Thursday, July 31, 2008

Perspective from the Dead

Somehow when a patient dies after an intense and emotional code, and you go back to the rest of the patients, their complaints about flank pain just don't seem to matter so much anymore.

I'm just saying.

Calling the Code

There is always a big letdown when the Doctor looks around the room and says, "does anybody else have any ideas?" and you know that nobody does, and you don't either.

It is the way things go and I am okay with it - in fact, I think in many cases it would just be cruel and disrespectful to continue beating on a dead body, but somewhere deep down in the back of my mind, there is just a voice screaming, "NO! DON'T GIVE UP!"

Can you tell how my day went today?

He Was Already Dead, Jim

Come to think of it, it is weird to read in the local news that a patient was "taken to ABC General Hospital where he died," when you know full well that he was dead long before he walked in the door. He was just declared dead at ABC General.

He's Dead, Jim

It is always weird to read about a death in the local news and then realize, "hey, I cut his pants off and started his second IV line."

Kind of brings a whole new angle to the story.

Cruel Joke?

Why is it that the most critical piece of equipment that we use in the ER sounds exactly like a cheap video game?

Wednesday, July 30, 2008

One at a Time, Please

I hate having two rooms open. Yes, it is nice to be able to have a little breather, but it almost always means I am going to get two patients at the same time, and anyone who works in an ER can tell you that almost every patient encounter is extremely front-loaded. When a patient comes in, they are going to get a whole big pile of stuff dumped on them at the beginning of the visit: assessment by the doc, and assessment by the nurse, labs, IV start, EKG, radiology tests, registration, medications, and a whole host of other things. Then we enter the sit and wait phase, while the lab tests get done, the x-rays get read, the medications do their work, and the IV fluid infuses.

As the RN, I am very heavily involved in the initial phase - I'm doing an assessment, making sure the EKG is done and the urine is collected, starting the IV, giving the medications, etc. During the sit and wait phase, I'm mostly sitting and waiting with the patient. I generally like to do my own vital signs, but that is certainly a task that can be done by the Tech.

So if I have an open room, and my other patients are in the sit and wait phase, I have no problem receiving a new patient. In fact, it is nice, because I like to stay busy. when I get another patient and I'm still somewhere in the initial phase with a patient, then things get broken up. I don't want to leave the new patient just sitting and waiting to get all those things done, but I can't just leave my current patient to sit and rot, so I end up trying to bounce back and forth as much as I can, which, in the end, is slower, because each time I go into a room, I have to regain my bearings about just where we are.

Despite all that, this is part of life in the ER and one of the things you just have to get used to.

So all of what I just said was to set up this scenario from a while ago:


I had just triaged an ambulance patient - 17 year old with arrythmia and atypical chest pain. I got in there and completed my secondary assessment. I tried to do it quickly because I knew we were getting full and I had another open room, and I didn't want to still be in the middle of the initial phase with this kid and then have to start at the same time with another patient. The assessment was slow going, because the kid didn't know much about medical history or meds or what was currently going on, or really anything, for that matter. I felt good, though, because nobody had popped thier head in the door to say that I was getting anybody in my other room.

Then I stepped out in the hall.

12 people were standing outside of my other room with IV trays and drug boxes and stethoscopes.

Someone had coded in the hospital and was brought to the ER and put in my room almost 15 minutes earlier, and for some reason nobody had bothered to tell me. So I went in the room (remember that I just finished the secondary in the other room and so I haven't even seen the chart yet, and my third room had a patient who had just gone to CT scan, and who I had just inherited from another nurse and knew very little about) and found that the charge nurse and the float nurse had the patient sedated and restrained and had given Ativan and had started two IV lines. That's nice. But nobody had charted anything, so I walk in and there are crying family members and chaplains and pharmacists and lab techs and ER techs all over the place, and the charge nurse looks up at me and says, "maybe you should get an ER record sheet and start writing down what is happening."
Okay. Maybe you should have someone pop their head in my room and let me know that I'm getting a coding patient. But I didn't say that. I don't like conflict.

The other two nurses helped me for a few more minutes and even put a foley in the poor lady and then left, with the float nurse asking me if I needed more help. Well, at the moment, I didn't need any more help with this patient, I just needed to get my hands around what the situation was and do a secondary and start paperwork for restraints and all the other little legal stuff that goes along with ventilated patients, so I asked her if she could keep an eye on my other two patients for a little bit, and mentioned that the doctor had said something about pain meds of the 17 year old before I had been sucked into this room.

Anyone who has worked with newly ventilated patients can tell you the struggle it is to keep up with all the paperwork and the legal requirements regarding restraints and sedation and vital sign monitoring. Add to that trying to balance the different sedating medications (Propofol, Ativan, Fentanyl, etc), IV fluids, ventilator settings, family sensitivities (a greatly overlooked skill in nursing), and GCS assessments, and you have an extremely time-consuming task.

