year...new....happy

geez madness why don't you get all serious and shit

We don't think about this much but we see tragedy every day as ER nurses.We almost get used it. Some are worse than others. Some stay with you and haunt you.  You think about the person for days afterwards.

There are two kinds of tragedies: Those that happen to people through no fault of their own and those that happen because of stupid choices in life.  The inclination would be to feel more sorry for those that happen to people at random.  In the end, its all the same for whatever reason it happens.  The person will suffer.  The family and friends will suffer.

One thing about being an ER nurse, you really just how unfair life really is. You realize how much a lot of people are suffering in this world. Its reality and it hits you in the face on a daily basis.

How do we, as nurses, cope with it? I've been doing this a long time and I wonder how I have lasted so long considering all the bad stuff you see. Most of it I leave at the door when I go home.  I've developed the ability to let it go, maybe put it in a box.  I think people in ERs use humor a lot to get through.  We develop tough exteriors as a way of protecting ourselves.  That's only natural.

The thing is there are those cases that stay with you for a while.  Eventually you let them go too.  You just hope for the best for that person and their family.  Its all you can do.

hahahahahaha

working in the ghetto

I was thinking how much my ER has changed over the years. When I started, even though we were in the middle of a poor neighborhood, we were more like a suburban ER.  Our clientele was more suburban, white, very few neighborhood folks came in.  They went to another hospital in the neighborhood.  Then that hospital closed.

More neighborhood people starting to come in, but a lot of them still went to the county hospital downtown. I think eventually they figured out that if they came to us, the wait was less. They also figured out the chance of scoring some narcs was higher with us.

Now our ER has become what it always has been: an inner city ER in the middle of the ghetto.  We see lots of neighborhood people now.  We are seeing more of the folks living on the edge of society: drug users, criminals, drunks. People you would expect an ER in our location to see.  Its not unusual to have a heroin OD in one room, a crackhead in another and some guy getting arrested in yet another.

The rest of the hospital still maintains its suburbanite feel for the most part.  The areas of medicine that the hospital specializes in attract people from all over for admission. The specialties are where the money is in medicine. Thats where the money goes.  Those areas are brand new.  They have to be.  They attract the people with insurance where the reimbursement is better.  Its what those with insurance expect.

Meanwhile the ER looks like the  neighborhood we serve: rundown, falling apart.  We aren't a priority in todays healthcare.  Our patients are on medicare and medical assistance,  not money makers.

We live in a different world in the ER, compared to the inpatient side. We are like run down  island of the poor and dysfunctional in the midst of a shiny suburban mall.  No one pays much attention to us.

a Madness Christmas Eve

So I worked Christmas Eve.  I hadn't worked it in years.  I don't have to work holidays anymore because I have been a nurse since time began.  I did it for the money.  Yes, its true, it wasn't out of a need to soothe fevered brows at Christmas. I make triple time on Christmas.  Its all about the benjamins. I worked an evening shift.

Now, naive me, I thought it would be slow because, really, who is out on Christmas Eve? Everybody is all nestled snug in their beds and shit, right?  Waiting for the arrival of the Big Guy. Wrong. It was no different than any other night.We had the usual fun patients.Here's an ode to one of my favorites...

Join me kiddees as we sing that old favorite: "Sally the Crackhead Prostitute" (to the tune of Rudolph the Red Nosed Reindeer):

There were neck pains and chest pains, and headaches and finger lacs,
earaches and sore throats, and  calf pain and people with sore backs,
But do you recall, the most irritating patient of them all?

Sally the crackhead prostitute,
Had a very bad tooth pain
And if she didn't leave soon
We would all go insane.

All of the other patients,
tired of all of Sallys screams
knew that this ER visit
would cause them to have bad dreams

Then about eleven twenty three
The Er doc came to say
Sally with your silly antics
you won't get any narcs from me
Then all the ER staff loved him
they had to take no more
Sally the crackhead prostitute
get your ass out the door!

on this day

On this day when we all get together with our families, I ask that you remember our soldiers who are away from their families all around the world.  Right now 150 marines are waiting to go into a very dangerous situation Sudan to rescue Americans there. Say a prayer for all of our brave men and women today.

