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.

ER Math Quiz

Okay, school is back in session.  Everybody please put your books away and sharpen your number 2 pencils.  No talking during the test.

And let's begin:

1. You are assisting a primary nurse with charcoal administration down an orogastric tube. The room measures eight feet by twelve feet. The patient starts to retch before the tube is pulled. Knowing that charcoal can spew out of a tube in a five foot radius (even with a thumb over the opening) and the stretcher is two feet wide, how many feet per second do you have to back up to get less charcoal on you than the primary nurse?

2. Doctor A picks up a chart out of the rack. S/he finds that it is a repeat patient with abdominal pain. Doctor A puts the chart back. Doctor B picks up the chart five minutes later and also returns it to the rack. Doctor A leaves the nurses' station heading south at three miles per hour. Doctor B leaves the nurses station for the doctors' lounge at five miles per hour. How long before the patient is at equal distance from Doctor A and Doctor B?

3. You were assigned two large treatment rooms and the gynecologic room. By the end of the day you have cared for ten patients. Four patients were female over the age of 80, all complaining of weakness. Two patients were male, ages 72 and 50. The last four were female, between the ages of 24 and 40, all complaining of abdominal pain. It is 3:00 p.m. and time to restock the rooms. How many bedpans will you need?

4. You are the primary nurse for an elderly patient with congestive heart failure. The IV stick was exceptionally difficult, but you are able to start an 18 gauge catheter on the second attempt. You leave the room to check on another patient. A relative thinks that the IV has stopped dripping and opens the clamp. How much IV fluid will infuse before you return?

5. You are sent for your morning coffee break. You need to use the restroom but can't find one unoccupied and have to walk down to the lobby. The coffee pot is dry and you have to make more. When you get to the cafeteria, the line extends ten feet into the hallway. You can't remember exactly when your break began. How much time do you have left?

6. You are the primary nurse taking care of a particularly shy female in the gynecology room. Her private physician arrives to see her, but you can see that he is not in a particularly good mood. After much coaxing, the patient agrees to a pelvic exam. How many people will open the door during the exam?

7. An elderly man arrives in the Emergency Department by rescue squad. Twenty minutes later his wife arrives and registers him. She is shown the entrance to the department and slowly shuffles in. How many rooms will she walk into before she finds him?

8. You are assigned to the EENT room. You have a patient to be checked for a peritonsillar abscess. The ENT physician has been paged and expects to arrive in 45 minutes. Three hours later, he arrives and is at the patient's side, asking for a flashlight. Lightly jogging at 22 miles per hour, how many rooms will you have to search before you find one?

9. You have been asked to cover a coworker's rooms during her break. One of her patients is an elderly, confused male with an enlarged prostate. A catheter has been inserted and his physician is coming to see him. Somehow he manages to get off the stretcher. The drainage bag is firmly hooked to the side rail. Knowing that the catheter is 16 inches long and the drainage tubing is three feet long, will he be able to reach the door before pulling out the catheter?

10. A college student named Muffy is brought to the Emergency Department with a sore throat. She has no relatives in the area. Will there be enough chairs in the waiting room for deeply concerned significant others?

No, I didn't write this one, but I found it today hidden amidst my big pile of word files that have collected from here and there over the years.  Luckily for you, me, and my lawyer, I had included the author and source when I saved this to a word file.  This was written by Myka Clark, and appeared in the JEN Volume 21, Number 4, August 1995.  Amazing how nothing has changed in that time.

Dear Mrs. Floor Nurse

I'm a really nice guy, and most people I meet like me a lot.  I think that perhaps if we had met in circumstances other than those of tonight, we would get along just great as well.

But I have a couple points that I think are important for you to hear.  First of all, I had thought that we as nurses were over calling our patients "hon" and "sweety" and "darling."  And maybe I'm just a little sensitive, but if I were an octogenarian and admitted that I was now several inches below 5 feet tall, I probably wouldn't appreciate your comment about all those "cute geriatrics" who are all "hunched over" and keep "shrinking."  And maybe when you giggled and said "you're so cute" I may have felt a tad belittled.

