The things we do...

OK, our management has finally decided that there has been a big issue since we have moved into our new ER, namely nurses are disappearing faster than than free food left in the break room. And not just the new nurses either. Nurses that have worked 10+ and 20+ years in our ER have and are leaving. Some of the reasons I have posted in previous blogs.

Which brings us to their solution. Let's pay incentive. They are offering 6.25 extra an hour for each additional shift picked up along with a 500 bonus if you work 60 extra hours in a 6 week period. Oh, they get us where it hurts! They know most nurses will not turn down an incentive like that. So for 6 weeks, we might be fully staffed, although it will be with tired, overworked, grumpy nurses. And the clincher is that you will lose everything if you call in even 1 day. So our call ins will go down as well.

But I have been doing the math here, pretaxes, I will only make an extra 875, and the OT. Now my OT is pretty good, but I would rather make it in a less stressful department, i.e in my old unit. There they pay 75 for a 8 hour or less shift and 125 for a 8 hour or more shift, straight up, this averages to somewhere around 10 more an hour. Now they are not offering the 500 dollar incentive for 60 hours in 6 weeks, but as for straight up overtime, you can not beat it. I have 2 and only 2 patients, the same 2 patients all night long. And these patients are either intubated, recovering from open heart surgery or both, so they do not whine very much and are very appreciative. It is a strictly nurses run unit at night, we have a practitioner that handles all of the problems that we cant (which are few and far between, we are expected to be able to handle pretty much anything), she calls the MD if she cant handle it. We can eat at the nurses desk. we have the radio playing in the background. We surf the web when we are not busy. We carry morphine and syringes in our pockets with out "the joint" Nazis making a scene, We have techs that stock and check off crash carts and do all of those non patient care things that we are required to do in the ER, every last one of our patients is truly sick, it is heaven.

BUT.... i am a trauma junkie. I love it. There is no rush like the rush you get from a GSW or bringing back a car crash victim that has coded on scene, or a full arrest that actually makes it, not just a rhythm, but with full function. Or a stroke that get tPa'd and you start seeing them regain what they had lost a few hours before. A heart attack that survives because they get to the cath lab in less than 20 minutes and the blockage is removed. I like never knowing what is going to come through the door next.

I love my people in the ER, quirkiness reigns. Not just anyone can work there. It is also the only place I have seen where the docs and nurses work like a true team. Even in my small unit with 4 docs, it just isn't the same. Our ER docs have our backs, and we have theirs. We hang out after work, we know each others families, we celebrate birthdays, life and death. We drown our weekend sorrows on Monday mornings in margaritas with each other at 0700. We laugh over the stupidity of patients and each other and cry over the defeats. We tell dirty jokes, are inappropriate, and the lot of us could be the poster children for sexual harassment and how not to be politically correct.

I guess i am pulling my extras in the ER the next few weeks. Single parent with Christmas just around the corner, can't look a gift horse in the mouth. I just wish management would come up with a longer lasting plan, ie hire more people, more support staff, and slow down the flow. Wait for my bed to be clean and dry before you throw a 21 year old on it whose "emergency" is a cut left pinkie toe. Waiting 10 more minutes so I can chart, pee, or drink something will not make this guy die. I will probably be shooting myself in the foot come next month, but oh well, I start next week on my extras. Pray for me.

Weekends Suck

My weekend seemed to have "theme nights" all weekend long. I worked with the same doc all weekend and he is one of my favorites, so that is probably the only reason I did not sign myself in under Sunday night's theme. On Friday night, we were like trauma central. 8 level 2s, 4 level 1s, including 2 peds, 2 trauma arrests, including 1 ped. That is my kinda ER night, we were humping all night long, but I actually felt I did some good in the world. We also had 1 heart alert (our jargon for a heart attack that needs to go to the cath lab), a stroke alert, 2 full arrests and a head bleed that turned into a full arrest. I also think there was 4 intubations. For the first time in a long time I felt like I was doing true emergency medicine and not free clinic work.



Then on to Saturday night. That was the march of the vaginas night. And, of course, all of the male nurses in my department were on my end, so I ended up being tootie girl all night. I think I did 9-10 pelvics with the doc that shift. I felt like I needed some kinda symbol like batman, except it would be a kinda inverted leg symbol for them to flash when they needed me and I would come with speculum and swabs in hand, rolling the pelvic cart. I have a theory about pelvics and the weekend that has to do with a long, wild night on the town, followed by regret and fear, and winding up in the ER, because 2-4 am is consistently tootie hour. You can bet on any given night between those hours, there will be at least 1\3 of the patients out there females complaining of lower abdominal pain and\or vaginal bleeding.



Sunday night, this was, the loony bin let everyone out with weekend passes and they wound up in our ER. Over half of the patients on our end that night were psych evals, and every single patient I had was a psych eval, save 2 traumas. And these were not run of the mill psych evals either. These were scary crazies. 1 one mine had beat up 5 cops, while in handcuffs, sprayed 4 times with pepper spray and tasered 5 times, I am not exaggerating one bit. I also think I forgot to mention that he was about 6' 5 and weighed no less than 350. the only good thing about this guy, was he seemed to like the nurses, so he ended up not being too bad, until he would catch sight of the security guard that was posted at his room, then he would go ballistic again. the worst thing about our new ER and psych patients is that we no longer have a psych eval room, so we have to pull everything out of the room before putting the patient in it. This gets tiresome, and crowded when over half of the patients are there for psych evals and so your hallway is full of stuff from all of the rooms. The other bad thing was I had an attempted suicide placed in a room that was not visible from the nursing desk, so until she went upstairs, I practically had to hang out right by her room, so nothing could happen. I am so glad the weekend is over!!!

