Sunday, November 30, 2014

nursing school in a nutshell

This is probably the most accurate description of nursing school that I have ever seen.

Friday, November 28, 2014

pet peeve #678

Pet peeve #678:

Any health care worker that makes a point of wearing their name badge when they bring a friend or relative assuming we will treat them "special" because of it.  Especially arrogant doctors. you are going out to the lobby just like any other person.

Doctors who call in to say a friend of theirs is coming what...

Tuesday, November 25, 2014

an ER doc goes to work

"I’m about to go to work. I’m an emergency room doctor and I work the 10 PM to 8 AM shift."
"What’s been your proudest moment as a doctor?"
"Probably just the moment when I finally felt comfortable— it took about three years, and one day it just kinda clicked. Starting a shift in the emergency room is like the feeling before a giant battle in a movie like Braveheart or Lord of the Rings. You just have no idea what’s going to come through the door. Sometimes five serious cases can come in at the exact same time, and you have a lot of decisions to make, and you have to know exactly how long each procedure takes, and what can wait, and what can’t. I think my proudest moment was when I finally stopped feeling nervous, because I’d reached a level of experience where I could make the correct decisions without thinking about them.”

Doctors and Nurses Fight Back; Proposal to Link Hospital CEO Salaries to Employee Satisfaction Passes Senate

Hilarious story on one of my favorite blogs: the Gomer blog


Genocide: the deliberate killing of a large group of people, especially those of a particular ethnic group or nation.

Monday, November 24, 2014

young people die in the emergency room too

Sometimes a couple of hours into a 12 hour shift something bad happens.  Your patient dies. And its a really young patient.

Its really rough. A young life gone. A family in shock.

The thing is this happens in the middle of a very busy day. The day doesn't end because this happens. It goes on. There are more criticals. The lobby is full. You have to move on. You have to move on after you tried to close the eyes of the young patient and they wouldn't close. You move on after you talked on the phone to the hysterical family. You don't get to go somewhere and think about what just happened.

You move on to the next one. The next one could be a stubbed toe. Or it could be another critical patient. You spend the next 10 hours running your butt off. That patient is still on your mind. You are exhausted. Cranky. The shift seems to go on forever.

When you get home, that's when you can think about the patient, wonder about how their family is doing, look at your son and feel thankful he is OK.

Friday, November 21, 2014

patients are products on a corporate medicine assembly line

OK its official. I am overwhelmed. I have been an ER nurse for 25 years. If your arm was dangling by a thread from your shoulder, I would calmly take you back to the stab room. If you unexpectantly go into v fib, I would have the patches on so fast, your head would spin even though you are dead. In other words, I have seen a lot of stuff and can remain calm under lots of stress.

However, I am getting to the point of no return with the amount of information and job requirements there are these days.

I work in a large inner city ER in a hospital which does all kinds of fancy-dancy shit: LVADS, ECMO, CRT, interventional radiology, robotic surgery. You name the complicated medical condition and we probably do it. My point? Our ER is filled with complicated chronically ill patients on a daily basis. These patients are not your ankle sprains, lacerations, appys. They are people who are quadriplegics on dialysis with complicated heart histories. Those patients make up a good proportion of our patients.

The other population we serve is the neighborhood hood rat element. They use us as a clinic. They bring their dysfunctional lives into the ER with them. We serve a large immigrant population. We see many, many mental health patients.

In other words, our ER population is heavy duty. So we are already running around like banshees trying to keep it under control.

Now add to that the 20 emails I get daily about different changes to policies, procedures. Add to that the 10-15 education classes I am supposed to complete every quarter, preferably during my shift. Add on being preparing for various organizations that come every couple of months to certify the hospital in one thing or another: LVAD, magnet, bariatric care, stroke management, chest pain, etc. Add on to that a new drug dispensing system that has been put in place in the last month. Add on to that BLS, ACLS, PALS, TNCC. Add on to that the ebola scare and preparing for that. Add on to that JCAHO, CMS, Department of Health visits.  Add on to that monthly staff meeting, quarterly charge nurse meetings.

How much more can nurses take, seriously? In all of this ridiculous frenzy of information and certification, interaction with the patient seems to be the last thing on anybodys mind. The patients have become products on an assembly line of corporate medicine. The human element of todays corporate medicine, the nurse, has no time to talk, empathize with, care for, the patient. They are too busy trying to keep up with all the certification/regulatory bullshit.

Wednesday, November 19, 2014

31 uses for duct tape in the ER

Its an oldie but goodie....

1)IV pole broke: Tape the IV bag to any nearby surface: the monitor, the wall, the patients relative, etc.

2) Demented Donald trying to get out of bed? Duct tape will keep him in bed.

