dying or just died and the family is grief stricken about the unexpected loss. In room 2 you have someone who came by ambulance who has a sore throat who wants footies, a warm blanket and some juice. Trying to reconcile in you mind how to deal with this kind of situation makes you bang your head against the wall. Its not possible. It is normality in the ER.

My conclusion? You would probably think it is that I can accept this is the way it is and just do the best I can.


I can intellectually tell you that I understand all of this. Here's the thing: I am a human being. The human part of me continues to fight all of this. I could work in the ER for 50 years and it still would piss me off.

Monday, July 23, 2012

you so trashy

I can't stand it. I am about to lose the little mind that I have left. The hospital is going to drive me completely crazy. Why? The waste disposal system has become a frickin' nightmare. There are seven different ways you can dispose of trash. Seven different containers. You are expected to remember which container everything goes in.

We're talking putting IV bags in zip lock bags and throwing them in black containers. Is your chux fully saturated or partially saturated with blood, it makes a difference where it goes. Putting drugs down sewers. Syringes with needles with part of the drug still there goes into something called the dual sharp container. There are 15 drugs that are hazardous and by penalty of death need to go into the black can.

I think the waste containers are having babies. Every year there seem to be more of them. Pretty soon they are going to take over the hospital.

Me, I think we need a trash coordinator. You set up a room where they sit. You present them with your trash and they put it in the proper receptacle.

I propose this person also be a part time commode locator. Apparently, per those rocket scientists at JCAHO, commodes can no long be kept in the soiled utility room. Why not? Commodes are considered "clean" so they can't be kept in a "dirty" environment. now we have to find different places to put them around the department.

This, my friends, is the modern healthcare system. We spend more time locating trash cans and commodes then we do taking care of patients.

Sunday, July 22, 2012

red flags in ER

summer rerun

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, July 20, 2012

living on the borderline

You might think I'm going soft reading this. Oh well. Yesterday I attended the annual "de-escalation/self protection in dangerous situations" class. I approach these classes with a couple of thoughts:

1) Oh man I have to sit through this for 8 hours.
2) If they want to pay me to sit through this, well OK.

I DO pay attention. I even got a couple of things out of it. Sort of a new perspective as it were...

These classes center mostly around dealing with mental health patients. A group I have a lot of sympathy for, actually. They talked about a fairly new approach to mental health care: trauma informed care. Basically it approaches care of mental health patients with the idea that the majority of them have had some kind of trauma in their lives that has led to/contributed to, their mental illness. Many have PTSD from childhood trauma. Certain situations can cause them to re-experience the symptoms around their trauma. It attempts to recognize triggers and teaches the patients, and caregivers how to deal with them. There is a lot more to it than that too.

One of the statistics that struck me is that 81% of those with boderline personality disorders experienced some kind of trauma. How does that apply to the ER? We get many people in the ER with the symptoms of this disorder.

What is borderline personality disorder? ".. an emotional disorder that causes emotional instability, leading to stress and other problems....your image of yourself is distorted, making you feel worthless and fundamentally flawed. Your anger, impulsivity and frequent mood swings may push others away.." Often times the continual stress of their lives manifests itself physically with vague symptoms, chronic medical conditions. We see this every day in the ER. These are those difficult patients that are so hard to deal with.

My thought: Wouldn't it be nice if using this information and a different approach, we could learn how to deal with this type of patient? It would make our lives, and theirs, a lot easier.

my prayers to you

My thoughts and prayers are with the victims and their families in Aurora. I am also thinking of the first responders, paramedics and ER personnel who, I know, provided exceptional care under horrendous circumstances.

Wednesday, July 18, 2012

the escape artist

Many people who come in for mental health don't realize that we in the ER take the following words very, very seriously: I am suicidal. Once you make that statement you pretty much guarantee yourself a bed. You aren't going anywhere. You can either go voluntarily or you will be put on a hold.

The vast majority go voluntarily. Some people get pissed. They say we can't keep them there, la la la. We can. Some people try to run. They don't make it far. Our security are pretty fast on their feet. They end up being tackled and then put in restraints. Its a big ugly scene with a lot of shouting, crying, screaming a lot of the time.