Selected pics that remind me of some of my favorite bloggers

ERNursey, letting you know all ER nurses feel how you do.....

Scalpel, for your cat fetishes and your bucking the system personality.....




The Docs over at MDOD, to counteract the antidarwiniasm of medicine....



Whitecoat rants- maybe your ED of the future could include this for pain management....





Monkeygirl, cause she loves her Pirates....




CharityDoc, here's hoping you stop procrastinating and start back blogging.....





Nurse K, this just reminded me of the Speaker, and we all know how tight yall are.....






And I am probably going to hell for this one, but it was so funny I couldn't resist it.

Lawyer Bloopers

Here are some attorney bloopers that put the chart bloopers to shame...

These are from a book called Disorder in the American Courts, and are things people actually said in court, word for word, taken down and now published by court reporters that had the torment of staying calm while these exchanges were actually taking place.

ATTORNEY: What was the first thing your husband said to you that morning?
WITNESS: He said, "Where am I, Cathy?"
ATTORNEY: And why did that upset you?
WITNESS: My name is Susan!
____________________________________________
ATTORNEY: What gear were you in at the moment of the impact?
WITNESS: Gucci sweats and Reeboks.
____________________________________________
ATTORNEY: Are you sexually active?
WITNESS: No, I just lie there.
____________________________________________
ATTORNEY: This myasthenia gravis, does it affect your memory at all?
WITNESS: Yes.
ATTORNEY: And in what ways does it affect your memory?
WITNESS: I forget.
ATTORNEY: You forget? Can you give us an example of something you forgot?
___________________________________________
ATTORNEY: Do you know if your daughter has ever been involved in voodoo?
WITNESS: We both do.
ATTORNEY: Voodoo?
WITNESS: We do.
ATTORNEY: You do?
WITNESS: Yes, voodoo.
____________________________________________
ATTORNEY: Now doctor, isn't it true that when a person dies in his sleep, he doesn't know about it until the next morning?
WITNESS: Did you actually pass the bar exam?
____________________________________
ATTORNEY: The youngest son, the twenty-year-old, how old is he?
WITNESS: Uh, he's twenty.
___________________________________________
ATTORNEY: Were you present when your picture was taken?
WITNESS: Are you shitt'in me?
_________________________________________
ATTORNEY: So the date of conception (of the baby) was August 8th?
WITNESS: Yes.
ATTORNEY: And what were you doing at that time?
WITNESS: Uh.... I was gett'in laid!
___________________________________________
ATTORNEY: She had three children, right?
WITNESS: Yes.
ATTORNEY: How many were boys?
WITNESS: None.
ATTORNEY: Were there any girls?
WITNESS: Are you shitt'in me? Your Honor, I think I need a different attorney. Can I get a new attorney?
____________________________________________
ATTORNEY: How was your first marriage terminated?
WITNESS: By death.
ATTORNEY: And by whose death was it terminated?
WITNESS: Now whose death do you suppose terminated it?
____________________________________________
ATTORNEY: Can you describe the individual?
WITNESS: He was about medium height and had a beard.
ATTORNEY: Was this a male or a female?
WITNESS: Guess.
_____________________________________
ATTORNEY: Is your appearance here this morning pursuant to a deposition notice which I sent to your attorney?
WITNESS: No, this is how I dress when I go to work.
______________________________________
ATTORNEY: Doctor, how many of your autopsies have you performed on dead people?WITNESS: All my autopsies are performed on dead people. Would you like to rephrase that?_________________________________________
ATTORNEY: ALL your responses MUST be oral, OK? What school did you go to?
WITNESS: Oral.
_________________________________________
ATTORNEY: Do you recall the time that you examined the body?
WITNESS: The autopsy started around 8:30 p.m.
ATTORNEY: And Mr. Denton was dead at the time?
WITNESS: No, he was sitting on the table wondering why I was doing an autopsy on him!____________________________________________
ATTORNEY: Are you qualified to give a urine sample?
WITNESS: Huh....are you qualified to ask that question?______________________________________
And the best for last:

ATTORNEY: Doctor, before you performed the autopsy, did you check for a pulse?
WITNESS: No.
ATTORNEY: Did you check for blood pressure?
WITNESS: No.
ATTORNEY: Did you check for breathing?
WITNESS: No.
ATTORNEY: So, then it is possible that the patient was alive when you began the autopsy?WITNESS: No.
ATTORNEY: How can you be so sure, Doctor?
WITNESS: Because his brain was sitting on my desk in a jar.
ATTORNEY: I see, but could the patient have still been alive, nevertheless?
WITNESS: Yes, it is possible that he could have been alive and practicing law

Layperson CPR

I used to think that the more people who knew CPR, the better off we would be as a population, until last night. Had a call from EMS that stated they were bringing in a patient that had received bystander CPR, patient had a oulse and had in fact never appeared to lose one, vital signs were stable. Pt was complaining of chest pain. Apparently, Papa had passed out drunk in the floor, and Mama and son, got scared and immediately started into CPR, WITHOUT FIRST FEELING FOR A PULSE. So as they were going to town on chest compressions (they had to be doing very adequately, the patient had 3 cracked ribs), the patient awakens from his drunken stupor and starts swinging. Ems arrives to see the son on the dad doing chest compressions, and about 30 seconds later, the dad startwildly cussing snd swinging. Only injuries noted was a very bruised sternum that extended to the left side and 3 cracked ribs. And we could not get the family to understand that they in fact DID NOT save their dad's lofe. They were bragging to everyone that once CPR started, the dad awakened quickly, hmmm, wonder why?

