Life in hell

Many a time I have found myself wondering what life in hell is really like. This is certainly an important line of thought. It turns out that those who wander over for a visit end up staying a long, long time.

Well luckily for me, I don't need to wonder thanks to such religious leaders as Rowan Atkinson and Southpark. It turns out that, despite what logic may tell you, neither a Hillary Clinton Rally nor that patient you had last night meet the true definition of hell.

Southpark

Rowan Atkinson (Mr. Bean himself)

It would appear that they disagree somewhat on what group is saved from hell. Perhaps an arm-wrestling match could decide this one.

Money quote: "You must be feeling a right bunch of nitwits."

Call light idea

So as I was putting my 1 year old to bed, I was telling her that unfortunately, the call light was broken, so I may not hear her crying.

This got me to thinking.

The PCA pump trigger that we use in our ER looks remarkably like the call light that we use. (no TVs in our ER)

How unethical would it be to accidentally switch out the call light for the PCA pump trigger? I mean, really, what possible benefit could I offer that can't be matched or exceeded by 0.3 milligrams of Dilaudid every 8 minutes?

I'm just asking.

Hope my boss isn't reading.

Image stolen borrowed from Clay County Memorial Hospital website. Thank you CCMH and Google.

What is Doctor K up to

So Kevorkian has been out of prison for almost a year now. What has he been up to?

I hear he has gone into pharmaceuticals and is nearing completion of a new suicide drug.

I think he is calling it Dammitol.

I scents a joke

Angry Nurse has a post from a couple weeks ago that deserves mention. Ever wonder why nurses have to abide by the no scent policies but patients dont?

He mentions a few of the more common ER fragrances that get sprayed on you as you walk by (just like at the mall) as:

“Ode to rotten foot”

“Essence of Melena”

“Trifle Incontinent”

“Urine” by Harry Homeless
“I went No. 2”

Classic. I'm going to have to add him to my list of must-reads.

A couple that I run into in my ER:

"Colostomy Breeze"

"Axillotica"

"Pleasant Inebriation"

Do you have any favorites?

I love AHA movies

Having completed my ACLS recert today, I have been subjected to an inhuman number of cheesy American Heart Association videos.

I love watching really cheesy instructional videos, and this course provided no shortage of laugh out loud moments. Two really brought the house down for me:

1. Man goes down in front of a hotel while wheeling his luggage in. Four people are standing at the top of the stairs just outside the hotel. One runs down and begins BLS care by asking if he's okay and then shouting up to the other three people who are just standing there to call 911 blah blah blah. (pause for a second. Okay, I get it: this video is to demonstrate 1-rescuer BLS. But if I'm doing CPR on a guy and there are THREE people just standing there (albeit standing there looking very concerned), I'm going to start throwing things at them to get them to come help me. Seriously. Even when the guy brought the AED, he just sat there while the other guy stopped CPR to set it up.) That isn't the funny part, though. So this guy goes through his first cycle of 30 chest compressions and now it is time to do 2 breaths. So he reaches in his pants pocket and pulls out a full-sized face mask. In his other pocket he had a chest tube tray with three different sizes of tubes... oh, and a ventilator. And a dialysis machine. Just in case. And you thought Parker Lewis couldn't lose.

2. Doctor and Nurse are standing at the bedside. The Doctor goes over the risks and benefits of TPN with the patient and then turns to the nurse. "I have discussed the risks and benefits of thrombolytic therapy with the patient and she has agreed to the treatment." What I would have said as the nurse: "Um... yeah. I was there. Remember? 10 seconds ago? You on one side of the bed, me on the other? Got it."

3. ER doc to nurse: "Give 4000 units unfractionated heparin and start a drip at x rate, and give clopidogrel if ordered by the cardiologist." So now I need an order from the doc to follow an order from the doc?

Stop Fat Bolt

So I have been locked away in a huge dim room for two days along with 60 other people renewing my ACLS certification.

You will be pleased to know that if you drop to the floor in front of me and have no pulse and no breathing, I will be able to administer shocks, push epi and vasopressin and amiodarone, organize a team of nurses to rotate CPR every two minutes, get a bag of saline hanging on a pressure bag, and demonstrate perfect closed-loop communication.

You'll still die.

At least according to my megacode results.