But it's okay, because we are a team, and teams work together.


So finally I get a chance to get away for a minute after about an hour. I pop my head in the room next door and make sure the patient is alive and I ask Mom if other nurses have been in to help them. She says that yes a couple nurses came in, and so I am relieved, and head back in for round two on the vent patient. Nearly an hour later as I'm finally getting to a point where my paperwork is done and the patient is satisfactorily positioned and sedated (and it was a very hard battle because the Propofol was hung almost 20 minutes after the RSI, so we were constantly behind the curve). In walks another nurse with my 17 year old's chart. She pulls me aside (kind of) and says, "don't you realize that this is a yellow chart and there is nothing at all charted on here?"

So much for teams working together.

It turns out that someone went in that room to fix the Oxygen Sat monitor, but that was all that was done and nothing was charted. And although I felt betrayed and angry that nobody thought to watch my back while I dealt with the critical patient, the blame was technically on me because that patient was technically under my care. The charge nurse pulled me aside (kind of) and proceeded to tell me that I need to be sure to assess the patient every hour and chart it whenever I have a yellow chart. I bit my tongue again.

I asked the doctor about where the order was for the Toradol he had said he was going to give the patient, and he said, "I gave you a verbal order for that. Why should I have to write it down?" Well, Dr. E, because 1. verbal orders are not permitted in non-emergency situations, 2. because even when they are permitted, that is only when they can be writtn down by the nurse and read back to you and I didn't have the chart, 3. because you never said it as a verbal order, and 4. you didn't give any specifics (dose, route, frequency). And frankly, I don't think that "we'll give this patient some Toradol" qualifies as an appropriate verbal order.

So perhaps you can understand why I was frustrated and a little angry on top of the soreness and fatigue I was feeling from working as much as I have been lately.

You might even understand why I was not my usual sympathetic and empathetic self with the poor lady who came in with right flank pain and was squirming all over the bed and not holding still while I tried to get her vital signs (where was my tech, anyway?) and start an IV.

And hopefully you will understand my distress and remorse when I learned that it wasn't kidney stones, but rather a hemorrhaging Renal mass that required ALS transfer to a higher-level facility. Luckily for me, I was able to make it up to the patient and by the time the ambulance gurney wheeled out of the department, the patient held my hand and thanked me for my wonderful care (the best reward I ever get as a nurse).

Moral of the story: No matter how much things fall apart around you, in this game, you have to keep your cool.

Tuesday, July 29, 2008

Need Help Paying for Those Meds?

A website that I learned about a few years ago that you might want to learn about as well is the Partnership for Prescription Assistance.
At the time I was working in an allergy/pulmonology/sleep clinic and many of the medications that we prescribed regularly (Allegra, Advair, Provigil, etc) are expensive and do not have generics, so we gave out a lot of samples and filled out a lot of prior auths. One day somebody tole me about pparx and since then I have referred a lot of people to it. The website is a collaboration between a number of pharmaceutical companies and prescription assistance groups and acts as a resource to help you find ways to get your prescriptions for cheaper or even for free.

To test it out, I selected Prilosec, Synthroid, Atenolol, Klonopin, Xanax, Provigil, and Advair (a med or two from each patient I had today) and made up some basic information about myself (they don't ask for any identifying info, just stuff like what your salary is and if you have medicare). I made myself a relatively poor (1000 per month) medicare recipient in a 3 person household and they came back with 7 different programs to help cover my prescription meds. I glanced at the overviews for a couple of them and they seem like genuinely helpful legitimite programs (for instance, did you know that GSK offers a huge list of medications for free to needy families - such as Advair, Coreg, Avandia, Augmentin, Zofran, Flonase, Paxil, Requip, Wellbutrin, Imitrex and on and on and on?) Me neither. But now I do.

Anyway, for those of you that have a list of medications, and may be struggling to pay for them (or even if you aren't, it is worth seeing if there is any deal you can get), or for those of you who may have patients who struggle to pay for meds, go check this site out and put it on your list of helpful resources.

Do I sound like I'm getting paid for this? Maybe I should be.

Image borrowed using Google Image Search. I'll give it back. I promise.
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Thursday, July 24, 2008

An Open Letter

To the young lady who we had to restrain:

Dear V,

Everybody has their moments. If you don't believe me, come find me when the voice on the other end of the phone comes on after I've been on hold for 45 minutes and tells me that "your call is important to us."

You had yours today.

