It wasn't me, it was my evil twin

I have an evil twin. The evil twin comes out of the patients room and grumbles to herself, using words like "idiot, moron, fool". My evil twin has to keep herself from dozing off as you drone on about your myriad of problems. My evil twin talks trash about you to her co-workers. My evil twin silently shouts "whadda think of that sucker!" when she gets an IV after you said no one can ever get one. My evil twin thinks you should be able to find your own way home....you don' need no bus token or cab voucher...you found your way here - now follow the yellow brick road back home Dorothy. My evil twin doesn't want to hear a history of all your medical problems going back to that traumatic experience in Haight-Ashbury in 1968. My evil twin doesn't want to hear that you are sorry that you peed all over the floor. I'm sorry too. My evil twin thinks you are nuts if you have more than three allergies in three different categories. My evil twin feels sorry for the nurse upstairs who has to take care of you for 8 or 12 hours, but is glad it isn't her. My evil twin knows you are on something so don't bullshit her. Remember she's evil. Never forget she's evil. Remember she has the sharp objects.

HELL WEEk

I approach hell week with trepidation, as  I do every time.  Who is really ready for hell week? You can't really prepare for it.

Hell week.  When I think of it, I think of the Navy Seals. Here's a glimpse: " During Hell Week, candidates participate in five and a half days of continuous training, each candidate sleeps at most four hours during the entire week and runs more than 200 miles." Sounds like hell week to me.

During hell week I work five 12 hour shifts in 7 days.  Sixty hours. I don't sleep much. I probably run 200 miles. And let me tell you, its under combat conditions. I work in an inner city ER in the ghetto OK? You never know whats gonna come through the door: a violent drunk, an almost dead heroin addict, a hysterical migraineur, an ex con drug seeker.  We take all comers.

The first day of hell week is the worst, especially because it falls on a dreaded Monday. Why are Mondays guaranteed to be bad in any ER?  Do people wait because they don't want to ruin their weekend?

Here's how a hell week typically goes:

Day one: I'm hysterical. Its Monday, the beginning of hell week. 'nuff said.

Day two: I'm draggin' , Monday sucked of course. I'm a little peeved.

Day three: I'm angry now. I hate the place. My life sucks. My co workers suck. The patients suck. Everything sucks.

Day four: I'm in a rage. Everybody and everything is stupid. I catch myself running toward the door a couple of times.

Day five: I am burnt to a crisp. Stay away. I might resort to physical violence. Road rage on the way home.  My husband has a shot of Jack Daniels waiting. I down it before I take my coat off. I fall to a puddle on the floor, weeping hysterically until I fall asleep and my husband carries me to bed.

I HATE HELL WEEK.

oh well there's always....

Even at my advanced age, I can still enjoy a Man Candy Saturday...

from ingenue to hag

Here I am getting "pinned" at my graduation, fresh faced and eager...

Here I am last week, old and tired...

Nursing takes its toll...

good to the very last drop

Some of our PAs are insufferable. They order things piecemeal.  Everyone gets a damn IV.

Here's a new one: Give patient 1045.5 ml bolus.  @#$%! You are frickin' kiddin me right? I'll make sure I give that last 45.5 ml as if my life depended on it. No doubt you have a complex formula you learned during your time at Bobs International school of PAs school in the Caribbean.

Oh and by the way, I ain't doin' that rectal temp on someone who is a normal person perfectable capable of putting a thermometer under their temp.  You want a rectal temp, do it yourself.....*****

****finding pictures to go with these blog entries is the highlight of my day!

nothing is what it seems

No I wasn't on something when I wrote the last post, just tired.

Anywho....

In the ITS AS ANNOYING AS SHIT DEPARTMENT here at the madness blog I offer the following:

When an ambulance is coming in we get a call at the triage desk from a place called "medic control". Apparently this is the communications departments for the rigs in the city. So medics call them, tell them where they are going and what is wrong with the patient.  Then medic control calls us and gives us the following info:

1) Rig number
2) Age and gender of patient
3) What is wrong with patient
4) acuity level:  red - critical
                       yellow - stable
                       green -  minor -never should have called an ambulance
5) How far out the rig is.

Here is my complaint: When we get the call from medic control most of the time it is about a two word answer to what is wrong with the patient: "abdominal pain" "chest pain" "hip pain", etc.  Thats it.

