New Change of Shift

Amanda over at this crazy miracle called LIFE has the newest Change of Shift and it is a sort of spooky ride on the medical train, baby! (this last sentence brought to you by sleep deprivation.  Babies: have one today!)

And in other news, I'm linked.  Twice.  It must be my overwhelming talent and all the lovestruck hordes rushing madly like packs of wild, ravenous cheerleading fools to submit my entries in desperate attempts to win my affection.

Or maybe I e-mailed Amanda and said, "hey you can post these if you want."

Either way, I'm published.  Baby.




(This entire post brought to you by q2 hour baby feedings.  All day.  All night.  Without cease.)

They Aren't Dead Until They are Informed and Dead

Tex has a post up about funny nursing school stories.  This one made me spit my coffee all over my computer*:

While working the afternoon shift on a busy medical ward a patient
passed away, something that isn't new. An "older" nurse asked this
student to go and make the patient look comfortable for the relatives
to say good-bye to. Off this student goes and sets the patient up
complete with reading glasses and newspaper. Before anyone saw this set
up, rigormortis had set in and so they had a dead gentleman reading a
newspaper.

If you didn't just laugh out loud (or at least gasp in horror), then you need to take a minute and picture that scene when the poor family members come in to the room.







* Actually I don't drink coffee, and I wasn't drinking anything at the time.  But if I did and if I were, then I might have.

Musical Interlude

I need a break from the political posts and the medical mayhem.  So lets enjoy some beautiful music courtesy of our friends at American Idol and America's Got Talent:

Eli Mattson - Walking in Memphis and Nobody Knows and Against All Odds and All I'll Be.  How did this guy not win?

David Archuleta - Imagine and The Long and Winding Road and Smoky Mountain Memories and Sweet Caroline and Longer.  How did this guy not win?

David Cook - Billie Jean and Music of the Night.

Brooke White - You're So Vain and Love is a Battlefield and You Must Love Me.

Jason Castro - I Don't Wanna Cry and Memory and Travelin Through.

And since I can't seem to get away from controversy, compare the singing ability of Neal E. Freaking Boyd and Eli Mattson in this duet.  How did NEFB win?






* Yes, I know that Imagine is stupid communist garbage, but it is so beautiful when Archuleta sings it.  I just don't listen to the insipid lyrics and I get through just fine.

Hatin' on the Disabled

I've already talked about hatin' on the drug companies, now it is time to bemoan those who be hatin' on the disabled.

And by disabled, I mean me.

Okay, so I'm not technically disabled in the park-in-the-handicapped-spot (legally, at least) kind of disabled, but I do have this recurrent OCD kind of behavior that only pops up every once in a while...

like when I walk down the halls at my hospital.

Please excuse the blurry picture, but at least you can see the mental anguish and torture that I go through every day as I walk to the cafeteria for lunch and find myself zigzagging aimlessly down the halls following the randomness of lackopattern that some id on the design team came up with.  I can deal with having to zigzag down the hall as I follow the green line to safety, but exactly what do they expect me to do when I come to the crossroads and have to choose one of two branching paths?  I suppose that I could take one branch and then follow it back around, but I am afraid that I would get stuck in a lunch-break-eating loop of incessant green-line-following.  And we all know the famous adage: "Where loopy green-line-following occurs, mumbling-to-oneself cannot be far off."

That is why I rarely venture outside the safety of my department.

Political Humor - Or Laughing at Dumb People

I know I said i would try to make my Obama post my last political one (though I'm mulling over a McCain post after girlvet's last comment), but I couldn't resist this one.

I've seen this idea before where an email gets sent around telling people of one party to vote the day after the election, but never before on official letterhead.  I think it is supremely funny satire in its more innocent form, but I do question the use of official paper to send it around - this borders on fraud in my mind.

Anyway, my opinion is that anybody so uninformed as to not recognize this as fraud should probably not be allowed to vote anyway.

Here is the flyer

Here is the snopes

So to reiterate:  This is a joke and everybody should show up on November 4th to vote.

peace out.

Lawyers and Hatin' on the Drug Companies

This started as a comment in response to a post by WhiteCoat about the pending supreme court lawsuit of Wyeth v. Levine (although shouldn't it be Levine v. Wyeth?) but grew to the point where it asked to be it's own post.  To understand what I am referring to, however, please go read WhiteCoat's original post.

Back?  Good.  Here is my comment:

That is so ridiculously ridiculous of ridiculousity.  First of all, and in the woman's defense, Phenergan already comes with strong warnings about using it IV, and the PA in this case (based on my totally incomplete knowledge of the facts) was in the wrong with how he administered the medication.  I can't imagine giving the medication by an IV route that doesn't verify line patency or placement.  In fact, in my ER, when we pull Phenergan out of the Pyxis, we have to sign that we will dilute it and give over at least two minutes (actually slower than manufacturer's warning).  I don't have access to the manufacturer's label, but Gahart's IV Drug Manual (perhaps the Bible of IV medications) says:

A vesicant; determine absolute patency of vein; extravisation will cause necrosis... ISMP suggests administering through large bore veins but prefers use of a central venous catheter.  Administration through hand or wrist veins is strongly discouraged.