I Love This Game!

This is one of the things i love about college football, especially in my favorite conference, the SEC. You have Kentucky and South Carolina with undefeated records right now, these two teams are usually near the bottom of the East(although granted the gamecocks now have the one of the best coaches ever in college football so they were expected to improve), with Vanderbilt having a winning record at 2-1. The "powerhouses" of the east, Tennessee and Georgia both have losing conference records(0-1), while Tennessee just has a losing record(2-1)and has fallen out of the top 25(oh it kills me so....). Florida is sitting at the top, which even though they won the BCS last year, it was not believed that their offense or defense would hold up this year.

Now onto the West. Alabama which was not even ranked preseason, is top of the conference, with LSU right behind. (Al has played more conference games than LSU presently). LSU has arguably the best team in college football this year. Mississippi State beat Auburn, who was previously ranked fairly high in the polls. Arkansas and Auburn both have shown disappointments. About the only team who has not surprised anyone, as of yet, is Mississippi.

Unless you have lived in the South, I do not believe anyone truly understands the deep significance it plays in our lives. ERs and stores are ghost towns, college towns populations quadruple, RV's park outside of stadiums, long road trips are planned to away games, weddings and other important things are scheduled around ball games. Teams can go all season long losing and as long as they beat their rivals, the season is salvaged (Alabama and Auburn, Tennessee and Florida, Mississippi state and Mississippi, etc) or vice versa, you can win all year long and if you do not beat your rival, all those other wins are insignificant. Everyone replays all of the games the next day in great detail, everyone becomes a football expert. Bragging rights are held all year long to the winner. It is the strongest conference hands down,our weakest teams can hang with any team in any other conference and can beat most, maybe not the conference champs, but usually the second or third teams. There are no easy conference games for anyone.

How can anyone not love college football?

Never Expected This...

Had an unresponsive drunk 18 year old brought in frantically by his parents. We are cutting of his clothes, putting him on the monitor starting IVs, cathing him etc, all the stuff we do in this situation. Sats and vital signs are fine, but this guy is not responding. Not with the 14 gauge IV stick, not even with the Foley insertion. The ICU nurse in me kicks in and I start doing all of the mean things to elicit a response. Now you should know that I am the nurse that people come to get when they have an unresponsive patient because I can usually make ANYONE respond to pain. I am very vigorous at eliciting response to painful stimuli. Quotes one nurse I work with, "If I am ever brought in unresponsive, don't let bohica near my room". Now before you go thinking I am some kind of sadist that gets off on people's pain, this is so not true. I am trying my hardest to truly assess a patients neuro status. I don't just jump right in with the vigorous sternal rubs and nipple twists, but do get there if nothing else elicits a response and if those do not work, I will do nail bed rolls. Back to the story. So this guy does not even flinch on Foley insertion, which tells me 1. he is not faking 2. he is really close to comatose. Now I am not wanting to intubate this patient if at all possible so I give him a sternal rub and I get a little twitch of the mouth. I proceed to do a nipple twist, and what does this drunk guy do? He smiles, rolls his eyes,moans and has experienced a sudden rush of blood flow to a certain medial lower organ. The doc and I had to run out of the room and died in a fit of laughter.

Newer does not equal better

We have remodeled and built a new ER. Apparently this has been in the works for years and "a lot of thought, planning, nurses, doctors, techs, RT's and patients advise went into planning this ER." Well, we have now learned that apparently not enough of these things went into it. Some issues:

1. If you build it, they will come. Especially if as part of your PR campaign you get on all the local news stations bragging about how much more efficient and how much shorter the wait times will be. We saw double the patients last month than we did the month before and since this is still a work in progress, it also doubled the wait time.

2. Less beds equal longer wait. Even if it is only 2 less beds. Especially when your fast track area,which used to have 10 beds now only has 2. and especially when you used to have 6 less beds that are open all night long than previously.

3. Heavier work loads equal less efficiency. In our old set up, we tried to put our more critical patients on the end with 6 nurses all with a 1:2 ratio and maybe a hall patient (or 6). In the new place, there are only 2 nurses period that have a 1:2 ratio, and critical patients everywhere. This leaves all nurses busy and unable to help out each other because we are all drowning, especially since we really don't have the staff to have the built in extras, i.e 3 float nurses to help out, and God forbid we close beds.

4. Location, location, location. We are further away form the OR, radiology and 85% of the rest of the hospital, making transport suck. Also much further away form the important tings like the cafeteria, corner store, parking deck, and smoke deck(for those who utilize this).

5. Call lights on the remote control. I do not know what idiot thought this up, but there are 2 buttons on our remotes. One is for the TV (it turns it on and changes the channel) and one if the nurses call light. Inevitably 22 calls an hour are because a patient thought that the button with the little picture of the nurse was the down channel button.

6. Floor plan. While in theory it is super nice to have a huge amount of vastly open space and not be crowded over one another, it sucks to have to walk all over creation to get what you need or go where you need to go. On top of this, only a hand full of rooms are visible from the nurses desk, so you can not keep an eye on all of your patients while charting or talking to the doctor. also, the doctor's rooms are as far away from the nurses desk as imaginable, which irked the doctors and nurses both, we have to travel to ask them questions and they have to travel to have orders put in and so forth, so usually, the doc ends up staying at the nurses desk, which is too small to begin with and traveling to their office to look at xrays and stuff, cause apparently, nurses are not allowed in the docs office, although no one, doc or nurse,is really sure who came up with that rule and why. The blanket warmers are located just about as far from the trauma areas as possible. And most of the supplies are as far from all the rooms as possible and we still are not quite sure between the three supply rooms what is stored where.

