Monday, June 30, 2008

Wyoming, where are you?

Since the announcement three weeks ago that my site would be hosting the Change of Shift, the number of visitors nearly doubled overnight. Since posting the Change of Shift 4 days ago, the number of visitors has skyrocketed to a point that the number of daily visitors over this period is nearly 10 times the number of daily visitors 30 days ago.

I have had visitors from dozens of countries as disparate as Denmark and South Africa. Canadians have come out in force - from every province - to read what this USA dude has to say. I've had visits from London and Manchester and Edinburgh, and even Newcastle-upon-Tyne (yes, you.)

New Zealand has even sent me some traffic (how cool would it be to live in a city called Dunedin?).

And 56 of the 57 United States have stopped by, but Wyoming remains completely uninterested.

Why, Wyoming, Why? Did I offend you in some way? Do you just not need nurses in your state? Was it because I didn't show enough respect for your Geysers when I toured Yellowstone? Is it because you are too busy admiring Fossil Butte National Monument?

I love Wyoming. I'm an Ansel Adams fan. Really, I have a calendar and everything. The Beaches of Cheyenne is one of my favorite Garth songs. I really liked the movie Casper when it came out (but mostly because I thought Christina Ricci was cute). Yes, you don't have any major sports teams, and your minor league baseball team is the Casper Ghosts, but your state dinosaur is the Triceratops - and you don't mess with a Triceratops (unless it is really sick and then you have to look through it's droppings to see what is wrong, but I work in an ER and I do that kind of stuff all the time. well, okay, not with a Triceratops because they don't really check in that often, but with other patients who may also have lived during the Cretaceous period) And I love your state motto: "Equal Rights" (a little odd, perhaps, given that Wyoming is nothing but 50 year old white men... or at least that's what I've heard).

So come on, Wyoming. I've been a friend to you. Why can't you return the favor and be a friend to me, too?

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No I here

New to the blogosphere is No Cap Here, who tells her story of life in the ICU. Recently she put up a post about the stupidity of the little competitions she has seen in nursing school, and now in orientation (I'm glad I never had any of that), and the importance of team work.

It is interesting, so check it out.

But really, the reason I couldn't resist linking to it is because she has the title "There Is No I In Teamwork" and everytime I see that, I can't help but point out that there is also no U in teamwork.

I'm just saying.

Was It Something I Said?

So I host Change of Shift, and then within a few days The Angry Nurse, ERNursey, and Monkey Girl all go away.

Hey guys, next time I'll wear deodorant. Promise.

Thursday, June 26, 2008

Change of Shift

Ladies and Gentlemen (and those not quite so sure which they are, and those too immature to be categorized as either, and any well-trained animals who have learned to surf the internet, and Jerry Springer, if you are reading this), welcome to the Change of Shift. I am honored to be hosting this week's celebration of the nursing blogosphere and thrilled that you could make it. So grab a seat (why were you standing, anyway?), settle in, and get ready to meet some of blogging's brightest.

I have only been an RN since last year, and at that only in the ER, but before that time I worked in rehabilitation of developmentally disabled adult criminals, as a CNA in Long-Term Care, as a Med-Surg CNA, as an ER Tech, as a Staffing Coordinator of a large hospital, as an LPN in a very busy Allergy/Pulmonology/Sleep clinic, as an LPN in Family Practice, as an LPN in Pediatrics, and as an LPN in Urgent Care. I've been around the nursing block a few times and have seen what a wide wide world it is.

So I thought it appropriate that this week's Change of Shift should celebrate diversity, because nursing is certainly a field that has huge amounts of it. I'm not talking about black or white, conservative or liberal, gay or straight, Muslim or Catholic, funny or Braden, or any of those standards of diversity. I'm talking about the vast array of distinct careers that make up the profession of nursing. Most people have a fixed idea in mind when they say "Nurse" (just ask the Animaniacs) but they don't realize just how different a nurse in one area is from a nurse in another area. True, we all start from the same roots, and everybody's job description is filled with mumbo-jumbo about assessing, diagnosing, planning, intervening, and evaluating, but go ahead and look at what nurses say about their specific jobs and you may be surprised to learn how similar, yet different we all are.

I have assembled a crack team of Nurse-blogging sharpshooters* and told each of them essentially the same thing. That is to share with the world why their kind of nursing is unique and special and what makes them want to do that more than any other field of nursing. I asked each nurse to submit this post to their own blog either last night or this morning, so I am almost as much in the dark as you are about what they will say. Unfortunately, I could not get a blogger for every type of nursing I wanted, so we'll just have to use our imagination on some of these. further ado, let's meet the contestants, in completely random order:

Emergency Nurses - Of course I start with what is nearest and dearest to my heart. Did you really think I would be that random? From the outset of my Nursing career, I never wanted to do anything other than ER Nursing - even when the big push came to rename our unit in a manner as to suggest that we need sildenafil - and it is all I have done as an RN. To introduce you to life in the unpredictable lane is EDNurseasaurus, the self-proclaimed "world's oldest diploma nurse and BSN undergraduate." Go for a prehistoric walk on the wild side and learn what makes her an ER Survivor. Her description of ER Nursing resonates very much with me and in a few short paragraphs, she paints a perfect picture of what life is like in the Emergency Room.