It further says:

The ISMP recommends administration of a single dose over 10 to 15 minutes administered at a port furthest from the patient's vein; observe continuously if given into a peripheral vein.

And even further says:

The ISMP recommends 6.25 to 12.5 mg as a starting IV dose and suggests considering the use of alternate drugs.

All of that said, Phenergan, when given properly via the IV route is a safe and effective drug - if somewhat more dangerous than others - and the idea of suing the drug manufacturer for ineffective labeling on this issue is moronic.  I love Zofran and really could care less if Phenergan were taken off the IV list (except it is really nice when the Doc orders it with Dilaudid because they are syringe compatible, where Zofran is not).  Despite this concern of convenience, I'm worried, because if this case succeeds in front of the Supreme Court, then there will be precedent for disallowing IV administration of so many other drugs that can cause arteriospasm, including such mainstays as IV Ativan.

Yes, you read that right.  No more Ativan.

Now are you concerned?  Me too.

Solution?  Send all our crayzees over to the Supreme Court so that they know what they are facing.  Tell them "sorry, we can't do anything because you took away our vitamin A."

That'll learn them.

I'm Glad My Saline Cured Your Chest Pain

The other day I had a totally BS chest paineur with severe SOB which seemed to be triggered by medical professionals being within observational distance.  Every time I happened to walk quickly by the room and glance in, the patient was doing just fine, thank you very much, but when I would go check on her, suddenly the theatrics began.  No significant vital sign abnormalities, no ST segment changes or altered labs, no dysrhythmias, no decreased O2 sats, but one big stinking load of pain.

Per doctor's order, I gave her a half milligram of dilaudid, which instantly cured the pain and made her feel oh so much better.

For about 30 minutes.  Then the theatrics began again.  The doctor ordered 1 more milligram of Dilaudid.  I went in to give it and discovered that the IV line was questionable, and since she was getting admitted to rule out MI (no comment), she would need a new line anyway, as hospital policy dictates that pre-hospital lines have to be replaced on admission.  So I decided to save the admit nurse some effort and got my IV start kit and put a new 18 gauge in her other arm.  The whole time I was talking to her about this and that and everything else.  I love chatting with my patients - even the BS ones - because I love people.  This time, the conversation was quite a distracting one, and I forgot to flush the line after putting the extension tubing on.  We talked for another couple of minutes and then I remembered that I needed to flush the line, so I grabbed my saline syringe and flushed it out as we kept talking.

When I was done, I started reaching for my carpuject and the dilaudid, when the patient exclaimed, "whoa!  I feel so much better.  That is some really great stuff you just gave me!"

Eyebrows up.  "So your pain is better?"

"Try completely gone!  Thanks!"

"Okay, that is great to hear.  I'll come back and check on you in a little bit."  The Dilaudid is casually slipped back into the pocket and I'm out of there.

I don't know if I need to fill out an incident report over accidentally giving the patient Placebatrol instead of Dilaudid, but as long as it worked, right?

Incidentally, I did end up giving the Dilaudid to her an hour later as she was getting ready to go upstairs because "that medication doesn't seem to last long."

I felt guilty at first, but then I never made any claim that I was giving her a drug.  I merely flushed the line, and then prior to giving Dilaudid I assessed her pain and found it to be inconsistent with the need for narcotics at that time.


UPDATE: It has come to my attention that a comment made in this post was understandably misconstrued, thus changing the tenor of the post. I do not want this blog to be about nurses vs medics, and I have nothing but respect for almost every medic that I work with, so I have taken out the comment and offer my apologies to any who may have been offended by it.

Please Do Not Vote for Obama

I will try to make this my last political post.  I don't want to turn
off the lefterly-leaning readers of my blog too much, and I don't want
to make this into a political blog, but as we reach the homestretch, I
am more and more scared of the idea of an Obama presidency.  Some
reasons:

• Obama has shown himself to be a poor judge of personal character
  - often associating with crooks, liars, criminals, and - yes -
  terrorists.  I know that just about every politician has to sell their
  soul to some degree, but the list of Obama's questionable associates is
  far beyond the norm.
• Our government is already beyond control in size and influence,
  and every time Obama opens his mouth, he promises to enlarge it.  A
  telling point was in the first debate when asked what he would be
  willing to trim given the state of the economy.  Obama went over a huge
  list of new spending proposals, but refused to identify even one area
  where the size of government could be reduced.
• Socialized healthcare.  Everything Medicare and Medicaid touches
  it screws up.  Obama wants to give the government more control over our
  healthcare decisions.  Yes there are serious problems with the system
  now, and I don't hold the insurance companies guiltless by any means -
  but government insurance is always worse than private insurance in my
  experience.
• The danger of a one-party monopoly - regardless of who is in
  power, I am scared of having the house, the senate, the executive
  branch, and (very likely) the judicial branch of government all
  controlled by the same party - especially if the majority in the Senate
  is filibuster-proof.
• I am fearful of the plague of victimization and increasing claims
  of entitlement that are rampant and becoming more so in our society. 
  Everything about what Obama says and does indicates that he will
  continue to push in this direction, and as we separate ourselves from
  what made this country strong - individual ingenuity, character, and
  hard-work - in favor of a full day's wage for a partial day's work (or
  no work at all), we will continue to lose our edge in the world.
• Obama continually validates the rejection of personal
  responsibility.  This goes to his oft-cited ability to inspire.  The
  problem is, that when he blames our high-school dropout rates on
  schools instead of parents and the students themselves and when he
  blames the foreclosure problems on wall-street instead of on the
  individuals who made poor financial decisions, and on and on, it only
  inspires further rejection of personal responsibility for our actions.
• Obama will be tested.  For once I take Joe Biden at his word when
  he guarantees that within six months of Obama being elected, the world
  will test him.  His ineptitude and inexperience combined with his
  defeatist, appeasement mentality are perfect fodder for tests of his
  mettle.
• Obama: “It’s not that I want to punish your success, I just want to
  make sure that everybody that is behind you, that they have a chance
  for success too. I think that when you spread the wealth around, it’s
  good for everybody.”

Don't get me wrong here, I am a strong believer in helping out those in
need, in lifting up the sick and desolate, in sharing with others who
have less, in condemning greed, in supporting children and giving them
every possibility.  That is why i am a nurse.  That is why I am
religious.  That is why I give a substantial part of every paycheck
away to support charitable organizations.  I believe it is a
requirement of every moral and responsible person to help others - I
just do not believe that the government is the best - or even a good -
way to do this.  And I speak as the head of a one-income family who has received charitable aid - government and private - in the past.

To sum it all up, please take a minute or twelve and listen to what Fred Thompson has to say.  I was never a huge Thompson fan while he was running, but I identify with what he says here, especially this quote near the end:

...in
this country we have a different view.  We know that people do better
when given opportunity and responsibility.  It has to do with our view
of the nature of man.  We don't believe that man is supposed to be
kept, fed, and protected from the elements by a master.  We believe
that man was meant to be free.  Entitled to be free.  It's an
inalienable right.  Endowed by our creator.  When free and inspired,
man can achieve great things for his family, his community, and his
nation.  In fact this belief is what we built our nation on.

Okay, I will try to get back to being a nursing blog, and I'm ready to accept whatever comes, but please please please if you are on the fence and leaning Obama, keep these points in mind.

ADOBSO

From Crzegrl via Pink, Warm and Dry comes the term ADOBSO, which so totally defines me.  Emily explains it this way:

“Well, it stands for: Attention Defic—-OOOOhhhhh Bright Shiny Object!”

I discovered this post because while I was busy writing a post about tipping, I got distracted by the episode of The Office that my mother-in-law was watching, and that got me wondering how much it would cost to buy my own health insurance, which led me to wonder if my email was set up correctly.  Then I had to put my older daughter to bed, following which I got distracted watching another episode of The Office.  Then I checked my Google Reader.  Now it is two hours later and I have a post based on Scalpel's post and now this post based on Pink, Warm, and Dry.  But my post on tipping (incidentally based on Voodoo's post) is still sitting there.

ADOBSO?  Yes, that is me.

I Vote Scalpel

perfect.

More Tinkering

I'm the kind of person who gets on a roll and just keeps rolling.  I need to be in bed, but instead I'm still tinkering with my blog.  Among the changes:

• I created a new email address for anyone who wants to get in touch with me to ask questions, request autographs, or serve subpoenas.
• I created a new mini-blogroll of my select few favorite blogs to see how I like it.  I will probably keep both kinds of blogrolls and just have the auto-update one for the 5 or so blogs that I look forward to reading the most.  This will likely change from time to time.
• I added a blog birthday banner for those looking for an excuse to buy me a gift.  Note that my birthday comes just a couple weeks after my blog's, so make sure to buy two gifts.  For that matter, my wife is a month before me and my daughter a day after me, so just max out that credit card, will ya?
• I stayed up doing pointless stuff while I should be sleeping.  I'm going to regret this when Little Kitty wakes up every 30 minutes like she did last night.
  
• Goodnight.