7. No break rooms. Except for the doctors and it is outside of the actual er, and I don't know any of them who utilize it except for a coat closet, contrast it with the nurses "break room" which i swear my walk in closet is bigger than, that has one chair, a mini fridge and a microwave. and since these"break rooms" are attached to the nurses desks, we are no longer allowed to have drinks at the desk, yet we can not do any of our actual work in the break room, so we just stay less hydrated, which I guess works out since we do not have time to pee.

8. No reports from ambulances. This is not exactly true, but the nurse who used to get the patient would take the ambulance report. Now one nurse is assigned to take all the reports and make the bed assignments. Since we can not see all the rooms, there is no definite way of knowing when an ambulance or patient is coming, especially if an enterprising doctor goes to see the patient before you do and the chart gets placed in the orders rack, which you are not looking in because you have no reason to have orders because you thought you had no patients.

9. Nursing staff leaving in droves. For various reasons. When we had a section that was strictly designated for non emergency Dr office type stuff, everyone was more or less happy. Those nurses who loved that kinda thing signed up to work there and whose of us who would rather hammer nails under our toenail beds and run a mile than to take care of those type patients, were mostly spared of the majority of these patients. Now, you have people complaining because they have not done real emergency medicine in years and having to take critical patients and people complaining because they do not like to take care of people who need to go to a walk in clinic. We are understaffed and overworked, which means more people leave which makes us even more understaffed and overworked. Patients are unhappy because of the wait, nurses are unhappy because they are exhausted and the docs are unhappy because they are overworked.

10. No support. There have been numerous meetings and committees and all other kinds of bureaucracies, but nothing appears to be changing. if it is it is at too slow a speed to even notice and by the time they fix it, they will not have any employees left.

I feel a little better at venting. Some things just makes me wonder if the higher you climb up a corporate ladder in the healthcare industry if you don't have to sacrifice half of your common sense for each rung climbed. What exactly do they not understand about unhappy nurses=no nurses=no hospital?

drug seekers

Since the cool thing to do seems to talk about those who use the ER to get their pain med fixes, and people are telling their, you will never believe what happened stories, I, being the little follower puppet I am, am going to share with yall the patient that pushed me from the naive little nurse I was to the jaded veteran I am (haha). It was a relatively slow night in our er. At about 1130, a patient comes via ems "fully packaged", i.e. cervical collar, backboard, the whole enchilada. I am getting report as we are putting this patient on the bed and the EMT tells me that they picked this patient up, who was with a sibling, because a door had come off of its hinges and hit this patient in the head. Ummm, ok, why fully packaged? The sibling demanded it. The sibling comes in with the patient in one of those soft cervical neck collars that looks like a sock full of rice. Mind you, I could have fit my neck in with his neck, the thing was so loose. The sibling starts talking about the reason he made them keep the patient on a backboard is because he has a bad neck problem and he knows the damage that could be done to his siblings neck permanently. The sibling keeps going on and on about his "disability".

I turn to assess my real patient and the first thing I notice is that there is a hospital emergency id band on the right wrist, from the hospital not even 2 miles up the road. I ask the patient about it, and the patient tells me that the hospital staff was mean and rude to them, even talked bad about their shoes! I get the rest of this patient's history, chronic fatigue, appendectomy, spleenectomy, migraines, degenerative disc disease, and, I kid you not, pancreaectomy(did I spell that right?) This patient is also allergic to everything under the sun and tells me that due to not having a pancreas, they can not take any PO meds, it makes them way too nauseous. This patient wanted me to believe that there is no longer a pancreas in their body! That is just to give you a taste of how crazy this patient is. I just happen to know a coupla nurses that work over at the other hospital's er, being a semi small town, the nurses sometimes work at both places, and I decide to give them a call.

Before I call I read the ambulance report and almost cry trying to keep from laughing. Apparently the patient was picked up two blocks from the other hospital at a gas station in the back of the taxicab. So, our medic had to get the patient from a seated position onto a backboard and secure c-spine....hmmmm. So once I recover i call one of my colleagues at the other hospital. They tell me, unofficially of course, that the same story was given to them, they did ct and xrays, everything was clear. They were about to give PO pain meds when the patient started going on and on about how because of the pancreas being removed, they are unable to take PO pain meds, they need a shot. Well that hospital has more balls than ours, they held their ground, and apparently, the patient ripped off the c-collar, and stomped out with the sibling trailing behind. The nurse also throws in the bonus that they have both been trespassed in the past at their hospital. If I can get the patient to sign a release, they would be more than happy to fax us their copies, bonus is that our radiologists are the ones that read that hospitals ct and xrays overnight.

So my mission was to get this patient to sign a medical release form, which I knew from prior experiences was not going to be easy. What did I do? I merely told the patient that high doses of radiation can be harmful, especially with as many medical problems as the patient has, so instead of repeating the studies that were completed at the other hospital if you sign this, we can just get their studies and not have to expose you to more radiation, which could cause your leukemias to act up. The patient replied "you know what, you are absolutely right." So I got the signature and faxed it to the other hospital.

I give the doctor the heads up about what is going on, and let the doc know that the fax was coming back. While awaiting the fax, my patient's sibling has disappeared. My house supervisor calls me laughing so hard he can barely talk and tells me to look at our security cameras. I look in the lobby and lo and behold, but who do I see, the sibling sitting out there, rolling his head back and forth in that ragged soft collar, it really did look ridiculous. Then I stop laughing because I see that the sibling has signed himself in for neck pain. Ohhh, boy.