On the other side of the water, my favorite impactEDnurse shares bits of wisdom and insight in his free e-book emergency nursing unscrewed.

Or for those who appreciate their humor a little on the dark and dry side, go check out anything on Nurse K's blog, such as her latest tongue-in-cheek social commentary on poverty and inappropriate use of the ER.

Critical Care Nurses - Tracey at Nighttimenursing has been through it all as a nurse in the ICU. In the unit, even more than the ER, you are the captain of your own ship, and when things start going south, there is you and the patient and not much else. Sometimes, even the most stable of patients can go downhill quickly, and just keeping them alive is a task that falls right into the nurse's lap. Tracey shares just such an experience and gives you a flavor of all a Critical Care Nurse goes through in moments like that, and what makes it all worth it.

For a more nuts-and-bolts perspective, Nurse Sean (hey Nurse Sean, where did you go?) shares a day in the life of a new ICU Nurse on his blog and lays out in excrutiating detail why I don't want to be an ICU Nurse.

ICU Nurse Kathy takes us back to the good old days when nurses would make a frequent practice of stripping with her post, To Strip, or Not? No, it isn't nearly as exciting as you might guess... in fact, it is actually quite technical and might make you wonder, "why are you giving free publicity to this travel agency by posting this?" To which, of course, I answer "so that I can make a joke about nurses stripping, of course. Oh, and because this gives some light into the technical world of ICU nursing and stuff."

School Nurses - Alison at Schoolnurse's weblog talks a little about the mindset that a school nurse needs to have, while Penny at My Son Has Diabetes just made the switch from Home Health Nurse to School Nurse. It doesn't appear to be primarily a nursing blog, but you can read a little bit about her feelings on the change and her initial thoughts on the new job. Room Nurses - If I didn't do ER, I would likely do OR. I had the chance as a Nursing Student to witness several surgeries, including a 4-way heart bypass, a brain surgery, a laparoscopic appendectomy and others. If it wasn't so darn hard on my feet, I would have been very interested in OR as my first priority. Of course, OR nurses do much more than just stand on their feet for a long time. To give you an idea of what life is like in their shoes, Unsinkable Molly Brown at Livin' Large has put up a post to tell you what is so special about being an Operating Room Nurse in I Choose OR Nursing, and be sure to click the link halfway through to her post about the OR personality.

Flight Nurses - Ready to swoop in at the most critical times to take care of the most critical patients, flight nurses are an amazing breed. When a Flight Nurse is called to the scene of an accident or to take a patient to a higher-level facility, they know they are going into a war zone and have to be ready to accept a patient on the verge of death, and keep them stable with absolutely nobody around to back them up. Crzegirl at Crzegirl, Flight Nurse has a two-part series about what a flight nurse is, first in words, then in pictures.

Med/Surg Nurses - It is almost unfair to lump all of the Med/Surg Nurses together. After all, this title can be given to Neuro Nurses, Ortho Nurses, Oncology Nurses, Surgical Nurses, Renal Nurses, and more. Fortunately for all you readers who do not have an entire 12 hour night-shift to kill, I'm not fair. Besides, I didn't get anybody to write a post for me about Nursing. I admire nurses who can do "floor" Nursing. I can't. I did plenty of it in Nursing School, and before that I was a CNA on the floor. For one thing, I can't fathom not being able to walk up to the Doc and ask a question. Using a telephone? It isn't my thing. Fortunately for me, it is for a lot of other Nurses. You can read about some experiences on Med/Surg by NewGradNurse at Call A Code.

Also, Oncology Nurse Laura has a post about 1:1 patient care and how it harms productivity. I have to say that this hits home for me. I don't like getting mad at suicidal patients for taking away my ER Tech, but sometimes I do feel that way, and it makes me feel bad. So there are a lot of downsides to 1:1 nursing, but is there a solution that is feasible?