3) Duct tape that irritating drunks mouth shut.

4) No security available to watch your suicidal patient? Duct tape will keeep them in bed and SAFE.

4) Out of arm slings? Fashion one out of a piece of cardboard and tape.

5) Patient hairy and need to put him on the monitor? Duct tape will remove that hair for lead placement.

6) Backboards all in use? Take the sliding board, some rolled towels and tape and fashion your own version of spine stablization.

7) Duct tape your manager to a chair.

8) Low on suture or staples: A quick and easy laceration repair.

9) Tape patients gown together for trip to bathroom.

10) Out of adult diapers: use towel and duct tape substitute.

11) Tape NG, ET tube, foley in place.

12) Tape patients wig or toupee in place.

13) Never lose it again: tape you pen, scissors, roll of tape, stethoscope to yourself.

14) Make letters RN on uniform so patients will know you are their nurse. You know how everybody gets confused...

15) Afraid your patient might wander off? Put their name on it, room number and attach to gown.

16) Cheap shoulder immobilizer.

17) Confused grandma will never pull out her IV again.

18) Tape your nostrils together for that smelly clean up

19) Cheap eye patch.

20)  Patient has hyperactive kid that keeps running around.  Tape to wall (see picture).

21) Duct tape educator to chair - no more of those irritating online quarterly education classes.

22) Patient keeps coughing in your face, won't cover their mouth - use as a mask.  Hey relax...they can still breathe out of their nose...

23) Doctor order an enema?  Duct tape them out at the triage window.

24)  Never get lunch? Tape a snack to yourself.  Tape a water bottle to yourself.

25) Tape the ER entrance shut when you get too busy.

26) Tape the annoying family member/friend to their chair so they won't stand at the door looking annoyed when the visit drags on and on....

27) Cheap alternative to restraints.

28) Tape OCD/candy man/overordering  doctor to chair. 

29)  Tape the clipboard carriers into their cubicles sans computer so they can't come up with more annoying new policies.

30) Cheap hazmat suit.

31) Hold JCAHO/CMS/Department of Health, chest pain/stroke/magnet/any assinine certifier hostage at least til the end of your shift...

Your thoughts?

Saturday, November 15, 2014

California mandates full body suits and respirators for HCWs taking care of ebola patients

Here's an interesting development: The state of California has mandated new regulations about ebola training and PPE gear for hospitals.

It requires full body protective suits that leave no skin exposed or unprotected. It also requires respirators. It is mandatory for hospitals along with training.

This is quite an accomplishment for the California nurses union.  Last week 18,000 nurses in California were on strike around contract negotiations as well as what they said were inadequate equipment to care for potential ebola patients.

Actually the respirator part of this makes a lot of sense. It actually could prevent HCWs from getting ebola.  If you don't have to wear a mask but instead have a respirator, it will be a lot more comfortable. You will be able to spend a lot more time in the suit. This would mean less nurses rotating into the room and having to don and doff the equipment. With the current equipment, wearing the mask and all the other stuff, I don't see how you could do this for more than an hour or two, requiring multiple donning and doffing in a shift and more potential for contamination.

What people don't realize is that the four hospitals with biocontainment units in the US use this equipment to care for any patients they have. Supposedly these people are experts in this area.  So why the disparity between what they wear and what an average nurse in the US is supposed to wear?

I can guarantee you that most hospitals will not adopt this. Too expensive. They will play the odds that they will never get an ebola patient.

One other thing California has included in the regulation is a whisteblower section. It guarantees that health care workers won't lose their jobs if they report non compliance. Employers are VERY sensitive about their preparations for ebola. I have found that if you bring up any kind of concern about their preparation, they immediately jump on it and go to lengths to explain why you are wrong.

Friday, November 14, 2014

sometimes triage is a cesspool

The triage lobby is a weird place.  Its like a  dysfunctional little community out there.  Sometimes it takes on a life of its own.

There can be children running in circles around the lobby.  Drama queens loudly telling their tales of woe so everybody knows the details.  It can be a scary place with scary looking people.  Maniacal laughing, weeping,  Angry exchanges. Wailing children.  Stinky people.  People vomitting.  Thats Penny the prostitue sitting next to Clara from the suburbs who is sitting next to the homeless guy who hasn't had a bath in a few months. Sometimes you have no choice who you sit next to. People chow down on entire meals out there. People fall asleep. People pace.  Its a cesspool of the human condition.  You never know what your gonna get.

Different days have different atmospheres.  Some days its quiet.  You could hear a pin drop.  Other times its a dull roar of different conversations.  People talk to people they don't know.  Tell their stories.  Some days it feels like they are conspiring against us.  I see them looking at us. They are fomenting revolution, coming for us, I just know it....har.  Some days people are angry.  The wait has been long. They hate us.