I know it seems unfair that your friends made you come into the ER because they thought you were overdosing on benzos to kill yourself. You say that you weren't. I understand. I don't take sides in situations like this, but when we get that kind of allegation, we have to look into it. You weren't in a good mood, and understandably so. That is why I took a lot of time to help you understand where we were coming from with everything that we were doing. I told you that if you are straight up with us, then we'll be straight up with you.

Then you decided that you were going to leave. "It's my right," you said.

No. It isn't. We tried for 15 minutes to talk you down, to help you understand. During that time you tied up the doctor, myself, three techs, another nurse, four security guards, and eventually, five police officers. I told you that we didn't want it to become a struggle, and you scoffed. Trust me, though, we really didn't want it to become a scuffle. If we are in this business, it is because we care about people and want to be healers.

But there comes a point where we just have to do what we have to do, and if we have any doubt about you being suicidal, we have to keep you. Yes, you read that correctly. We HAVE to. No choice.

I'm sorry that you ended up getting thrown onto the bed. I'm sorry that the police were gruff and rude. I'm sorry that the restraints made you feel like a criminal. I'm sorry for how the whole thing went down. But I don't say I'm sorry to transfer blame onto myself, my coworkers, or the police. In fact, this whole thing rests entirely on your shoulders. All you had to do was stay with us for just a little bit. If you were "framed", then we would be able to get a pretty good idea of that and let you go. No problems, no questions.

What is really ironic, V, is that just a few minutes after that cop pulled out his taser gun, the urine results came back. No benzos. Just before you stood up and started pulling wires off, the social worker was literally walking across the ER toward your room to interview you. You would have been out the door in 30 minutes. Free to enjoy the rest of your night as you pleased.

Instead, we had to keep you for several hours while we waited for you to calm down and the Haldol to wear off.

I'm a nurse. It is my job to make sure that you stay safe and healthy, and I'm willing to do whatever it takes to do that, even if it means pages of notes and assessments every 15 minutes while I try to care for two other very sick people; even if it means standing there for 15 minutes to assure everyone's safety while you have that chat with your angry family member when I would rather be doing the 10 other tasks I have on my plate. I do it because I care.

See, what you may not understand now - or ever - is that everything I do is to help you have better outcomes. That is why I am a nurse.

So next time life throws you a curveball and you think the situation sucks, just roll with it. You are going to get through it, and we are there to help. So, in the words of the great philosopher Tom Cruise, "Help me help you."

Always there for you,


So that's how you are reading my blog.

A couple weeks ago I asked how you were reading my blog and got 17 responses. to everyone who stops by to take a peek into my world and for those who took the time to respond to this and other posts. Other bloggers know that getting comments are the highlight of our blogging day!

Oh, and the other day, my Google Reader total jumped from 18 to 34, so perhaps it only updates every few weeks.

And it seems like I remember someone asking in one of the comments somewhere about how I get my totals for Google Reader and for how many people are visiting my site.

For Google Reader, all you have to do is bring up any blog and at the top right part of the screen there is a link that says "show details". It will tell you how many posts per week the blog has (it says 0 for me...) and how many subscribers (which, now that I'm looking at it, has jumped to 39).

As for all the other details that I get (like when people from Wyoming come to visit), I use Google Analytics for that. To get Analytics working on my blog, all I had to do was copy and paste some code to my blog. Using blogger, I just added a page element at the bottom of the blog and put the code there. Within a day, I was starting to get numbers and it keeps track of stats for 30 days.

* No bloggers were paid in the making of this advertisement *

Welcome, Wyoming!

I know that everyone will be thrilled to find out that finally, after all these years months weeks days, Wyoming has finally put itself on the map, thanks to a devoted reader from Casper.

Dear Mr or Mrs Casper,

Thank you so much for taking the time (2 minutes and 28 seconds, to be exact) to stop by my wonderful Wyoming-friendly website (www) and leaving your footprint on my world.

You may feel as though you are just one, and that in a sea of thousands, what does it mean, but let me assure you that although you represent just 0.03 percent of visitors to my blog over the past month, you represent at least 0.04 percent of my heart. Please, do come back again.



Wednesday, July 23, 2008


I just gave Dilaudid PO.

Seriously, like 20 minutes ago, right before I walked out the door, I went to help a nurse who was swamped and looked at what the doctor wrote: Dilaudid 2 mg PO.

I didn't know Dilaudid came PO. I went in to give it to the patient, and he said, "are you sure that's Dilaudid? I've never seen it in a pill before." Even my frequent fliers have never seen Dilaudid PO. I've only ever seen it in injectable forms. Is this a new thing or am I just ignorant to the ways of the Gods of the Council of Hydromorphoneus?


She had low abdomen/pelvic pain for 3 days and was experiencing headache symptoms. On my paper that I take into the room with me to keep my notes straight since my memory lasts approximately 15 seconds, I wrote:

vag bleed

Okay, so I remember why I wrote the last two, but PIGI? What? I walked out to the nurse's station and got on the computer to put in the secondary, and stared at the paper for a couple minutes trying to figure out what I meant by PIGI. I still don't know.