Merry Christmas.

an ER night before Christmas

TUESDAY, DECEMBER 20, 2011

an ER night before Christmas

Gather around kiddies and let Madness read you an ER version of Twas the Night Before Christmas:

'Twas the night before Christmas,the ER is jumpin'.
The chaos at triage is really quite somethin'.
The charts are all stacked in the new patient bin,
I think to myself: we NEVER can win.
The patients are nestled all snug in their beds,
while visions of Dilaudid dance in their heads.
The doc has his gloves on, and I have the tray, its off to that abscess, as I lead the way..
When out in the lobby there arose such a clatter, I sprinted for triage to see what was the matter.
The lobby was chaos, a sight to behold, every other person seemed to have a bad cold.
When what to my disbelievin' eyes did appear,
a frequent flier named Herman we do not hold dear.
With a shuffle, a groan and blood curdling scream, (oh no this can't be happenin' its all a bad dream!)
He appeared with a backpack, along with a sack, and shouted quite loudly: there's somethin' wrong with my back!
He was cursin' and cryin' and carryin' on, he looked around widely and asked for nurse Don,
Or Susan or Wendy or Alan or Fred,
Do something somebody and get me a bed!
By the way I am hungry, haven't eaten in a week, I need a warm blanket and footies for my feet,
I need a glass of water with a whole lotta ice, Now go please hurry, I don't wanna ask twice!
He went on a cart, told you gotta wait your turn, you been here enough, when are you gonna learn?
I turned back to triage, looked straight ahead, trying to stave off that feeling of dread
As I stifled a yawn and was turning around, Up to the window this jolly man came with a bound,
He was dressed in scrubs except with a red and white cap, His face appeared tired, like he jus' woke from a nap,
He was pushing a cart that was laden with sweets,
Some kind soul had come through with the sweet treats.
He asked to be let in, and rolled the cart on through, stopped at the reg desk to give a cookie or two,
He walked back to the HUC desk, gave a wink to the crew,
Asked everybody: What can I get for all of you?
He resembled Santa in a very odd way,
He smiled and laughed and had this to say:
Tomorrow is Christmas, oh what can I bring?
What can I bring to make your heart sing?
Oh Santa, dear Santa, somebody spoke up and said: we just want some peace, all this racket to cease,
Santa nodded and said he'd see what he could do, to make a nice christmas for this emergency crew.
"Goodbye!" Santa said as he rolled the cart out, "Merry Chirstmas to all!" he said with a shout,
I went back to triage to see what difference I could make,
I looked around slowly, did a quick double take
Herman was gone, his bed tied up with a bow,
I asked another nurse: where the heck did that silly Herman go?
He was here just a minute ago, I swear it, I do, yelling and cursing and crying boo hoo.
We searched back and forth and to and fro too,
Then sat in our chairs and gave one collective: Whew!
Oh Santa had been there we all knew it clearly, the man with the scrubs had blessed us quite dearly.
Herman was gone, it was all just so good,
We had a good Christmas Eve that night in the 'hood.

the Airing of the Grievances

I'm a little late with this...Festivus was officially yesterday, but I've been busy.  So I have to do this today.  Yes, its time for the "Airing of the Grievances", one of the hallmarks of any Festivus celebration.

So, of course, my grievances will be geared toward my job. (what a shock)

#1 I understand the need for more efficiency and clarity when it comes to charting, thus the coming of the electronic medical record. Hey I really don't mind it, except it has done nothing to make things more efficient.  It has added lots of time to charting. As time goes on, "tHe EvIl ChAnGerS" (see Dec 12 blog post), are coming up with more and more blanks to fill in. My job has mostly become blank filleriner.  So, don't lie and say EMRs improve health care.

#2 I understand the need for more safety when administering medications, thus the invention of the drug scanning device. Every medication we give now requires us to log into the computer, scan the wristband,
scan the med, chart the med...no big deal right? Wrong. ER nurses often give multiple meds. (You can never give too many meds right?)  We can give compazine, benadryl, zofran, dilaudid for the simplest case of nausea and vomitting.  Safety comes at the expense of more time consumed.

#3 Once again, I understand the need for more safety when administering medication, thus the pharmacist these days check every med that we administer.  They have to approve it before it appears in the pyxis and we can take it out.  Wonderful right? No mistakes. Wrong.  It can take, depending of the day, up to 45 minutes to get the approval.  Delaying care, making care less efficient.  We can override a lot of meds, but no oral meds, including things like tylenol, motrin, aspirin.  We can't be trusted to take those out without approval.

#4 I appreciate when I get a gift from someone in an effort to show appreciation for what I do through the year. However, when that gift costs about $1 and bears the logo of the group giving it out, I'm sorry, perhaps I am ungrateful, but don't bother. I break my butt for our ER and you and this is the thanks I get? Another nail in the coffin.

Thus ends this years Airing of the Grievances. Good night.

Dear Mr. drug seeker..