I suppose it is some consolation to me that the other four people in my megacode group all killed their patients as well. As far as I can tell this pretty much mirrors the success rate of the real codes I have been involved with.

Well I passed anyway. Apparently you cant save everyone.

Besides, I feel better knowing that my patient started out with no arms or legs... or eyes, or hair, or internal organs... Perhaps I was doomed from the start.

On to the title of my post. Am I the only person that can not, to save my life, remember what all the different H's and T's are? Not only are they extremely forced (Hydrogen Ion for acidosis, for example), but every single H stands for hypo-something, meaning that they really aren't H's at all. Frustration!

So during one of the more boring lectures (hopefully none of the ACLS instructors will be reading this blog), I took the time to try to come up with some kind of mnemonic that I could use in a code situation to try to figure out what is going on. I came up with one that helped me a great deal in the megacode, and I think if I write it down and refer to it once in a while it may help in real code situations. Here it is:

STOP FAT BOLT

Excited yet?

S - Sugar
T - Temperature
O - Oxygen
P - Potassium

F - Fluids
A - Acidosis
T - Tamponade

B - Blood Clot
O - Overdose
L - Lungs
T - Trauma

A few points on this list:

* You will notice that the first 5 are things to do more than anything else. To rule out hypoglycemia, hypothermia, hypoxia or hypercapnia, hypo or hyperkalemia, or hypovolemia, you need to check these things.
* The rest of the list is a little more complex, and for many of them, even if you determine that they are the cause, there is nothing you can do. I can't fix an MI or a PE while my patient is in cardiac arrest, nor can I do much about trauma until I get the heart pumping again. I suppose I could have the doc siphon off a tamponade or dart the chest if we suspect those are causing the problems.
* Overdose is tough unless you happen to know by some kind of eyewitness account that the patient overdosed on something. Maybe they got too much Vitamin A as they walked into the madness ER.

Anyhizzle, this may or may not prove helpful to you, faithful reader, but I thought I would share, because it was helpful to me... even if my patient still died.

Note: the megacode video linked to above is not me. You can tell this because this guy goes for 30 seconds without making some kind of joke. This is not possible for me. And doesn't he sound convincing when he is making sure everyone is clear before the shock?

I Hate Alcohol

Jo over at Sinus Arrhythmia has a powerful post up about the effects of alcohol. Go check it out. It got me thinking.

I hate alcohol.

I hate that it takes control away from those who choose to drink it.

I hate that it has become socially acceptable to self-medicate with it.

I hate that it makes people lose their inhibitions and do things that they never would have done otherwise, go places they never would have gone otherwise, and let people do things to them that will scar them for the rest of their lives.

I hate that everyone assumes that if they only drink in moderation it will not affect them.

I hate that they don't realize that it will affect them. Can't they see that ninety percent of alcoholics started by "drinking in moderation".

I hate that so many of these people never realized that they were no longer drinking in moderation until they ruined their lives, or until they ruined somebody else's life.

I hate that you think that you are only drinking in moderation and that everything will be okay.

I hate that those who make the well-thought-out and wise decision to stay away from alcohol are ridiculed and scorned by those who don't understand that life can be even more fun, relationships more rewarding, and intelligence better fostered without the false promises that alcohol offers.

I hate that it has cost us as a society untold billions and trillions in lost wages, and productivity and lives.

I hate that it has cost untold millions of lost relationships and lost innocence.

I hate that patients come in to my Emergency Room on a daily basis because they are so drunk that they passed out in the street again, or because they have ulcers or seizures or jaundice or hypertension or infections or depression or malnutrition or cancer or heart failure caused by their inability to stop drinking.

I hate that patients come in to my Emergency Room because they were driving home to their families and singing along to the radio when out of nowhere somebody locked in the trance of alcohol runs into their car.

I hate that I have to be in the room when the doctor declares them dead.

I hate that wives and even husbands come in to my Emergency Room because they have been abused by spouses who have been drinking again.

I hate that children come in to my Emergency Room because they have been abused by parents who have been drinking again.

I hate that there are wives and husbands and children that don't even know that they have somewhere to turn when their loved ones have been drinking again.

I hate that the nurses and medics that surround me every day and see these same things still go out like idiots and get drunk at parties and become the same people that they complain about all day.

I hate that miracle drugs get pulled off the market because of side effects that are experienced by a few, but alcohol not only remains available, not only remains legal, not only remains easy to obtain, but also remains encouraged and even sensualized by society.