I'm going senile in my old age.

Friday, July 18, 2008

It's What Ply?

You are going to have to trust me on this: I don't want to spend too much time talking about my booty; suffice it to say that I am somewhat of a fan. In fact, my booty is there for me all day long whenever I need it to provide wonderful padding for my seating needs.

As a reward, I splurge and get the nice toilet paper from Costco - not that Kirkland Signature stuff, but the, quilted stuff that kind of feels like I'm stealing someone's old comforter when I use the bathroom. I believe it is approximately 187 ply.

I don't expect everyone to follow suit. My parents get the Kirkland Signature stuff, so when I go over there I know I will be using toilet paper that is about 1.25 ply. It aint the best, but I can live with it.

The hospital where I work, however, has found some magical means of developing a toilet paper that is actually a negative ply number. I keep watching the Discovery Channel in a vain hope of learning how it is possible to take sandpaper and whittle it down to it's basic neurons, converting it in the process to a completely transparent form that dissolves completely on contact with water or human skin. I'll keep you updated if I do discover this secret.

In the meantime, I never thought I would be jealous of the box of tissues we give to patients who have to use the commode chair.

Wednesday, July 16, 2008

I Don't Need the Beamer, I'll Take the Hyundai

Me: Do you have any allergies to medications?

Patient: Percocet.

Me: That's an unfortunate medication to be allergic to.

Patient: No, it's great; it means I get Vicodin!

Tuesday, July 15, 2008

It Has Come to This: My Wife Left Me

I'm not sure if it was something I said, but this morning my wife took her stuff, took my 1 year old, and left.

She said something about "seeing other people", and mentioned parents and grandparents and siblings and cousins and barbeque chicken with mashed potatoes.

So we said our goodbyes and went our separate ways.

But it's okay. I know she'll be back one day (I have the Wii, after all).

In the meantime, I have scheduled myself to work two extra shifts a week for the next four weeks. Between now and when the family returns, I will work 207 hours, including approximately 10,000 hours of overtime. Wish me luck on that.

Speaking of Nashville Star (good segue, huh?), what is up with the people who keep voting for Coffey? The general talent on that show goes something like this: Gabe rocks, Melissa has got serious pipes, everybody else, including the judges really, really sucks. So why am I still watching? Because I'm trying to gain empathy for my patients who experience intense pain.

Sunday, July 13, 2008

The Pain Scale you do not already know my opinion of the pain scale, please refer to my blog title.

That said, pain needs to be treated. I've been in very severe pain before and I know it is terrible and not fun and makes everything hard to deal with. My wife has a relative who suffers from severe chronic pain, and it has taken huge chunks out of the quality of her life. But how do you treat it when it is so hard to quantify?

How can I take the 1 to 10 scale seriously when person a skips into the ER talking on his cell phone and drinking a Pepsi, all while complaining of 10 out of 10 pain, and person B is throwing up while blood gushes from a gaping wound and they are screaming in pain, only to tell me that it is at least a 5 out of 10?

And then you have the kids. We use the FLACC scale to try to determine pain in preschool children and the Wong-Baker faces scale in older children. Neither of these works any better. Seriously. I don't think I'm exaggerating to say that 90 percent of the kids that I show the faces scale to point to either the 0 (because it is smiling) or the 10 (because it is crying), and I used to work in a pediatric office, so I've done this thousands of times. FLACC has a place, but almost every kid that comes into the ER gets a 5 on the FLACC scale off the bat because it is a scary, uncomfortable place with lots of strange people walking in and out and trying to put stethoscopes all over the place on them.

I don't know the solution to this problem. I just try to do my best with every patient who comes in for some pain-related issue (85 percent of our patients). The only really useful thing that the pain scale does from what I can see is it helps to compare a patient to what they were an hour ago, but even then, I've had more times than I can count where I walk back in the room after having given a couple of dilaudid and the patient tells me, "oh I feel so much better now. Really a world of difference. Let's see, my pain was a 7 before; now it is probably a 6 or a 6.5." So now I have to chart that the pain went down one point. I'm just waiting for my day in court when the lawyer asks me why I didn't give the repeat dose of pain meds when their pain was still a 6.