Nurse Practitioners - the Life-saving Nurse Practioner at The Nurse Practitioner's Place grants us a peek into a day in her life. It sounds like getting a Master's Degree in nursing is no escape from the hated paperwork. If you read over her blog and just can't get enough of her, go and check out her other website, NP's Place, full of her thoughts, information about Nurse Practitioners, a very disturbing and cool picture of a Nurse Practitioner who follows your mouse around the screen, and links to ARNP sites and blogs, as well as other great nursing blogs. Mine isn't there, but I'm sure it will be soon... ;-)

Speaking of Nurse Practitioners, Max E. Nurse over at It Shouldn't Happen in Health Care has some thoughts on what was really meant... both for the patients, and for the providers (I especially love the translation for "There should be a bed on the ward for you any moment"). I like his blog much more than that of his cousin, Mr. Pad.

Public Health Nurses - Most nurses work with one or maybe a few patients at a time and in a controlled environment. Public Health Nurses work with everybody, and most of the time their patients don't even know that they are being watched over. Such is Sheila from Ordinary World, who shares her thoughts with us about why Public Health Nursing is important and what drew her in that direction in her post, Pump and Circumstance. Thank you, Sheila, for serving so many every day.

Outpatient Clinic Nurses - Rae, an Oncology Nurse from the aptly named raecatherine wants to share her journey of discovering what kind of diversity Nursing has to offer. Follow her through her winding road, and learn why she is a Clinic Nurse, and even more why she loves Oncology in her post never say never and how I got there. Check it out to see her journey, check it out to see a cute pediatric nurse, check it out to get a new perspective on end-of-life care, but most of all, check her out to see today's best usage of the phrase "small poos". When you have read that, go and read her little warning about how we judge our patients, and how quickly the tables can be turned back on us.

Student Nurses - Being a nursing student is not really a profession - or at least if someone is a student nurse for long enough to call it a profession, it is probably not someone that I want treating me - but Student Nurses bring to the table a special energy and interest and vitality that all-too-often fades as we get into the "real world" of nursing. La Bellota at Nursing School Chronicles recently graduated and started looking for work. Not too long ago I was in her shoes (they were a bit snug on me, I must say), and I remember the joys and the heartaches and, of course, the odd timing of everything falling into place, and then falling all apart. Read her five-part tale (1 2 3 4 5) of NCLEX to hiring as a brand new grad. Honesty and integrity in nursing? Who would have thunk it? Now let's go one step further with Nursing Student loco lorenzo from the loco days of locolorenzo and his thoughts about the power of love. I think this is a specialty of nursing students... and perhaps something that we should seek for in our profession as actively as we seek after the alphabet soup that comes after our names.

And while we are talking about Student Nurses, let us all give a big welcome to Nursing Student Kaitlyn, who just wrote her first post on the Learning to Fly blog, and after an apologetic beginning, she gets right into a beautiful discussion on what Nursing really means and how it has already changed her life.

Finally, to all you Student Nurses out there, please take a few minutes and head over to prn penguin's place to read her extremely well thought out and educational post on how to survive as a 1st year nursing student. Then read it again.

Administrative Nurses - Where would the nursing world be without managers? Perhaps it is best if you don't answer that question. Anyway, many nurses become Nurse Administrators and help to keep hospitals and clinics running smoothly. My brother was a manager of a busy inpatient surgical floor of his hospital. Of course, in an attempt to save money, the hospital made him work as Charge Nurse three days a week and Manager two days a week and there was no way to do everything a Manager needs to do in just two days, so he saw the light and now works at an ER 20 miles down the road from me. And working nights nets him the same salary he was getting as manager. Wait, do I digress? Perhaps that is because I was not able to find a blogger to represent Administration. One interesting blog that I found, however, was Paul Levy's. He is CEO of a large Eastern US hospital, and shows a remarkable amount of approachableness (made up word of the day) and transparency on his blog, Running a Hospital.

Travel Nursing - Do you remember that Army kid in school? The one who came in halfway through the year and then moved just before school ended? Yeah, that's like the Travel Nurse. They can be in any department, but like the sale at Macy's, they are for a limited time only. It is a fascinating lifestyle, and invariably makes the rest of us lesser-paid Nurses jealous, and I'm sorry to not have a blogger to introduce it to you. However, for those who are attracted to the magical aura of Traveldom, Christina from shares a huge list of resources for you.

Alternative Nursing Careers - Hueina Su is not only a nurse, she is also a Certified Empowerment Coach (yeah, I had to look it up, too). She submitted an article about the power of the mind, and how Nirvana is Only a Thought Away. Holistic/Alternative care is not necessarily my cup of tea (no pun intended), but there are plenty of people who find happiness and healing through it, so go see what she has to say. Besides, how can I say no to a CEC?

Everybody Else - The list of different types of nurses could go on and on, and so in the interest of time and lack of volunteers, I will recommend to you Mother Jones at Nurse Ratched's Place for psychiatric nursing, May at about a nurse for telemetry nursing, At Your Cervix for Labor and Delivery Nursing, and The Mayor of Crazytown at All That Matters To Me for Home Health Nursing.