But that is not really why I am writing to you.  I'm really writing to you about your attitude and your waste of my time.  Yes, I'll admit that I'm a little upset.  You see, in the Emergency Room (or department, if you are WhiteCoat) we have a little rule of thumb when it comes to vital signs that are a little off, and it goes something like this: TREAT THE PATIENT, NOT THE NUMBERS.  So yes, I can understand the moment of alarm when I told you that the patient that I brought you had dropped her pressure into the 80s with the last measurement (despite all the previous measurements being in the 90s and low 100s), but perhaps if you had taken just a cursory glance at the patient before going all trippy on me, then you may have noticed that she was just fine.  Because, you see, perhaps the low blood pressure was a transient state due to the nitroglycerin patch that I took off of her chest before coming up.  I may have been concerned with this reading had I not looked at the patient.  But I did look at the patient, and I saw a pleasant, non-altered, ambulatory patient with no EKG changes, no pulse changes, good skin color and perfusion, and no diaphoresis or dizziness.

My dear floor nurse, I don't blame you for wanting to get a blood pressure machine and check for yourself.  That's fine.  But why did you feel it necessary to try to make a really big deal about it in front of the patient?  You could very easily have said, "okay, I'm going to go and get some vital signs now."  And then when you asked who the nurse was that took care of this patient and I answered that it was me, did you really have to say "well I'll have a talk with you when I'm done here!"  And if you were really so concerned about this patient, then why did you not try doing something so simple as, say, look at her, or check a pulse, and why, after scampering out of the room in a huff, did it take you more than 5 minutes to come back with a blood pressure machine?  When I asked you if you had obtained a tele unit, did you really need to be snarky when you answered that you "obviously have something more important to deal with right now because I need to find out if I have to bolus this patient"?

I know that life on the floor can get quite boring sometimes and it is really exciting to have something to worry about.  I sympathize with that.  But try to leave the patient out of it, would you?  Instead, you keep muttering about how bad this is and how closely you are going to have to watch her so that nothing goes wrong with this dangerous pressure.  Maybe this was all some great device of yours to help raise the pressure by making her get stressed out.  I don't think she even caught it, but her son clearly did.

But it's all good.  You got your vital sign machine and found that her pulse was great, her rhythm was sinus, her oxygen was dandy, and her blood pressure was 111/70.  Not one to be defeated, you checked the other arm and found 117/68.  Still not one to be defeated, you declared that this was just because she had just stood up to transfer to the bed and surely the pressure would go back down.  But at least now you were willing to go and get the tele unit.  It is a good thing that you were done with your "more important" tasks.  Or were you?  You came back in with the weight scale.  Okay, so it is really vital to you that you see what her weight is right this second while the ER nurse stands by waiting for you to get a tele unit - after all if her pressure keeps dropping she could sweat off several pounds and you would have no way of knowing her exact weight on arrival.  But it got a little bit ridiculous when you finally brought the tele unit into the room, set it on the bed, and then pulled out a paper and started to  interview the patient about her home medications.  Now we have gone past the option of you just being so disorganized that you don't understand priorities in patient hand-offs, to the point where you were obviously trying to "punish" me for daring to bring you a patient who was terribly unstable as evidenced by... well, nothing really.

You see, you have no way of knowing that I was at the end of my shift and had already reported off to the next nurse on my other patients, and so that makes it all the worse that with all your huffing and self-righteous puffing about how unstable this patient was, you could have been endangering my other truly unstable patients in the ER who were without their nurse while you ho-hummed through this unnecessary debacle.  Your childish and selfish reaction to this whole episode placed in jeopardy the confidence of this patient and her family in our hospital, and could easily have placed my other patients in the ER in jeopardy as I waited for almost 30 minutes for you to move your molasses.  And for what?  For some misguided sense of urgency and adventure.

