ebola is here

A couple of months ago we started asking people if they have travelled out of the country.  This was around the ebola outbreak in Africa.

Today there is a report that the first ebola case has been confirmed in Dallas.  This is really scary for
those of us who work in emergency rooms. We're literally at the front lines. If someone slips by and we are exposed we take it home to our family and they are exposed.

Shit just got real.  The symptoms of ebola are fever, headache, muscle aches, weakness, vomiting. Symptoms we see every day of the week in the emergency room. Symptoms may appear anywhere from 2 to 21 days after exposure, average being 8-10 days.

I wonder how this patient came into the hospital  No doubt it was through the emergency room, exposing lots of ER staff.  The question is did they have any idea this could have been ebola when the person came in or did it take a couple of days for the hospital to figure it out?  Did those staff go home to their families before it was known?

We live under the illusion that somehow this won't get here.  We will stop it at the airport.  There are CDC quarantine stations at airports around the country that deal with those ill from other countries.  They determine whether they can enter the country.  Here's the thing:  They may not yet be manifesting the symptoms at the time they enter the country.

So what's the solution?  I don't know. You can ban people from coming here. The on
ly solution lies in Africa, stopping the spread there. That's being worked on.  In the mean time we're sitting ducks.

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I been robbed

Here are the top ten things stolen from our emergency room:

1) syringes - before drawers were locked

2) linen - sheets, towels and wash cloths

3) phones off the wall

4) fetal doppler

5) lap top

6) bandaids, bandages

7) box lunches

8) gowns

9) oximeter

10) staff purse

11) thermometers

12) TV remotes

13) box lunches

14) scrubs

15) wheelchair


exta added bonus points: Christmas ornaments in the lobby

yup

mc saturday - its the pitts

reality is a bitch

You know when something hits you and you say to yourself: Of course...duh.  I had a thought about work.  From now on, just about everybody is going to be either a train wreck or a nut case.  The days of getting normal people into an inner city ER are over.  Bye bye.  Never coming back.

People have too many other options these days.  They have shiny new suburban ERs.  There are more and more urgent cares.  There are orthopedic urgent cares.  Any kind of normal person is going to them first.

I kept thinking, okay, yes the train wrecks and nuts are increasing, but eventually it will balance out again.  It won't though.  Here's a sampling of a typical shift:

drunk woman who was beat up a few days ago and her whole face is bruised over

ex con guy convicted of attempted murder

16 year old who was stabbed in the back

chronically ill 300 lb woman who is now having another problem

women who is shouting baaabaaaa like a sheep

confused grandpa who lives alone with no family

16 year old heroin overdose

The days of ankle sprains, lacerations, strep throat are over.  Those people went to Bob's urgent care emporium.  Why would they want to sit in the lobby with the hood rats and junkies and STDs and moaning back pains?  It scary and gross out there.  I don't blame them.  Bob's is clean, new, has a fish tank in the lobby.

So welcome to the modern inner city/ghetto ER....where there is a constant stream of train wrecks. nuts, ineffective copers, junkies, drunks, neurotics.  This is our life now. Reality is a bitch.


  

the freak show that is triage

I take my seat at the window.  No one is in front of it, thank God. I have already transformed into the incredible hunk as I do every time I am assigned to triage.

 I hate our triage set up.  It was designed to drive the staff insane.  There is a camera that looks at the entrance, so we have a screen where we can see cars pull up, people walking up. Its a long way from our entrance to the desk.  A ridiculous design.  A cruel design.  It allows us to watch people walk a distance to the desk.  This allows many to put on a performance.  Sometimes a person who strode up to the entrance on camera will be practically crawling when they get near the window.

Let the freak show begin. It often resembles the cantina scene in Star Wars. There are goths.  Tattoed people. Pierced people. Women with so much cleavage,  I worry the girls will escape.  Twitchy people.  Falling asleep people.  Yelling people. Hostile people.  People who go to the floor. People who want to show me something on their butt people.  Drunk people.  People who have smoked dope.  Reek of cigarettes and beer.  People who make you feel like you are in the twilight zone.  People who make the hair on the back of your neck stand up.  Whispering people.  People who brought gruesome "samples" in little jars.  Vomitting people. Coughing people. People who can't breathe.  People in pain. Pale people. Flushed people.  Bleeding people. Broken people.  Sad people.  Crying people.  Anxious people. Dirty people.  Smelly people. Plain people.  Good looking people. People in wheelchairs.  No english people. Funny people. Mean people. Nice people.

