I don't work in an ER anymore

It is getting to the point of ridiculousness with the tests that are ordered in the emergency departments.  I mean for shits sake PET scans, stress tests, CT cardiac angios.  MRIs are commonplace.  Its like the hospital purchased all this shit so it has to be  used.  Here's the thing, when you are ordering all these sophisticated tests, people stay for hours on end in the ER, taking up beds.

Don't even get me started on the 20 fricking orders for every patient that comes in.  I mean seriously if you have a stubbed toe you get an IV and dilaudid and maybe a little zofran for your probable nausea.  We are no longer an ER but a outpatient high acuity med/surg/tele/neuro diagnostic unit.

These days there are 3 groups of people who use ERs on a regular basis:

1) elderly people
2) poor people who use us as a clinic
3) the chronically ill

The other people are going elsewhere, either to their doctors or urgent care.  Urgent cares are popping up left and right.  It seems like we are not getting much of the smaller trauma like fractures, lacerations, minor MVAs anymore.

I mean lets just call this what it is.  It isn't emergency medicine anymore

an ER nurses advice about the approaching cold and flu season..

welcome to triage....

Jus' when you think you seen it all...

Yup. Seen it all..nope. Patient presents accompanied by their own home literally. I shit you not. My patient presents because everybody is against them and cruel to them and life ain't fair, etc etc etc. And my living situation has not worked out and NOWYOUHAVETOHELPME and SAVEME and GIVEMEABEDANDMEALS because EVERYBODYISOUTTOGETME.

Did I mention the patient came by ambulance? Did I mention that they came with all their worldly possessions? We are talking suitcases and boxes and animal paraphanalia and other assorted junk that is so much it has to be put out in the triage area along a wall and is probably 10 feet wide and five feet high worth of stuff. It could have fit in a small moving van.

Now I have seen people bring in some shit - especially those of the mental health persuasion - they pack a couple of suitcases, a 24 pack of diet pepsi..but this was one for the records books.

My question is: How did they fit it all in the ambulance? Never got a chance to ask. Was patient admitted? I dunno. I left before that happened.

am I dreaming?

"One person dies every 19 minutes from a prescription drug overdose in the United States." "Approximately 80% of the world's pain pills are consumed in the United States, according to 2011 congressional testimony...."  This from an article on CNN today. 

The article talks about a proposal by the FDA to tighten control of our old friend Vicodin (aka Lortab, hydrocodone).  It would no longer be possible for docs to prescribe the drug and refills for months.  The patient would have to go back to the doctor for refills.  Wow...what a concept.  It also moves it from schedule 3 drug to schedule 2 drug which would put more restrictions on its use. 

Its funny, because a couple of months ago I was having this very discussion with one of our docs about this problem and what could be done about it.  Her answer:  "Who am I to judge whether someone is having pain or not?" The typical cop out. So I told her that the only way this problem will slow down is for the government to regulate it.  An lo and behold...its happening. 

How will this affect the ER? Who knows.  Might not change much.  Docs only give out a small amount by prescription anyway.  However, they may be less apt to prescribe it now with the restrictions 

What a pathetic commentary on doctors in this country who are responsible for this epidemic (Ain't no one else writing those scripts).  They couldn't regulate themselves so the government has to regulate them.

your neighbor is 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.

boom boom

When I hear a new thing I feel obligated to share it with you, the blog reading public. Me, I'm old, I don't know what the hell is going out there in hipster land.  Once in a while I will hear about it in the ER.  Latest thing: Boom Boom party.

What is a Boom Boom party you ask?  Well I'm about to enlighten you...Its a sex party.  You go there to get your freak on with people you know or may not know.  Now you are probably saying to yourself, this ain't anything new, its been going on for years.  Yup.  But nowadays people can't just have sex, it has to be enhanced with various pharmaceuticals.  Here's the thing, somebody might just shoot you up with something and you won't know what it is. Bummer.

Well, when that happens, when your little walk on the wild side turns bad, where you gonna go? Why, right on down t your local ER of course.  Your face is gonna be red when you have to tell us what happened.

shit yeah

I'm sorry but I could not resist sharing this photo with you.  Is this man pretty or what?

WTF???!!!!