Of course, no post about the diversity of Nursing careers would be complete without talking about some of the other healthcare professionals who surround us and make our jobs possible. In addition to our fellow Nurses, let us take some time to celebrate these fine men and women who work side-by-side with us, easing our troubles and coming to our rescue when needed:

Respiratory Therapists -You hear it all the time in the hospital: "Respiratory Therapy to room 704." Where do these angels with the vents come from and what were they doing before magically appearing at your bedside to help save your crumping patient? Keepbreathing at Respiratory Therapy 101 wants to help us nurses know just what it is that RT is all about. Not only does he do a masterful job explaining the ins and outs of his profession, but he does so while correctly using the word plethora. Bonus points. Go check out A Nurse's Guide to Respiratory Therapists.

Social Workers - Until I started working in the ER, the Social Workers were just this nebulous group of people that did stuff sometimes. I never really understood their role. Now that I have interactions with them every day as I dump suicidal patients and drunks and battered wives on them, I have nothing but respect for what this stalwart group does. Hoping to help you understand a little bit, Still Dreaming, "a brand new social worker working with the lowest of the low" took the time to write a post especially for you at Awake and Dreaming about what it means to be a Social Worker. Go over to her place and get educated with I'm a What What Worker? don't forget that some Social Workers come in the Doctor variety. Therapydoc at Everyone Needs Therapy (ain't it the truth) wants you to know why Alice the waitress in room 7 has suddenly become Olga the conqueror.

Medics - What? I included the ambulance drivers? That's like putting a picture of Manny Ramirez on a Yankees Blog! But wait... not so fast there, cowboy. Perhaps we can work some of our differences out. At least that is what Epijunky from Pink Warm and Dry hopes as she introduces you to the elephant in the room. You are right, Epi, we do have a lot in common. And thank you for that entertaining and insightful look into what EMS is all about. Any nurse who understands the life of a medic will have nothing but respect for them. And for another not-to-miss post from Epi's world, check out her tour of the inside of an ambulance. Humor and education all in one... who could ask for anything more?

Emergency Doctors - I didn't get anybody responding to my call for ER Docs, but please check out Scalpel or Sword or 10 out of 10 to get some insight into the mind and madness of those suture-wielding warriors we call Emergency Physicians.

Somewhat related, JC from Brain Blogger has a philosophical question as relates to Emergency Room Doctors. What do you do when a patient comes in who requires a specialty doctor, but you don't have one on call? How long can your patient wait for surgery?

Hospitalists - The Hospitalist is a fairly recent invention. Back when I was a kid, the PCPs admitted their own patients and then came around the hospital to see them before or after clinic hours or between tee times. This meant that a patient who needed to see the Doc at 0800, was granted immediate access to his or her doctor... at 1800. Fortunately, now we have Doctors who do nothing but help inpatients. The PCP or ER Doc decides to admit a patient and from that point, the Hospitalist takes over and does everything that is needed to help the patient and the Nurses achieve good outcomes. From all that I have seen and heard, this program works very well and results in shorter hospital stays and happier patients and Nurses. The Happy Hospitalist is an interesting and popular blog that chronicles the adventure of one such brave soul. Have fun.

Parent nurses - Sometimes, the most unwilling Nurses can be the most caring. Parent Nurses have no training in Nursing, and do not even choose the path they take, but for love and devotion to patients, nobody tops Mom and Dad. It is every parent's worst nightmare to have a child who suffers from chronic conditions, but it can also be one of life's biggest blessings. Hannah's Dad at Kintropy In Action writes about what it means to be a Parent Nurse and how it can change a life in Our Unexpected Nursing Career. After reading about their journey, go and feel the joy with the family when you read about finally giving up the ventilator.

And I'm not sure I can think of a better note to end on. Thank you for taking this journey with me through the amazing and inspired world of Nursing. One thing really stood out for me as we walked along the road of Nursing, and that is that nearly everybody who posted articles trying to explain why they do what they do said the same thing: I want to make a difference in people's lives.

And that, my friends, is truly what it is all about.

* Submitters were selected using a scientific method I call complete randomness. Generally I tried to find nurses who update their blogs regularly, who seem relatively articulate, who have a blog generally devoted to one specific kind of nursing, and as much as possible who do not receive a lot of traffic to their site (with a few notable exceptions). Endless thanks to all who took the time to help build the theme for this Change of Shift. If you feel snubbed or if I did not include your particular brand of nursing, please feel free to write a similar post on your blog and link to it from the comments.

Pictures found using image search on Flickr. If I'm using your picture and you don't like it, please accept my apologies and let me know and I will take it down. Final picture borrowed from Careways Trust.