Dear Mr. drug seeker:

Some friendly advice: When you come in for pain and nausea and after you are triaged, tell us you are heading for mickey d's before you go back to a room, then you chow down in the lobby, we are probably not going to take you very seriously...

In fact, we will look at you as a moron.  The triage staff will document your activity in the waiting room.  The doctor will look at it and you will get tylenol.  Except for your gourmet meal at Micks this was a waste of your, our, and the taxpayers, money.

Sincerely,

and with a shitload of affection,

Madness the nurse

man candy saturday

our social worker is a softy

Y'all probably think I hate my job reading this blog.  You'd be right. Har. Bada bing.

Seriously there are things I like about it.  One of the things I like best is how funny it is. You might think, how the hell can an ER job be funny?  Being about tragedy and shit? Yeah thats true some of the time.  That part sucks.  What what keeps us coming back are the funny parts.

Like yesterday.  I'm in triage.  A guy comes up to the desk and asks to see the social worker. Thats it. Doesn't want to be seen, just wants to see the social worker.  Whatever.  I call our long suffering social worker and she agrees to come out and see this guy.

Oh BTW, did I mention that when he originally came up to the window, he asks if he could take the pop cans from the recycling bin home?  I said no, I don't think we can let you do that. You know me, I'm a bitch.

So anywho, the social worker comes out and goes out to the waiting room to talk to him. Turns out he came to ask if he could get some money for Christmas presents... Well, unfortunately our Christmas present fund was at zero, so sorry, we won't be giving you any Christmas present money.

But now listen to this! Our social worker told him he could take the pop cans! She said, ONLY FOR TODAY THOUGH, you can't come back..  What a softy.

And that folks is why we keep coming back.

bad mom

The blogs been a real bummer these past couple of days.  Here's a change of pace.

Remember when you were little and you just couldn't wait for Christmas morning to open your presents?  You begged to open one early?  Please, MOM, JUST ONE?????!!! Well Mom finally gave in...

Its worth watching the whole thing.

hospital killings

The epidemic of violence in this country comes to medicine. In last month there have been 3 incidents in hospitals and one at a doctors house.

1) In Reno today two people were killed, others injured when a gunman came into a hospital.

2) A nurse in Texas was stabbed to death and 4 others injured in a hospital in late November.

3) Man killed fleeing from Childrens hospital in Milwaukee after brandishing a gun when police tried to arrest him there in mid November.

4) In my area a doctor was killed when the son of a former patient killed him at his home.

Scary fact: From 2000-2011 there were 154 hospital based shootings with 235 victims.  (from 2 minute medicine) 

Not only do we have to worry about violence by the patients, now there is increasing violence from the outside as well.

Our ER has no metal detector.  We are wide open.  Its scary.

Do you have metal detectors? How do you control movement in and out of the ER?

don't forget them

Sorry about the lack of blog posts this week.  I have been making lots of bracelets for the customers in my etsy shop.

Today we learned that 6 American soldiers died in a blackhawk helicopter crash.  Keep their families in your prayers.  Please don't forget the soldiers who are deployed this holiday season.

man candy saturday

sex brought me to the ER

Just when you thought it couldn't get any weirder, I see an advertisement for a new ER reality show: "Sex sent me to the ER" on a cable channel coming this month to a TV near you. No doubt this will be a real laughfest...

I've been in the ER a long time and I have, for the most part, missed out on sexual shenanigans that brought patients in, although I have heard stories from my co workers. Mostly along the line of somebody put something up their butt and they can't get it out and oh by the way, its still buzzing for everyone to hear.  People getting stuff stuck on their johnson and it has to be cut off.

Hearing these stories amuses us, but seriously ya heard one of these you heard 'em all.  Whatever. Mostly we just look at people in these situations as stupid.

This is brought to you by the same people who do the show "Untold stories of the ER".  They contacted me once and encouraged me to send in an unusual story.  The kicker is they want you to be on the show to be part of the story.  Ah...no thanks.  So I'm wondering will that be the case with this show?  Will the doc or nurse be on the show?

Lastly, what kind of person would agree to have their sex problem stories be told to the world at large? Morons, that's who.

where evil lurks

They live in the basement, back in a dark, damp corner.  Thats them with their laptop, sitting on their cot, conniving against us.  They exist in the shadows, never coming out into the light. They slink around the hospital... unseen but always looming, always waiting, ready to pounce. Who are they?

They are the people who make your life a living hell.   The people who MAKE THE CHANGES. (ThE EVIL cHanGerS)  They are the ones who decide to buy the stupid new products because they get a good deal.   They change the electronic charting to "make it better".  They come up with irrelevant new policies.