Medical assistance in my state can restrict you to one hospital, one doctor, even one pharmacy.  It can be for a couple of reasons.  They can assign you to an HMO and you have to pick a hospital.  Probably the biggest reason is because you are a, shall we say, frequent user of hospitals.  In your frequent hospital use, you tend to go from hospital to hospital.  I would imagine the most common reason you go from hospital to hospital is because you are looking for narcotics, but then thats just my personal experienced opinion...I mean if you don't get what you want at one place, try another, right?

Of course, people always act like they are shocked, albeit horrifed,
(what the fuck???!!!!), that they are restricted to one hospital, and lo and behold, it isn't this one.  Either they are stunned or they say, "Oh I changed all that, I'm now assigned to this hospital".   No.  No you aren't.  Sorry.  Nice try though. A for effort.

I don't know if the ER gets paid for the visit or not.  I understand that they don't get paid if they are admitted
inpatient.

Here's the thing, people on medicaid are not stupid, even if we think they are.  They know the system.  They know we can't refuse them, with EMTALA and all.  So why should they give a shit if they are restricted. We are going to see them and our doctors are going to treat them, like they would treat anybody else, including give them narcotics.  So in effect, this program is a joke.  It no doubt employs an office full of people who run it who get a paycheck, but other than that it is completely useless.

I'm glad we are employing people to do this.  This, along with the office full of people who make sure 25 year old healthy adults on medicaid get their taxi rides too and from the ER helps me sleep at night.

you can't make this shit up

I could make a million dollars selling this button to ER nurses.

ex cons, dead people and drunks: welcome to work

You know its gonna be a bad day when you note that there are overflow patients in the area you are about to open, and one of them is dead.  No one has had time to arrange for them to go to the morgue. 

You pass triage and some guy is saying in a loud voice: "I just broke my Dad out of jail". 

You pass a room and another guy is loudly telling a nurse that he, "just got out of the penitenary 3 weeks ago". He's drunk.

Okay there is a theme developing and I don't like it. 

Its downhill from there ending with a drunk guy who doesn't speak english and proceeds to talk loudly for the next 2 hours in his native tongue and of course he is right near the desk...

"staff to triage for assist out of car"

Its that dreaded page: "staff to triage for assist out of car"...you never know what your gonna get when you head to the car.  Could be some goofy person with back pain.  Could be a woman giving birth.  Somebody shot...

Anyway, its a typical day, the teeming hordes presenting with their various tales of woe.  I have a moment of respite, sit down for a moment.  I get a call.  Somebody is calling before they get there to say they will need a wheelchair for their friend.  Yeah...whatever buddy..

So they get there and a couple of people go out to get the friend. Friend gets up, sits in the wheelchair and promptly dies. Ride provider/wheelchair requester has already left. Why, who knows?

When I first saw Friend, they were being rushed down the hall by a nurse, almost losing limbs the nurse wase going so fast.  They legs were swinging out to the side, bumping into things.  Friend had that DEAD look.  No color.  He was in cardiac arrest. Uh-oh.

Friend was put in the bed.  CPR was started until we could get the CPR device (automatically gives compressions). I started an IV and we started the meds.  It went on for an hour.  Meds, shock when he came back with a shockable  rhythm. On and on and on. Like we always do.  Finally he was declared dead. He was 53.

And thats how life in the ER can change in an instant.

another fun day in the hood

The caliber of folk we get in the ER gets lower and lower. Witness: Women with 3 kids under 5, now pregnant with 4th kid comes in to be seen. It is late evening and kids are tired and what do kids do when they are tired? They rev up and start running around. Of course rocket scientist mom does nothing to stop them.

Family #2 also in to be seen. They have a couple of kids under 5 in same situation: tired, ramped up. The kids are whooping it up. Rocket scientist mom calls Family #2's kids motherf----ers.

Security is called before a fight breaks out. All is once again calm in the lobby. Another fun day in the hood..

yeah I'm evil like that

who in the hell are you?

Have you ever heard the patient say: "Who in the hell are you now?"

I was thinking today how coming into a hospital is a ridiculous experience for the patients.  They tell their stories to people over and over.

First they tell it to the triage nurse.  Then they tell it to the nurse in the room.  Then they tell it to the physician assistant or NP.  Then they tell it to the ER doc. The ER doc tells it to the hospitalist or the resident who ask the patient the story.. The ER nurse tells it to the inpatient nurse who asks the patient the story when they get to the room. The resident may have a medical student come to see the patient.  They tell it to the  1st year resident who tells it to the the 3rd year resident.  The doctor, be they resident, hospitalist, intensivist, brings in the specialist.  The speicalist asks the patient again for the story.  So far the patient has told their story to eight people.