My Blogroll

I updated my blogroll to remove a few entries from blogs that are no longer active or those that I don't read very regularly and which do not link to me.  Several others I kept even though they were on the borderline.  This is because either I do read them sometimes even though they don't link to me (sniff, sniff) or because even though I don't read them very often, at least they send people my way.

I also added a few others which I read and enjoy but have not as yet put up due to my CLS (Chronic Laziness Syndrome).

Is your blog missing from my sidebar?  If so, and you want to be included, let me know and I will consider it. 

A word of warning:  I may say no.  I do not want a huge list of every blog on the internet just because.  I want my blogroll to be primarily a list of blogs that I truly recommend to others, and at the risk of being politically incorrect, if your blog is one that I do not plan to visit frequently, or if I find your blog objectionable, or if I get an acute flareup of CLS, you may not see your blog appear here.  Also, I generally do not embrace a new blog right away.  If I come across a blog that seems interesting, I will usually either bookmark it or subscribe via Google Reader and follow it for a while to see if it stays interesting.  And by a "while" I mean a while measured by ERST (ER Standard Time - for a definition of ER Standard Time, please sign in to an ER, go up to the triage nurse and ask how long your wait time will be).

And if you do not link to my blog and request that I link to yours, you had better have a very entertaining blog.

For Comparison...

This is our first child 1 day after she was born.  Methinks they look a lot alike.

Watch Out, World!

K.J.

Mrs. Braden and I are pleased to announce the birth of our second child, Little Bradenette, yesterday morning at a few minutes to 6.  We went to the hospital the evening before after slowly increasing contractions all day.  I was actually in the middle of a staff meeting when Mrs. Braden called and said,  "you had better come home now."  I didn't need any more incentive than that.  I rushed back into the room, grabbed my papers, and literally ran out the door.  A short while later we were on the road to the hospital 20 minutes away (the hospital that I work at doesn't have labor and delivery - thanks, lawyers!).

At first, the doctor was threatening to have us sent home because, despite contractions 5 minutes apart and painful, they were not opening the cervix compared to a check earlier at the doctor's office.  This caused much distress in the pregnant one and a lot of concern for me and the expectant Grandma as well (Since the contractions are already close together and we can't tell if her cervix is changing, if we go home now, how will we know when to come back?)

Luckily, an hour of walking madly around the floor to the point of exhausting even me brought about more frequent contractions and a slight cervical change.  And a call to the midwife instead of the doctor brought about a decision to keep us, and eventually a visit from God himself the anesthesiologist.

Labor progressed slowly and without note until the baby decided to suddenly engage in the birth canal, setting off all kinds of alarms as her heart rate dropped into the 70s.  People came running in and repositioned Mrs. Braden and they determined that delivery was imminent.  Within 30 minutes she was pushing, and after just six contractions, out came a burst of emotion as our second baby was laid on Mommy's tummy.

Now we are just past the 24 hour mark and everything seems to be going fairly well.  Baby sounds alternately like a cat and like the baby velociraptor from Jurassic Park with all her little grunts and whines, but the doctor said multiple times while assessing her that she is "perfect", which I'm sure is a word that she does not say on every baby that she sees, but rather saves just for our baby.

So now we are hoping to be able to go home tonight, and if we are lucky, get some sleep some time in the next several years.  Wish us luck!

No Room In the Inn

This may be an everyday occurance in some ERs, but for us, it is pretty rare to have more than 4 or 5 admissions pending at a time.  Despite having an abnormally large ER for a small hospital (There are less than four times as many inpatient beds as ER beds - meaning that for a large 400 bed hospital they would need to have a 100+ bed ER to be equivalent), we usually get patients through within a few hours.

But on this day, things on the floor just weren't going very well and we were backed up like I've never seen.  This picture was taken before part of the ER was open, but of the 19 non-fast track beds that were open, 11 were being admitted.  Two of those admits were my patients (one a Korean-speaking chest pain - talk about lost in translation!).

Compare this to yesterday while I was in Triage and saw maybe 10 admissions all day.

And I don't remember taking this picture at 12:17 am.  More likely it was 12:17 pm and my clock was not calibrated correctly.

Too Good Not to Pass Along

Via Charity Doc (who I had never heard of before today) comes an 8 minute documentary that needs to be seen by all who are interested in politics.

This goes straight to my main political and health message: personal responsibility. 

Money quote: "So if you can get coverage, don't wait for Washington, go out and get some.  Go on."

Chest Compressions

Yesterday I was the "float" nurse, which means that my job was to give breaks to other nurses and generally help out where needed.  I was busy helping a nurse with a complicated patient when I came out and saw a bazillion people standing outside a room.  This invariably means code, so I wandered over to see if there was anything pressing I could do.  I saw the medics about to get the patient transferred to our stretcher, and I saw the medic who was doing chest compressions.