About then, our night got bad, real bad. One of our own comes in unresponsive with a huge lac to the back of the head and no one knows what happened. Ends up having a huge subdural with a shift and must go to have an emergency craniotomy. So that takes up a long time. When I leave that room, I see my patient up in the room walking around (the doctor has not had a chance to see them yet), going to the side of the bed and grabbing the c collar off of the floor. I ask what was going on. apparently my patient got tired of lying on the back board and getting told that the doctor must see them before any meds could be given and the backboard got flung across the room. Our lovely tech just went in and set it up against the wall, told the patient there was a trauma and the doc would be in as soon as possible, all calm like. Apparently next, the patient ripped off the c collar and flung it too, this was largely ignored by all involved. So I was coming out of the trauma and witness my patient walk over to the side of the bed, pick the c collar off of the ground and out it back on, upside down and sideways.

I nonchalantly walk into the room and apologise about the wait, tell the patient that they are next to be seen. The patient then proceeds to tell me that the neck brace isn't feeling quite right, could I fix it? Keeping a straight face and playing the game, I put the collar back on right, though my nurses notes clearly show the real picture.

I feel I have done my civic duty by giving our doc all they need to treat and street this person. But to my utter dismay, we repeat all the studies and we have ordered 1mg of dilaudid! i am so mad I can spit. I go in there and am about to start the IV when the patient informs me that they have a port a cath. I ask the patient why they have a port. This patient proceeds to tell me that their family practice doc knows what small veins they have and if they are ever in a wreck or anything and needs an emergency transfusion, they need something that can be accessed. I am standing there utterly flabbergasted. I want this docs name to yank his license. I have never heard such bull in my life! That is what central lines are for, we would never resuscitate someone with a port anyways, the gauge is too small.

End of the story, patient got dilaudid and phenergan, everything was stone cold normal. C/O 8\10 pain on discharge, doc ordered a Lortab which the patient took without regards to the missing pancreas, didn't even bring it up and was surprisingly spry springing out the door with sibling who was not as lucky and got the a doc that does not believe in handing out candy to keep the pilgrims happy, his motto? If you feed them, they will come.....

Children in the ER

Here is yet another thing I can not comprehend about some people. Our ER has instiituted a new "family friendly" policy that allows children to come back to see patients. Prior to last week, if at all possible, we really stressed that children be at least 14 before coming back. I say if at all possible, because we do get patients that come in with there children and no one to watch them, so of course, the children have to come back with the patient. I have some issues with this policy. First off, there is no reason for children to be in our ER. Our hospital has a pediatric ER, the only children we get are level 1 traumas, all others go to the other ER. This being said, our ER is not child friendly. It is a big, scary place, It scares me most days. We have crazies, people with appendages hanging off, people with tubes coming out of every orifice imaginable, beeping noises everywhere, traumas and full arrests coming in through the middle of the hallway, etc. Not too mention, the ER is where sick people come. There are the worst imaginable germs, EVERYWHERE. About the only other place I can think of that might have more germs is in an ICU that keeps septic people all the time. I am all for sick people being able to see their kids and grandkids and nieces and nephews. I think that more visitors speeds the road to recovery. The ER, however, is a place where (hopefully), the patient will not be for too long. Hopefully, we will get the patient stabilized and treated and either discharged, to a room or the ICU. Then, as long as the patient is on the floor, for the most part, family members can throw a reunion if they want to, with hardly any interference from the nursing staff, esp if you share the food. I say all this because the other night while working, I had 4 different patients' family members bring in young children. When I say young, 2 of these children were less than 3 weeks old, 1 was 18 months and the other probably about 6-7 months. The children were well behaved, in fact being it was between midnight and 230 when these patients were here, most of them spent the visit sleeping. Now I understand that they were worried about their family members who were rushed into the ER by ambulance, but there is NO WAY I would even consider bringing my newborn to our ER. I didn't even take my newborn to walmart or church or anywhere else for that matter, until they were 6 weeks old and had their beginning immunizations. As for older children, well some of the images I see stick with me and give me nightmares, what about a 7 or 8 year old? I just don't think any good can come out of children being able to visit in the ER. Oh, the funny part about the 4 family members? The patients themselves are were discharged to home within 4 hours of their arrival.

College Football Here at Last!

I am a HUGE college football fan and I am tickled pink to have watched my first official game of the year, hate that MSU got blown out, wish it was a better game, but it was at least a college football game and an SEC game at that! Bring on the sleepless saturdays, (I work every Fri and Sat night), BBQ, chips and cheesy fight songs, too bad Lee Corso has to be in on the deal too. Still, I can not wait until Saturday.

Crack Kills?