Anyway, on to the point for which I was headed when I started this post: I've been sitting on a post from Ten out of Ten for a couple of months that I found interesting regarding a test to determine the severity of a patient's pain. A little whimsical, but it is a good reminder to pay attention to more than just what a patient says. (In fact, one of my favorite things to chart: stated pain out of proportion to physical presentation.) Then a few days ago, Scalpel posted about the Delta P. I was ready for an intelligent discussion of a new airline product, but was disappointed to just get a post about pain management, but at least it was an interesting post about pain management. The idea of his post is that if someone who normally has 6/10 pain presents with 10/10 pain, then they are not as urgent than someone who normally has 0/10 pain and comes in with 5/10 pain. Of course, this all hinges on their stated pain levels accurately reflecting what kind of pain they are in.

I don't think either approach would stand up in court (but your honor, she winced with the BP cuff and her Delta P was only 2), but they are useful in our individual assessments of how a patient is really doing, and may come in handy when we are trying to prioritize between three or four needy patients.

How do you deal with the broken pain scale system?

Saturday, July 12, 2008

Dr. Mario

One of the great video games ever made is the simple and fun Dr. Mario.

Now it has come out for the Wii as a downloadable add-on, which, of course, I instantly downloaded, remembering all the nights of fun competition my wife and I had enjoyed playing the original NES version.

Oh what fun!

But even more important, I learned a very important lesson on fighting disease that we should look into implementing in our healthcare system.

Dr. Mario first introduced us to the concept of determining what color a virus is and trying to find pills that are a similar color. Despite the logic of this approach, this has not, in fact, revolutionized the health care system.

But now the good Doctor is back with a new strategy: Get together six or eight doctors and run really fast into the crowd of viruses and just running in place really fast until you finally push them away.

I think it has great potential.

So to all you Docs out there, lets see if we can get together in groups and start running. It might work best if we put the patient at the end of a big treadmill. Any other thoughts on how we might implement this strategy?

You Know It'll Be a Good Day When...

Apparently not every day brings challenges in the ER. A few days ago was one of those days.

You know it is going to be good when...

* You come on shift and only two of your rooms have patients in them.
* One of those patients gets discharged before last shift's nurse leaves.
* The other is a drunk holdover from last night, but gets up on the first try and walks to the bathroom. Gone 30 minutes later.
* Your next patient is a wound recheck that involves approximately 3 minutes of your time.
* Your next patient's only complaint is nausea for 1.5 hours. That's right. No vomitting, no chest pain, no paresthesias, no back pain. Nothing. So IV, Zofran, labs to rule out heart probs, see you later.
* You get assigned an ambulance patient with chest pain... and find it has resolved by arrival to the ER. Yeah, he's there for a few hours waiting for a room to rule out MI, but your main job is to make sure vitals are charted every hour and the pain doesn't come back.
* You don't get any other patients for 4 hours.
* When you finally do get a patient, you are at lunch and so the IV is started, the medications are given, the labs are drawn, and all that is needed is a quick secondary exam.
* 5 minutes after you are done with the secondary exam, the patient is moved to another room because of a doctor switcharoo.
* You admit your chest pain patient and hove NOTHING AT ALL TO DO for the last hour and a half of your shift.
* You want to see if anyone needs help, but everyone else is seeing if anyone needs help as well.
* There are never more than 10 patients in the Main ER for the entire shift, and as few as 4.
* There is a surprise going away party for one of the nurses, so you don't even have to buy lunch (although it is sad to see a good charge nurse leave).
* Your day pretty much involved two IV starts, hanging three liters of fluid, giving Zofran twice, Nitroglycerin 3 times and putting on a Nitro patch. Oh, and getting vital signs. Oh, and a wound check (any pain? no. any discharge? no. redness? no. discomfort? no. Great, see ya)

Okay, so some people might not call that a good day, what with the boredom and all, but after the past couple of weeks, it was supremely nice to have a bit of a break.

That's the ER for you: sink or swim.

Crass-Polination Blog

I just want to say that my favorite ER Nurse blog to read is over at Nurse K's place.

Somehow she finds time to post something just about every day, and they are always interesting and insightful, and "If you're dying, she'll save you, if you're looking for narcs, she'll show you the door. Nurse K knows her stuff, and loves her work, and her blog shows why being an ER nurse is one of the best jobs around" (oops did I accidentally put that in quotations to make it easier for Nurse K to cut and paste it into her sidebar? And then did I conveniently provide her with a link to 20 out of 10? Sorry about that. My fingers must have slipped.)

Go check her out, but whiny entitled commies need not apply.

Thursday, July 10, 2008

How Are You Reading My Blog?

There are 18 people who subscribe to my blog using Google Reader. Compared to the number of visits I get every day, that is an incredibly meager number... even moreso when you consider that at least 6 of those are directly attributable to my family members.

So besides those who just come here casually via a link from another nursing blog, how are the rest of you reading my posts?

New Poll

I have a new poll in my sidebar. Take a moment and let me know how it is on your unit when it comes to anti-nausea medications. If you want to comment on the issue, do so here.

You Know It'll Be a Bad Day When...

