It's good to want stuff.

If you are a 30ish, solidly middle-class, slightly yuppie mom, and you bring your cute-as-a-button four-year-old into the emergency room at ten o'clock at night on an evening where pediatrics is completely SLAMMED with sick kids (including one whose VP shunt is clogged and who is lethargic and vomiting, and a sickler with severe pain, and several whooping babies), you are not allowed to complain about the wait.

Especially when the complaint is "stomach pains" and your kid is running around the waiting room, terrorizing everyone.

ESPECIALLY when you and your stomach pain kid are sitting in my little triage cubicle and the kid is SHOVELING strawberry-filled sandwich cookies (but they're ORGANIC so they're GOOD FOR YOU) into his freaking little pie hole as fast as he can chew. Seriously, crumbs everywhere. And when I ask him, "Honey, can you point to where it hurts?" the kid shakes his head and keeps shoveling. "So, Mom, any vomiting or diarrhea? Fever? No? Nothing? Eating normally?" (obviously...)

You are especially not allowed to say to your kid, while waiting in the ER, when he is whining to you about how he wants to go home, that HE (again, four years old) should come over to ME and tell ME HOW SICK HE IS FEELING. Do you really think I can't hear you? And it's not acceptable to come back to my door every time I open it to see another patient and ask again and again how much longer until you're seen. And please don't try to be assertive or whatever by saying, "I really want him to be seen soon. I'm sure you can make that happen."

Lady, we all want things. Right now I want a bag full of hundred-dollar bills and some heroin but THAT'S NOT GOING TO HAPPEN EITHER.

Please please

PLEASE stop referring to chicken pox as "Chicken Pops."

PLEASE.

Especially stop doing it when I say, "Do you mean chicken POCKSSSSSSSSS?" and you reply, "Yeah, chicken pops, like I said!"

And then do it over and over again: "That mark on hims face ain't a pop is it? It look like a pop! You sure it's not a pop? I think it a pop."

OH DEAR JESUS IT'S NOT A FUCKING POP! IT'S A ZIT! NOT A POP! or pox. or anything. just go wait over there. please.

Black Humor

After bringing in one of our regular “methadonians” who was found nodding out (and breathing about 6 times a minute) on a local street, the paramedic sung softly in my ear (to the tune of “Horse with No Name" by America) “He went to the dealer, bought some horse with no name/Narcan’d him twice and he’s still not the same...”

Seriously? Really?

So, the other night I was covering the charge nurse while she went on break and was covering our small asthma area as well.

I got a call from our contact in the admitting office. Ms. So-And-So, the sister of someone who works in a clerical area, was out in triage; could I do anything to bring her back sooner? Hmph.

I walked out to triage. Our triage nurse had about 12 people still to do and was working as fast as she could. I looked through the triage slips and found the paper that Ms. So-And-So filled out when she came in. It read, “bump at bottom of spine hurts to sit or stand.” Uh, yeah. Pilonidal cyst, anyone? I decided against bumping her to the top of the line; there were definitely sicker people waiting. And I was definitely NOT bringing her inside; there were already a lot of people waiting to be seen in the main ER.

On my way back, I mentioned to the ambulance triage nurse that I hated when people tried to get special favors for their relatives because they work in the hospital, especially when the relative is not that ill and really shouldn’t be in the ED at all.

Then, the security guard at the ambulance ramp comes running up, saying that there’s a car on the ramp, and the driver, a woman, is screaming that her father is dying in the backseat. Of course, I grab a stretcher and start running to the ramp; one of the MDs follows. The patient is a middle-aged man. He’s bent over in the backseat, crying and vomiting, unable to sit up straight. He complains of a sudden onset of right flank pain that is the worst thing he’s ever felt. No history of kidney stones, but had slight abdominal pain and pinkish urine this afternoon, and had planned to go to his PMD the next day to get it checked out. He’s panting, diaphoretic, pale, and in the classic kidney-stone crouch. Typical renal colic. I stick him, get bloods, put in an IV, and give him 30 mg of Toradol. Then I take him to the ambulance triage nurse to be triaged.

She actually glared and me and sucked her teeth. “You know, this is the same thing,” she says.

Uh, what?

“Just because someone comes up the ambulance ramp doesn’t mean they deserve to be in the ER. You putting this guy in a bed is just as bad as bringing someone back from out front because they are a relative of someone.”

Again, uh, WHAT?!? Seriously. I think she was just pissed I made her get off her duff and triage someone, instead of sitting there and drinking coffee.

