Wednesday, September 26, 2007

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.

Tuesday, September 25, 2007

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!!!

Wednesday, September 19, 2007

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?
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.
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?
ATTORNEY: And what were you doing at that time?
WITNESS: Uh.... I was gett'in laid!
ATTORNEY: She had three children, right?
ATTORNEY: How many were boys?
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?
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?
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?
ATTORNEY: Did you check for blood pressure?
ATTORNEY: Did you check for breathing?
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?

Tuesday, September 18, 2007

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?

Monday, September 17, 2007

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?

Wednesday, September 12, 2007

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.....