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Tuesday, June 24, 2008

Voluntary Divert

So we just had the busiest day I've ever seen. I was working second triage and we were slammed with an endless parade of chest pains, possible AAAs, and severe hypotension patients, all salted with the usual complaints. I had to triage one pretty convincing varicella case in the quiet room. Hope those vaccines work. Top that off with ambulance traffic that would rival the traffic to K-Mart on any average day, and we were really cooking. Hallway beds were everywhere you looked, and we were occasionally putting pretty serious patients in the hall.

Needless to say, everyone's nerves were just a little on edge. I walked by one of the fast track PAs, I said, "make it stop!"

"Easy," he replied. "Get a paper and a marker and make a sign to put on the front door: FREE BEER AND PEANUTS AT SAINT CARINGANDSHARING GENERAL.* That should clear everybody out pretty quickly."

If only...

* Name changed to protect the innocent

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Monday, June 23, 2008

Chantix and Side Effects has been a bit of a back and forth lately between Nurse K and Mother Jones about a study involving using Chantix on PTSD patients. I don't know much about the actual study, and I'm far too busy (read: playing too much Mario Kart Wii) to read up on it properly, but I can't resist throwing my two cents in this ring where it concerns Chantix and its side effects.

I was working at a pulmonology clinic when Chantix came out and sat in on several presentations from the drug reps about it (always take the drug rep lunches with a grain of salt). Since that time I have worked in a HMO clinic and Urgent Care Center and now in the ER. In all that time I have seen dozens and maybe even hundreds of people taking Chantix. For a few, it didn't work. For the other 90 percent, it worked like a miracle.

Number of people I have seen who have complained of serious side effects: 0.

Granted this is a very unscientific survey, and I've read the stories about the side effects and the chance of very real problems.

But if we are going to pull yet another miracle drug from the market or over-regulate it, while a 16 year old can buy alcohol from the corner market with a fake ID, and have even worse side effects occurring much more commonly (how often do we see psychotic and/or suicidal patients in the ER after pulling a few swigs off the old keg?), then I'll know we have gone completely and hypocritically bonkers.

And by the way, peeps, it's ChantIX, not ChantRIX, which every patient alive seems to say (kind of like Atenonol)

Image borrowed from Found via Google Image Search.
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Sunday, June 22, 2008

Submissions for Change of Shift

Calling for submissions for this week's Change of Shift. Please e-mail them to me at either pererau at gmail or at braden at bkellis dt com

Also, for the theme this week, we will be looking at the diversity of nursing careers, and I have e-mailed a long list of bloggers asking to return my email to take part in this. Many I have heard back from and confirmed support from, but there are still many that I have not heard back from or who seem to not be receiving my return emails. I need help from nurses who work in the following fields:

Emergency Nurses
Critical Care Nurses
School Nurses
Home Health Nurses
Labor and Delivery Nurses
Med/Surg NurseS
Telemetry Nurses
Long-Term Care Nurses
Psychiatric Nurses
Surgery Nurses
Student Nurses
Administrative Nurses/Managers
Nurse Educators
Nurse Practitioners
Outpatient Clinic Nurses

Also I would love to hear from:
Emergency Doctors

For all of these categories, I have sent e-mail messages out and have not heard back or have not received confirmation. I tried generally to pick lesser-known bloggers (though in some cases I took what I could find and asked some big names), but it is much more important to me to have a lot of participation rather than a particular person... and I can always use more than one perspective.

So if you are reading this and fit any of the above descriptions and want to help me out with the Change of Shift, please email me at the above addresses or leave a comment with your email address and I will get in touch with you.

If you know anyone who fits the above descriptions, send them the link for this post and have them contact me please.

Saturday, June 21, 2008

If You're Gonna Light a Fire...

So the flight nurses come in to transport the 80 year old C5 fracture to a level one facility. A couple minutes later, one of them runs up to the nurse's station and urgently says, "where's the narcan?"

So you can give two and a half of Valium to our already-drugged up patient, but you don't have Narcan? Tell your manager, that it tends to work better than the sternal rub you just tried.

Oh yeah, and try not to code our patients - at least not while they are in the ER. Thanks.

Friday, June 20, 2008

Let's all say it together now...

FAST track.

Say it again: FFFAAASSSTTT Track.

So why does the charge nurse come up to me and say, "oh, by the way Braden we are going to put an acute onset chest pain in room 1. Don't worry, we'll get her to another room soon, I just need you to start an IV line and give some meds."

Dear, dear charge nurse: Have you ever given ACS meds before? I'm just asking, because there is nothing quick about giving initial ACS meds. So while I am busy doing that, the rest of fast track becomes stopped track.

Oh, and 6 hours later when I went home, the patient was still there. In fast track.