Just to be clear: This man was WAAAAAY more acutely ill than some lady with an ass-bump. I wouldn’t have left him outside EITHER.

Then again, I should remember where this nurse is coming from: This is the person who brought back a lady whose main complaint was: “Poured rubbing alcohol in left ear TWO DAYS AGO and now it is burning.”

And now a word from the Tourism Board...

Come to our exciting city! perhaps to see an old school buddy! bring a friend! There’s plenty of things for a couple of twenty-eight-year-old guys to do!

See the sights--maybe do a little shopping! Score some recreational substances of exotic origin and dubious content from our fun "outdoor pharmacies!"

Kick back and relax! Enjoy your recreational substances and relax so much that, when your buddy comes home from work, he finds you and your traveling companion unconscious--your friend blue and in PEA, and you in acute pulmonary edema with pink froth and vomit pouring out of you.

Experience an action-packed urban adventure...as two teams of paramedics attempt to intubate and restart your friend’s heart, and as you gasp for breath with the help of oxygen and a bag-valve mask. Feel the thrills of being transported at high speeds through the city streets to the emergency room, where doctors and nurses will continue to try to bring your friend back. Encounter fascinating people like the respiratory therapist, who, as you vomit gouts of bloody puke, introduces you to the ventilator after you are sedated and intubated. Feel the suspense as as the doctors and nurses watch you throw PVC after PVC, as you work your way into v-tach and get coded yourself--and then die.

Experience the heart-rending drama as all the parents arrive from two states away after driving for hours: your mother throws herself on top of your lifeless body and screams for you to wake up, wake up...as your friend’s parents are told that their son, who was coded and essentially pulseless for 45 minutes, probably will never wake up...as he is put on pressors as his body begins to shut down...as he develops DIC and bleeds from every opening in his body even as platelets and blood products are being forced in...as his parents beg the doctors to do everything, please, do everything, please, save him...

Return home with stories to share! Oh wait, you’re in a box. Bet your families will always remember your big-city adventure!

zzzzzzzz...WHA?!?

Sick. Then sicker. MISERABLE. Then one night of no sleep with snot constantly dripping out of me (seriously, like a freaking quart of mucus at least); then up the next day to go to my ENPC (Emergency Nurse Pediatrics Course) class for eight hours. Then home to study and sleep. Then up again for work from 11:30 am to midnight. Then home again to study and sleep, and then up again after four hours of sleep for the second part of the class and for the test.

I was BEAT. By six PM I was ready for bed. It felt like midnight to me. All I could do is veg out in front of the TV. DR had a rehearsal and would be gone until after midnight.

Cuddled up with the dogs, relaxing on the couch, and then screams and crashes and bangs and more screams and louder screams. The dogs leaped up and started barking, I jumped off the couch and ran to the door--the screams were coming from the hall. I looked through the peephole and didn't see anything, then cautiously opened the door. The screaming continued, from an apartment across the hall from us. Was someone hurt and calling for help? Down the hall, our other neighbor was peering around his door too. The screaming escalated, and I could make out words here and there, and then a big bang and another crash. It was obvious the residents of the apartment were fighting. I banged on the door, and my other neighbor banged on the wall--no answer, the noise didn't stop, and we retreated back into our apartments.

We live in a nice co-op apartment building. It's clean, attractive, relatively well-managed. Mostly owner-occupied. The neighborhood is working- and middle-class, urban, ethnically mixed (really mixed: Orthodox Jews, Poles, Russians, black people, Bangladeshis, Pakistanis, to name a few).
We know everyone in the building by face, if not by name. This was totally scary and freaky.

What do you do? Do you ignore it? Hope it just stops? Bang on the door again until someone answers?

I called 911. After about ten minutes, the noises across the hall stopped. A few minutes after that the cops called me; there was a patrol car downstairs, and I went down to speak to them. They came upstairs, and, after I scaredy catted it back into my apartment, I watched like a looky-loo through the peephole as they knocked on the door, spoke to the people inside briefly, and then left.

Was I a busybody?

Now I'm waiting to find a flaming bag of poop on my doorstep.

When Docs Attack

ERnursey, one of my favorite bloggers, has a post up called “When a Doctor Assaults a Nurse.” Now, fortunately, nothing like that has ever happened to me. But it did remind me of one situation I had recently. (Sorry for such a looooong post; I'm kind of venting here.)

Early one morning we got a trauma--an elderly person who had been hit by a motor vehicle. This person had some head trauma and several other fractures, had been intubated and placed on a ventilator, and the neurosurgeon was paged and subsequently accepted the patient to his service. No beds were available in the ICU at the time, and the nursing supervisor was contacted and started scrambling to arrange a bed.