I hate that so-called scientists who want to find reasons to continue enjoying their drinking habits participate in shoddy and unprofessional "research" to come up with any possible silver lining that is the storm of alcohol.

I hate that most of the people who will read this post will be trying to come up with reasons why I am wrong and why alcohol isn't that bad.

I hope that someday we will be able to be honest as a society and let go of the crutch that is alcohol.

I hope that someday we will embrace life and learn to love it as it comes to us, without the mind-deadening effects of alcohol, without the body-rotting diseases that come along for the ride, and without the fear and pain and embarrassment that follow behind.

I pray that maybe one person who reads this post will stop long enough to truly ponder what I am saying and give up alcohol for a better life.

If alcohol were a prescription drug, no doctor would ever prescribe it because whatever positive effects it may have are drastically outweighed by the endless list of negative side effects, and even if a doctor wanted to prescribe it, they wouldn't because they would get sued until they had nothing left to give up.

So why do we continue to prescribe it to ourselves?

Blood Cultures (times) 2

Back when I was a kid, we had to walk uphill in the snow with bare feet to get blood cultures. Then after 15 minutes, we had to walk uphill in the snow on our hands while holding our breath to get them again from a different site.

Apparently somewhere between then and now, they have decided that the whole uphill and snow and bare feet and wait 15 minutes and different site things were a little old-fashioned and kind of grandma-y. Now, at least in our ER, when ye olde doc orders BCx2, the lab tech goes in the room, draws an extra syringe of blood, and badabing, they are done. My feet are saved for a rainy day.

Why we are still collecting two sets of blood cultures if we are doing them at the same time from the same site is beyond me. I suppose there is some theoretical benefit because "what if one of the bottles gets infected?"

Maybe it's just me (most things are), but this just really seems like yet another colossal waste of money and time. Go over to madness for the discussion that sparked these thoughts. Then go over again in 15 minutes and make sure that everything is the same.

Braden

(oh, and note that I'm famous over there! top o' the link pile. Maybe you should do the same on your blog... I'm just saying)

Attention Supply Department

Memorandum to supply department
- for immediate release -

Given the recent cut backs in funding and the subsequent budgetary restraints,

To aid in this process, management requests that you take inventory of vital supplies and place them on a priority stocking list, whilst less important items (such as vigileo monitors and IV tubing) be placed on a lower priority list.

As part of this process, we ask that you also carefully consider which distributors you choose to do business with. Here in administration, we do not want to feel that all we do is give orders without providing some of the leg work as well. Therefore, after lengthy interviews with ER staff, we have determined the highest-priority items, and upon searching, came across some very good deals for these items. Attached, please find a flier demonstrating these potential cost savings.

Thank you for your time.

-Hospital Management-








attachment:

Bizarre ER?

So a kid sticks a little lego piece up his nose.
So a man gets cellulitis on his foot.

Everyday ER events? Pretty pathetic compared to dozens of stories that any ER nurse could come up with? YOU might think so, but apparently the producers of this British show were wowed. Granted, the man's foot looks pretty disgusting, but somehow they turn an ER course of IV antibiotics and and I&D into a 5:30 section. Money quote: "left untreated, it could lead to a serious blood infection, or even the loss of the whole limb."

Duh.

Please pull over for this guy

Madness has an interesting post up featuring ambulances from around the world. Go check it out for the whole thing, but I wanted to share this one, because wow.

An ambulance from Canada:



Can you say inferiority complex?

Stand Up Comedian on the ER

I'm not overwhelmed by this guy - maybe it is the weird faces and noises he thinks are making him funnier - but he does have some interesting observations on the ER, most notably on the silliness that is the pain scale.

For my opinions on the pain scale, please refer to my blog title.

If you are in a hurry, fast forward to 5:40.

Enjoy!

Change of Shift

The latest Change of Shift is up at Nurse Sean (dot) Com. Go check it out.

Check it out for the pictures of Europe.

Check it out for the great posts that he links to.

Check it out for the spin he puts on it.

But most of all,

Check it out because he linked to me!

Next week it will be hosted at Life in the NHS.

