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.

Altered!

Imagine being a recently married young woman and coming home from a night shift at a fast food restaurant to find your husband sitting in bed covered in poo and not able to remember anything or answer any questions.

Yeah, I'd be a little concerned, too.

Such was the patient that I had last week. And a strange presentation it was, too. He could remember his wife's name and his birthday, but he would get easily confused and answer questions inappropriately. Grips were equal, no nuchal rigidity was noted, and I couldn't elicit a positive Kernig's sign (although later I realised that I don't think I did it properly), pupils reacted as expected, sensation was intact (in fact as we were cleaning the poo off his feet, he was complaining about it tickling). He was oriented to place - kind of (he could state that he was in an ER, but not the city or country. He could say his full name, but with a question in his voice each time. He had no concept of time. But then there were the signs that maybe he was faking it (although it would take a really devoted faker to lay in poo), such as the times when he would seem totally lucid, like when I would explain what was going to happen next. His medical history was unremarkable except that he had been complaining of bad headaches over the past 10 or so days. The wife said that she hadn't brought him in because they didn't want to pay for an ER visit and she thought it was "one of those things that you just sleep off."

After the requisite Head CT and chest xray and EKG and labs, the doc got set up to do a lumbar puncture, but got nowhere with it, because he would alternately be cooperative and oriented and then confused and combative. Ultimately he was sent down to radiology for a fluoro guided LP.

The doc and I had a little debate about what it could be because the presentation didn't fit any diagnosis very well. The vice-grip headaches for days preceding his arrival seemed to point to meningitis, but with no fever, photophobia or nuchal rigidity, we were skeptical. The AMS in an otherwise healthy young man indicated possible head bleed or tumor, but there were no hematological changes and his CT came back clear. His tox screen was negative and according to the wife he didn't drink or do drugs anyway. He denied any pain the entire time he was with us. It was unlikely to be a drug reaction or serotonin syndrome as he took no home medicaions. And finally, he had no known psychiatric history.

So we waited.

I took advantage of some time to get away from the room to go answer the urgent call of my 19 year old nausea patient who was kind enough to put away her cell phone and Doritos long enough to tell me that she wanted to go home because she'd been here forever (3 hours) and I hadn't even been in her room to see her in the past hour. I resisted the urge to go medieval on her heinie and lecture her about the 75 year old AMS (turned out to be from low blood-sugar) I had next door and the young man I've been talking about, both of which rank significantly higher on my list of priorities than a 19 year old princess with an attitude who has demonstrated no actual sign of disease, and who would eventually be discharged with a diagnosis from the doctor of "there's a bug going around." But at least she took up a room and kept me from getting anything more demanding while I tried to sort my real patients' problems out.

Finally, we got word from the lab on the CSF studies: Meningitis... not bacterial or viral; but fungal. Yeah, fungal. I've looked around a little since, and found some information on it, but I have to say that neither I nor any of the other nurses I was working with had ever even heard of meningitis caused by a fungus.

I took time the next day to go up to his room and see how he was doing, expecting to see him looking and feeling better. I have to say I was quite disappointed to find essentially the same person that I had last seen 24 hours earlier. For his wife's sake I tried not to let my surprise show, but it was there nonetheless. Fungii can be hard to treat. For his sake, I hope they didn't wait too long to come in.

Disappointed Excitement

Excitement because I found out from my neurologist today that I don't need to worry about all the scary things that she was testing me for.

Disappointment because I still have all the symptoms, but with no explanation.

So on to the next steps: EEG and referral to Neuropsychiatrist (that sounds scary!).

Bed Sports

So I had a really nice couple today and the wife was a little anxious, so she got a small dose of Ativan that seemed to do the trick fairly well (c'mon, when does Ativan not do the trick?).

As the husband walked her out to the car, he said, "it is time to go do some horizontal sports in bed."

I think he was genuinely surprised at all the gaping-mouthed expressions around the nurses' station.

"I meant snoring!"

WWSFT?*




* What Would Sigmund Freud Think?

Change of Shift

I'm a day late, but the Change of Shift is up over at Kim's place. For anybody who reads my blog and doesn't already read hers (there might be one of you out there...), go check it out, yo.

Click picture above for link.

Experiment Results

Well, thank you to all those who participated in my experiment from a few days ago. The results are nothing short of amazing.