This patient required very close monitoring, so when I came in for my shift, I was assigned to provide one-to-one care. (For the first few hours of my day, I’m a float nurse. My job is to give people their lunch breaks and then take over an area.) This meant that the rest of the nurses got shortened or no lunch breaks. The whole ED was aware of the seriousness of this patient’s condition and was pitching in (with almost no complaints) to ensure that this patient got the best care we could provide.

The patient’s family was at the bedside, and I answered any questions I could about what was going on, explaining the different readings on the monitors, explaining why we were keeping the patient sedated, why the patient had loose restraints on, what the different medications I was giving were for, and trying to maintain a quiet and soothing environment as best I could in the ER. The family was distraught but calm, and thanked me for being helpful and informative.

I worked with the residents and PAs as they bustled around with orders (some that I found questionable) that were phoned in by the neurosurgeon: extubate the patient (despite a possibly expanding head bleed and the previous orders for sedation and narcotics for pain medication that could compromise the patient’s respiratory drive), a stat second and then third CT scan (as I ran alongside the stretcher with an ambu bag, concerned about the aforementioned respiratory drive), starting drips and then abruptly stopping them on orders from the absent neurosurgeon. A lot of action with not a lot of results.

Finally someone in the ICU was downgraded, a bed opened up, and I had to give report. Just as I finished getting my last set of vital signs and was leaving the bedside to go to the phone, the neurosurgeon showed up, the family anxiously gathering around him as if he was the second coming of the messiah.

The neurosurgeon was in the room as long as it took to give report to the receiving nurse in the ICU. I turned around from the desk and encountered the patient’s relative, staring at me and ranting about how if his parent didn’t go “upstairs in the next FIVE MINUTES” he was going to have the patient transferred to another hospital. He loomed over me and declared that we had DONE NOTHING for the patient all day long, how DARE we keep this patient down here in the filthy dirty ER ALL THIS TIME AND DON’T YOU KNOW THE PATIENT IS BLEEDING IN THE HEAD?!?! Wasn’t I aware that the patient was SEVERELY INJURED and in VERY CRITICAL CONDITION? WHY HAS NOTHING BEEN DONE! He said, sotto voce, “We could SUE YOU, you know.”

What the heck? Apparently the neurosurgeon (who accepted the patient to service at 6:30 AM and FINALLY DEIGNED to SHOW UP AND EXAMINE THE PATIENT at SEVEN PM) had told the family that it was a travesty that the patient had not been assigned a room and had even gone so far as to say that if we could not accommodate the patient WE (the ER staff and administration) SHOULD HAVE TRANSFERRED THE PATIENT to another hospital.

Never mind the fact that the patient was under the NEUROSURGEON’s CARE since about seven AM, and if anyone was responsible for transferring the patient, it was the NEUROSURGEON. Never mind the fact that the neurosurgeon had not even MADE AN APPEARANCE in the ER to even SEE the patient until TWELVE HOURS LATER--had just phoned in orders to the residents and PAs.

And then the doc had the nerve to come in, look at the patient, and undermine and denigrate all of the work the whole ER (the docs, who helped the neuro residents out when they needed help with a central line, the nurses who gave up their breaks, and who had helped me with the patient when I needed it) had done. I was at the patient’s bedside, doing everything that would have been done in a bed in the ICU, doing everything that a nurse is supposed to do: caring for the patient, advocating for the patient, maintaining the patient’s safety, and educating and speaking therapeutically with the patient’s family.

I was completely speechless. I could not even utter a word. I managed to stammer out that I had just finished giving report on the patient and would be taking the patient up within twenty minutes. For the first time in my ED career, I was close to tears. I was shaking with anger, and actually had to go into the bathroom to splash cold water on my face. I felt as if I had been slapped.

Postscript: The patient made it upstairs without incident, and was discharged from the hospital for a rehab facility about ten days later, conscious and speaking.

Guilt Day

So, I’m sick. Feeling washed out, scratchy throat, and congestion that’s heading down into my chest. I just feel crappy. Whatever this is, it’s making the rounds through the ED--a couple of residents and a few other nurses have had this same thing.

I’m sick enough that I won’t be any good to anyone, since my head is full of wool and I’m coughing on a regular basis. But I’m not so sick that I couldn’t take a few cold pills and suck it up and go do my twelve-hour shift and then come home, feeling worse that I am now and then recuperating over the next three days that I have off.