I had my first official train wreck a few nights ago. Now when I said train wreck in my old unit, it was a patient that was sick as all get out, on all types of pressors, intubated and circling the drain with a thousand comorbidities and septic. Not here in the good ol' ER. I had an actual train wreck. Gentleman fell asleep on the tracks, was hit by the train and thrown approximately 40 feet into a concrete abuttment. Our good folks at ems gave us the heads up as they were bringing in other patients, medic 4 is working a pedestrian vs train. I slowly set up my trauma room, really not expecting to get this patient, I mean dude was hit by a train and thrown. After 30 minutes, I was about to go grab a bite to eat, really thinking that this was not going to make it to our hospital when the radio goes off. Giving us report. Ped vs train, vital signs stable, noticeable deformities to left arm and right femur, gcs of 14. I am floored. Not only am I getting this guy, but he is stable and talking!!! They bring him in and he does have two very nasty breaks, his r humurus is sticking out or the skin and the arm is at an awkward angle. The left leg is quite a bit shorter than the right with and obvious deformity to the femur. We intubate, so that we can adequately control his pain, and possibly reset some of his fractures. This guy has no other injuries. And, prior to intubation, he was totally with it and quite angry at the fact that we "ruined his buzz". BAT was 402. Positive for cocaine and thc. Now in my few months in the ER I have decided that crack, in fact, does not kill. It gives superhuman strength to people and allows them to survive the wildest traumas imaginable without a scrape on them. Roll your ATV off the edge of a 70ft cliff? No problem, if you are positive for benzoylecgonine (fancy word for cocaine, technically it is its metabolite, but whatever) you will have a 6 inch lac on the back of your head, no other head injury and no broken bones (and of course you were not wearing a helmet). Contrast this with the gentleman sitting at the red light that gets rear ended by a car whose brakes had failed, neither positive for any drugs or alcohol, crash speed estimated at around 35-40 mph, and the driver of the stationary car dies and the driver of the failed brakes car is a paraplegic. If we had thrown some crack into the equation, think, both of these lives could have been spared. I also am fairly sure that crack is also a highly potent fertility drug, but the verdict is still out on that, my er dr's aren't quite into proving my theory by ordering urine drug screens on all my pregnant patients for my sake of research=(.

Only One more Day....

I should have known that last night was gonna suck big, cause Friday night went too well. I had time to go to the bathroom twice, actually sit down and eat my dinner without having to rush, and go and see some people from my old unit to talk for awhile. We had time to sit at the nurses desk and shoot the breeze. I opened the night with my favorite doc and closed it with an ok one. Even had time to try out Nurse K's fake poo recipe....Then last night.....ugh. 4 GSW, 1 DOA and unable to return the rhythm. The DOA made me even more mad when I found out that the paient had been laying in the street for over two hours according to bystanders, and no one thought to call for help! And they admitted this when someone finally decided to call 911. Two of the GSWs were together in the same bed and got shot up, none above the waist, and 2 in a very unfortunate place, between the two there were over 10 wounds, they pissed someone off... the last GSW and I quote" found a rifle in the woods behind my grandfather's house, accidentally shot myself, and threw it back into the woods, I have no idea where it is now." Likely story esp since this was a drop and run in the ambulance ramp. 2 stabbings, one which was a steak knife, 1 inch cut in the neck, which pierced the aorta, talk about an unlucky hit, didn't make it through surgery. A heart alert, a full code and an intubation, and these were just mine and my bed partners'. Didn't have time to find out about the rest of the ER. Foolishly ordered out, and brought the food home for breakfast, and still have one more night, oh well, time to hit the sack and hope for a better night.

What sense does this make?

Ok, I wanted to keep this blog out of politics and strictly on what I see in work, but had a converstaion that really got my ilk up. It was about raising the minimum wage. Now I don't know what kind of logic these people are raised on, but it is not sound. What part of the word minimum do these people not understand? Let's say that you have worked at a place for 3 years and when you started, you made minimum wage. After being a faithful and good employee, you have worked your way up to 6.75 an hour. Now all of a sudden, the feds have decided that minimum wage needs to be increased to 6.50 an hour. You have essentially just lost 1.35 of your hourly income, because do you think that corporations are going to raise anyone's income besides those at the bottom? NO!!!! So those making minimum wage are now, *gasp* still making less than anyone else in the country currently legally working, and those who have clawed their way slightly above minimum wage are knocked back down to the bottom. Now also keep in mind that the money to pay these people more has to come from somewhere, so prices will be going up to make up for the diference, this is called inflation. So what we have are people, still making minimum wage, although it is a higher amount, prices going up, and the only ones making out are the government(increased tax revenue) and politicians (it actuallysounds good on paper to propose this).

HUH?

I love almost all the docs I work with, some more than others, but for the most part they are a great group and listen to us and we work as a team to get patients out of our er as quickly as possible whether it is up to the floor or out the door. But there is this one doctor, that I just feel really has it in for me. I don't know if I have pissed this doc off or what, but there have been a coupla incidences that have made me go, huh? First one was an honest mistake on my part. I was a new nurse to the er, from an ICU that was pretty much run by the nurses, we made ALOT of patient care decisions. We also responded to codes on the floor which were run by residents, who did not have alot of experience, ergo the nurses ran the codes. I had a patient that came off of the ambulance into a bed (in a tootie room no doubt), and started "acting funny". She couldn't sit still, she was all over the bed and was complaining of lower back pain, that spread after sublingual nitro given en route, and leg numbness. Well I placed her on the monitor and was getting her history. In the middle of the history fhe gave me the Q sign. I yell out for the crash cart and help, position her in bed, and sure enough, no pulse even though there is a juctional rhythm in the 30's on the monitor. I have one of the other nurses bvm her, a tech do compressions and I put her on the defibrillator. I bust open the cart and give an amp of epi and an amp of atropine (both 1 mg), the doc has not made it into the room yet. I send another nurse for the doctor, we resume CPR, and in 3 minutes, I give one more amp of epi, monitor is showing and accelerated Juntctional rhythm at 80, still no pulse. It is then the doc shows up, and is mad because I have already given 2 mg of epi and 1 mg of atropine and the doc was not aware of the code. Well, I informed the doc I was a little busy and figured when I called for the crash cart, it might get someone's attention(which it apparently did since everyone in the er who did not have an md liscense had made their way into the room), as I have said, bad foot in mouth disease. Patient ended up not making it, and I apologised to the doc for my words and explained that I was new and we did things a little differently where I was from, but I was covered under ACLS protocols. I thought we had made up and all was good until....