I saw a rise in actual visitors to the page that was truly stunning to behold.

On the first day after my request to have people visit the site, I had 2 more people than the previous day.

Stunning, I know.

On the second day, I had 5 less.

Hmmm...

But seriously, thanks to all those who commented. I appreciate the nice comments and it is good to know that I have regular readers hanging on my every word. I'll try to do you justice.

Word.

Help Me With a Little Experiment

So the number of visitors to my site skyrocketed after I hosted the Change of Shift a couple months ago (thanks Kim!), then it made a slow and steady decline to a point that it has held steady for nearly a month now. I thought it was because I don't always put deodorant on before I blog, but then I realized that while the number of visitors to my blog has declined, the number of people subscribing to my blog in Google Reader (and, I would assume, other feed readers that I don't know how to measure) has gone steadily up.

There are now 50 people who read my blog on Google Reader and many others who use other services, and since I have my blog set to publish the entire text - even when it is long and rambling like this one is starting to be - there is no incentive for you to actually click the link and go visit my actual webpage. I'm not about to change that, because the great thing about a feed reader is that - gasp - you can actually read the feed and not just get teased by a few lines that you then have to click a link to go read the rest. About the only blog that I let get away with such attrocities and still maintain my regular patronage (was that a sentence?) is Crass Polination (please note that there is onlly 1 l in polination, because everybody knows that you shouldn't add a second l. That would just be sily, and would probablly keep you from getting publlished on the littlle side bar of your favorite nurse who is llike totally your homey but who judges you based on simplle speling mistakes. No, I'm not bitter. Why do you ask?)

Anyway, if you skipped all that to find out what my experiment is, then you are probably an ER Nurse who has learned to ignore most of what a patient says until they finally get to the point. Congratulations. Here it is:

MY EXPERIMENT:

Those of you who read my blog in a feed reader, please click on this post to actually bring the blog up in your browser today. It will just take a second and think about how much you are benefitting humanity by doing so. If you want to be even cooler, leave a comment.

Thanks,

Your Humblle Correspondent and all-around good speler

Overheard

Overheard after a frustrated nurse couldn't understand an Ativan-induced mumble:

"Does anybody speak Ativan?"

Best Compliment of the Day

While SVN was in progress and Solu-Medrol was being pushed in the IV line, the doc comes in and listens to the patient's lungs:

"Well, you sound better, but you still sound crappy."

Can You Connect the Dots?

What do the following have in common (no, they are not new diseases that I have recently come down with):

Periorbital blowout fracture
Blunt abdominal trauma with early symptoms of shock
Spontaneous pneumothorax
Intractable nausea and vomiting
Peritonsilar Abscess
Severe lower back pain with abdominal distension

Stay tuned

Whatever you do, be careful!

I got this in my inbox this morning:

Dear Braden


We are pleased to inform you that your new @#$$%!@# order Has been carefully packaged and shipped via USPS.

I'm so glad to know that it was carefully packaged and not just randomly thrown in a box. I'll let you know just how carefully it arrives.

It is also quite reassuring to know that the people who will be carefully packaging my shipment have also carefully left the word "Has" capitalized and very carefully left two spaces between "shipped" and "via".

Thank You For Your Urine

So among the gaggle of tests ordered by my neurologist was a 24 hour urine collection to look for heavy metals ("We're sorry, Braden but it appears you have Panteritis with a slightly elevated Megadeathicus level").

Anyway, I got the urine collection container from the lab and she brought it out in a plastic bag that said "Thank You Thank You Thank You Thank You Thank You Thank You" on it. Seriously. 6 Thank You's down the side of the bag and then below that in small letters "for your patronage".

Umm... You're Welcome?

The Name of That Disease!

I posted a couple days ago about what could be the presenting complaint and ultimate diagnosis for the person receiving 7 kajillion tests, and it seems like people tended to coalesce around fibromyalgia or ETOH.

The initial presenting complaint was fatigue worsening over a period of a couple years and ultimately getting to the point of disrupting daily life. Also worsening over the past several months was difficulty focusing and worsening short-term memory. Incidental to that was paresthesias in both feet - worse at night.

I suppose it is a little misleading to have this on an ER blog, as the patient was never seen in an ER for these symptoms, but it's my blog and I can do what I want.