Now lets talk about how many people the patient comes in contact with just in the ER:

triage nurse
ER nurse
EMT
PA or NP
ER doc
lab person
xray person
CT or ultrasound person
registration
housekeeper?
volunteer?
charge nurse?
transport person

That is a potential 13 people going in and out of the room.

The lack of efficiency is astounding.  Why do so many different people have to ask the patient their story, espeically in this day of electronic records?  Why can't we read the story on the computer and not ask the patient the same questions?  Is it because we don't trust each other?  Is it because we are afraid of losing our little piece of the pie?

Its insanity the way we practice. I wonder if it will ever change.
 

I'll meet you in 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.

no shit sherlock

Sometimes the ER smells like a pig pen. Literally. Shit is running off of carts and on to the floor.

Speaking of poop, why does anyone ever come into the ER with constipation? ATTENTION ALL CITIZENS OF THE US:

*****CONSTIPATION IS NOT AN EMERGENCY. I REPEAT. CONSTIPATION IS NOT AN EMERGENCY. THAT IS ALL. GO ABOUT YOUR BUSINESS.*****

If you come into the ER with constipation, you will be viewed as the frickin' idiot that you are. I don't care if you are 102, the fact that you haven't had a bowel movement in 3 days is not an emergency. While we're at it, why is it that old people are obsessed with having bowel movements? Its like if they don't have a daily poop, its a crisis...

By the way, I don't believe you when you say you haven't crapped in 2 weeks. Don't believe you. Sorry. You wouldn't be able to eat, drink. Go home.

Attention all ER docs: IF YOU ORDER AN ENEMA, ESPESCIALLY A TAP WATER ENEMA, YOU WILL BECOME A HATED FIGURE. THAT IS ALL. GO ABOUT YOUR BUSINESS.

When I see a constipation coming my way, I run for the med room, staff lounge, bathroom, pop machine, develop a sudden interest in my patients personal life.

sex in the ER

Got your attention didn't I? heh heh heh

Sometimes I feel like we should put up a sign at the ER entrance: NO CONJUNGAL VISITS ALLOWED IN ER...I don't know how many times I have gone into a room and the patient and their significant other are in bed together. Or the girl is sitting on the guy's lap. Sorry to interrupt.....but I am your nurse....
I have had to stop people from making out in front of the triage desk. ah.....AHEM! You know how there is a mile high club? Maybe there is an ER club...

I have had patients out in the hall in the doorway of someone elses room having a deep discussion with the person next door. Hey can I get your number...maybe we can have coffee later....Ladies here's a piece of advice: ER is not a place to find boyfriend material...

Some people come to ER dressed like they are stopping on the way to the club. They present to the triage window with a top so low cut it practically goes down to their belly button...Ladies here's another piece of advice: Don't wear a low cut top to an ER that sits in the middle of the 'hood.

Some people think the nurse is dear abby and tell us things we really, really don't want to hear. Advice folks: I don't want to hear about you significant others kinky porno preferences...Leave your sex life at home....I really don't want to hear about it or see it.

just trying to make it through

Why did you become a nurse?  Most people would say the old reliable "I wanted to help people".  They have some kind of bullshit "calling".

I didn't become a nurse to help people.  I was 28.  I had been laid off of my job.  I had 2-3 years of college credits, but no degree.  I realized that unless I wanted a low paying job for the rest of my life, I had to get some kind of degree.  I had worked in hospitals a lot, as a HUC, admitting clerk, dietary aid, nursing assistant.

I told myself I would never become a nurse.  I didn't want to do bedpans and shit like that.  But there I was, on unemployment.  I had always had an interest in medicine.  So what the hell.  You could always get a job in nursing, its flexible, there were a lot of different things you can do.  So I went for it.  I became a nurse because it seemed practical.

Like a lot of other nurses, it was inevitable that I would become something like a nurse. I grew up in a house where I learned to be a caretaker like most nurses.  People in my family were alcoholics, like a lot of nurses.  These are the kind of people who become nurses, whether we want to admit it or not.  We are the people who will put up with a job like this.  A job that is often abusive.

I liked some of the things about nursing.   It was interesting, challenging, still is.  I didn't have to work a monday through friday 40 hour week.  I liked meeting all the people I took care of and hearing their stories.