Once in a while there is a Marilyn.  You know Marilyn who was on the Munsters.  She was the only "normal" member of the family.   The rest of them were monsters.  Marilyn allows you to relax for a moment.

ATTENTION ALL STAFF: ***SHUT THE FUCK UP!!***

Attention all staff:

DAMN IT.  I have told you this shit before.  You dunces can't seem to get it.  So here it is:

*********SHUT THE FUCK UP!!!!!!!******

Surveys have shown that you people are talking too fucking loud at the desk again.  You are laughing.  You are sometimes acting like YOU ARE ENJOYING YOURSELF.  This disturbs the patients.  They are lying pathetically in their cots, having just spouted their tales of woe, gleefully anticipating gallons of dilaudid in .088888 seconds.  Your laughter must mean that you are not making a full out sprint to the pyxis to retrieve said dilaudid.  This makes the patients feel unwanted.

How many times have we told you that this environment should not promote a sense of frivolity.   We are in the business of saving lives here. THAT IS SERIOUS BUSINESS YOU BUFFOONS. People suffering from stubbed toes and STDs should not be subjected to a joke about your Aunt Loretta, no matter how funny it.

I am afraid you have give me no choice.  Effective immediately, any laughing, talk above a whisper, smiling will result in disciplinary action.  Since all of you idiots can't understand the concept of being a serious  MEDICAL PROFESSIONAL, there will be a mandatory inservice on your day off.  We will be bringing in consultants to train you in taking your jobs seriously.

In the mean time...I hate to have to take it this far, but you leave me no choice... I have procured a hat, cone shaped and had the following words sewn on to it: I  HAVE BEEN NAUGHTY AND  HAVING TOO MUCH FUN AT WORK.  There has been an area set aside in the corner of the ER which will be designated the "ER STAFF TIMEOUT CORNER".  A chair has been procured.  Periodically throughout the day (and suprise visits off shift), a member of management will suddenly appear and observe staff for any laughing, snickering,  tee heeing, smiles, smirks, etc.  Any observations of these things will result in said cap being placed on your head and you will be placed in the timeout corner for not less than 10 minutes or more than 30 minutes.

I regret that it has come to this. You brought this on yourself people...

IDIOTS

The Management

what I am really thinking at the triage window

how I became a bitch

Working in the ER changes you.

It is unlike any other place in the hospital. You are dealing with a constant stream of people who are having some kind of stressful event in their lives.  We may not think it is a crisis, but for them it is.

The ER never ends. It never closes. Its 24/7.  There is never a break. It can be quiet one minute and chaos the next. You can be dealing with a stubbed toe and in rushes someone with a gunshot wound or a cardiac arrest We live our life on the edge.

You are dealing with everyone from A to Z.  Many of the people who frequent ERs are living dysfunctional lives. They bring that dysfunction into the ER with them. They can be drunks, junkies, criminals, the homeless, the mentally ill, the neurotic.  We deal with violent drunks, drug seekers,  homeless people who haven't bathed for months, out of control psych patients, manipulative people who can turn on a dime if they don't get what they want.

We work in a chaotic environment of ringing alarms, yelling patients, ringing phones, overhead paging... When it ramps up its overwhelming.

You know all of the above going in, or at least you think you do.  When you choose to take a job in the ER, you are the kind of person who thrives on chaos and crisis.  Bring it on.

Here's the thing about the ER that people don't get: It is not like ER on TV.  We are not constantly dealing with a car accident, a shooting, a cardiac arrest.  We get critical patients. Often. That's actually the fun part of my job. Ninety nine percent of the time it is routine, dull even.

My job is the everyday world of the ER: the abdominal pains, back pains, chest pains, mental health, etc. etc. etc. that make up the daily operation of an ER.  Its boring really.  Its predictable.

Being an ER nurse, you see a lot of tragedy.  Tragedy in the form of suffering people with cancer who are dying, terrible chronic diseases or conditions, unwanted elderly people..  People die.  Families suffer.  It is sad.

Then you see people who are such ineffective copers that a cold sends them over the edge and into the ER.  They are the type of people who will never have their own doctor.  There lives are such chaos that the concept is foreign to them.

Every day you deal with drug seekers in their various forms.  They lie and manipulate to get what they want.  You learn to recognize them a mile away.