Every day brings new challenges in the ER. Some more than others. A few weeks ago was one of those days.

You know it is going to be bad when...

* You come on shift to find the board full of nothing but yellow charts
* You are just walking out of triaging the chest pain patient who came in by ambulance, and without a chance to check on your dyspnea patient who just came back from MRI (for possible spinal cyst!?!?), you see the medics roll into your room with a 91 year old.
* You go in the room to deliver critical medications for your chest pain patient only to learn - as your saline flush explodes all over you - that the medic messed up the IV and didn't get it inserted properly... tack on 30 minutes of trying to save the site and eventually starting an IV on the opposite arm. Hope your other patients are all right!
* All three of your patients have admission orders... at the same time.
* One of your patients is getting out of bed to leave AMA, the other is threatening to do so in order to go smoke, and the third is more confused now than when she got there, but you don't have time to check it out.
* The Tech comes up to you and says, "I'm thinking of just putting a big ABD pad on that scalp lac and then wrap a bunch of tape around his head to keep it in place"... and she is serious.
* As you walk in the door to start your shift the 550 pound patient is checking in. You have an open room. Yeah.
* You look up on the tracking board and see more patients in the waiting room than there are in the ER.
* You take just "a minute" to help settle this ambulance patient for another nurse and find out that she has become completely unresponsive. Completely. As in no response from sternal rub or fingernail pressure or baseball bat to the temple. Nothing. How do you spell life flight to a Level 1?
* You are busy complaining about how difficult this day is and look up at the board only to realize that your load is no more difficult than anyone else's.
* Senior Management chose today to do a walk-through and start nit-picking about stupid stuff.
* Really, do they remember what it was like to work on the floor?
* Unit Manager was there, too, and had no choice but to go along with Senior Manager on the stupid stuff.
* Don't fire me.
* You finally get your lunch break - your first break of the day - 7 hours into your shift.

You know that you are in the right career when...

* Your day includes all of that for 10 hours, and as you walk out the door, you think to yourself, "well that was fun."

Wednesday, July 9, 2008

Verbal Orders

From my above post about Doctors and Nurses, I got the comment from Vitum Medicinus asking:

I haven't been on the wards enough to know the rules, but wouldn't this
be in the best interests of the patient ie. so they can get their pain
meds faster??

Just asking, I admit ignorance...

Vitum, I have heard arguments for why verbal orders can be helpful, including such ideas as speed of medication delivery and eliminating handwriting problems, but as a whole verbal orders can be a dangerous thing.

First off, at least in my state in the US, a verbal order has to be written down by a nurse and then read back to the doctor and charted as such, so where a doc could just write "dilaudid 1 mg IV" a nurse would have to write "VORB dilaudid 1 mg IV by Dr. Peel/Braden, RN". So there goes the time-saving thing. Secondly, while there is the potential for me to mis-read a Doc's handwriting (and we have a couple Docs in my ER who I swear write with a pen stuck in their nose just to see if it can be done), there is equally the potential to mis-hear the Docs order as you are writing it. Also, a doc has to sign off on the verbal order at some point, and I have seen it happen where the doc remembers differently than what the nurse wrote down, or where the nurse didn't write anything down so that they could get the medication to the patient faster, and later the doc went in and wrote for different medications.

For my part, unless we are in a code situation (in which case there is a recorder), I hear what the doc has to say, flip the chart to the order page and hand it over. They scribble their note, and then I go get the med. It takes 15 extra seconds.

So in conclusion: If you go and write the order on the chart, then A. there is no need to remember what you ordered, B. There is no need to go back later and cosign it, and C. you know that at least the order was put on paper properly. It takes a few extra seconds, but it is a few extra seconds well-spent.

Of course that is all for the ER. On the floor it is a different story completely, as there are no Doctors hanging out on the floor and so it involves paging and telephone calls and faxes and whatnot, and that is one of the reasons I don't want to be a floor nurse.

Wyoming Update

A couple weeks ago, I put a call out for Wyoming peeps to show their faces. One commenter hinted that she might be from Wyoming, but if so, then Google doesn't think so. Wyoming still remains the only state not to send someone my way according to Google Analytics.

Some other things we learn from Analytics (WARNING: BORING STATISTICS AHEAD! TURN BACK NOW!):

* Montana and West Virginia are also pretty much slackers. Each state has only deemed my blog worthy of 1 visit.

* Besides my state (which isn't first), California, Texas, and Pennsylvania have visited most frequently. Do people actually live in Pennsylvania? I thought it was just a front for some Tom Hanks movie.

* Rhode Island and Vermont have only stopped by a handful of times, but when they come by, they stay to visit many pages per visit.

* People in Arkansas stay the longest (by a wide margin) when visiting my site. I'm not going to comment on why that may be.