The problem comes with what seems like a minor complaint: arm laceration, headache, foot injury, etc.
The triage nurse is thinking:  OK they can either go to urgent care or we can triage them and send them to the lobby.  The nurses in the back are thinking: Hey an easy patient. Yeah!

Most of the time it doesn't turn out that way. That arm laceration is a drunk who was found laying on the street bleeding. That headache is a guy with a trach, brain injury, g tube, foley.  That foot pain is a quadriplegic on a chronic vent who got their leg caught and possibly fractured during a transfer.

Why can't they give us JUST A LITTLE more information? Huh? Just a little?  I don't ask for much.

Nothing is ever what it seems in the ER.

professor poopypants is my friend

My brain is at capacity people. Maybe its because I am getting old and it is shrinking.  All I know is that I can't retain too much more information.

One of these days my head is going to start spinning around and I will cry: SYSTEM OVERLOAD! SYSTEM OVERLOAD!  There will be a flash of light, some smoke and  I will crumple to the floor into a million pieces.

 Either that or I will become a blithering idiot sitting in the corner drooling..

Every day that I drag my tired old butt into work there are 10 emails about changes that happened while I was gone, will happen today or will happen in the future. Oh by the way, the change we made yesterday, that changes today. Todays changes are cancelled. Tomorrows changes got together and had babies and now there will be 5 changes instead.

I am not a computer with unlimited memory banks. I am a human who can only remember so much. It is getting to the point where there is so much information that I can't remember anything.

I have an idea. We should all be assigned a robot. Then when we can't remember something we can ask the robot and they will always know.  I'd name my robot Professor Pippy P. Poopypants.

15 minutes of fame

man candy saturday x 2

I missed last man candy saturday so here are two to make up for it.  Its an athlete theme..

no emergency no service

Here's an interesting development: In Washington the state refuses to pay for visits that are not emergencies for medicaid patients. They have a list of conditions that they don't consider emergencies and neither the hospital or DOCTOR will get paid if they treat these conditions.

There has been a 10% decrease in visits, saving $34 million dollars in a year. They track frequent flyers who hospital shop.  They use the state prescription tracking program to track narcotic prescriptions and have reduced the prescribing of narcotics by 24%.

Will this go nationwide? Hopefully. You might think that this program discriminates against patients on medicaid.  The thing is, if you work in an ER these days you know that the people using the ER as a clinic are those on medicaid. Sure there are a few people with insurance who do it too but the vast majority are those on medicaid.

As I have said before, todays ER patients fall into 3 categories:

1) people who use it as a clinic
2) the chronically ill
3) those who have an actually emergency: trauma, cardiac events, other critical events

"Regular" people with insurance are not going to ERs for routine illness or minor things. They are either going to their doctors, urgent care or just not coming at all. As far as them still being able to go to ERs for nonemergencies, that will probably stop also in the future.  Insurance companies will probably start doing this too.

What I find interesting about this is, once again, government is having to intervene and change things because the health care system refusing to change on its own.
 

don't let the bed bugs bite

When a patient comes in with bed bugs I am scratching for the whole day.  Its like the idea that I was even around a bed bug creates this psychological need to scratch.

So let me explain the havoc a small little bug can cause in a hospital:

1) When you have a patient with bed bugs we are supposed to don this plastic jumpsuit (see picture). (You can imagine how an old woman like me looks in this getup.   I can barely manage to get it on).
2) The patient undresses and all the clothes are double bagged.
3) The patient is supposed to shower (doesn't happen much).
4) This is my favorite part:  If you observe a bed bug you are supposed to have a specimen cup at the ready and put the bed bug in there. So let me get this straight: you want me to chase the bed bug around the room and try to convince it to jump into the cup?  Come on....come on...little bug jump in...I don't think so.  You have to draw the line someplace with this job.
5) Send it to lab for identification.

Here's a suggestion: don't come to the ER if you have bed bugs. Simple really.

They don't pay me enough.

a thousand times why

1) Why does the IV pump always go off as soon as you leave the room?

2) Why does a critical patient come in 15 minutes before the end of your shift when you are the stab nurse?

3) Why does your replacement have car trouble when you have had the shift from hell?

4) Why does your least favorite frequent flyer show up in the middle of a chaotic shift?

5) Why do relatives/friends like to stand in the doorway and watch the nurses at the desk?

6) Why when your patient just had a massive stool has the rest of the staff suddenly disappeared?