Did you even notice that while you were neglecting to do your job I put the portable tele unit on the patient, wished her well, got handshakes and big thanks from her son and daughter, and left?  You see, she and her family liked me a lot.  Maybe that's because I was caring and friendly and watched out for her for 4 hours before she came up to you.  Perhaps it is because I took great care of her and watched her vital signs and all her needs very closely.  Maybe it is because I called her by her preferred name and respected her as a person and not just my "hon".  I don't think I'll ever know for certain all the reasons why they liked me, but I could certainly read the look on their faces as you scampered in and out of the room paying no attention to your "darling", and I think you have a bit of an uphill climb ahead of you.

You certainly didn't make a great impression on me.

It is too bad you kept me past my time to go home, because I would have very much liked to have that promised conversation with you so that I could have explained a thing or two to you about caring for patients.  Yeah, I'm still a fairly new RN, but it would appear that I could probably teach you a couple things, sweety.

Oh, and one more thing: if you had responded when I first faxed report to you instead of making me wait over an hour to bring the patient, then you wouldn't have had to worry about me telling you about the low blood pressure at all.

Yours,

Braden

Prescription Drug Competition

A big "selling point" in Barack Obama's plan is his idea that there should be competition from other countries for Prescription Drugs.

Senator Obama, do you not realize that the reason that drugs are so expensive in the United States is because lawyers such as yourself require amazingly stringent testing prior to a drug being released on the market and then sue the skin off of drug companies if anything - foreseeable or not - goes wrong once the drug is released?

Do you not realize that if you open up the competition for drugs with other countries, what you will do is push the US drug companies out to other countries with less stringent standards?

A few years ago, it was estimated that the cost of developing a drug, from idea to market, ranges from 500 million to more than 2 billion dollars.  And we wonder why costs are so high.

Help Me Understand This

A constant argument that I hear from those on the left who would pursue universal health care is the idea that we do not want an insurance company getting between a doctor and a patient.  As with most ideas that come from the left, this is one that sounds really great.

The problem is that those who are pushing this line of reasoning are the same people who are pushing for more coverage a la Medicare.  This does not add up.  As one who has worked in a private medical office and now in the ER, I can say without any hesitation (and I dare you to prove me wrong) that no reasonable, mainstream insurance anywhere (I'm excluding the fly-by-night outfitters here) has anywhere near the limitations that are found in Medicare, Medicaid, Tricare, and other government-sponsored insurances.

From my time in a private office, I came across way more prior authorizations than I would have liked to deal with, and many times became frustrated at insurance companies for second-guessing the decisions of doctors, but the red tape of insurance companies was like a walk in the park when compared to the difficulties of dealing with government-sponsored plans.  Most of the time an insurance company would give way when a doctor insisted on a treatment or a medication, whereas Medicare or Tricare would make you jump through many more hoops, be much more difficult to contact, require more conversations with more bureaucrats, and in the end bend considerably less than any other insurance plan I ever came across.  Now that I work in the ER, the only time I find insurance becoming an issue is when it is Medicare.  If a patient is going to be transferred to another facility, for instance, the HUC (I hate that term) always looks at the insurance information.  Why?  Because if it is Medicare, then we have two or three additional forms to fill out in the desperate hope that the government will pony up for the necessary treatments, and if exact qualifications are not met, then guess who you find standing, immobile, between the doctor and the patient?  That's right: Uncle Obama Sam.

So when we have conversations about improving health care in the United States, I'm all for it, because I know that there are many problems; but can we at least do away with this idea that it is the insurance companies that are the biggest culprits for standing in the way of getting needed treatments?

Change of Shift

The newest Change of Shift at crzegrl.net pays homage to International Talk Like a Pirate Day.  Unfortunately, she doesn't link to my blog (of course, I didn't submit anything so that may have a wee bit to do with it...)

Click picture above for link.

Hi Governor Palin!

I have to admit that I got a little jealous when Scalpel was visited by Sarah Palin.  Even more jealous when I looked at his sidebar and didn't find my blog listed.  Whats up with that?