The patient presented to his PCP (with great encouragement from his wife) for the fatigue to see if there was anything beyond depression to explain what was going on. He had tried provigil a year or so before with great benefit but had long since run out. The doctor ordered a smattering of blood tests (TSH, CBC, CMP, B12, etc) and gave a couple samples of provigil. The Provigil helped a lot, but not as earth-shatteringly-lot as before. A week later, he got a letter saying that the B12 level was low - 212, and a follow up appt should be made. In the follow-up, the doctor re-ordered the B12 along with a couple of specific markers and a Folate, and prescribed weekly B12 injections. The new labs came back even worse than the originals - 189 - but the Folate and homocysteine/methymalonic acid were normal.

Enter referral number one to Hematology (one month later because that is the soonest to get in). At this point the fatigue has taken a back burner to the neuropathy because, though the fatigue persists, the neuropathy is becoming worse quickly. The Hematologist seems somewhat unconcerned about the B12 levels and thinks it is an incidental finding. He orders a repeat B12 to see how the shots are working, along with Anti-parietal cell antibody markers and anti-intrinsic factor markers, and refers the patient to the neurologist.

A week later, the patient is sitting in yet another new exam room when in walks the Neurologist with a big shotgun and KABLAM! fires away with every test known to man along with referrals to rheumatology and gastroenterology (which were politely refused).

So now here I am, a generally very healthy 28 year old, having my blood drawn regularly, seeing more Doctors in two months than in the past 2 years, and stuck on a regular diet of pills every day (okay not that many: Vitamin B12 tablets (grape flavored!!), Provigil (1/2 tab usually only on days I work evening or night shifts), Gabapentin (just at night to see if it helps with the neuropathy), and mouthfuls of ibuprofen and tylenol (the ER is killing my feet and back!!!)).

Now I tell you what tests have been ordered and you all jump to fibromyalgia. I just have one word for that: itbetternotbeflippingfibromyalgiamymotherinlawhasfibromyalgiaanditreallyreallysucks.

And somehow I think that ETOH problems are fairly low on the list of likely answers.

So what are the answers? It may end up being as simple as some depression causing the fatigue (although it really is very severe fatigue and the memory lapses and difficulty concentrating or staying focused is quite disconcerting. That, and while I find myself with low energy and difficulty finding impetus energy, I'm not actually sad or... you know... depressed) and maybe just muscle strain causing the neuropathy. But it could also be a bunch of other things, and looking at where that shotgun was aimed, it seems like the doctors are thinking of:

* Pernicious Anemia (though the neuropathy keeps getting worse even though my B12 levels are now back to normal)
* Diabetes (c'mon pregant peeps! That glucose tolerance test isn't anywhere near as bad as it gets made out to be)
* Mercury Poisoning
* Multiple Sclerosis (hence the MRIs)
* Systemic Lupus Erythematosis (I know almost nothing about this disease and I'm scared to learn about it)
* Rheumatoid Arthritis (Really? I'm 28. I thought it was just the LOL's who got that)
* Syphilis (what? You've gotta be kidding me. If it is syphilis, my wife has some splainin' to do)

One thing I'm fairly confident that it is NOT: A very drunk old man passed out and fell off a bar stool. And yes, Sean, you are a comment hog - but as an old cowboy once told me: "You're welcome at my campfire anytime."

Interesting aside (because, frankly, if you have read this far, you are so invested in this post that I can pretty much say whatever I want now): both the anti-parietal and anti-intrinsic factor tests came back negative, meaning that my body should have no problem absorbing B12, and since I am not a vegan and I drink plenty of milk and my total lifetime alcohol consumption equals a couple of chocolates while I was living in France, that leaves us pretty much no idea why my B12 would be low.

Another interesting aside (why not, right?): Vitamin B12 in pill form is usually cyanocobalamin. Without a doubt this ranks among the coolest names for a medication, and it is much more fun to write cyanocobalamin on a history form at the doctor's office than boring old b-twelve.

Name That Disease!