7) Why when you finally got a chance to go get a pop, does the machine keep your money and give you nothing? &#*$((@!

8) Why does the manager come along when you are texting someone at home?

9) Why do the medics "forget" to call in when we have no beds and there are people in the halls?

10) Why do people somehow get their relative into the car, but need us to take them out when they get to ER?

11) Why does the train wreck from podunk that is a direct admit to ICU, crash enroute and have to come to the ER?

12) Why does the nurse from Dr Jahosafats office want to give us a "heads up"  about one of their patients coming in when there are 10 people  at the triage window?

13) Why are we always out of what the gnarly ENT  doc needs for that bad nosebleed in room 6?

14) Why when I finally get a chance to pee, the bathrooms are always being used? #&%)@)!

15) Why didn't I leave this job years ago?

screeching grandma

Or screeching Grandma just settled down..

BTW, this pump looks WAY TO COMPLICATED to me...

how to make everybody happy 101

Hey I have this scathingly brilliant idea: an IV station at triage.  I would say about 90% of the people we see end up getting IVs.  This would save a lot of time and trouble.  Put the new nurses out there to practice. They would be experts in a day.

ER docs philosophy these days seems to be: Everybody could use a liter of saline so why not give them one.  It will make them feel like we are really doing something.  It gives them something to concentrate on while we wait for the myriad of other unnecessary tests to come back.

The patients can play it off with thier accompanying relatives or friends and tell them: See I told you I was sick! I have an IV! I am so sick I need an IV...

This is a win-win-win-win scenario:

1) New nurses get practice startings IVs.
2) Patient is happy.
3) Doctor can bump up level of care and make more money.
4) Nurses in back don't have start all of the IVs. They can run, not walk, to the pyxis to get all those meds like zofran, dilaudid, ativan... Patient is in la la land faster.  Everybody is happy.

Yeah I think I'm onto something here....

oh no

taking anal retention to a new level

So I gave TPA the other day.  So I had to take the patient to ICU myself.  Normally we have the float nurse take the patient up, but in this situation the dreaded "mutual neuro exam" must be done.  This is a requirement whenever there is a patient with a critical neuro problem who goes from ER to ICU.

So I get to ICU and there is the nurse sitting waiting for the patient. I take the cart in the room.  The performance begins.

The patient is slid from ER cart to the bed. The patient is rolled to get all of that messy ER stuff from underneath them: extra sheets, blankets, half eaten sandwiches, etc. As we roll, of course the nurse must stop to listen to the lungs, assess the skin.  The patient is repositioned. The gown is changed.   Ah...hello I gotta get back...The patient is placed on the monitor, BP oximeter, etc.  This takes about 10 minutes.

Now, this being ICU, staffed by ICU nurses, everything has to be straightened out before anything else can happen.  I like to tangle the IV lines as much as I can before I came because I know this will drive them insane.  So about 10 minutes is spent untangling the two IV lines.

The patient has to go to the bathroom.  The bedpan procedure is done.  Another ten minutes.

Finally 30 minutes in, its time for the mutual neuro.  Now the real performance begins: The patient is examed head to toe, doing 30 different actions, some of whom I have no idea what they test.  Is this a neurologist or a nurse? Is she showing off?  Hell, I'm happy if they can talk and move their arms and legs.

Finally about 45 minutes later, the deed is done and I head back. The charge nurse asks me: "Where the hell have you been?" I sigh and walk away.  I hear my name over the intercom saying I have a call on line one.  Its the ICU nurse has a few more questions.  Of course she does.

uh....that's a red flag son

"Whats going on today?" Thats my usual greeting when you sit down  in the triage chair, along with asking for a picture ID and telling you to take your coat off.  You tell me.

I may ask a couple of questions.

Well it seems Johnny had an accident and he injured arm.  There is slight swelling there.  No big deal. As Johnny takes off his coat I note a hospital band on his arm and inquire if he had been at another hospital.  He tells me thats from a couple of days ago. Hmmmmm....and you haven[t bathed since then and taken it off? Okay....red flag.

So back we go to urgent care. I told the staff there about the other hospital band I had removed.  Of course I did. It turns out Johnny had been to another hospital earlier and was here in our hospital for "a second opinion".  "Second opinion" = I didn't get the narcs I wanted at the other hospital.