* People in Mississippi stay an average of 5 seconds. Speed readers.

* I thought it was a joke at first, but Kannapolis really is a city, and it is 5th place, after "not set", my city (hope management isn't reading... I'm going to have to mind my manners), Seattle, and Los Angeles. Interestingly, Minneapolis is right after Kannapolis.

* I don't think I could live in a city called Kannapolis.

* I also don't think I could live in Cabot or Bradley, but they are next on the list.

* My Change of Shift post has attracted 10 times more people than the next-highest individual post, but only 1/3 of the total traffic to my blog.

* The next-highest totals are my posts on Alcohol and Calling Codes.

* The blogs who refer the most visits to me, in order, are Emergiblog, ERNursey, Madness, Nurse Ratched's Place, EDNurseasauras, Crass-Pollination, and Medscape Nursing, with several of the blogs that I linked to at Change of Shift coming in behind those.

* Still at the top of the heap for how people find me are from direct visits and Google referrals.

* 57% of visitors to my blog are using Internet Explorer (why?) and 34% use Firefox.

* Internet Explorer 7 was released in late 2006 and yet only 67% of my visitors have upgraded.

* One person is still using IE 4 (released in 1997).

* Almost 9 out of 10 visitors are using Windows. Next is Macintosh, followed by - are you ready? - IPhone.

* My wife and I also keep a family blog. In the last thirty days, it has had 1/10th the number of visitors as this blog. Of course, we don't advertise that blog and it is mostly family and friends that come by.

Interestingly, although visits to my blog have gone through the roof, the number of subscribers to my blog through Google Reader has not changed at all since the Change of Shift. This despite me touting Google Reader as the best invention since Charlize Theron.

New Poll

I need a new poll for my sidebar, but I'm failing in the highest degree to come up with one. Any ideas?

Charting - President Bush Style one of my coworkers gave me a lunch break and when I came back I found a note on a patient's chart saying that the patient had gone to "nucular nuclear imaging". She actually pointed it out to me and we had a good laugh at the gaff, but I think if Bush saw that note he would have asked, "Hey, why did you guys cross it out and then spell it wrong?"

Speaking of getting words wrong, why can nobody in the entire world say Phenergan? Nobody I see seems to take that medication, though I've met a lot of patients who take Phenegren. In fact, even when the doctor prescribes it to go home with and I explain it to the patient and it is there right in front of them on the page in black and white, neatly printed from a laser printer, I still get questions like, "how long should I take the Phenegren for?"

I suppose it is that same mentality that results in me being called Brandon or Brady all the time.

And I can't leave a post about messing up words without mentioning the old holdout "jewelry", which is oh-so-frequently called "jewlery". I'm not sure what jewlery is, but I think it involves a funny little cap and a prayer book.

Update: I did a Google Image search for jewlery and came up with 163,000 pictures. Seriously. These are the people we get in the ER with random objects stuck up their noses.

Tuesday, July 8, 2008

Respect and Arrogance

Guitar Girl talks about an incident where she corrected an intern, and leaves the implication that the intern didn't take it too well. Madness has a different take on the story, and feels that it is silly for us to try to be careful of the doc's ego while they crush ours all the time. Go read those two posts before reading my take.

You back? Okay, here is what I think: two wrongs certainly don't make a right, and just because we sometimes get mistreated doesn't mean we have carte blanche to return the favor.

In the case of Guitar Girl's story, I don't see any reason why she needed to say anything in front of the patient. The danger to the patient wasn't imminent and because the facts were on her side, she would have had support from others outside the room. This is a situation where the only danger to the patient would have been if the nurse had gone and picked up the medication and administered it, so there was plenty of time to talk to the intern in the interim.

It would be a different story if she were in the room and the doctor had pulled up 60 of Toradol and was getting ready to push it, or in the middle of a code situation when you notice that something is being done incorrectly. In situations where the danger is immediate, then I think whoever notices the mistake has the responsibility to at the very least stop the action and pull the person away from the patient to explain, or if necessary, to say it right there and then; because you are right: safety trumps ego.

But here it is about more than ego for the doctor. Here we have a patient who is now doubting their treatment. If Ego gets undermined, who cares, but now we have credibility undermined, and a patient who doesn't think she is going to get the treatment she needs. Not only does this lead to lower satisfaction scores (who cares), but it leads to worse outcomes for patients. I'm a strong believer in the power of the mind over healing, and I have seen time and again that a patient who does not believe that they will get good care somehow doesn't get good care, regardless of what the caregivers actually do. Anything we can do to help a patient feel like they are getting the best possible care will improve outcomes, lead to better results, and improve patient satisfaction and Press Ganey scores.