We had a patient come in whose ICD was firing like every 10 minutes. The monitor showed a paced rhythm with varying runs of Vtach, though it was a perfusion vtach. When the runs were long enough, the ICD fired, just doing its job. Sats were 94%, but this was on a NRB. I ask respiratory to get me an ABG, she does and the PO2 is like 52. I show this to the doc (who is on the phone to cardiology about the patient). When the call is over, I am asked, who ordered this? I said that I asked for it to be drawn, that I thought it would be a good value to know since hypoxia could be causing Vtach, which is causing the ICD to fire, hearts act really irritable when there is not enough o2. And I get told that the order will not be signed off since this doc did not order it. I am standing there slackjawed and flabbergasted, this patient's pO2 is only 52 on 100% O2! It is not like I stuckthe patient and the gases ended up being ok. Luckily I knew the cardiologist on call very well and he wrote the order to cover my butt, but I was so madI could spit! Can anyone tell me why this doc might not have wanted ABG's?

Now that I have been there a little while and gotten to know this doc a little better we are feeling each other out little by little and getting along a little better, in fact I like this doc as a person, just not my favorite one to work with.

wrong time

Apparently I was born in the wrong era of nursing. Don't get me wrong, I love the great strides we have made as a profession and how doctors respect us more now than before (still have some ways to go there though) or how we now make a little more than minimum wage. I also don't think I could have survived in the little white uniforms (wearing essentially pjs to work every day pretty much sealed the deal on the decicion to become a nurse) seeing that 1. I hate dresses 2. I hate white 3. I am the world's messiest person, hands down. However, for all of the forward strides we have made, we now have two huge brass balls (and not the good kind like nurse k's), one chained to each leg that are slowing our strides and pulling us back, named HIPAA and one named JCAHO.

I understand that they are supposed to make things safer and more private for my patient, but, like all things beaurocratic, they have made what should be simple and easy, common sense if you will, into red tape and hoops. Let's look at what JCAHO has done to me at my job first:

1. I am no longer allowed to carry any supplies or drugs in my pocket. Nor in my ER are we allowed to keep supplies in our rooms. So let's say you are having abdominal pain, and you need pain medicine, but first an IV. I have to gather all of my equipment in the supply room (and pray to God I don't forget anything), start your IV, and flush it (if I remembered to grab one, since I used to be able to have that on my body and I am not used to having to grab one). I must then go all the way to the med room and get your meds, draw it up and label it. Then head back to your room, verify your name by your armband, you saying it, have you state your allergies, verify my med, dose and order and then give it to you. (Now I am all for the double and triple checking identity, I do believe in that part of JCAHO's fiendish plot). Let's hope you are not having a real emergency when I get in there and we need an IV started immediately, cause I have none in my pocket and there are none at the bedside.

2. If your IV pump starts beeping, I can no longer just go in the room and stop it and flush your IV. Nope, I have to stop the pump, go to the med room, get a flush and then go back and flush your IV.

3. This is the one I really do not comprehend. In our ER we have 4 sections. We have a trauma end where the really sick patients go, a middle area that stays open all night for less acute patients, and end that stops accepting patients at 2300 that is also less acute, but somtimes stays open "boarding" patients, and a fast track "urgent care" which closes at midnight. In the two less acute areas, if you happen to get a patient that needs to be intubated (which happens more often than you would believe) I have to pray I key in the right code to get into the medicine room, remember my code to get in the medicine pyxis machine, to get a key and run about 100 feet to another coded locked door, go in and unlock 2 old narc cabinets to get a locked tackle box which contains the "rsi" drugs. Then go to the patient's room. Now keep in mind that this patient is in ACUTE DISTRESS needing to be RAPIDLY intubated. Also remember that our doors keep you locked out after 3 missed tries on the coded lock, have you ever tried to type in 4 numbers on an itty bitty pad while your adrenaline is pumping through you? It can be hard. How is this making patient care better?

4. I used to be able to make it through the shift ok just kinda "grazing" at the nurses desk. Have acoupla of light weight snacks sitting below the counter and you really don't realize you haven't had a chance to eat, because you are grabbing handfuls as you chart or call docs or gather equipment and your stomach is not completely empty. In steps JCAHO, I am no longer allowed to have anything but a drink with a top on it. Now my tummy is constantly reminding me it has been 23 hours since anything has been put in it. Now I dont know about other er's but there are nights that I cant make it to the bathroom down the hall, much less to the breakroom to eat, so having a snack at the nurses desk at least kept my stomach growlings to a low roar. Now even that is gone. And I spend all night grouchy.

5. Apparently you cannot have mesh shoes or shoes with holes in them for fear of being exposed to body fluids. Now inal traumas we wear gowns and shoe covers that protect us, but in other areas, we don't. So just how is the mesh on my shoes any worse than the clothing I am wearing. If I have a spurter, and it hits my clothes, it will seep through just like if it drips on my shoes, I am exposed! So unless you are going to make me wear leather or polyesther scrubs,your reasoning makes no sense. (I have probably opened a can of worms and now they will require us to wear leather scrubs, I apologize to nurses everywhere).

6. We now have to write up "discharge" meds for our patients on their home meds sheet and fax them to thier primary doctor so their is a "continuance of care". #1. Probably 90% of our patients consider our ER docs their primary care doctors and we have their records already, why do we need to write it again? 2. The ones who have primary docs, I work nights, not just nights, weekend nights, what if I fax it to the wrong number? I have no way of knowing and we are talking MAJOR hipaa violations. 3. We don't require their primary care docs to fax us their meds prior to coming, what about our continuity of care? 4. We have ALOT with their primary docs OOT (out of town), how do we get their fax numbers (some of these docs I would really like to get a hold of, to become my primary, putting someone on 12 mg dilaudid every 2 hours, that's my kinda doc). ISSUES.