If chest compressions are supposed to be to the beat of "Stayin' Alive", then these were to the beat of "Holiday".  I walked over, turned on the fancy little CPR metronome that we have on every crash cart and walked away.  As I looked back, the speed of chest compressions was much improved.

The code was called about 5 minutes later, so I'm not sure I changed the world, but I was glad I didn't have to get after that medic in front of the patient's family.

HIPAA

It's dumb.

The end.

No Go

...and it's a no go.  I was hoping desperately that my wife would get me off of work today, but alas, I got to sit in the triage chair for 12 hours helping people with "soar" throats and leg "complainds" (and one surgical tech with a textbook perfect case of toxic shock syndrome - you really get the sick person in great contrast when you keep seeing not sick after not sick).

So it is off to more waiting, which is okay, because we really aren't at the due date for another 5 days.

Wish us luck!

15 Minutes

The contractions are fifteen minutes apart now.  Not enough to get me to stay home from work today, but just enough to get me nervous to leave.

Further bulletins as events warrant.

McCain the Comedian

I have seen politicians try their hands at comedy before and rarely do I ever find it very funny, but John McCain's speech at the Alfred E. Smith dinner had some truly laugh out loud moments, including a few jabs at himself and some remarkably straightforward pokes at Obama and even the Clintons.  But amidst all the jabs and jokes, he does take a few minutes to give genuine praise to Obama.  Classy, that.  Regardless of your opinion of McCain, go check out these videos and enjoy a few laughs.

McCain Part 1

McCain Part 2

Obama also delivered a roast at the event, and it also had some good lines, but never seemed quite as funny or as well-delivered as McCain's.  Perhaps that is just my bias, but I didn't find myself as impressed.  His address is also in two parts:

Obama Part 1

Obama Part 2

Oh yeah, and nursing is cool and stuff (see? This post is all about nursing)

Poll Results Finally In

The official 20/10 poll results finally came in today for the question, "which anti-nausea medication gets ordered most often on your unit?"

And the results: Zofran 54%, Phenergan 12%, Reglan 14%, Other 8%

Okay, so these results have been in for a few (98) days, but I haven't had anything interesting to say about them, so I've been putting it off.

But now, faithful readers, I have found something interesting to say about them:

"cool."

With that off my chest, I can now move on to my next poll... once I think of one.  Stay tuned.

Get Ready for the Blurry Pictures

No matter where I go, I always have my PDA phone (XV6800 for those who must know) with me, and I take advantage of it's built-in camera from time to time when I come across something amusing or interesting.  Today I finally got around to downloading a lot of the images that I took, and so over the next little bit you may see some grainy blurry images that I've taken.  I'll start out with something simple and straightforward.  Of course I'm referring to the talking wall:

New Never Event

From WhiteCoat's blog again:

One study cited in this commentary showed by genetic “fingerprinting” that an outbreak of Pseudomonas aeruginosa
in six hospital intensive care units was due to contaminated bottled
drinking water. When the ICUs stopped using the bottled water, the
infection rates steadily decreased.

If I'm not mistaken, pseudomonas is the bacteria that gets blamed for Ventilator-assisted Pneumonia.  So I wonder if that ICU had to fight to get payment for the illnesses that ensued from the bad water...  Sounds like we need to making drinking water into a never event.

Never Events on a Serious Note

Tongue-in-cheek post aside, as I was looking through the list of never-events on the cms website, I was blown away by this one: "patient death or serious disability associated with patient elopement for more than four hours."

Isn't the very definition of "patient elopement" that they leave without anybody knowing about it?  Because if we know about it, then we tell them that we don't want them to leave and then it is called leaving against medical advice and we usually get a signature.

Then there is "suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility."  I can understand this one if a patient is known to have or at least show signs of SI, but working in an ER, I know from family members and loved ones that many many times people show no outward signs right up until the moment that they carry out their plans.  Sure, many times you can go back in retrospect and say, oh, she was calling out for help by buying a new car or whatever, but it seems that cms wants nurses to be telepathic or they wont pay.

Another one that blows me away is "Maternal death or serious disability associated with labor or delivery on a low-risk pregnancy."  What? So because someone meets the artificial definition of "low-risk pregnancy" they can never have complications?

And then there is the infamous "restraint or bedrail" use that discourages the use of (you guessed it) restraints and bedrails.  I've seen the guilt-laden videos in training classes trying to make us feel really bad about the patient who climbed over the bedrail and fell to the ground and oh how tragic, ignoring the fact that were it not for the bedrail, the patient would have simply fallen to the ground without having to go to the effort of climbing over anything.  Invariably, they recommend a bed-alarm instead, so that at least by the time the patient is falling toward the ground and toward the inevitable OR ortho suite, the staff can already be on the way in to the room.  And invariably, these kinds of rules get taken to the extreme.  I remember back in my dark days of working in a Nursing Home that several patients had the wonderful dignity of being able to sleep on a thin mattress on the floor.  No kidding.  That's how I want to live my last several years.  I wonder who will pay for the chronic back pain developed by the nurse who has to change Mrs. Johnston's diaper?