Somewhere along the way, all that changed. I forgot about what I liked, replaced with what I didn't like. People are too hard to deal with.  The job is thankless and exhausting.  It always feels out of control. All the negative parts overwhelm the positive parts. Its hard to think about the positive parts anymore.  I'm too tired and just trying to make it through.  
+

sic 'em fido

You know what I hate? (no, what do you hate?) Well, I'll tell you.   I hate people who come in for dog bites.  The ones that get bit by an "unknown dog".  We have to give them rabies shots and it is a pain in the ass.

We give two kinds of shots for rabies exposure: the vaccine and some immune globulin (IG) shit.  The IG part is based on weight so it can be quite a bit of fluid.  I had one recently that was 12 ccs. So this 12 ccs is supposed to be "infiltrated" around the wound.  In other words, you are sticking them with a needles about 6 times around the wound and trying to inject the fluid in. If you can't get it all in (which you can't in some places like fingers), the rest has to be given as a shot.  So recently I was only able to get in about 3 ccs and had to divide the rest into shots.  This plus the shot of vaccine. By the way, the vaccine is a lovely shade of neon pink.


All in all, an unpleasant experience for all concerned.     Then you have to come back for 3 more shots.  The dog would have to be foaming at the mouth for me to go through this.

Thats my personal opinion, it shouldn't be yours.  Per the CDC there are about 2 cases of human rabies per year in the US.

Obamacare: no room at the inn

Yea! Yippee! Obamacare is here!!  Step right up folks, register today!

Don't get me wrong, I am all for Obamacare.  I think it doesn't go far enough.  I think we need universal health care.  My problem with it: Who in the blue hell is going to take care of all of these new people? 30-40 million of them?  Its funny, no one has talked about that.  They talk about how all the shiny new insurance cards will allow the uninsured to do preventive care, blah blah blah.  The question is, who are they going to do preventive care with? People WITH insurance now can't get appointments.

There is always talk that the uninsured don't go to the doctor for things because they can't afford it.
Then they get really sick and end up in the ER and the hospital, costing lots and lots of money with a condition that maybe could have been prevented.  So now all those people have the golden ticket to prevent that.  Except the golden ticket won't get them in anywhere.  So where do you think they are going to head?  Why, to the emergency room of course.  Just like all the other people with insurance.  Its where you head when you can't get in to see the doctor.

ERs are crowded now.  Its a daily struggle to find inpatient beds.  A lot more people who should be in the hospital will be sent home because there is no room at the inn.  You are going to have to be dying to get into the hospital.

You all probably think I'm being the boogeyman.  It won't be that bad.  The system will handle it.  The system is chaos NOW, it won't handle it.  If anything, its going to be entertaining to see what happens.  The fact that it starts January 1st, right in the middle of the flu/pneumonia/the crud season makes it all the more fun.

nurses are tired

This comment about my last blog post really struck me:

Anonymous
"We don't rotate shifts in the south. There is no way I could do that at my age. I've had maybe 2 good managers in my whole career. Now it's a business and nurses who are managers are kiss ass sell outs and mostly newer nurses management can mold. We see 400 a day some days and we are stuffing these mofo's into every nook and cranny in the dept just to move the meat. No time to look at labs or even talk to ppl. Of course we advertise no wait time. What a joke."

It made me sad.  It pretty much describes  nursing in a nutshell.  I have the feeling this person is probably about my age.  They have been a  nurse for some time. They have to keep the job to make a living,  they have  a lot of time in, because what the fuck else are they gonna do at this point?  They have good hours, seniority, finally a decent wage.  They are stuck.  They ain't going anywhere.

It makes me sad that nurses have to feel like this. We work so damn hard. Our job is impossible. It is thankless. It is so fucking exhausting. We are all so damn mad about it but too tired to do anything about it.  We go to work and feel out of control for many reasons.  The environment itself is pretty much always out of control.  Its the nature of ER and nursing in general.   We feel like we don't have any control over our jobs. People who sit in offices control our jobs.  JCAHO and the like control our jobs.  Potential liability control our jobs.  At some point we give up.  We tell ourselves whatever. We just try to do our jobs and go home.

The thing is it eats away at our soul, all of this.  The anger, the mental, physical and emotional exhaustion.  I have been doing this a long time.  I don't think I'll
ever figure out how to be at peace with this job.  I don't think its possible because I am human. I'm not a robot.