Here's the thing, Johnny wasn't smart enough to remember to take off the other hospitals name band so he came up empty at both places.  Well, on to the next hospital...

the 300,000 dollar raise

Here's an interesting factoid:

The CEO of the corporation that I work for makes about 2.5 million a year as of 2012. In 2011 he made about 2.2 million.  Then come 2012 he got a raise of 12%., about 300,000 a year.  Lets see, that about 25,000 dollars a month.  That 1250 dollars a day or 156 more dollars an hour.

In 2012 I got a 2 percent raise.  Thats about 80 cents an hour.  About 96 dollars a month. (I work 60 hours every 2 weeks.  That is 1,246 dollars a year.

So lets sum that up

2012

Mr. CEO - 300,000 dollar raise for the year (156 dollars an hour)

Madness the nurse -  1,246 dollar raise for the year (.80 cents an hour)

I don't do what the CEO does. I am not responsible for a complex corporate system.  I am not answerable to a board. I don't have to worry about the corporation staying afloat.  That must be very stressful.  I don't expect to be compensated in the same way.

But heres the thing: If I make a mistake, you die.  If I don't pay attention, you go down the toilet. The environment I work in, although a very different place, is very, very stressful.  I deal with everybody from a junkie prostitute to Mr CEO's pals. I am the backbone of the corporation.

I can hear you all saying, hey Madness, you could have gone into health care administration, you could have been in administration.  True that.  I didn't chose to.  Its not my thing.  My point is: Does the CEO deserve a 300,000 dollar raise in one year?  No.

killing two birds with one stone

You are out in the suburbs visiting a friend.  Can't get a ride home.  You also have a hankering for some dope.

What to do? What to do?

You do what  you have been doing for some time now wander down to one of the main streets. You limp into a local business and ask them to call an ambulance.

The ambulance arrives. You tell them you twisted your ankle. u You put on a good show, barely able to walk, lots of groans and facial grimaces.  When you get inside the ambulance and the pain is much, much worse. Of course, the paramedic, wanting to do her job, starts an IV and gives you a narcotic pain med. Ah....much better.

You tell the paramedic you want to go to X hospital, that one being nearest to your house.  This is quite a distance into the inner city.  Takes that ambulance off the road for a while.  Hey that's not your problem right?

You arrive at the hospital, a place that has become familiar with you and your various ailments. You know they won't give you more narcs. The minute the nurse leaves the room, you get up and walk out.

You have achieved your goal: 1) a ride home
                                              2) narcotics

  

the case of the missing IV bags.

So here is something I didn't know: There is a shortage of normal saline, specifically 1 liter bags. We use a whole lot of saline in the ER. So this affects us greatly.  The FDA's suggestion: Use smaller bags or think about alternatives.

I don't know why there is a shortage...could it be we use too much??? Could it be that every Tom, Dick and Harry who comes into the ER gets a liter of saline even if they don't need it? I've often thought we should just have an IV station in triage. Everybody who comes in gets an IV out there.  That way they will already be in place and save a lot of time.  Everybody gets one anyway, so what the hell?

Wouldn't it be nice if, with this shortage, doctors began to rethink starting all of these unnecessary IV's.  Uh oh  -there I go, using common sense again. Thinking that people can actually drink water. Foolish.

In trauma, this will be a problem.  You can't exactly use 500 cc bags in the rapid infuser. Maybe LR will be used, who knows?

old and alone

She was fragile and thin, like a lot of old people, somehow managed to stay in her own apartment despite having no children or close relatives. Today would change all that. She tripped and fell, ended up with a fracture that will change her life. She's headed for a nursing home, never going home again.

I know this, even though I only spent a couple of hours with her.  I see her future because I know how this kind of situation goes. I know what happens to old people who don't have anybody.

She was in a lot of pain. She was so old, we walk a tightrope giving her narcotic pain meds.  On the one hand, we want to relieve her pain and on the other hand, we don't want her to stop breathing.  At one point we had to move her around for something and she cried out in pain and it just broke my heart. (yeah I still got one)  Seeing old people in pain sucks.  It just seems like, they have made it this far, they shouldn't have to suffer.  But they do.

Hopefully she will make it out of the hospital. Hospitals are no place for fragile old people.  The risk of complications is high: pneumonia, UTIs, etc.  Getting her out of here quickly would be the best thing.

I wish we didn't warehouse old people. I wish we treated them better.

why oh why?

Why oh why????!!!