Anyway, a little hunting has helped me realize that not only has she stopped by my site, but she has stopped by 4 times.  Not that I'm bragging, but on June 1st, July 6th, July 18th, and August 26th, I've been graced by the presence of one Sarah Louise Palin of Wasilly, Alaska.  Or maybe it was Todd.  Doesn't matter - they are both cool.

She has been a little busy since that time, so I'll forgiver her conspicuous absence... for now.  I expect to get a lot of Washington DC visits starting in January, though.

Now the only thing I am missing is an official Sarah Palin signed baseball.

Overheard on Day 2 of ENPC

Overheard on Day 2 of ENPC Class:

* Teacher: "Neonates are irritable little things." Nurse: "And the ones who never get over it become politicians."
* Teacher (on telling parents that she was making a CPS referral): "Of course, I'm always worried that the parents will go off and get violent, so I make sure I bring our 90 year old security guard with me for backup."
* Teacher (German-born) (after several failed attempts at saying purpuric rash): "purp... pur... that purple one there!"
* Nurse in front (looking at picture on screen of a baby getting an LP) "That's a baby?!?" Teacher: "No, it's a puppy."
* Teacher: "SIDS is a life-threatening event."
* Teacher (on strategies to deal with crisis and post-traumatic stress as a nurse): "here is the next one: 'be rested, fit, and eat well'... okay, well I'm going to leave that one right alone!"

Other tidbits from the day:

* Innapropriate use of the word Literally award: "Sometimes you have to kickstart the kid.  Literally.  Kickstart them."
* Culturally insensitive word of the day: "phagocytosis"
* Typos of the day: "Meningococcocemia" and "Immedite Danger"

Oh yeah, and I passed, so you can go ahead and let your kids get sick now.

Overheard on Day 1 of ENPC

Overheard on Day 1 of ENPC Class:

* Teacher (on allowing families to visit): "Most ER rooms aren't designed for families.  They are designed for one patient and a really small nurse."
* Teacher (on cultural sensitivity): "When you go in a room, do the patients ever ask you where you are from?" Nurse in back: "They usually tell you where you can go."
* Teacher: "Nurses are trusted by families.  Doctor's are way down on the list."  Other teacher: "In some places, the Doctor is still next to God."  Nurse in back: "especially in his own mind."
* Teacher: "Infants are obligate nose breathers.  What does that mean?" Class: *stunned silence*  Did she really just ask us if we know what that means?
* Teacher (on age-appropriate care): "You wouldn't ask a 9 year old to take their shirt off in a hall bed."  Nurse in back: "But some of our 35 year-olds will."
* Nurse (on HIPAA and age of consent for treatment on issues of sexuality): "Isn't sending a bill to the parents a HIPAA violation?" Teacher: "No.  Most bills are really hard to decipher."
* Teacher (on causes of pediatric overdose): "Maybe the kid ate three of Grandma's Whateverolol."
* Teacher (on questionable parenting practice): "I know that as Emergency Nurses we always talk about Stupid Parent Syndrome..."
* Teacher (on advances in medical science): "Any time someone says it will never happen, that means it will happen tomorrow." Nurse in back: "I'll never get a raise."
* Teacher: "Another cause of pediatric trauma is lack of experience.  They have only been around for 3 or 4 years and have a lot to learn about the world."  Nurse in back: "Sounds like Barack Obama."
* Teacher (showing a picture of kid with tire marks on his back): "...tire track marks..." Nurse: "tire?!?" Teacher: "you know, the four round things you find on the bottom of cars..."
* Teacher (on assessing for abuse): "I'm not trying to give anyone any ideas, but if you put a pillow over the child first and then punch, you wont leave a bruise."