Of course ThE EVIL cHanGerS make twice the money you do. They haven't seen a bedside in 20 years. They have a lot of letters after their name. They wear REGULAR clothes.  They like to gather in groups to scheme about new changes. They seem to breed like rabbits.

They buy things like the new .5 mg Dilaudid syringes which take a rocket scientist to figure out how to use and actually come with a video to explain it. They buy IV tubing in which connecting tubing to a saline lock or connecting a piggyback requires 20 attempts. They change charting to "become more efficient".  The thing is it requires 20 more steps to complete. It makes charting a blood transfusion akin to building a nuclear reactor.

They give us more gray hair. Make us want to go running screaming from the building.  Want to wring somebodys neck.  Make us spend the majority of our time away from the patients filling in blanks.

They are  ***ThE EVIL cHanGerS****.  Some day the nurses will rise up.  They will hunt them down and there will be hell to pay.

ain't no flo

I got to thinking: Why do I do the blog?

I have been doing the blog for 8 years now. I'm one of the few that are still around when I started. I miss those other guys. (Tex, Nurse K, hood nurse, scalpel, etc.)

This blog started as a place to let off steam.  I have been a writer all of my life.  So it was a natural thing to do.

At the core of this blog is the idea of presenting a realistic picture of what it is like to be a nurse, particularly an ER nurse.  To tell you how bizarre it really is to work in the ER. To tell my fellow nurse, hey you are not alone. I go through the same things you do on a daily basis. And lastly, to give my opinion on stuff related.

Perception and reality in nursing are at the opposite ends of the scale. What the public perceives about who nurses are and what they do is way out of whack.  I think they still perceive us as florence nightengale types who fluff pillows, hold hands, soothe fevered brows and are always smiling and caring while they do it.  When in actuality, nurses are highly educated, tech savvy multi taskers who hold the medical system together. We keep you alive. End of story.

Even nursing students have no idea what they are getting into.  They learn an idealized version of nursing in nursing school and are often shocked by the reality. Healthcare corporation executives, doctors, mangers, etc. hold expectations of nurses that are impossible to meet.

People who become nurses care. We probably care more about people than your average person. Otherwise we couldn't do the job.  So we have a gooey center. As the reality of how damn hard this job is sets in, we develop a shell around the goo.  We have to if we are going to survive. We are in one of the most demanding jobs you can have.  Changes happen daily and many times they are not small changes. Technology becomes more complex. Demands on what we have to do increase daily. Every single day of being a nurse is stressful and challenging. Lives depend on us. A mistake could kill someone.

And then there is the taking care of  people part. Oh yeah that. Most people are nice. Then there are those are shitheads.  There are more in the world than you think. They are just plain mean, manipulative. We have to deal with them whether we like it or not.

So this is the reality of nursing. Its what I try to communicate here. A lot of people, including a lot of my fellow nurses, would rather pretend that nurses are florence nightengales  I just can't do
that. I ain't no Flo.

no goodbye for Dad

One of the hardest things about my job is watching families deal with elderly Mom or Dad. Dad is, lets say, in his 80's.  He is in bad shape for various reasons.  He isn't going to get better.  In fact, he is going to get worse.  He is worse today.

Here's the thing: he's full go.  He is so fragile that if CPR was performed, several of his ribs would break.  He would never get off the vent. In other words, its time to just keep him comfortable and enjoy the time that has left.

Of course thats not going to happen. Family is not ready to let Dad go.  Daughter is crying during Dads current visit.  Everybody else is tearful.

Dad says he feels fine.  He sits on the ER cart getting treatment that anyone would find uncomfortable.  It has become a habit for him to be brave for the family. He doesn't want the kids or his wife to suffer.  When the doctors have asked him about resuscitation he went along with being a full go.

So Dad will keep coming in, spending repeated visits in ICU.  Family will keep hoping that somehow he will get better.  He won't.  This will go on until one time he arrests. We can't revive him. Family is devastated.

They didn't get a chance to say goodbye. To tell him what a great Dad he was.

man candy saturday

yes

 

Its Christmas at the candy store

I've been working more lately.  Picking up shifts.  Son of Madness is in college.  Thus the sparse blog postings.

Why is it that working an 8 hour shift, especially a 7-3 seems to fly by?  I like it.