What is the diagnosis code for that

I'm cleaning up my desk and came across a little note that I clipped from somewhere a couple years ago. I don't know where it is from to give credit, but I do have the name of the submitter of this little story:

"While transcribing medical audiotapes, a colleague came upon the following garbled diagnosis: 'This man has pholenfrometry.' Knowing nothing about that particular condition, she double-checked with the doctor. After listening to the tape, he shook his head. 'this man,' he said, translating for her, 'has fallen from a tree.'"

Oops. Seriously, though, have you ever heard doctors when they dictate? I don't envy the transcriptionists.

Sometimes I've thought about being a school nurse...

...so that there is one less job opening for idiots like the ones described here!

Is it really free?

I was recently at the mall with my wife and daughter. We stopped at the food court (okay, let's be honest. We started at the food court) and ordered our meal - Torta and Burrito for those keeping score. While waiting for the food to come, I walked my daughter around in her stroller so she wouldn't get bored. As I was walking around, three different restaurants (can anything in a food-court really qualify as a "restaurant"?) enthusiastically offered me samples of their food.

I love free stuff!

But I said no, and here is why: is it really free?

Let me give you another example, this time relating to health care. Our ER would like all the nurses to know how to do splinting even though it is typically a job for the Techs. This makes sense, because sometimes you don't have a tech and even still, the tech is working under your license and so the splint is ultimately your responsibility. So in this class, there were about 16 of us nurses and the two guys from 3M giving the presentation about splinting were handing out splinting material like candy and walking around helping us practice on each other. It was educational and informative. As the teaching part wrapped up, one of the reps pointed to the huge pile of boxes in front of the room and said, "if you want to take some material home to practice, go ahead."

Did he really just say that to a room full of ER nurses?

Swarms of nurses fought their way to the front of the room and picked at the carrion as if their very lives depended on it. It was shameless. I was in front of the line. I walked away with several pre-made splints, some scissors, more rolls of coban than I know what to do with, and sundry other items, and I didn't even have the biggest pile of loot. I felt pretty good about myself.

Until the mall food court. Is it really free?

Let's think about it before jumping to any conclusions. I'll start by saying that I love capitalism. I think that the free market system works very well for the vast majority, and the principles of the free market system are sound principles; and I understand that companies have advertising budgets and figure in to those budgets that people will abuse their "free stuff" policies. Hopefully, even though my thoughts on this may not seem to be supportive of the free market, I think by the end I can show that they actually are.

In this scenario, we were all together in a class about splinting and needed to have materials to learn. We did. When he offered to have us take some material home, it was so that we could practice. This is fine. Most of the people in the class went up and got enough material to go and practice splinting at home. Then most of the people went back and got more. And more. And more. I was among them, and I don't find anything "sinful" or "evil" about it, because he did say to take whatever we want.

But I do see a problem.

The material that the company reps brought into the classroom was at least several hundred dollars worth of goods. The money to produce that material had to come from somewhere and the money that could have been made selling those goods would have gone somewhere. But, you say, 3M is a big company, and can easily eat up that cost.

That is true; however, they aren't really "eating up" that cost. What they are doing is shifting that cost onto the rest of their products. Now it might be 1/10th of a penny more per splint so that they can cover the cost of that class. This may seem insignificant to you, but to me it doesn't and that is because when the hospital pays the increased cost of splinting materials, they don't just eat up the extra cost, they pass it along to the person who got splinted, who passes it on to the insurance company, who raises premiums for employers, who decrease benefits to the employees, and on and on.

My point is, by taking everything that is offered free of charge, we may actually be punishing ourselves. In the case of the mall food court, the result of getting two samples of yum-yum chicken (yes that is what it is called, and yes, it was offered twice to me as I walked around, and yes, I refused both times because I knew I wasn't going to order it) may only be an small increase in the price of a yum-yum chicken meal. In the health care industry, however, when I take undo advantage of free samples of splinting materials, or when I abuse the kindness of drug reps, I am ultimately hurting my patients who now must pay even more for their health care, because that money for my "free" items has to come from somewhere.

So when you are considering something for free, I would encourage you to pause for just a moment and think about what you are about to get. In many cases, the free items will be helpful for you to learn and grow or determine if a product is worthy, and in those cases go for it. In many other cases just stop long enough to realize that you may be helping to inflate the cost of health care. Does that make you a good patient advocate?