-when you put a morbidly obese woman on the bedpan they never actually pee IN THE BEDPAN, but instead all over the bed?

-when you get someone on a backboard, with a fractured hip, the first thing they want to do is pee?

-when it is the shift from hell inevitably a couple of your frequent flyers will show up?

-when you have a potluck, you won't get to eat it because its too busy?

-someone has to have surgery, you go in the room and they are eating something their family gave them?

-it could be -30, there could be 3 feet of snow, but the STDs, sore throats, back pains can still make it in?

-the smaller the lac the bigger the baby?

-someone brings in elderly grandma who can't speak english, tells you they have to get to work and leaves?

-you get to work, the place is a disaster and here comes Dr $10,000 work up to start his shift?

-you finally get to the end of a shift from hell, only to learn that your replacement will be late?!!!

oh well.....there's always man candy Saturday

I'm just about done

The acuity in our ER is off the charts. Sometimes I feel like I work on a med/surg/tele floor,  not an ER.

Gone are the days of fractures, lacerations, etc. that used to be what an ER did, replaced by the chronically ill.  The people who have 3 or 4 underlying illnesses and now they are having an exacerbation of one,
or some other problem.  They are the kind of people that get the $10,000 work up. They are the difficult IV start, the people that need to be cathed, etc. They take a lot of time and are there for hours. A lot of them are morbidly obese and we break our backs trying to take care of them..

Other folks in the ER these days: people on medicaid who use us as a clinic. The thing is these days, with the patient satisfaction sweepstakes, even these people are way overtreated.  Hint of nausea: IV, zofran, a multitude of labs. I actually had a provider recently order Morphine for someone who HAD NO PAIN. No, sorry I am not giving a narcotic to someone with no pain.

We don't have enough staff to handle the increasing acuity.  We won't be getting any more any time soon. I am starting to think that I've had enough. Tired of the stress.  Tired of feeling like a truck ran over me at the end of the shift. Tired of not having enough staff. I had a plan of when I would leave and I think it will come a lot sooner than that.

that about sums up today

I predict: DEATH

From the wonderful world of pharmaceuticals comes news of a product that has been developed called Zohydro.  It has 10 times the potency of Vicodin. TEN TIMES.This drug is being marketed as a drug for those who have chronic pain not eased by the usual narcs. It won't be used as a prn med.

From what I read, some medical board that looks at this stuff for the FDA unanimously recommended against its approval.  Twenty eight states in the US have voiced opposition to this along with many people working in treatment centers, police, mental health.  But guess what?  In its infinite wisdom, the FDA has decided to approve it anyway.

So we are gonna have a drug out there to add to the mix of prescription drugs, heroin, meth and cocaine. The more the merrier right?

People are going to die from this drug.  It will get on to the street, there is no doubt.  It will be mixed with other drugs and people will overdose and die. They probably won't even make it to the ER.

sexy it ain't

There have been articles written about this subject: the portrayal of nurses as sex objects.  Who hasn't seen the sexy nurse outfits or heard about porno films about nurses?  Its bizarre because nursing is as far from sexy as you can get.

Why does this stuff go on? There are theories that men feel vulnerable and powerless when they are being cared for by nurses, so they sexualize them.  There's the old nurses give bed baths and you know what that can lead to....(wink wink).  The fact is nurses see naked bodies every day.  Its part of the job.  Its part of the job to see your junk sometimes. Sometimes we even have to touch your junk.  Believe me, we don't want to.

Seeing people naked becomes routine. One of the first things I'm going to do in the ER is to tell you to take your clothes off or take them off for you.  Ho hum.  Ninety nine percent of the bodies we see aren't all that much to look at.   Most of the time they are wrinkled and old or fat.  Its not that exciting. I can't remember the last time I had a guy whose body was anything to look at.  Healthy men in good shape don't tend to come to the ER or into the hospital.

As far as the whole sexy persona of nurses, consider this: the average age of nurses nationwide is about 46.
Middle aged. Nurses are tired, stressed out.  The job becomes more and more challenging in many ways every day.  Its overwhelming what we are expected to know and do.  Most of us are just trying to make it through a shift.

Sex is the last thing on our minds.  Get real.

The above picture is from the blog impacted nurse.   There is an interesting article there about this subject.

monday in triage

Some things we could use in triage on a Monday......

man candy saturday

As the winter from hell continues...all there is to look forward to is man candy saturday.