So yes, there is absolutely no reason that doctors should arrogantly boss us around and make us look like fools, but there is also no reason that we should return the favor, unless we are saving our patients from immediate threat.

From the comments at Guitar Girl's post come two very good points: "Never go to a teaching hospital in July" and "Why is an intern giving a verbal order for a non-emergency med anyway?"

Saturday, July 5, 2008

Sweet Gig

I remember one nurse I used to work with who had a pretty sweet gig...

He worked Saturday and Sunday from 8 am until Midnight. The first 8 hours were standard pay and the second 8 hours were overtime pay. So in 2 days, he accumulated 40 hours worth of pay and had the rest of the week to himself.

Pretty sweet... if you can handle it. I'm not sure I could.

Thursday, July 3, 2008


Yesterday I gave a plug for Google Reader, because it has made my blog-reading life easier. Now let me plug ScribeFire, which is a Firefox plug-in that has revolutionized my blog-writing life. No, I am not getting paid for this.

With ScribeFire, a simple post is just four amazingly easy steps: 1. When the inkling takes you to post something, just click the little orange notepad icon or press F8. 2. Give your post a title (remembering to capitalize all words or your brother gets mad). 3. Type stuff in to the body of the post. 4. Click the publish button.

But what if you want to have a little fancier post? Well, since ScribeFire pops up at the bottom of your screen, and the size is adjustable, you can still surf the web and look at websites while blogging. When you come to a page that you want to link to, follow these amazingly easy steps: 1. Make sure that the page you want to link to is visible in your browser. 2. Highlight the text you want to make into a link. 3. click on the link button. 4. ScribeFire automatically populates the URL box with the page you are currently looking at. Verify and click OK. Done.

Want to add an image? Click where you want the image, click the image button, and then either enter the URL for the image from the internet or find it on your computer. The image is imported and you can resize and relocate the image.

Want to add tags to the post? or Technorati links? You can do that, too. Want to be working on multiple posts at once? (right now this is one of six that I'm working on) not a problem. The posts are saved in "tabbed" format so that if you aren't quite done with it, but have another you want to work on, you make a new tab and come back to the old one later.

Changing fonts,

  • making
  • bulleted
  • lists,

bolding or underlining words, correcting misstaykes mistakes, changing font color,

adding long block quotes from another person or an article that you just read and having it separate from the rest of your text so that people can look at it and know that this is something that somebody else said and now you are going to comment on it or ridicule it or praise it,

all of this is not only possible but incredibly easy. Remember, I'm not getting paid for this, even though it sounds like it. I just love this little add-on so much that I can't help but get excited about it. It is the only reason that I was able to put together such a long and involved Change of Shift recently.

So if you are not using Firefox already, why not? And if you are, go to the add-ons page, and get ScribeFire. You'll be glad you did.

Can millions of people be wrong? (okay, so they can, but not with ScribeFire)

Not For Me

When I was in the job hunt I signed up to get automatic updates from a hospital in my city. Every once in a while I would get an email listing the new RN positions that were available. Fast-forward a half a year, and despite having a good steady job and no longer living in the same city as that hospital, laziness on my part has kept me receiving these updates.

Today, as if I needed it, I got one more reason that I will never work at a nursing home:

Posting Title: Registered Nurse (RN)

Shift: 1 - Day Shift


Employment Status: Full-Time

Salary Minimum: 19.82

Salary Maximum: 28.70

External Description:
Long Term Care Nurse (RN) - $3000 Sign-on Bonus!

Yes, you read that correctly, they are hoping to attract "Skilled" Nurses, and to do so have been authorized to delve deep into their pocketbooks to offer a salary that is about 12000 dollars per year less than any other RN job in the state.

But fortunately, if I work long and hard and get years of experience, that rate will keep going up until it is competitive with starting RN positions at every other facility.

Granted, I would not do LTC even if the pay was better than other places - just not my thing - but really, less than 20 bucks an hour? No wonder Nurse K gets patients with unstable vital signs.

NurseExec? Can you help me understand this?

Wednesday, July 2, 2008

Google Reader

While I still have people taking the time to come visit my blog, let me take just a minute and plug Google Reader. No, I'm not being paid by Google.

When I find a blog that is interesting enough that I want to see what else this person will have to say in a day or a week or a month, I subscribe to the feed using Google Reader. It is simple, intuitive, and extremely efficient. Not only that, but I don't need any additional software, and it works whether I am using Firefox (my main browser), Opera, or even if I am for whatever reason reduced to Internet Explorer. When I go to work and get on the computer in the break room, I can log in to my Google account and check my feeds if I want.

And I never miss anything that Nurse K or Kim or Scalpel have to say.

Go check it out. You'll be glad you did.

And for all you doubters out there: if my mother can do it, so can you. Hi, Mom.