Okay, for those who skip to the end of the article to just read the conclusion, here you go: Free is good. Samples and free offerings can help us determine if a product is good, and aid in getting information about a product out. I'm not trying to say that you should avoid free samples. Also, I'm not trying to make an argument about the morality of taking free items. You can go back and forth on that, and I've learned that morality is so subjective that it is a nearly impossible battle. I am talking about the financial cost of the issue. You can come to your own moral conclusions.

-Braden-

Addendum: My wife found a story online that I wanted to work in somewhere and couldn't find a good place. Apparently a drug rep organized a dinner at a nice restaurant and invited a number of nurses and doctors to come and enjoy the meal and her presentation. As the meal was winding down and she was putting her things away and taking questions, a doctor came in and ordered 4 racks of lamb to go and drank two glasses of wine while waiting. When the to go order came out, he took it and left. 10 minutes spent at the restaurant and $150 dollars spent for him to gain nothing from the meeting. He probably walked away thinking that he had stuck it to the man. But really, the man doesn't care, because they will just stick it to the patients by selling the drug for more money.

Paying it forward

Inspired by this post from Stephanie at the Fat Lady Chronicles, we paid for the dinner of a military service member last night. It only cost us a few bucks, but it made us feel great to be able to give something back to those who serve us to keep us safe. So now I'm tagging you. You're it. Go find a fire-fighter or a marine or a missionary or someone who makes a difference and makes your life better and do some little random act of kindness for them. You'll see how great it feels.

A little mindless fun for you

There is a new article up on Snopes, exploring some funny stories that get passed around about doctors and patients. Some of them are obviously not true and only jokes, and some may well be true stories (I think every ER nurse has at least one similar story to tell).

Have fun!

EMS Ride-along

In an effort to help us gain some empathy, or at least understanding of what happens pre-hospital, our ER is putting us in the rig for a day with the local fire department. One of my co-workers went last week and came back excited that she had the chance to poke a hole in a wall during some training exercises. I was looking forward to my trip, but I had muted expectations.

I loved it.

I'm not ready to hang up the scrubs and put on the blues, but I had a great time, and I came out of the whole event with a huge respect for the Medics. It is really a family, and after just 8 hours, I could feel the love these guys had for their jobs and for each other. I understand now how firefighters across the country felt the pain so deeply after 9-11.

I came home and my wife asked me how the ride-along went. I told her that it went okay... I watched sports, had a woman throw her clothes at me and got free dinner.

No. Really. I did.

When I got to the station, the medics had just returned from a call, and we watched the local baseball game while eating lunch. After eating, we went out the Medic 1 unit and had a good conversation about ER nursing vs. EMT and I think we all came away with a greater respect for each other. A couple hours later on our first (and ultimately only substantive) call of the afternoon, the 50-something portly woman who we were transporting decided that just changing into a gown wasn't good enough. She had to do it to music. Provided by herself. While twirling her bra over her head. And letting it fly. Guess who it hit. Yeah.

Later in the evening, one of the EMT's got a check for several thousand dollars from an investment group that he had been a part of. Need I say that he was mildly excited? So we all went out for dinner at an expensive Italian restaurant on him. Then we got back to the station and everything was quiet until it was time for me to leave. Well, it was quiet unless you count the noise from the NCAA basketball championship game.

So to all you ER Nurses and Docs, please give respect to your FD Medics that come in to your ER. They are good people who live life on the edge, ready to respond to anything and to walk into any situation without a clue what they are about to come onto. They want to make our lives easier, and for that I now declare myself a fan.

Medications continued

Last week I posted about funny medication spellings. Here are some more to add, these from a typed list:

L-Throxine
Asprin
Paroxtene
Propo-N/Apap
Allergy to "Alchol in shape or form"
and finally: Metocaranide

What we wish we could tell our patients

Over at EDnursasauras she has a post from last month about her dream sign for the triage area. Go check it out and have a good laugh.

I particularly enjoyed these morsels:

"If this is your third or more
visit with the same non-urgent complaint this week and you have not
followed any of your discharge instructions from your previous visits,
we probably can't do anything more for you. Most of our advice is based on common sense, and there is no prescription for a congenital absence thereof."

and

"Please do not inquire as to why someone has been brought in to be seen ahead of you. The triage nurse is very experienced, and if she thought you were as sick as you think you are, you would be in a bed too."

I worked in the fast track area today, and I can attest to the timeliness of that first piece of advice.