I really don't like it when we have to restrain somebody. Usually after we restrain them, we sedate them because they are out of control. It feels really barbaric to put someone in that position. The thing is what choice do we have? We can't let them leave. They are out of control, could hurt themselves or us. Sometimes they do hurt us.

When someone is restrained its a huge deal. They have to be carefully monitored. All that monitoring has to be recorded every 15 minutes. Its very hard to do in a busy ER.

Our ER is not set up well for mental health. We don't have a specific place for it. The rooms are scattered throughout the ER. Its less than ideal. Often it takes hours to complete the process of admission, so people sit there and think about how miserable they are. Sometimes they become more agitated. Its an accident waiting to happen.

I wish it were different.

Sunday, July 15, 2012

when the shit hits the fan

Why is that when you have such a nice day. As charge you send a couple of people home early, Then BOOM! a half hour before you are supposed to go home here come two criticals who need to be intubated...

Friday, July 13, 2012

we got a 487 in progress

You can have your car valet parked at our ER. Some hoighty toity shit. Does your ER do this? Its pretty weird really.

It doesn't happen that often. Most people just park the car in the ER parking lot. Lately, I had a couple of rocket scientists leave their keys in the car like they are at frickin' Mortons or something.


This has happened twice in the last month. When I told them to go get their keys unless they want their car stolen, they ran like a bat out of hell. Fortunately, in both cases, the car was still there. It was their lucky day.

I need help getting my husband out of the car!!!

Ah, good old back pain. The bread and butter of the emergency department.

Presentations for back pain vary greatly. They range from the calm and cool, chronic back pain that is "worse than usual and I can't get into my doctor" to the person who the relative states "needs help getting out of the car, probably a stetcher". Oh, there is drama, lots of drama with back pain.

Hey I know back pain hurts. I once did something to my back at work and had to go home. By the time I got home, I couldn't stand up. Here's the thing: I took NSAIDS, used heat and ice, rested it. It went away on its own. Never went to the doctor.

My point? I know there are a lot of people who have serious injuries, but most are a simple muscle strain that people don't treat the right way. Then it gets worse and becomes a chronic problem. Many, many people, probably including many nurses have "bulging discs". They cause occasional pain but they live with it.

Why so much back pain in this country? Obesity. Out of shape. Stress.

Back pain is probably a billion dollar industry. Lots of back surgeries that don't work. Thousands and thousands of narcotic prescriptions written. Chiropractors making milllions. What I always think about all these people coming in for back pain is how do you know if someone is really having pain? Is there some physical exam you can do to tell? You could easily lie, carry on and walk out with a script for Percocet.

Monday, July 09, 2012

annoying shit

Annoying things that drive you crazy:

1) In my state those on medicaid can get rides to and from medical appointments. Many times they will call for a ride home from the ER. The other day someone called for a ride home. Their house was 1 1/2 blocks from the hospital.

2) You come in unhappy with the care you received at XYZ hospital. You tell me you heard our hospital "gives really good care". Sorry, that won't score any brownie points, you're still going to the lobby.

3) You had major surgery at another hospital and have developed a problem. You come to our ER, instead of going back to the hospital where you had the surgery.

4) You come up to the triage desk and try to get us to make the decision about whether you should be seen.

5) You don't know the last name of the person you want to see or you can't spell the last name. You think that we should be able to find them with just the first name. / You don't believe that someone is not there and get mad when we keep telling you that they aren't.

Thursday, July 05, 2012

Wednesday, July 04, 2012

welcome to Dysfunction Junction

What is it about holidays that brings out the wackos? Yesterday toward early evening there was a change in barometric pressure and they all started coming in. You know the kind of people who shall we say "live life on the edge of society". In other words, they look like they have been run over by a truck. Disheveled, dirty, smelly. Drank a liter of vodka earlier today. The kind of chap whose first words are "fuck you!",who tries to pick a fight with security.

Of course, I am charge. I am the mayor of what I like to call Dysfunction Junction. This is the kind of day when detox is sending patients to US. Its the kind of day when a patient caused a big scene at another hospital, was thrown out and when they got to the street, called 911 to take her, where else, to us. Here's the thing that hospital called our security to tell us and off to the waiting room she went.

Staffing gave 25 low need LOAs because the census is low, but of course none of them came our way. Maybe its the heat. Maybe its the holiday. Maybe the world is coming to an end.

Monday, July 02, 2012