But what really makes me the most angry about the never events, are that so many of them are just an example of our society moving further and further away from personal responsibility.  Yes, ostensibly it seems that they are encouraging institutional responsibility, and yes, many of the never events are truly events that are caused by negligence on the part of healthcare workers, but so many of them involve the absolution of personal responsibility by patients that it is disgusting to me.  For instance, a hospital can do everything in its power to keep an endotracheal tube free from infection, but when the concerned family member gets concerned by something and places his grimy hands all over the tube, what is the hospital to do?  Or when a patient elopes... now that's my fault?  Or if a deep vein thrombosis develops after surgery because the idiot patient is non-complient with the range-of-motion machine, or goes home and doesn't move around like they should, heaven-forbid that person be blamed for his own actions.  And of course the ultimate is the suicide one, because nobody should ever have to be held responsible for their own decisions.  We should solve all their problems for them.

It Isn't a Never Event if it Isn't Called a Never Event

Over at WhiteCoat Rants, WhiteCoat rants about never events and the potential unintended consequences that we may see from them.  I completely agree that these ridiculous rules are ridiculous and do not anticipate the unintended consequences that will invariably come as they are enforced.

But mostly I remember something said by the ICU nurse who was teaching the ventilator class that I attended when I first started working in the ER (or ED if you are Bayer Pharmaceuticals):

"...we used to refer to it as VAP, or ventilator-associated pneumonia, until the Centers for Medicare Services decided that they wouldn't pay for VAP, because it sounded like something preventable.  So we changed the name, and now they are paying for it again."

Perhaps we could implement this same idea:

• Falls could be re-labeled as "creative groundings"
• The Unacceptably long Catheter-associated urinary tract infection could be called "antibiotic seeking behavior"
• Surgery on the wrong body part might be referred to as "weight loss surgery"
• Mismatched blood transfusions can be called "diversification therapy"
• Foreign bodies left in a patient after surgery are now "parting gifts"
• Preventable post-operative deaths could be simply "applied Darwinism"
• Major medication errors can be excused because "4 rights don't make a wrong"
• Decubitus ulcers could be re-labeled as "body modifications"
• Surgery performed on the wrong patient gets charted as "practice"
• Administration of contaminated drugs can be "multidrug therapy"
• Hospital-onset hypoglycemia in the future may be referred to as "low-sugar diet"
• Air embolism is now "inflationary therapy"

Anybody else have any creative charting tips?

Go To the Dollar Store

I followed a link from WhiteCoat's latest post (gross picture warning) to another gem from last year about a dollar store pregnancy test.  Far down in the bowels of the comment section is this intelligent comment:

"Maybe she didn’t like the condescending suggestion of the “dollar”
store, which was meant to be cutting and was. I have seen my share of
snippy ER people. And I have insurance, as do most people who go to the
ER."

I hope that this mindset is not too widespread, because if it is, I am going to be in big trouble.  I tell nearly every patient that comes through the ER (or ED if you are pfizer) that they should go to the dollar store to get the ibuprofen that the doctor recommended for them, because it is the same thing as Motrin or Advil for 1/5 the cost.

I never intend for it to be cutting, but then again, I never intend any of the advice I give my patients to be cutting, even when I am supremely frustrated (I may let some of the cuttingness out on my blog, but never in person).

And as an aside, a couple years ago when we were trying to get pregnant the first time (okay, as an aside to my aside, I have to admit that I was not, in fact, trying to get pregnant, although with the success that Mr/Mrs Thomas Beattie has found with the issue, perhaps I should have been trying to get pregnant as well - it would have helped with the sympathy), we bought a dollar-store test and it came back positive, and we pretty much said, "not gonna believe it," so we went out and bought the fancy dancy sachs fifth avenue brand, which - suprise surprise - came back positive as well.  A week later we went to a local "free" pregnancy clinic (this happened to be a pretty hard financial time for us and we were in between jobs) to get an official pregnancy test done and read by a Registered Nurse.  So we go in and they pull open a drawer full fo pregancy tests... from the same dollar store as our original test.

Luckily, though, this RN had received extensive training to know the difference between a single line and a plus sign, and was able to confirm that we (she) were (was) indeed pregnant.

Connecting the Dots

I just realized that I never answered my post from almost two months ago.

The answer:  all of those patients were triaged as blue charts (ESI triage category 4) and sent to fast track, where I was working that day.