And during our megacode practice:

* Nurse: "I can live with the pupils 5 mm and sluggish." Teacher: "Yes." Nurse: "I'm not sure in the patient can." Teacher: "Who cares about the patient?"
* Teacher (after giving brief history of the presenting complaint on critical 3 year old): "...and everybody else is at lunch so you are all by yourself."  Nurse: "I'd hate to work in that ER!"
* Teacher (reading another scenario of an unresponsive, suicidal 16 year old): "...the parents found an empty bottle of Verapamil in the trash can in the bathroom..." Teacher pauses, looks up, "well, at least she was tidy."
* Nurse (while doing megacode for two month old brought into ER): "do I see any vomitus or loose teeth?"
* Nurse (after pretending that her patient was just intubated): "do I see positive color change on colorimetric detector?" Teacher: No." Nurse: "Do I hear anything over the stomach?" Teacher: "You hear lots of gurgling." Nurse: "Do I need to let the Doctor know?" Teacher: "You do if he's walked away." Other nurse: "And while you are at it, take his license away."

Are You Kidding Me?

Non-nursing post here:

My wife and I watched the results from America Has No Talent tonight, and in the end it came down to a toss up between a run-of-the-mill Elvis dude and the obviously talented baton twirler Jonathan Burkin.  So the Hoff goes first.  This is the drunk man who told Jonathan that he was "probably... the best baton twirler in the world" but then he casts his vote for second-rate Elvis.  Then Sharon, who wants to make babies with Elvis boy voted for Jonathan.  Okay, chance to redeem.  Then Piers votes for Elvis.  Seriously.  On a show where they keep touting the trip to Vegas, they are voting for yet another Elvis.

I suppose I shouldn't be too surprised.  This is, after all, the show that puts forth the bat-eater's wife, the drunk has-been, and the arrogant evil angry Brit as the true arbiters of talent.  Then they accomplish the impossible by selecting a host who makes Billy Ray Cyrus look good by comparison.

And can we please just do away with this idea that weepy whiny boy is as talented as Paul Potts?  If you still have doubts, compare the two.

At least my boy Eli is still in it.  If he gets kicked off then there is truly no talent left in the competition.

Update: If you look at the fine print on the title of the show, it actually says


"America's Got Talent but you wont find it here"

Emergency Rooms Are For Emergencies.

My first visit to suburban doc's blog yielded a brilliant skewering of an ER-as-PCP proponent.  I'll be back for more, but in the meantime, go check it out.

Pay Grades

Another comment-turned-post:

WhiteCoat has a post up bemoaning US priorities based on census reports.  My comment ended up taking a long time to write, so I may as well get some readership out of it.  Go read his post first, and then my comment:

It can at least partially be explained by the amount of training involved and the difficulty in replacing some at the higher end of the spectrum.  My brother was a school teacher until this last year when he got fed up with the increasingly shocking behavior of America's unparented youth and the low pay of teachers.  And there were dozens of potential teachers standing in line to take his place, so there was no motivation by the district to try to keep him.

On the other hand, managers, doctors, nurses, computer programmers and the like are more difficult to replace so there is motivation to keep them.  I dare any fast food worker to say to their boss "unless you give me extra vacation and a 5000 dollar raise, I'm leaving."  They will probably get help out the door by means of the manager's shoes.  Moral of the story?  I suppose it can be summed up in the words of one of the greatest minds of our times: "You know, education, if you make the most of it, you study hard, you do your homework and you make an effort to be smart, you can do well. If you don’t, you get stuck in Iraq."

As for the gender gap, I don't know the details about how they come up with that figure, so I can't say too much on it.  If a manager is paying a woman less money to carry the same responsibilities, then that is just plain wrong, but I suspect that even if common decency does not motivate one to equalize pay amongst their employees, the threat of lawsuits will, so I have to wonder about the figures.