Then there are the just plain mean people. You learn just how many of them there are in the world. They yell at you, verbally abuse you, threaten you, may try to hit you and succeed. They are the out of control people down the hall yelling at the top of their lungs because they didn't get what they wanted.

All this changes you.  Hardens you.  Makes you cynical..  You develop a shell that protects you most of the time. It changes your view of people, the world.   It exposes you to things most people don't see. It gives you a perspective on your own life and how it ain't so bad.

Being an ER nurse is so very difficult.  You cannot understand how difficult unless you do it. The only things that saves you is the occasional thank you, the thought that you made someone feel better or participated in extending someones life at least enough to get them out of the ER.

Last but not least, you will work with people who are hilarious, smart, dedicated and some of the nicest people you will ever meet.  They keep you coming back.

a belated mc saturday

DING! DING! DING!

There is a game we play in the ER. Its called the ER charge nurse bed game.

You are charge, the phone rings. There are 2 chest pains in the lobby and an ambulance on the way. You have 5 minutes to come up with 3 beds...GO!!!

Go directly to docs area, with a stern look on your face, ask docs who can go to the hall. Docs say nobody can move. You move their patients anyway! You come up with the beds! DING DING DING You score 25 points.

You are charge, the phone rings. There is a critical 3 minutes out. All the beds are full, including the stab rooms! GO!!! You do a 2 patient room switch and the ambulance rolls in just as a bed goes into the stab room! DING DING DING You score 25 points.

There are fifteen patients waiting in the lobby. The natives are restless. The triage staff is threatening mutiny. You are waiting for beds for 4 admits. GO!!! Y
ou quickly called the supervisor, threaten to go on divert to ambulances. She comes up with the beds. DING DING DING You score 50 points.

Final score: 100 points. You win: $16.00 extra ($2/hr) for being the charge nurse for 8 hours. You stop and pick up some cheap wine on the way home.

Thank you for playing the ER charge nurse bed game.

m. c. saturday

Joan Rivers, free standing ERs and that one in a million bad scenario

There is a free standing ER that is located in a nearby suburb which is connected with our hospital.  A free standing ER is an ER that has no hospital at the location.  Any patients admitted are transferred to our hospital or another hospital. These free standing ERs operate the same as any other ER.  They can do anything a normal ER can do.

I was thinking about the whole Joan Rivers thing and the news that she probably died of airway compromise related to vocal cord spasm.  I don't know anything about how something like this is dealt with.  I mean I don't know if you can do a cric or what.  Its obvious that an outpatient clinic isn't prepared for something like this.

Got me to thinking about free standing  how vulnerable free standing ERs are. Yes they have qualified highly trained ER doctors who can manage just about anything.  I wonder if there have been cases across the country where something has come in that can't be handled or a delay in transfer has caused a death?

I remember one time when a young girl came into our ER.  She was about 6 years old.  She was in anaphylactic shock.  It was very difficult to intubate her.  Fortunately there was a pediatrician who was in the special care nursery and helped with it.  What would they have done if he hadn't been there?

I guess thats the chance you take with outpatient settings.

why should we care?

I get dropped off on the days I work by my husband at our entrance.  So I have walked into our entrance probably thousands of times.

So I step out
of the car and the sidewalk to the door is all dirty.  There is a garbage can and typically there is a wet stain draining out of it down the sidewalk.  I walk in the automatic door.  The carpet looks like some remnant thing they got at Menards on sale.  It is dirty and worn.  The walls are scuffed.

You walk up to the triage window.  Over to the right is our waiting room.  Bolted to the ceiling are 2 TVs that were bought in the 1950's.  The lobby is dimly lit. The furniture is worn and dirty.

Welcome to our ER.  This is just the initial impression.  First impressions are  everything they say. Doesn't bode well for us.

The ER itself is old, very old, hasn't been remodeled in years.  It is run down, falling apart.  It is too small.  There is not enough seating for the staff.  It is noisy and congested. The walls are scuffed, the floors in the rooms are dirty.

Conclusion: Obviously the hospital doesn't care about what the ER looks like, what kind of condition it is in.  If thats the case, they obviously don't care about the patients.  Why not? My cynical old self says its because we are in the inner city, our patients don't have insurance, they don't demand new stuff.  Our patients are neighborhood people, old people, the chronically ill.  Middle class white folks ain't coming to our ER  

Why would I say this?   Every ER in the corporation I work in has been remodeled except ours. Only one other ER they own is in the city, the rest are in the suburbs where the people with insurance live. They just built a brand new free standing ER.