There is the usual tomfoolery going on in the ER like always. There are stomach bugs going around.  Of course the non-copers among us run to the ER at the first sign of nausea.  Like the guy who came in and cried and whined while 3 of us tried to get an IV in.  No success.  I mean seriously dude, if you are going to come in for a frickin' stomach virus this is what you are going to go through...you shoulda stayed home.  You'll get no sympathy from us.

Here's a question for the ages: Why is the BLUE HELL do we have to put an IV in every Tom, Dick and Susie that comes in with one episode of womiting or a wittle tummy ache.  ODT Zofran was invented for a reason guys.  No one under the age of 60 should get an IV for a virus unless they have at least 10 underlying diseases.  Thank you.  And they certainly don't need Dilaudid for their tummy ache.  Are you frickin' kiddin' me?????

So as you probably already noted, its business as usual at the candy store. Only difference these days are the two pathetic Charlie Brown christmas trees in the lobby that are decked out in a "neutral holiday hospital approved" fashion of beige and tan. Real festive...
 How many bulbs do you think will be left on December 26th?  Fa la la.


Oh BTW RIP Mandella

yup

Dear Person on Probation:

I hate to break this to you, but none of the staff or other patients in the emergency care about your probation officer problems.  We do not care to hear you talk at the top of your lungs to your PO about how you will probably have to go back to jail.  You are an idiot.

Sincerely,

the emergency department staff and patients

putting the G in ghetto

Okay here's a new one.  I think I saw a drug sale go down in our ER lobby.

So its a pretty nice evening. I'm at the triage desk. There is a guy sitting in the lobby - acquaintance or something of one of the patients.  Here comes an inpatient rolling an IV pole. He goes over to the guy sitting in the lobby  I swear I saw I saw money change hands.

Earlier the guy with the IV pole had come up to the triage desk asking for a pass for his wife to get out of the parking ramp.  So he's probably buying dope to give to her or they are gonna use dope together outside.  Am I being paranoid?  Probably not.

Oh BTW, it turns out the guy sitting in the lobby (probable drug seller) is with another guy who is here trying to get narcs for his back pain. He is busted for using a false name. He was probably there to get more drugs to sell

The shit that goes down our ghetto ER.

I betcha didn't know...

I make jewelry. Make me happy. Buy some. Click on beadnurse below.

thanks

Thanks for reading the blog.

YOU ARE BUSTED

Let me start out by reinforcing the fact that I AM EVIL. That has already been well established. With that in mind, I have to say that I get a perverse delight when we bust a drug seeker. Its like I want to go around and high fiver my co-workers.  Yeah! Score one for our side!

I am continually amazed at the sheer stupidity of some drug seekers. I mean seriously, you are telling me that you have an anaphalactic reaction to ibuprofen, toradol,, vicodin.....could it be that you want P-P-P-Percocet?!!!  Ding ding ding!  One point for me.  The holidays are so much easier with a little perc on board.

And whats this you have no ID and have never been here before and your name is Bob Johnson. The thing is the Doc recognizes you as Stan Smith he saw 2 months ago.

Exit stage left.  Life is good

yuck

drug seeker FAIL

What is lower than being a failure as a drug seeker?

Lets set the scene:  You have a headache. Never had one before and IT IS SO BAD.  "I don't know what's wrong with me!!" (Cue look of alarm).  You had even gone to your doctor and were given a non narcotic prescription which you tried....but alas, you had what could only be described as an anaphylactic reaction that involved your throat closing up.  Did you seek help with your anaphylactic reaction at the nearest ER?  No you went home, drank a lot of fluids and it resolved on its own.  Wow..

Do you have any allergies?  Why of course you do and they are all to the medications that are a non-narcotic choice for pain.  Here's the thing: You have the same anaphylactic throat closing thing with all of them.  You tell me about 8 of them and state "I have more but I can't remember what they are"...

You are taken back to a room where you tell the NP that the headache may have resulted from the terrible fall you took at work (the plot thickens)
.  By the way, you say, "I work in the medical field".  So you couldn't possibly be drug seeker/surely you'll be sympathetic because of that (the whole comraderie of medical workers thing)/I know what I'm talking about when it comes to this allergy idea.

Grade: FAIL

You really need to refine your presentation.      

the blood curdling scream

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

1) Nobody home: No one answers the phone...at all.

2) Limbo move: Put you on eternal hold.

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

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

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

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

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

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

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

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

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

dangerous nurse staffing is gonna kill your dad

In the past year legislation has been introduced nationally regarding nurse patio ratios.  This will be a long time coming if it ever happens at all.

Our ER staffs by volumes.  We have, for the most part, good staffing.  During the day shift it sucks.  We desperately need another nurse.  Something bad is going to happen.