One possible explanation is the Mommy effect.  I know that among my co-workers, many of the women who have children work a lot less hours so that they can be home more often with the children.  I don't know if that is accounted for in the figures.  Another possible factor is different jobs within the general categories.  For instance, in my scientific survey of healthcare providers (in other words what I've seen around me), there are many more male doctors and many more female nurse practitioners.  If they are lumped together in the same category than there will be a big discrepancy even if the MDs are being paid the same and the NPs are being paid the same.  And on another vein of the same branch of thought, a lot of fields that have been primarily dominated by men (such as doctors) are just now starting to catch up (the last teaching hospital I worked at had 8 female and 7 male residents), but still the ones with experience and thus higher pay grades are mostly the males - this, of course is excepting Obama, who apparently does not have a high enough pay grade to have his own opinions.

Just a few thoughts.

Not Around My Daughter

So we took our 17 month old with us to run a couple of errands.  We picked up some books from the library to feed my wife's voracious appetite,* stopped by the auto parts store to get a new brake light (who knew it was that easy to replace a burned out brake light?), tried the new nacho cheese chicken sandwich at JackintheCrack (yummy!), and finally went to the park to let the little one stretch her legs out.

We were swinging together on the big chair swing and I looked over and 20 feet away was a man walking along in the play area with his 2 year old girl while smoking a cigarette, and the smoke was drifting over our way.

Time Out.

I hate cigarettes.  At least alcohol has some plausible defensibility (though not much).  There is nothing redeeming about smoking.  I get mad at how many patients smoke, but I get even more mad at parents who smoke.

Okay, back to the story.  So I hand my daughter to my wife and walk over to the man (who is now about 10 feet away) and ask, in as non-angry a voice as I can muster, to "please don't smoke around my daughter."  He looks at me and says, "I wasn't around your daughter."

Seriously.  That was his response.  But at least he did put his cigarette out and slid it in his pocket.

Seriously.  He slid his cigarette in his pocket.

Perhaps better judgment at that point would have been to leave it be, but the nurse in me came out for one last moment and I said, "You shouldn't be smoking around your own daughter."  I guess I'm glad that he didn't respond to that, because I wouldn't have backed down, and I probably would have ended up spending a few extra unscheduled hours in the ER, but I was mad.  I wanted to deck that idiot.

If you want to kill yourself with cigarettes, that is your stupid decision to make (and my bill to pay for when you can no longer work at 55 and are racking up the bills for all your COPD hospitalizations that you can't pay for), but when you make that decision for others, and blatantly smoke in front of your child, I see red.  Ruin your own life if you want, but leave your innocent child out of it.  At best you are modeling a terrible habit, and at worst you are encancerenating (made up word for the day) your child.  I have to admit that part of me was secretly hoping maybe the cigarette wasn't put out completely when it went in his pocket.  Maybe that way he couldn't bring any more children into the world just to kill them slowly with his stupidity.

Wow, I just reread that, and it makes me sound very angry.  Good.  I am.

Iron Man

So after spending approximately 17 hours* ironing and barely having three outfits to show for it, I'm a little fed up with my scrubs.

I buy boring Scrub Wear brand scrubs from Uniform City because they have the kinds of pockets that I like and I can mix and match colors depending on my mood and what sports team I want to resemble on any given day. But when I wash them they always come out with permawrinkles - especially the pants. And it doesn't matter how quickly I get to them after the dryer is done (although admittedly tonight I let the scrubs stay in the dryer for a couple** of hours), I still get multiple creases all the way down the legs of my pants and scrub tops that look a lot like the floor of my living room after Christmas morning. Interestingly, though, the level of wrinkleyosity (made up word of the day) seems to be linked to the color of the scrubs. Seriously. The black scrubs are fairly easy to iron and the wrinkles come out like buttah, the dark blue is a little harder, the maroon gets difficult, and the light blue scrubs require exercises in voodoo magic and several small animal sacrifices to become wearable. Don't ask me why.

So to all the experts out there, what can I do? Is there some type of detergent or dryer sheet that works magic to avoid the wrinkles? Is there a pre-treatment that I can use before washing them? Am I just totally screwed and should just follow the "suck it up loser" solution? Those who don't seem to have any wrinklage problems, what do you do to get no wrinklation?