Okay, so here is a game:

Based on these ordered tests and referrals, guess that the presenting complaints and the disease:

24 hour heavy metals urine collection
TSH (Thyroid Stimulating Hormone)
Hep C Antibody Test
Magnesium Level
Vit B1 (Thiamine Level)
Vitamin E Level
Vitamin B12 Level
Folate Level
Fasting Blood Glucose
2 Hour Glucose Tolerance Test
RPR (Syphilis Test)
ANA (Antinuclear Antibody Test)
CRP (C-Reactive Protein)
ds DNA (Double Stranded DNA Antibody IgG)
ESR (Erythrocyte Sedimentation Rate)
RF (Rheumatoid Factor)
SPEP (Serum Protein Electrophoresis)
Lactate
Aldolase
CPK Total (Creatine Phosphokinase)
CBC (Complete Blood Count)
CMP (Comprehensive Metabolic Panel)
MMA (Methylmalonic Acid)
Homocysteine Level
MRI Brain without Gadolinium
MRI Brain with Gadolinium
MRI C-Spine
Referral Hematology
Referral Neurology
Referral Gastroenterology
Referral Rheumatology

I'm Excited!

Today at 7:30, I folded up my tent and sleeping bag and moved out of the ER for a few days.

In the 26 days since my wife left, I've worked 215 hours. That is an average of over 8 hours a day even including the days that I had off (of which I never had more than one in a row) and an average of almost 11 hours a day on the 20 days that I did work.

My back is killing me and my feet have officially fallen off.

I'm ready for a break.

But even more, I'm ready to have my wife and daughter back from their family reunion, and that is exactly what I'm about to do. It is amazing how energized I am given that I just finished my third 12 in a row.

You would be, too, if your family was as awesome as mine.

I Need to Say Goodbye to My Family

He handled an incredibly difficult tanking patient admirably well, but Dr. CF made one big mistake.

When your patient tells you that he is about to die, you don't tell him that he isn't.

Period.

Security! Please Escort God Off the Premisis

I heard a lot of yelling down the hall and so I walked over to the nursing station and looked over to the other side of the ER and I see a patient backing up, yelling at whoever is threatening him:

Patient: "Don't you know that I'm God?!?!?"

Then I see our recently-returned-from-Iraq no-nonsense tough-guy PA marching straight at him with shoulders set and an angry look on his face:

PA toughguy: "Yeah, well you are about to meet Satan!"

Later while in the break room I was talking to him about it, and he said, "I was really hoping he would lay a hand on me so I could beat the hell out of him."

My response: "He's God. You can't beat the hell out of him, but maybe you could have beat the heaven out of him..."

and such is life in the ER.

Crass-Polination Blog Take 2

Well I tried once to get included on Nurse K's sidebar, so maybe i was just a little too subtle. Let's try again:

Nurse K Freaking Rocks!

Nurse K is the only blogger I know who successfully uses the word "purveyor" in an "about me" sidebar. How much more coolness could you possibly want?

Public Service Announcement

Despite it's rather benign appearance on the outside, if you happen to pass a building that has big letters on the outside that say "Castle" and underneath, "Knights and Damsels Welcome", you should know that despite your wife's protests to the contrary, it is not, in fact, a dinner theatre, and is also not necessarily an appropriate place for your 14 month old Damsel.

This has been a public service announcement.

PS - Don't click that link above.

Too Little, Too Late

She was in for vaginal bleeding and cramping. She was 8 or 9 weeks pregnant. She had been to the doctor at her Tribal Clinic the day before and been told that there was a "threatening miscarriage".

When I asked if she took any medications, she said, "yes, I started taking prenatal vitamins yesterday."

I truly am very sorry about your loss, young lady, and maybe there was nothing you could have done anyway, but seeking care and starting prenatal vitamins 8 weeks in is far too little, far too late.

And I Never Want To See You Again!

On a comment about pens, Prisca said:

"On my floor, stealing a pen from someone can end a friendship!"

This may be true of the ER as well. In addition, there are several other things that I've found can end a friendship:

* Taking somebody's WOW - even if they haven't used it for the past several hours.
* "Oops, was that your food that we just threw away? It wasn't labelled."
* "You are in triage... again."
* Putting a patient in somebody's room and then forgetting to tell them.
* Helping out by stopping an IV drip, taking a pt to the bathroom, emptying a commode, etc and then not charting it.

Any other ideas?

Cruel Joke Revisited

I was just thinking: as long as we are having our ventilators play video game theme songs, why not just have downloadable ring tones?