When the wait has been long, one them finally has had enough, they approach the desk and ask: "How much longer will it be?  Where am I in the line?"  They tell us they are feeling faint, etc. They have to get to work.  Grandma is in a lot of pain.  They ask that age old triage question: "Why are other people going ahead of me?".  They are never  satisfied with our answers.  Its not what they want to hear. They may get mad, cuss a little bite, roll their eyes.  Sometimes they leave, deciding they aren't an emergency after all.  Most sit back down.  Here's the thing we know: Now they have done it.  They have given permission to all the other people in the lobby to make a pilgrimage to the triage window.  Now they are all mad together. Sending disgusting looks our way.  It gets to a fever pitch, about to explode.  Then the triage door opens, I say: "Fancy Parker, you're the next contestant...".  The tension is broken.   For now....

Wednesday, November 12, 2014

which ER supplies the softest, most cuddly and toasty warm blankie?

I'm thinking about starting a new local ER website. As a service to humanity.

On this site would be listings of every ER in the city and the waiting times on their websites. Listed in order of least waiting time to most. Length of typical visit.

In the interest of serving the community, there would be a list of whether the ER has:

1) box or bag lunches and their contents and rotation
2) types of (cold, icy) juice and selection of crackers
3) whether they supply warm, cuddly, toasty blankets.
4) footie availability and color selection
5) whether they have TV (with HDTV cable or DVD availibility)
6) probability of getting a cab voucher or bus token
7) probability of you scoring a script for percocet
8) probability of you taking an ambulance in for a sore throat and getting back to a room versus being put in the lobby
9) comfort of chairs in lobby and presence of TV, fish tank, vending machines (quality of snacks, selection of sodas), play area
10) whether your car can be valet parked on arrival

There would be a comment section in which you could name names about which docs at which ERs were Dr Feelgoods.

Oh the fun that could be had! The comments section could be entertaining in and of itself.

Hey...its a competitive world out there and patient satisfaction is the goal of every single solitary person in the ER, including of course, yours truly, thus 

Tuesday, November 11, 2014

donning and doffing madness

So we are finally donning and doffing at my hospital.  We are training with all the stuff we would wear when caring for an ebola patient.

Putting it on isn't hard. Its about covering everything and having someone check to see that you have.
Taking it off is a whole other ballgame.  After taking it off, I can't believe that 75% of the people caring for those with ebola haven't got it.

To say there are a lot of steps is to understate it. At my hospital there are 8 parts of the gear:

hospital scrubs
face shield
mask shoe and leg covers
two pairs of gloves

Here are the steps to take it off:

1) you and buddy go to dirty area
2) clean hands (foam)
3) look for any obviously nasty stuff on garments and clean them off
4) foam hands
5) take off shoe/leg covers
6) foam hands
7) take off apron
8) foam hands
9) look for any nasty stuff on garments and clean them off
10) foam hands
11) take off face shield
12) foam hands
13) take off hood
14) foam hands
15) take off outer gloves
16) foam hands
17) take off gown
18) foam hands
19) use wipe to clean shoes
20) foam hands
21) take off inner gloves
22) foam hands
23) put on new gloves
24) foam hands
25) take off mask
26) foam hands
27) take off gloves
28) take shower

Takes 15 to 20 minutes to doff. Most likely place to make a mistake: taking gloves off, in my opinion.

The idea is that there will be two nurses caring for the patient. One in the room who doesn't leave except for breaks. The other is a runner, who gets what the nurse needs.

The nurse in the room will have on all the gear and an N95 mask for hours on end. Not sure how thats possible.

The people working at the centers that have been designated for caring for highly contagious patients in such places as Nebraska and Atlanta wear different gear. Theirs come in less pieces.. They wear an actual respirator. There are nurses around the country who think this what is needed.

Monday, November 10, 2014

certify this shit head

I can't take it anymore. I can't take another CMS or Joint Commission "surprise" visit. Or the Department of Health either.

I don't give two shits whether the hospital is a certified  bariatric center, chest pain center, stroke center.

I am tired of advanced cardiac life support, basic cardiac life support, each of which I have taken at least ten times. PALS, TNCC arggggh.

Every quarter there are 10-15 education things online that we are supposed to complete at work or at home.

I don't want to learn take a class about de-escalation techniques and how to restrain a patient for 8 hours once a year.

It is getting to the point where we as nurses are overwhelmed with needing to be ready to be interviewed by agencies and credentialing centers or we are doing  hours of education ALL THE TIME. It is becoming overwhelming. I'm burned out on it.

Does all of this really help patient care, or does it fill a box someplace in some office housing another useless paper pusher and justify their job?