The periorbital fracture was transferred to a level 1 trauma center for an expert surgical consult.  The Blunt abdominal trauma was sent to the main ER where a code trauma was called and the patient was transferred to a level 2 trauma center, the spontaneous pneumothorax, I learned a couple days later, ended up not being a pneumo after all, but he sure had all the signs and symptoms (young, thin, tall, male smoker with sudden onset of left sided chest pain made worse with inspiration or sitting.  In fact, the only initial finding that was missing was diminished breath sounds).  The intractable N/V patient was eventually sent home after his third round of Zofran and his second liter of IV fluids and a course of IV antibiotics.  The peritonsilar abscess (adult patient), incredibly, was sent home after staying in a fast track bed for 11 hours and receiving 5 rounds of pain meds, 2 doses of Zofran, Levaquin, Clindamycin, Rocephin, several diagnostic tests, and 3 liters of fluids.  And finally, the back pain guy was found to be FOS.  Literally.  And the oncoming PA decided that it would be a good time and place to do an enema.  That's right - a curtain-partitioned room is a great place to free the poo.  Needless to say, I was more than happy to pass the buck to the oncoming nurse as I ran for the exit.  I had served my time.  Incidentally, I caught up with the nurse a few days later and he said that finally some sense had been talked into the PA and she let him go home with narcs, Robaxin, and a couple of poo-gliders.

I think the triage nurse was drunk that day.

From Day Two of TNCC

Happenings on Day 2 of TNCC Class:

* (After discussion of the principles of disaster triage) Nurse in back: "So what we learn from this is that if we are ever involved in a disaster, we should breathe really fast?"
* Teacher: "One hallmark sign of compartment syndrome is pain disproportionate to the injury." Nurse in back: "Wait a minute... all of our patients have pain disproportionate to the injury!"
* Me to nurse next to me: "What is this joint called? (it was the MCP)" Nurse: "um... it is your k-nuckle."
* License plate frame (as described by teacher): "ER NURSE: PASS ME NOW, SEE YOU LATER"
* Teacher (describing characteristic signs of patients involved in meth lab incidents): "Patients will often smell like ammonia, and you can tell because they will smell like cat pee." Nurse in back: "Oh, then I think most of my patients have been involved in meth labs."
* Teacher (regarding rule of 9s for body surface area): "the genitalia is only 1 percent.  The guys usually want to argue that point, but let me assure you guys that it really is only 1 percent."
* Teacher (bemoaning the inpatientification of the ER): "and legislation is getting more and more persistent.  Soon you will all have to memorize the Braden scale." Nurse in back (turning to me): "Thanks a lot!"
* Teacher (demonstrating motorcycle helmet removal from volonteer who was laying on a table with helmet on): "and then you rotate the helmet forward like this, and pull straight back like this..." *volunteer's head bangs loudly on table followed by involunary yelp* "...and you then repair the head laceration that you just caused."

Well that's all from today.  I'm not sure if there was just less funny business today or if I was just so tired and apathetic that I didn't write it all down, but there it is.

From Day One of TNCC

Happenings on Day 1 of TNCC Class:

* Teacher: "Just like my underwear, I like my patients pink, warm, and dry."
* Teacher: "So what do you do if your patient is going down the tubes?" Nurse in back: "In the ER? Narcan."
* Teacher: "And you always want to auscultate every part of the body except for the limbs... or the perineum."
* Teacher: "...you wont really be seeing that in the ER unless you are doing a lot of abdominal surgeries.  And if you are doing a lot of abdominal surgeries in the ER, that is bad."  Nurse in back: "At least it's better than doing breast augmentations in the ER."
* Teacher: "...and if you suspect that kind of infection, that's when you break out the Gidzillamycin or the Rambocillin."
* Teacher: "So what is the big problem with MRI exams?"  Nurse in back: "It's on the other side of the hospital."
* Teacher: "When people bleed, what do they bleed?" Nurse in back: "blood?"
* Teacher: "What do you do when you have a shock patient who refuses blood transfusions?" Nurses: *silence* Teacher: "You sedate and intubate.  When they are intubated, you can just say that you couldn't understand them."
* Teacher: "Autotransfusion can only be done when there are no abdominal injuries, and to be safe the general rule is no injuries below the nipple line.  And for the ladies in the room, that is where the nipples started, not where they are now."

and finally:

* After seeing slide after slide of disgusting dismemberments and gunshot wounds, we get treated to a particularly bloody slide of a traumatic amputation of a leg.  Fortunately for us, whoever put the powerpoint together (somebody at ENA) decided to put a black censor box over the - ahem - private areas.  Unfortunately for us, they missed the top half of the privates.  Nice thought, though.

The Pee is on the Counter

Said patient: "Oh, and the urine sample is on the counter."