The family members can choose from a list of thier favorite songs and assign them to the different alarms, so perhaps you could see some of the following options:

* If the tube is disconnected, we could get the theme from "Gone With the Wind"
* If the vent does not sense enough return of air, it could play "Waiting to Exhale"
* If the battery is running low, we could get Bryan Adams' "Can't Stop This Thing We Started"
* If the patient falls in too deep of a sleep, we could get Garth singing "The Thunder Rolls"
* Maybe if the ventilator senses several problems at once, we might hear "I'm Every Woman"

Any other ideas?


Technorati Tags: ventilator, alarms, ventilator alarms, humor, ringtones, music, satire, please don't kill me for my misogynistic ways

What's In Your Pocket?

Every nurse has their essential supplies. These are the items that are so important to you that you have to always have them with you as you do your job. It is interesting for me to see what some people have (do you really always need to have an 18g IV needle handy? What good is it if you don't also have a start kit and an extension?) and what some people don't have (stop asking if someone has an alcohol pad and start carrying a few around with you!).

That said, here is what I carry with me in the ER:

Pen
4-5 saline flushes
5-10 alcohol preps
Scissors
Hemostat
Assessment forms (little 1/4 sheet of paper that I put together to remind me to cover everything as I do assessments - though I use them less now that I have started taking the WOW with me into the rooms and doing my assessment straight on the computer)
Pocket PC (currently I have PEPID installed because my Davis is 3 years out of date and my Tabers is the same)
Penlight
Carpuject
I just bought some dry-erase markers with pen clips so that I can write names on the board of who's who.
Other: Sometimes I keep a couple 2x2s or some of my coveted nitrile gloves with me (so I don't have to use the crappy ones that are in most of the rooms). I used to do the hemostat-through-a-roll-of-tape-clipped-onto-scrub-top-made-into-a-makeshift-scissor-holder thing, but that just got in the way too much.

Well, know you know what's in my pocket; so what's in your pocket?

What a Nerd!

After work today (yay! my 60 hour week is over!) I stopped by Office Depot to buy more pens because I've finally run out of them after I bought two boxes last time.

It was while trying to explain to the salesman what I was looking for that I realized what a complete nerd I am. The pen can't have a big rubbery grip because then it doesn't fit in my pocket very well. It can't have a cheap plastic end piece (the little cone-shaped part) because those always slip down and make it hard to write. It has to be a click-pen because I would lose the cap off of a stick pen in about 2 hours. It has to be medium point because thicker than that turns into mud when I'm trying to squeeze a whole narrative into the two inch wide nurse charting section on our ER records and thinner just feels wimpy. It has to be a black pen because that's what nurses chart with in our ER. It can't be a gel pen because they don't transfer through to carbon copies very well. It can't be some crazy style or color because I tend to be very understated and conservative in my style (yup: plain, boring scrubs for me). It can't feel light because I need a good solid pen to write with.

The long-suffering salesman did his best to satisfy my needs, but in the end, nothing lived up to my standards. I realized halfway through that I was being picky about a freaking pen, but that didn't stop me from being picky. It is, after all, the item that I use the most often while working, so I have room to be fussy.

All I want is what I had before. Why do all pens have to suck now?


Oh, and I took care of some sick people and made them feel better and all that stuff...

Random Thought

Why do we use the phrase "stepping up to the plate" as some kind of heroic act?

Everyone in baseball steps up to the plate, and statistically speaking, only about 25% of the time do they get on base.

Perspective from the Dead

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

I'm just saying.

Calling the Code

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

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

Can you tell how my day went today?

He Was Already Dead, Jim

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

He's Dead, Jim

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

Kind of brings a whole new angle to the story.

Cruel Joke?

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

One at a Time, Please

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

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

So if I have an open room, and my other patients are in the sit and wait phase, I have no problem receiving a new patient. In fact, it is nice, because I like to stay busy.

But when I get another patient and I'm still somewhere in the initial phase with a patient, then things get broken up. I don't want to leave the new patient just sitting and waiting to get all those things done, but I can't just leave my current patient to sit and rot, so I end up trying to bounce back and forth as much as I can, which, in the end, is slower, because each time I go into a room, I have to regain my bearings about just where we are.

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

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

WARNING! RANT AHEAD!

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

Then I stepped out in the hall.

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

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

Okay. Maybe you should have someone pop their head in my room and let me know that I'm getting a coding patient. But I didn't say that. I don't like conflict.

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

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

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

Right?

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

So much for teams working together.

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

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

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

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

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

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