Thursday, June 19, 2008

Spontaneous Pneumothorax male comes in to the ER with complaint of sudden onset right sided chest pain while doing an activity at work that involved strenuous use of his right arm. He was in a lot of pain in his right upper chest and right shoulder which was worse with position changes and deep inspiration. Based on my secondary exam and the doc's review, it seemed like we were looking at a muscle pull. I told him there was a slight possibility that he had a collapsed young given his profile of being a young, tall, skinny male who smokes, but that really I was gearing up to go get the L&I paperwork for him as soon as he got back from x-ray.

Needless to say, the chest tube tray is in a different location from the L&I paperwork. We knew it was a possibility, and had even warned him of such, but I would have thought the breath sounds would be absent on one side (granted they were certainly diminished, but I attributed that to smoking. My bad.

A couple hours later as we were getting to send him to med/surg, a young kid who was visiting him came up to me and asked in the most sober tone, "Can a short, skinny male get a collapsed lung, too?"

Image borrowed from C&S Solutions - via Google image search.

Tuesday, June 17, 2008

Fast What?

So I had the pleasure of working in fast track recently. Generally I enjoy fast track, because it is in and out and as the RN I can concentrate on one of the aspects of the job that I most love, which is patient education. The downside is the ridiculous amount of paperwork required given the speed with which patients come and go. In this 10 hour shift, we saw 26 patients, which may not seem so impressive until you take a moment to consider some of the patients that should never have been fast tracked (with the exception perhaps of the fish bone):

* The 16 month old with a 102 fever of unknown origin. Fast track course: straight-cath (2 attempts needed), IV line (3 attempts and 3 nurses needed), abbreviated sepsis workup, APAP, Rocephin, etc...

* The 39 year old with back/flank pain and fever. Fast track course: IV line, 2 liters Normal Saline, Percocet, Dilaudid, Zofran, etc...

* The 21 year old with a sensation of "something stuck in my throat" after eating fish the night before. Fast track course: throat x-ray to confirm that there was, indeed, a fish bone stuck in her throat, several telephone calls and mountains of paperwork to arrange a transfer to a higher-level facility with ENT surgeons on call and to schedule an OR

* The 45 year old with elbow cellulitis here for IV antibiotics. Fast track course: after initial consultation/secondary exam, ER doc brought in to review the case, finally IV line and 90 minute infusion ordered

* The 5 year old with severe cellulitis of the thumb with streaking up to the elbow. Fast track course: IV line, pain medicine, skin marking, Rocephin injection, etc...

Combined ER time of those five patients: north of 16 hours.

Four IV starts are about what I expect in a regular ER assignment where the patients stay for an average of 3-5 hours instead of 45 minutes.

It was a day. All I can say is thank goodness for ER Techs.

As an aside: I went through my scribbled notes and as near as I can count, more than 10 of the 26 patients we saw were smokers. Compare that rate of 39% to the state-average of 18% smokers.

Requests from me to email you

I'm sure that I will be getting some traffic over the next few days from people wondering why I have left a comment on their blog to email me. I'm hosting the Change of Shift next week and this edition will be heavy on the audience participation, so if I emailed you or left a comment to please email me, that is what it is all about. I promise it isn't spam.

The hardest part...

I was recorder for an hour-long code today. The patient essentially came in the door with next to no chance at making it, but we gave it our all. I love the teamwork aspect of a critical situation. Everybody steps in and does their job and we all come together so well.

Today was no different. Everyone was doing what we had to do and we were all doing a great job of reminding each other if we saw things to be improved on. The atmosphere was very professional and efficient and we were doing very well and not letting the emotion of what was actually going on in front of us get to us.

The wife and daughters of the patient came in the room so that they could get some closure. By this time the code was still going on, but we had used up most of our medication options and the situation looked grim indeed. We all maintained the necessary clinical distance and yet were able to show the family the needed empathy in a terrible situation like this. It isn't something that you think about. You just do it. You have to. There is no choice if you want to survive in an environment where death is always just around the corner. We are all professionals and we all can do it.

The hardest part, however, was when the family started talking to the patient. It was not easy to hear this poor woman pleading with her husband, "please don't you leave me. I need you to fight and stay with me." But when reality started to sink in and the truth took hold on this dear sweet lady, was when it became next to impossible for the rest of us to stay out of the emotions of it. The tone changed from pleading for him to stay to giving him permission to leave. When she started saying, "I really love you and want you to stay, but if you have to go, then you can go." and the daughter said, "it's okay Dad, I'm going to look after Mom. She'll be alright" was when tears started flowing in the room.

I'm not sure that will ever get any easier.

Picture borrowed from

Friday, June 13, 2008

Baby does what?

Says the mother who brought her febrile baby in to the ED:

"This is not normal behavior for her. She isn't normally this calm. Normally she would be running around and getting in your drawers."