I don't have as much problem with HIPAA, just the fact that it can put you in awkward positions and it can come back and bite you when you least expect it.

My First day.....

My first post, kinda scary, I have been trying to decide what to go with, I think I will talk about my very first day as a nurse. I was a new grad who had precepted in the unit I get hired into. The unit was one that was high stress and had an extremely high turnover rate. My very first day as a nurse, my new nurse manager asked if I would not mind taking just one patient. This patient was post op day 3 from a VSD and would have been moving to the floor except all of the beds were full out there. So my enthusiasm for nursing overtook my common sense (this would set the precedent for my entire nursing career), and I said yes. She assured me that my preceptor would be able to help me with any questions or concerns.


All was going well until 915, when the patient started acting confused and talking out of her head. My preceptor was busy admitting 2 patients who had returned from surgery within 30 minutes of each other, so I called the nurse practitioner and told her that I think something was wrong with my patient, not sure what, but the patient just didnt look right. The NP said she would be back there in a minute. Upon arriving, my patient is now breathing like a guppy and I am feeling a bit guppy-ish too, I put her on a Non Rebreather mask and turned the O2 up to 15 liters.

"Have you drawn an ABG yet?" she asks.
Me standing there, looking slightly perplexed, "umm no".
"Well dont you think you should get one, you obviously think this patient is hypoxic since you went from no O2 to 15 liters" she said.
"Umm doesn't respiratory therapy have to get those?"
"The patient has an art line, don't they?"
"No it was taken out on anticipation of transferring out."
"Well page respiratory, now and get a portable chest"

So I page respiratory and x ray, and they come and get a gas and a film. The PO2 is 41 and this is after the patient has been on 100% O2 for a good 10 minutes. We page or anesthesist to intubate and notify the surgeon, who is in another case right now. The xray (according to the NP) shows an enlarged mediastinum and Pneumothorax, now I have no idea what she just said, but I do recognize the next words out of her mouth, "we are going to need a intubation roll, the crash cart at the bedside and you need to set up for a chest tube." Even though I recognize them, I had no idea what I needed to setup for a chest tube, I ask her to help me and we get it set up before the anethesist arrives. We also hung some dopamine because her blood pressure was soft and we apaced her using her epicardial pacing wires at 80.

The anethesist asks me to push 120 of succs and 20 of etomidate, I just look at him, I did not realize that I should already have the drugs. So I run and try to get them out of our pyxis, and my number does not work yet. I hunt down someone else to get the drugs. I come back apologizing while trying to pull up the meds, he is BVMing the patient, who at this point doesn't really look like she actually needs the drugs, but I push them in anyway. After successfully intubating the patient, looking at the post films, and talking to the surgeon, he decides that this patient is going to need a triple lumen and a swan. I explain to this dr (thank goodness it was one of the nicest drs I have ever met), that I had been a nurse exactly 3 and a half hours, period, and while I did not mind helping with this stuff, could he keep that in mind, and humor me if I was a little slow. Setting up a "4 way" (the device used to monitor arterial pressure, CVP and PA pressures) was something I could do in my sleep considering I had precepted as a nursing student here and this was a task that got delegated to me ALOT.

First day precepting 0700:
"Hey have you ever set up a 4 way" says Old nurse #1.
"No" I say.
"Here let me show you how it is done" she syas.

First day precepting 0800:
"Hey have you ever set up a 4 way" says Old nurse #2.
"Not by myself" I say.
"Here, I will watch you and help you out if you need it," she says.

First day precepting 0830:
"Hey have you ever set up a 4 way" says Old nurse #3.
"yes" I proudly say.
"Can you do it for me, I kinda got my hands tied" she syas.
From then on out, that became my specialty once word got around that i could do it, but i digress, back to the story.

So the patient is now intubated and I have the 4 way set up, but no clue what I need to get for the art line, central line or swan. My preceptor is to the point where she can help out and shows me what I will be needing before having to get back to her patient who just dumped 500 ccs blood in the chest tubes. I help the doc and everything goes with out a hitch, except I hook up the PA ports to the CVP port, but that was easilt remedied. The practitioner put in the art line without a problem. At that point the Surgeon has just made it to the floor, he also is one of the nice ones. He starts asking questions and I tell him what I know to the best of my abilities, he looks at the xray, and says that the patient needs a chest tube and also needs to go back to the OR. I also tell him that "I have been a nurse for only 4 hours now, and while I am not scared to help you, I want you to be aware. (while nice, he is also known for his temper tantrums if provoked)." He says ok and walked me through exactly what I needed to do. The chest tube got put in, the swan, art line and central line got placed, and the patient was intubated and heading back to the OR, and I had done it with minimum help (not because they were not willing, there were just alot of sick patients that day and they were short) and all within the first 1/3 of my shift!

After I broke down and cried because the NP came by and said "You did a really great job for a new nurse, but the fact of the matter is that the patient does not care if you have been a nurse for 2 minutes or 30 years, if they are dying, certain interventions need to be made. You chose to work in this unit, and you are expected to be able to anticipate what interventions need to be made when certain symptoms are present, this is LIFE or DEATH we are talking about. Just remember that", I took a deep breath, got some of the nurses to help me with my charting and waited for my patient to return. The rest of the shift went without a hitch, the patient came back from surgery (a pericardial window after the vsd patch leaked and caused a tamponade), and did well, went home after 6 weeks in the hospital. The practitioner told me months later, I never should have had that patient, VSDs have an enormously high complication rate, and I survived with more confidence in myself than Most after their first days. Talk about orientation by fire. Imagine my surprise when I returned to work the next day with a preceptor........