Said me: "Great, I'll go dip it..." *long pause as I look at the counter* "...on second thought, perhaps we should get a urine sample that isn't in a Propel bottle."

The Politics of Personal Responsibility

Warning: Political (mostly non-partisan) rant ahead with only a token tie-in to the ER theme.  Proceed at your own peril:

I have found myself beyond frustrated over the past few weeks as the credit crisis has remained the number one news item of the day.  Not because of the credit crisis, but because nobody around seems willing to put blame where blame belongs.

Yes, the Democrats had something to do with enforcing equal opportunity loans even to people who can't afford them, and the Republicans were guilty of too much looking the other way as the books were cooked, and the fat cats on wall street certainly didn't mind the extra income pooring in, and the lenders weren't always up front about the true costs of the loans, and on and on and on.  Everyone has a share of the pie.  But nobody seems willing to really, truly say where the blame falls.

Enter Daniel B, who, as far as I can tell is a political nobody writing for a political nothing of a blog that I found through the "recommended" part of my Google Reader.  In one compelling essay he lays out the case that I have only heard hinted at from any major news or political source (some credit to Palin in the debate for at least brushing by the idea).  Go read it.

This is one of the biggest issues for me and one of my endless frustrations in the ER: people don't seem willing to accept responsibility for their decisions, and when the vessel breaks and the pieces lie shattered on the ground, all we ever seem to get is a lot of finger pointing and a lot of denial.

Folks, it is time to suck it up, to admit that you made a mistake, to recognize the handwriting on the signature line.  I'm sick and tired of all the finger pointing.  Yes everyone had a part to play, but you are the one who signed the dotted line.  Accept that, and I'll be much more willing to help you out.

My One Recourse

I have no choice but to be a member of a union.  I hate that.  I hate unions.  I don't think that they do anything worthwhile for me, and I absolutely despise that my freedom of choice is taken away from me by them.

So it was with particularly great dismay that I got an e-mail this morning telling me about the new website on the official ANA page supporting O!bama and propagandizing for him and selling merchandise, and implying that all of the ANA members support O!bama as well.  I don't.  I can't.  I wont.

But I have no power against the board voting to ignore the will of a large portion of its membership (I know that even in my liberal town most of my coworkers are supporting John McCain) and use my money to go against my interests.

I only have one recourse, and it is a small one, but nevertheless a quite satisfying one:






In my letter of opposition that I just wrote to them (gova@ana.org), I concluded that I no longer wanted to be a part of the American Nurses Ass.

I don't normally like to abbreviate official titles, but I had run out of room.  What could I do?

A Couple Non-Medical Blogs

A couple posts that I came across today from other blogs that I read:

First is Cake Wrecks, a humorous and interesting dissection of some of the more attrocious cake creations floating around out there.  Today's cake is a great reminder that everybody over 50 should have a colonoscopy.

Second is a post about the Heart Attack Grill.  I've finally found a great backup job if actual nursing ever fails me.  I think I'd fit in just fine there, no?

Neal E. Boyd

Okay, I want a show of hands.  Who is responsible for this irresponsibility?

Neal E. Boyd?  Really, America?  Neal E. Freaking Boyd.

Why do you do this to me?

But it's okay.  I'll still buy Eli's CD when it comes out.

Chief Complaint of the Day

"Flesh eating abscess on my bottom butt"

Med Rec

I've been collecting a lot of ideas to post lately, but so far they haven't transferred from my scraps of paper to the computer.  Bear with me - it's been a busy couple of weeks, and with my second daughter due very soon, posting may continue to be somewhat light for the next little while as well.  I'll do my best to deliver to you, faithful reader, what it is that you are seeking from me.

Just as soon as I figure out what that is...

So here is my thought for the day (week?):

Why do we take the time to do medication reconciliation?  I had a case the other day where I went through and entered dozens of complicated medications into the computer system for a patient who had come into the ER.  It took me a lot of time to get it in, but it is important, right?  That way the admitting doc knows what medications to prescribe while the patient is in the hospital.

So thirty minutes later, the admitting doc is sitting at the desk next to me, taking way too long to do everything that he has to do so that I can get the chart back and actually care for the patient, and I hear him dictating on the phone.  He says "and the patient's medications are..." *pause while ruffling through the papers of the bedside chart* "...not listed.  I'll have to call the facility to get them."  So I interrupt and say, "actually, I entered the medications into the computer system for you."

He turns and looks at me and says, "well, then where is the paper copy that you entered from?"

Excuse me, Mr. Doctorman, but that is kind of the point of having the silly med-rec in the first place, no?  So that we don't need to have the original papers - so that the meds are already listed in the computer in a universal format that you can use to order inpatient meds.

It is really frustrating that I take the time to enter all the medications for every patient and then that effort goes completely wasted.