The big problem here is that my religion does not allow me to stand on my feet while holding an iron for longer than 54 minutes at a time*** and so I am very limited in how much ironing I can do. I need your help!





* okay, so it might have been more like 54 minutes or something. Big deal.
** okay, so it was more like 70 hours. Whatever.
*** okay, so it isn't against my religion, but I'm thinking of bringing it up as an idea to work into the next canon.

Nursing Home Transfer of the Week

Pt brought in by ambulance from across the parking lot (literally) to our ER because of "chest congestion since last night with difficulty clearing her secretions."

On exam I found a mid-70's woman having undergone a left total knee a week prior presenting with a well-healing scar on her leg with mild warmth and redness and discoloration (about what you would expect, actually). She was in no apparent distress, denied pain except around the upper mid chest when coughing, said the cough was intermittent and she had not been able to bring anything up, and was not short of breath in any way. Her vital signs were stable with a mildly elevated (140s) blood pressure. She was alert and oriented and pleasant, and appeared to be well-nourished. Her husband came over a few minutes after her and her daughter showed up within the hour. Everybody seemed supportive and knowledgeable about her care.

So why was she in the ER? I never could figure it out. I suppose for the possibility of a PE given the recent surgery, but don't you usually need more to go on - like unstable vital signs or presentation consistent with an embolism?

The doc on duty was one of the careful CYA types, and so Grandma Z got an EKG and chest x-ray and IV line and lab work. When it all came back clean (of course), she got a diagnosis of "Chest Pain - Uncertain Cause" and was sent packing. I called the NH and cleared a return trip by POV, and that is what officially happened, although based on what they were saying as I helped Grandma on the wheelchair, I think they just wheeled her across the parking lot. I checked later and the chair was back in its place.

No harm, no foul... But one big bill.

Bang! Crash! Pow! Bam!

No, not an old episode of Batman... the Respiratory Therapist trying desperately to free the ventilator from the evil clutches of a bevy of plugged-in IV poles, the difficult airway cart, the ENT cart, and a Bipap machine while the patient in room 7 continued to crash.

Time to reorganize, anyone?

New Change of Shift

The next Change of Shift is up at Nurse Ratched's place, and I'm happy to say that I am linked. There are several other good posts from around the blogosphere that are featured as well, so go give it a look.

Leaving Comments and Bad Pennies

Some may have noticed that my production level of new posts has declined somewhat of late. I'm not entirely sure of the reason for that. Perhaps part of it is because I have found myself leaving long, detailed comments on other people's blogs and by the time I'm done with that, I'm all creativity'd out.

Or maybe I'm just lazy.

Anyway, one solution to the problem is just to cross-post my comments here.

A minute ago I left a comment on my brother-in-law's blog. He likes taking on unusual projects and his latest shin-dig is to collect coins that he finds and keep track of what and where. Sounds like something that would entertain me for about 20 minutes, but it has kept him busy for over two months. So in looking at his totals, he came to the realization that he almost never finds nickels. His question: why is that?

In this season of political intrigue, the answer can only be a political one, so here was my response:

Well when you elect me President, I'll do away with the Penny... seriously - why do we even have pennies anymore?

And then everything will round out to the nearest 5 cents and nickels will reclaim the glory that they have lost thanks to the inept policies of the Bush Administration.

No, really, why do we even have pennies? Think about it. The reason that you have found 64 pennies (4 times more than the next highest total number of coins) is that they are worthless. When I buy anything at the cafeteria at work, any pennies that they give back go into the give-a-penny jar because they mean nothing to me.

So what would be the downfall of the no-more-penny law? I suppose that retail establishments might try to take advantage of it by making sure items come out to a total ending in 8 so that they can round up and get two free cents. Doing the math, and assuming a super-shopper who makes 10 retail transactions with cash every day (after all, there would be no need to change the credit card transactions). If, in each of these transactions, the customer lost 2 cents that she otherwise would have retained, then our shopper is losing 20 cents every day. If our shopper is doing this every day, including Sunday, then they are losing $1.40 every week. That comes out to a total of a little over 70 dollars every year.