When we get a critical patient it requires two nurses as a norm.  In the early morning hours we have 14 beds open, we have 3 nurses on.  Most of the time the 14 beds are full.  When that critical patient comes, that leaves 1 nurse to take care of 13 patients.  Often times the charge nurse is out in triage helping the one nurse out there because it is so busy.

Later on another nurse comes on the side with 14 beds. So now when we have a critical patient, there are 2 nurses to manage 14 patients.  It is not until 3 pm that the staffing becomes adequate.

I work in a hospital that specializes in cardiac care, stroke care.  The patients we see in our ER are complex.  They are not your in/out laceration, ankle sprain type patient.  Add to this an order happy medical staff and you get the picture.

It is commonplace in the ER to have 2 critical patients in the ER at the same time.  This ties up 4 nurses in a 35 bed emergency department.  Good luck to the rest of the nurses caring for those other patients.

This is a dangerous situation.  To think that our management expects 1 nurse to monitor 13 patients when there is a critical patient during a period of the day is crazy.  Or to expect 2 nurses to manage 7 patients each during another part of the day, is ridiculous and dangerous.  It is an accident waiting to happen.  That accident is coming any day now.

Now add this scenario onto the drive for patient satisfaction.  How satisfied do you think those other 13 patients are when they have 1 nurse to care for them?

exit stage left

People don't make sense.  You wait 2 hours in the waiting room, are finally brought back. It is busy, you don't get an xray ordered for about an hour.  You are up to go over there.  You dramatically announce that "I am leaving, I've been here 3 hours"  blah blah blah.

What kind of sense does that make? You are about to get what you came for.  Now you are being a martyr. By the way, did I mention that you had to be put in a wheelchair on arrival due to your pain.  You were brought to the room in a wheelchair.  There you are though, snagglepuss (heavens to Murgatroyd) , exit stage left, walking out just fine. Interesting...

ER patients kind of remind me of snagglepuss.  

you rat faced embicele

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....

march-december romance

I must say this has happened to me a few times over the years..

I go off the deep end

Is it too much to ask that the clocks in the ER all have the correct time?  I mean the daylight savings "fall back" happened 8 days ago. Don't these people plan for this?

I am being psychologically damaged by clocks that are actually still one hour ahead.  Picture this: Its busy, I glance up at the clock and am delighted it is almost 3 pm, half way though this God awful shift!  Then I go out to the main nurses area only to realize that it is actually closer to 2 pm. I am  stunned, speechless.  WTF"???!!! IT IS NOT ACTUALLY 2 PM instead of 3 PM.  Oh hell no. I burst into tears, wailing for a good 15 minutes. I'm inconsolable.

I am so upset that I ask to go home. I am told that is not impossible.  The despair turns to anger in an instant. Damn them. Damn this hospital.  And to think I bounced into work this morning, whistling a happy tune (har)...

your dad is a doofus

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

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

Red flags:

1) Medics wanted to give me report outside the room

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

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

4) He normally gets care at another hospital.

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

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

Periodically throughout the visit I hear WOOOOOOOOOOOO!!!

At some point daughter leaves in disgust.

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

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

are nurses being worked to death?

Here's an interesting development.  A man has filed a lawsuit against the hospital that his wife worked at, claiming that she "was worked to death".   He stated in an interview (CNN): the hospital was"regularly understaffed, causing some nurses, including Jasper, to work through breaks and pick up additional shifts"   "Additionally, she was routinely called into work while off duty because she was one of the few nurse qualifiied to work the unit's dialysis machines, according to the lawsuit." She fell asleep, veered off the road and hit a tree and was killed.

Will he win the lawsuit?  Probably not.  No doubt they will say she could have chose not to work extra, could have got another job. At least the lawsuit has put a spotlight on working conditions for nurses.

Hospitals staff hospitals at the bare minimum these days.  At my hospital they staff only for the patients that are there at the time.  They do not staff for admits.  So lets say its Monday and there are surgeries and ER admits...they count on discharges to happen for the floors to take those patients.  Often times that means ER and PACU are sitting on patients. ER waiting room fills up due to back up.   Direct admits are told to stay home until a bed is available.

Hospitals count on nurses to work extra to fill holes in the schedule.  And they do.  Lots of nurses work extra shifts.  Imagine if all the nurses in the country decided to not work extra shifts for a week.  Hospitals couldn't function.

Finally, how many times have you gone without a break or delayed it a few hours?   You willl do that hundreds of times over the course of your career just as a norm.