So the questions becomes: Why should the staff of my ER care if the hospital administration obviously does not?

oh by the way, the guy in the ambulance with the headache is a violent drunk

Sometimes I hate medic control.  Medic control is the county dispatching system in our area. They call us when an ambulance is coming to us.  They give us age, problem, ETA, triage level.

Here's the thing: THEY OFTEN  DON'T GIVE US ENOUGH INFO...  It is triage's job to decide where everybody goes, when they go.  The sickest go first.  As you can imagine, a lot of the times the rooms are all full.  So people go to the lobby. When we are full and an ambulance is coming in, sometimes we have to move people around or put them in the hall to accomodate it.  Sometimes we triage them and put them in the lobby if they called an ambulance for some numbskull reason like a sore throat, toothache, stubbed toe.  Or we might send the ambulance to urgent care.

Well here's what happens: We get the call, ambulance on its way in with headache or constipation. Okay, no rooms.  We'll triage them and put them in the lobby.  So here comes the ambulance. Oh what's this...that headache is sloppy drunk.  That UTI is a quadriplegic.  That sore throat has cerebal palsy.  In other words, they ain't going to the lobby.

So we now have medics with a patient on a cart with no place to put them.  GRRRRRR.....this pisses me off.  I have to tell the charge and either rooms are rearranged while the medics sit there or we triage them and stick that foul drunk or poor quadriplegic in back of triage while we mo ve rooms.

Why doesn't medic control tell us these LITTLE details?  I haven't got a clue....I know you work really hard. I know you have a really stressful job.  All I want is to add drunk to that headache, quadriplegic to that UTI...thats all.

I know more than you do...nahnah nah nahnah

Alternative scenarios: "My brother is a doctor......I was a nurse 20 years ago....I'm a nursing assistant....My dead husband was an opthamologist...I am a psychiatrist....That's not what they did on Greys Anatomy... Dr Oz said.....I saw a report on this on CNN...My auntie said....etc etc etc... 

call a damn ambulance

I can't believe I have made it this far in nursing without an injury.  Yeah...I have a backache lots but its nothing that doesn't go away.  I have seen people I work with require surgery for neck injuries, back injuries.

With that in mind people piss me the hell off! They somehow get 200 pound grandpa into the car.  Now grandpa is in a wheelchair.  There is a reason he is in a wheelchair.  He can't bear weight.

So up comes daughter to triage desk  Needs help getting grandpa out of car.  I specifically ask if she and I can get him in a wheelchair.  Yes, she says. So I dutifully go out there. You see where this is going don't you?

Yup, grandpa can't bear weight. Grandpa slants backwards.  I can't pick grandpa up.  He's too heavy. I'm a girl. I manage to get grandpa down to where he has his butt on the foot part of the wheelchair.  I have daughter run in for help.  No one is at the desk. Here comes admitting lady.  No way she and I are getting him up.  I tell her to go get security.  He manages to get him into the chair.

Grandpa is not injured.  I am not injured, except for some sore muscles. Nobody else is injured.  Its really a miracle nothing bad happened.

The thing is: THIS HAPPENS EVERY DAY.  People somehow drag a family member into the car, not calling an ambulance like they should.  Then they expect us to go out there and get them in. I want to scream at them.  We are supposed to wreck our backs because you are idiots! I'm fed up with it really.

Add this to the fact that in the last 2 weeks I have seen two 600 lb people come into our ER and you get the picture. Did I tell you we have a total of one lift in our ER? Yeah..one lift.

a true man candy saturday

unfortunately for you...

when a body becomes human

When a critical patient comes in they are a set of vital signs. They are heart rhythms on a monitor. They are skin color.  They are mental status. They are bleeding needing to be controlled.

They are lab results.  They are xray and scan results. They become something that has to be intubated quickly.  They need IVs and central lines.  They need fluids.  Often times, lots of medications and infusions to keep them alive.

They are foleys and ET tubes and nasal or gastric tubes. They can be chest tubes and splints. They are blood infusions and rapid infusers and ventilators.

They are ten people surrounding them, with doctors shouting orders.  They are respiratory therapists, lab techs, xray techs, nurses, pharmacists, EMTs.

They are a body that we do things to and has things done to it. Eventually they are
either stable or lifeless.  They become human to everyone when their loved one stands by their bedside, holding their hand, a tear running down their face. They become somebody that someone loves.