Please, ma'am, keep your baby out of my drawers. Thank you.

Thursday, June 12, 2008

Change of Shift

The latest Change of Shift is up at Nurse Ratched's Place.

Go check it out.

I am hosting the next change of shift here at little old here. If you have anything that you have been dying to get off your chest, please let me know in a comment or by emailing me at "pererau at gmail period company".

I have a couple of themes in mind that I am developing, but nothing solid yet. Keep your rapt attention right here and I'll let you know when I have a solid theme chosen.

Now go run to your keyboards and type like a million monkeys. Let's make some Shakespeare.

Wednesday, June 11, 2008

How do I do it?

A commenter over at another blog that I just found the other day said

"I don't know how you do it. Day after day of seeing tragedy and suffering. I'm not sure I could do it for long."

As for me, I can say that despite seeing some of the worst of the human experience (those who suffer, those who harm others, those who are trapped in addiction, etc), I also see some of the best of the human experience (those who have resolve to live through suffering, those who are overcoming addictions), and I have the incredibly rewarding opportunity of being an agent of change for those who are struggling. I can bring a warm smile, a laugh, relief from pain, and sometimes a life-saving hand to the scene.

At the end of the day, my feet hurt, my back is sore, and my blood pressure is still coming down from 12 hours of feeling like I was never quite caught up with everything I had to do, but at the same time, I feel that I was intellectually stimulated, and that I made a difference.

And that is all the thanks I need.

Tuesday, June 10, 2008

Nice idea, but...

Lofty Zahari over at MDOD links to this article about one idea to reduce the abuse of Emergency Rooms by Medicare patients.

From what I can gather, they spend 500 grand on a phone bank to call people who come in for nothing at all and tell them "don't come in for nothing at all."

Please forgive me if I am just a little skeptical of this plan.


In our hospital, we feel that it is very important to confuse everybody with how codes are announced.

Some of them are medical terms (code STEMI, code neuro...)

Some of them are colors (code yellow (trauma), code green (rapid response team), code orange (pt out of control), code chartreuse (35% off sale starting in hospital gift shop), code brown (grab some wet wipes and gown up, we're going in!)...)

Some of them are numbers (code 4 (code blue in every other hospital in the known universe), code 5 (I don't even remember, but I think it's bad)...)

The result, of course, is that every time a code is called, everyone pauses and looks around at each other until someone gets the courage to admit that they have no clue what was just called. Inevitably someone who actually does know spills the beans and finally the other 10 people who didn't want to admit ignorance as to what code (insert obscure number here) means, start running.

Add to that the non-specifics of how codes are called overhead, and things get worse.

At 10:30 pm a code 4 (you know, Code Blue, but we don't want to call it that, because we might scare patients, so instead we give it a random number that means absolutely nothing and just confuses everyone and makes patients ask what is going on) is called overhead to room 413*, so off goes an ER Tech with the airway box and the pharmacist and the respiratory therapists and one of our docs. 5 minutes later a code is called for "4th floor". Is it the same code or are there two patients going down? No way to know, so off goes the other ER doc and another tech and another airway box (leaving none in the ER, which brings up issues of supplies, but that's a story for another day).

Yup. Same patient. So we were left pretty crippled on an evening when we had 15 patients in the waiting room and an ER full of yellow charts. Lovin' it.

This is the third medical system that I have worked in in the past 3 years, and they all have widely varying systems for calling codes. Can we please come up with a national standard for calling codes? Please?

* room numbers changed to protect the innocent.


The first healthcare system that I worked in had a creative solution to the problem of "scaring" patients with code calls. Instead of calling a code blue, they would call a Blue Team. Similar enough for all the staff to know what was going on, but just different enough that a patient who wasn't paying too much attention might let it slide. Might.

But what is more is that the codes actually seemed to make sense - at least to me. A Blue Team was a patient who wasn't breathing (blue=not breathing... good), a White Team was a patient out of control (white=white hot anger... good), a Red Team was a fire (yeah, you can figure that one out), an Orange Team was a chemical spill (a little stretch, but it still seems logical enough to me). The one code that wasn't a color was the "Code 95" which meant a patient or family member who was escalating toward a White Team, with the idea that we might be able to stop it before objects were flying through the air. I can live with one numbered code because is the only one and so everyone knows what it means.

I have heard of hospitals paging strange "doctors" overhead, as in Dr. Pyro or Dr. Firestone, so that patients don't realize what is happening. I hope I never work in one of those hospitals, because I would end up ignoring all the emergency calls, because I was born with the ignore-overhead-pages-to-doctors gene (A114-3GF7 for those of you keeping score). Also, what happens when the hospital employs a Dr. Firestone (a quick white pages search found 79 Firestone families in my region) or a Dr. Cairo or Dr. Milo or some other similar name? Good thought, bad idea.