So here is a picture of the nursing staff of this nation: Exhausted from 12 hour shifts and nights, working extra hours beyond their work agreement, working nights, often not getting a break. Stressed out. These are the people who are caring for todays complex patients.

I encourage you to share this blog post around the internet.

get ready to rumble...its a cage match!

Ladies and gentleman...welcome to anywhere USA local emergency room on a friday night..  Tonight we have a four man cage match. Tonights goal: WHO WILL FINALLY DRIVE THE ER STAFF NUTS?  Lets get started...

In this corner is a woman who has been dying for the last 50 minutes prior to arrival but the medics won't let her die because middle aged people aren't supposed to die so young.   Within five minutes of arrival we let her die.  Then we hear the wailing begin.

In the opposite corner is a drunk who just called his nurse a "lard ass" and a "monkey" and oh by the way doesn't, shall we say "like" the race of the security officer watching him.  Delightful.  Oh and there are no detox beds.

In the next corner is a junkie who I am pretty sure just shot up in the bathroom because now they look a lot more relaxed then they did earlier.

And in the last corner is a 400 pound woman who is "too weak to get up", demands a bedpan and is having diarrhea. God help me...

Me, I gotta put my money on the 400 pounder...

women are veterans too

Give to Fischer House

excuse me....uh...fuck good samaritans

I hate good samaritans.  Why?  They feel the need to call 911 when they see a drunk sitting or laying on the sidewalk.

Dear good samaritans:

I hate to break this to you but drunks live on the sidewalk.  When they are too drunk to stand they sit down or lay down, often going to sleep.  They aren't hurting anybody.  I know they are unsightly.  Not something you want to see in your pristine city, but they are a fact of life.  So leave them alone to sleep it off.

Sincerely

Madness the nurse
on behalf of all ER nurses everywhere

You see Mr/Ms good samaritan, when you call 911 the medics are obligated to take them to the emergency room. They don't have a choice.  They can't leave them sitting there.  They bring them directly to us, your neighborhood ER.  When you are sitting there with elderly mom and hear that person shouting: "FUCK YOU! GET AWAY FROM ME!!" that is the drunk you called 911 about in all their glory.  Here's the thing that yelling is not going to end anytime soon.  It will continue sometimes for hours.  So sit back and enjoy the fruits of your good samaritan efforts.  Its only right you share in the experience.

No doubt that drunk has peed all over themselves. Yup thats them throwing food into the hall as you pass by. Just missed you huh? Uh oh...they took off their clothes...darn it...you didn't need to see that.  Here's the thing, detox is full.  They will have a starring role in the ER all night til they stumble out in the early morning light down to the street to beg for a few quarters for thier next bottle of listerine.
 

the dawn of a new ER day

I start my shift at 9 am.  I come in the ER entrance. ( I observe how many people are walking toward the entrance, how many cars are parked at the entrance.  There are five and two respectively.(CLUE #1 that this day will probably suck).

I look down the hall and see if any nurses are sitting at the triage desk.  They aren't, meaning they are busy. (CLUE #2 one that this day will probably suck)

 I never walk through the department when I get there. I go around it. Trying to postpone the inevitable I guess.  As I walk to the staff lounge, I see the ambulance board where the rig numbers are listed and the room they are going to.  There are five (CLUE #3 that the day will probably suck).

I go to the assignment sheet and look to see where I will be. I am on the end we all hate and then charge n
urse later (CLUE #4 that the day will probably suck)\

I look to see who I am working with,  I am am working with Nervous Nelly and Jumpy Jack, I grit my teeth. (CLUE #5 that the day will probably suck).

I go to my assigned area and look to see what doc is on.  Its Orville the overorderdering maniac. (CLUE #6 that the day will probably suck).

I look at the patient board.  There are two alcoholics sleeping it off. Granny in room 2 is yelling: "NURSE! NURSE!"  I recognize 5 frequent flyers on my end. (CLUE #7 that the day will probably suck).

I get report from my co worker who gives me a group of patients  from hell with families to go along with them. (CLUE #8 that the day will probably  suck).

The charge nurse comes by to say there are essentially no beds in the hospital. (CLUE #9 that this day will probably suck).

I am charge at 3 pm and we are down 2 nurses and staffing MIGHT have one for us...(CLUE #10 that this day will probably suck).

And to think, I haven't even seen a patient yet...

another mass shooting...*yawn*

It seems like shootings that capture national attention have become the norm.  There's a different one every week. They capture our attention for a day and that's it. Its funny how there are 32,000 gun deaths in this country a year, but we don't give attention to that.  It has to be a big splashy shooting or multiple victims for us to notice.  But..hey... I'm getting away from the point of this post.