Or perhaps a more reasonable transaction rate of 3 transactions per day 5 days a week would come out to 30 cents per week or 15 dollars per year. As president I would sign an executive order to give a universal tax rebate to everybody for 15 dollars. This would be paid for with the savings from stopping production of pennies and from the money made by collecting all old pennies and selling them to China.

Vote Braden/Barney 2008!

Classy (political post)

I'm going to try to refrain from getting too political in my posts, but I have to give a big shout out to the handling of the recently announced teenage pregnancy of Palin's daughter. Palin released a great statement about how her family and her daughter would be accepting responsibility for their actions and ensuring that this would be handled by the family.

But even more impressive to me was Obama's handling of the situation. As reported by Politico:

At a press avail in Monroe, Mich., Barack Obama on Palin: "Back off these kinds of stories."


"I have said before, and I will repeat again: People's families are
off-limits," Obama said. "And people's children are especially
off-limits. This shouldn't be part of our politics. It has no relevance
to Gov. Palin's performance as a governor or her potential performance
as a vice president. So I would strongly urge people to back off these
kinds of stories. You know my mother had me when she was 18, and how a
family deals with issues and teenage children, that shouldn’t be a
topic of our politics."


On charges that his campaign has stoked the story via liberal blogs:


"I am offended by that statement. There is no evidence at all that any
of this involved us," he said. "Our people were not involved in any way
in this, and they will not be. And if I thought there was somebody in
my campaign who was involved in something like that, they would be
fired."

This is a story that would be easy to try to jump on and run with as a low blow, but I greatly respect the way that he not only gave lip service to the idea of leaving it alone, but he reiterated that he himself was the product of a teenage pregancy. Putting his money where his mouth is.

I maintain that if family members inject themselves into a campaign (as Michelle Obama has on multiple occasions) then to that extent they are fair game, but personal lives of family members have to be off limits, and I'm impressed with the scruples to act accordingly.

I'm still a long long way from supporting Obama, but it is still nice to see this side of him.

Very classy, Senator.

Overheard

While charting at the Nurses's Station:

"Doctor G, I just put a patient in room 5. It appears to be a rectal foreign body - hot dog."

I didn't even ask.

Just Your Standard ER Visit

ERP has a good post up about some of the crap we have to deal with, so I couldn't resist posting a comment, and then I went to such work writing the comment, that I thought I should at least get some credit for it, so I'm reposting it here for your pleasure:


When I read your rant about obesity, it reminded me that I haven't had breakfast yet, so I jumped in the car to run over to Burger King. It was hot, so I had the top down, but the wind brought back my migraines, so the voices in my head told me to get care right away. I would have gone to my doctor but I'm in the process of suing him because he wont treat my pain. Anyway, I pulled out my cell phone and told the ER that I was coming over and they should get me straight back because the pain was so bad. The doctor was a total jerk and wouldn't even believe me when I told him that my sister had accidentally taken my prescription in her suitcase when she went on her month-long vacation. Then he tried to prescribe Ultram! I'm allergic to Ultram! I told him that, but he wasn't even listening. The only thing that works for me is that Dilatim or whatever it is called. And I couldn't believe that everyone out at the nurses' station was laughing. They were probably laughing at me. Don't they realize that there are really sick people in the ER? They need to learn to be more serious. Anyway, what really takes the cake is that they wouldn't let me plug in my adaptor for my Game Boy Advance, and the battery was low, so I just had to sit there for 3 hours. That's right! THREE HOURS! And when he finally did come with a prescription, it seemed like he was being disrespectful of my severe anxiety, because he just turned the light on, mumbled something about a patient next door who couldn't breathe or something, and gave me the prescription and said I should see a doctor. What, he isn't a doctor? I told him that I couldn't afford this medication, and he had the guts to suggest that I cut my smoking down to only 1 pack per day to free up some money. I can't believe how insensitive some people can be. Maybe I'll find a lawyer.