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Sunday, June 8, 2008

On a lighter note...

I didn't mean to get so heavy with my last post about wine, so here is something a little lighter:

I asked a patient how bad her tailbone pain was.

"Oh let me see, I think my butt is probably at least an 8."

Glad to know you are confident in yourself. Now tell me about the pain.

is wine good for you?

Longtime readers of my blog know how I feel about alcohol.

Now a new study out of the University of Wisconsin is getting a lot of press.

Every single article I can find breathlessly celebrates how wine is so very very good for you based on this and similar studies.

This makes me very upset.

First of all, from a simple logic perspective, resveratrol - the "beneficial" element in question is not native to wine. It is native to the grapes that make wine, so the alcohol from wine is not needed to get the benefits.

Second of all, from a medical perspective: even if wine had some non-specific, difficult to quantify benefits somewhere down the line, the enormous weight of the plethora of side effects of alcohol vastly outweighs whatever pretended benefit you may get. Not only that, but this is a benefit that merely mimics what you would get from eating a calorie-reduced diet, so it is not like you can't get this anywhere else. So to all of you wine-lovers out there, take a minute and think of wine like a medication. Do the benefits outweigh the risks?

It is funny how quick we are to jump on any bandwagon that permits us our vice of alcoholism despite shoddy research and grasping conclusions. The same people, it seems, who were so excited to attack vioxx for its occasional serious side effects, (a medication which truly was a miracle drug for so many people suffering chronic pain) are willing to overlook the staggeringly large number and seriousness of alcohol's side effects so that they can tout its few meagre and poorly understood benefits.

Oh yeah, how much wine do we need to equal the amount of resveratrol that the mice received? Only 35 glasses per day. But don't worry, one researcher was quoted as saying that due to some other compounds in wine, you might be able to get away with just 4-5 glasses per day. That's right. Just 1 whole bottle of wine every day. That is only 2-3 times the "recommended" daily amount of alcohol. Don't worry. You wont become an alcoholic. It could never happen to you. And you wont drink and drive and kill an innocent family of four driving home from Grandma's house. After all, you only had one little bottle of wine today. And it's good for you!

I hate alcohol.

And the drunk patient I took care of tonight didn't help the cause any.

Wednesday, June 4, 2008

Sorry to interrupt, doc...

I had a patient the other day who's heart rate was running in the low 40s and occasionally high 30s. I went to inform the doctor.

"well, is he symptomatic?"
"um, no, not really, but I thought you might want to be aware"
"I'll tell you what, Braden, when he becomes symptomatic, come back and let me know."

Okay then. I can just see how this conversation would go:

"Hey Dr. Dude, your chest pain patient in room 12 just died. Apparently his heart rate was dangerously low with no known history of significant bradycardia, but his blood pressure didn't seem to be too bad to me, so I didn't bother letting you be aware of the situation."
"Oh, that's okay Braden, because he wasn't symptomatic until right before he died. Oh, and by the way, did you catch the baseball game last night?"

Perhaps I over-dramatize just a bit. This gentleman really wasn't showing any signs except for some mild shortness of breath that he came in with. I'm still learning all the ins and outs of ER nursing, and one of the tricky battles is when to bother the doctor with a piece of information, but it seems to me that while it may be frivolous to let him know about a heart rate of 56 (unless it had been 120 a minute ago), perhaps it would be good information to know that a patient is flirting with the 30s.

Call me crazy, but after we had a 28 year old "anxiety patient" die suddenly of a PE a few weeks ago, I would rather ere on the side of caution in letting the doctor know of unusual vital signs.

Am I wrong?

Tuesday, June 3, 2008

Bladder Scanner Woes

So I'm still new to the world of RNing, but with my background as a CNA and LPN, I have some experience using a bladder scanner.

And yet I couldn't understand why I was getting readings ranging from 200 to 650 with each try.

One CT scan later I had my answer:

This poor guy had 2 liters in his bladder.


Seriously, are you even trying?

So we got a call last night from the pharmacy asking if, in fact, the PA had added to the prescription of this patient an order for

Vicodin Extra Strength #40


But wait, it gets better.

It was written in a different color pen.

Open letter to this guy:

Dear sir,

If you are going to forge a prescription for a controlled substance, please take the time to find a matching pen and learn the name of the drug you are trying to get. Perhaps at that point, the pharmacy may be willing to overlook the difference in handwriting. When you get out of jail, let me know and I'll enroll you in some intelligence lessons.

Oh yeah, and yelling and making a big scene in the ER in the first place didn't exactly endear us to you.

Keep trying. One day you just might get your fix.