It is really beginning to infuriate me how every time there is a mass shooting, the subject of mental health comes up.  There is talk implying that if only this person had received proper help it could have been prevented.  Politicians talk about need for "mental health care reform".  Blah blah blah.  Soon that dies out.

What infuriates me is that the average American has no idea about how bad the mental health care system is in this country.  They don't realize that mental health problems are treated very differently from physical health problems.  If you want counseling it will have to be pre-approved by the insurance company who will put a limit on the amount of visits.  Then there is the fact that there is a shortage of psychiatrists.  Good luck finding one or getting a timely appointment.

Then there is  hospital mental health treatment.  If you come into the ER in a crisis, your visit will be 4-6 hours.  It may extend up to 24 hours if there are no beds available.  You may end up in podunk city, 200 miles from the ER you came in to.  You may be transferred there because there are no rooms at our ER. Sometimes there are no beds in the state.  Then you stay in the ER, up  to that 24 hours.

Shy is mental health in such a state?  Lack of psychiatrists. Insurance companies don't want to pay for it like they do for physical problems.  A big part of it is the attitude toward mental health in the United States.  It is still considered a personal failing. You should be able to pull yourself up by your bootstraps and stop whining. There is a huge stigma.  We fear people with mental illness. For shits sake, there is talk of having a national registry of mentally ill people that can be accessed if they try to buy a gun. Well, good luck with that since half the population is on antidepressants.

My point?  Lets just stop the bullshit.  This country is not ready to really deal with mental illness. For it to be treated on the same level as physical illness, it would take a huge cultural change. That's not going to happen anytime soon.

the love of money is the root of bad patient care

I've been an ER nurse for an eternity.  Seen a lot of changes.  Seen a lot of changes with our doctor group.

When I started in the ER our docs weren't board certified ER docs, they were internal medicine.  As a nurse group, we had a great relationship with them.  They respected us, valued our opinion and because of that we gave really great care.  The doctors back then worked for the hospital.

Down the road they decided to form a group and contract with the hospital.  Thats when the changes began. Eventually they started hiring only board certified ER docs which is as it should be.

These two changes - the group separating and contracting with the hospital, hiring ER docs only, changed our ER.

This is only my perspective but when they formed their own group, it changed them.  It seemed to become more about the money.  When you contract with someone, you have to make the contractee happy.
What makes the hospital happy? Happy patients. Getting them to come back. Making money for the hospital.  Using the hospitals high tech equipment.

What makes a patient happy? Obviously, they want to feel better.  They want you to calm their fears that something awful is wrong with them.  They expect you to do things for them: run tests, relieve their pain, reassure them.

Now in this day and age, making them feel better takes the form of relieving any kind of discomfort RIGHT NOW.  Pain 4/10 here's some dilaudid.  Hint of nausea, zofran.  IV for everybody.  The days of giving you an ODT zofran, a vicodin and letting you drink water are gone.  More complex interventions make the patient happy, the more interventions the higher the level of care, the higher payment for the doctor and the hospital.  There is a money incentive to do excessive testing, over the top treatment.  Thats what our doctor group does these days. I realize that this is the norm in ERs across the country.  Is this kind of care good for the patient?

The other change, the coming of board certified ER docs changed it too.  Having worked in a hospital on call that trains ER docs, I saw the difference from our ER.  The docs separated themselves into their own area, having little interaction with the nurses other than around patient care. There wasn't the collaboration like at my hospital.  Basically the nurses were task monkeys.  They were there to carry out the doctors orders, their opinion wasn't sought out.

So that happened at our hospital too.  The docs and nurses no longer collaborate with each other like we used to.  It has affected patient care.

Then in the last couple of years, anticipating decreased reimbursement, our docs decided to start hiring PAs and went with the pit boss model.  The PAs see all the patients and collaborate with the staff doc.  PAs are a lot cheaper to employ, allowing that profit and salary to be maintained by the docs.

The introduction of the PAs has had a negative impact on our ER.  PAs, at least in our ER, are not collaborators.  They collaberate with the doctor and thats about it.  They have not been receieved well by the nurses, further alienating the relationship between the docs and nurses.  Once again, all of this has affected patient care.  Not in a positive way.

The point of this blog post: As money becomes more and more the center of medicine, the best care for the patient falls by the wayside, replaced by the pursuit of profit.

gimme that damn call light

This is me about five years ago.  What can I say?  I believe that a nurse should look like a
nurse and that includes the hat..

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.