If I am going to be required to constantly be doing all of the above, I want more than a 1% raisee a year, which is what it averages out to in the last 6 years. I am tired of being grateful I have a job, being understanding about decreased reimbursement, blah blah blah. I want  money for all of this.   M-O-N-E-Y.

Tomorrow 18,000 nurses in California will strike for 2 days because of an unsettled contract and for safety equipment for caring for ebola patients. I wish them well and support them 100%  More nurses need to get off theiir butts and do the same.

Sunday, November 09, 2014

Battered ER Nurse Syndome

Being an emergency room nurse is like being in an abusive relationship.  You go to work and are subjected to verbal and sometimes physical abuse.  The conditions are sometimes so bad that you tell yourself this is it...I have had enough.  I am getting out.

Then you have a few days off and you talk yourself into going back.  Oh, its not so bad. What other job can I have several days off in a row? That was just one of those AWFUL days. I like my co workers. What else am I gonna do?

So you go back, having refreshed yourself a little bit. Then the of your patients calls you a motherfucker....that drunk pees on the floor....that snotty woman in room 6 puts her light on for the 5th time
in the last hour.  You can't believe that you thought this was okay. You look at the clock, thinking about how you are gonna make it through the rest of the shift. You do. You go home.



You have a case of Battered ER Nurse Syndrome, my friend.

Thursday, November 06, 2014

Margaret the agitated, hallucinating schizophrenic visits the emergency room

She was seen talking to herself, minding her own business. I'm sure she talks to herself all the time, she is mentally ill. This is her daily life.

The police were called because she was talking to herself and making people uncomfortable. Of course she was confused. Police called ambulance. Ambulance brought her to us of course.

She was confused and agitated when they took her in the ambulance. So they restrained her. She arrived in restraints and on a hold.

When she arrived, we debated whether to keep the restraints on.  Here's the thing: she weighed 300 pounds. If she got out of control, somebody could get hurt. Decided to keep two restraints on. She went to the bathroom soon after arrival.  Spent too much time in there until I had to make her get out. Went back to the room and started pacing the room. After 15 minutes of asking her to lay down, she finally did.

OK, whew, at least she is under control.  Security on watch. Let me start the restraint paperwork which means charting about 15 things every 15 minutes.

She continued to be agitated, trying to get up.Security and I spent lots of time trying to redirect her.  I could tell she was in her own little world, talking to at least three other people. Eventually, I gave
her meds, not sedatives, anti psychotics. Didn't work.  Finally talked the doctor into something to sedate her. She calmed down some. I took the restraints off.

She went to sleep. When she woke up, she would pace the room, try to walk out the door.

Of course, she would be admitted for about the 4th time in the last 6 months. Here's the thing: no beds available at our hospital.  Getting a psych bed at our hospital is impossible these days. Of course there were no other psych beds in the city either. They were looking at a bed two hours away.

When Iest 12 hours later, she was still there, up walking back and forth in the room. She'll probably be there in the morning, pacing and talking to herself. This is the lot of mental health patients in emergency departments these days, waiting hours and hours, sometimes days for nonexistent beds.

Wednesday, November 05, 2014

more education = more money

Hospital jobs are increasingly calling for a bachelors degree in nursing.  At least where I live. I think its a good idea. If nurses want to be taken seriously we have to have the education. I am not saying that two year nurses aren't very good nurses. They are.  Nursing is increasingly complex and if we want to keep our place in it, we have to keep up.

BTW, I am a 2 year nurse.

So if nursing is going to a bachelors degree standard, then it makes sense that nurses should be making more money. If you have more education you make more money.  Right now bachelors degree nurses make about 1.50 more an hour where work.  One fifty an hour for two more years of school, two more years of debt. Hardly worth it.

When you have more knowledge you make more money. There are many studies on how people with educations make more money than those who have none. From what I have seen those with a bachelors degree make about 1/3 more than those with an associates degree.  So lets say the average salary in the US for nurses is 65,000 with a combination of associate, diploma and BSN workforce. . The bachelor degree nurses should be making at least 20,000 dollars more than the associate degree or diploma nurses. Now that would be an incentive to further your education.


Tuesday, November 04, 2014

no ebola training at my hospital yet

No full coverage isolation gear or mandatory training  yet at my hospital. Keep saying they are going to do it.

Monday, November 03, 2014

ebola can be fun

Here is a video parody about ebola by one of my favorite docs in the world: ZDoggMD:

how I became a bitch

This is a post I did about a month ago.  It was viewed over 23,000 times. It definietly struck a nerve. It got 160 comments. The comments were mixed with a lot of people agreeing with what I said and many saying I should get out of nursing. So here it is again. What do you think?

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.