Instead, I called out sick tonight for tomorrow’s shift, and I’m feeling really guilty about it. Guilty, even though I haven’t used a sick day for almost six months. Guilty, even though I have over a week of sick days in my bank. Guilty, even though as a healthcare professional, I think it’s wrong to work while sick, making yourself sicker and spreading your disease to everyone around you. So guilty that I even called around to most of the other nurses on my shift to try to cover it, even though that’s not my responsibility. So guilty that I drove poor DR insane tonight obsessing over whether I should just try to go in, just see if I can do it (yeah, right, like they’ll let me go home if I can’t make it through the day--that’ll never happen).

I feel guilty because there are nurses in our ED who will work sick, with streaming eyes and nose and who will work on and on, even when they look so bad they can barely stand. Of course the residents, who get maybe one sick day a year (and then have to make it up at the end of their residencies), work sick and miserable until they look like they’re going to drop.

It kind of makes me feel like a wuss.

Screw it, I’m sick.

Wall of Sound

DR and I went to see the Melvins perform the other night and the experience was incredible: so loud I could feel it in my chest, knocking the wind out of me—a listening experience become corporeal. It was oddly satisfying, having the sound completely enveloping the room and us.

The Melvins have been around for at least twenty years, and in this latest incarnation have two drummers: Dale Crover, who has been with the band almost since its inception, and Coady Willis (also drummer of the band Big Business) who has been with the band since 2006 or so. The power and precision of these two is incredible. Willis plays lefty and Crover plays righty, so their kits are a mirror image of each other—even sharing two enormous floor toms. The two play in unison, the same beats and fills—it’s like listening to the heaviest marching band drum line you’ve ever heard. When they’re not playing in synch, they’re crafting fantastic improvisations, playing off of and against each other.

The guitar (founding member Buzz “King Buzzo” Osborne) and bass (Jared Warren, also a member of Big Business) sounds were perfect, filling the spaces between the drums, tonally—and exponentially—expanding the sound experience. It was like feeling a motorcycle’s sound as it rides past, or like being at a parade as a loud marching band passes by, feeling the sound in your chest and lungs, making you a little out of breath. Or like being at the beach in some rough surf, and a huge wave towers over you, and you dive under it and feel its power as it sweeps over you and pounds the shore.

The band played for over an hour, with no breaks for chatting with the audience—just performing straight through. I was often torn between watching the action on stage (and observing the young’uns in the “mosh pit” that had formed in front of the stage) and closing my eyes and letting the vibrations and sounds wash over me. It was super loud, but I had my trusty earplugs that cut all of the unpleasant frequencies out. DR, of course, was in seventh heaven the whole time.

Crying Wolf

Sometimes the drug seekers actually ARE in pain. And the contrast is very interesting.

A frequent flyer came in by ambulance, and everyone immediately starts praying, "oh please, no, not my area, please nooooo..."

The last time he was here he was complaining of pain to his legs so bad he couldn't walk at all. He came equipped with a cane and brandished it to prove to all how disabled he was. It was extremely crowded and he was put in a stretcher in the hallway. He sat there, slumping half in and half out of his stretcher and sobbed and cried at full volume whenever anyone passed by, "please somebody help me oh I can't take it anymore oh please Jesus get the doctor oh the pain..." and would stop as soon as the person was out of earshot. (Of course that person--usually a volunteer--would immediately notify his nurse: "That man is suffering! Can't anything be done for him? This would happen about every six minutes.) The MD offered him our oral sickle cell protocol (PO morphine, benadryl, reglan, and motrin), which is what our pain team prefers we start with before we give IM or IV narcotics, and told him he would have to have blood taken for tests. The patient replied (of course), "That shit doesn't do nothing for me and I don't need some stupid ass tests, I know what's wrong with me and you better gimme my dilaudid." Of course, when we refused to give him anything more, he leaped off the stretcher (leaving his cane behind) and literally stomped out of the ER.

Last night, he was put in my area. I was busy with a bunch of other patients and mentally sighed when I heard him calling, "Nurse....nurse....please, nurse...." I went over and took a look. His shoulder was swollen and hot and he was cradling it with his other hand. I told him I was busy with other patients and would get to him as soon as I could (I had an acute MI that I was getting ready for the cath lab in one bed and a septic cancer patient who was getting a transfusion in another). I talked to the attending in charge of the area and got orders for the oral protocol, and went back to the patient to give the drugs and draw blood. He took the oral protocol without a peep, and then endured me sticking him, oh, five times in his nonexistent veins to get an IV in, fluids going, and the required bloods drawn. And then he thanked me. And then he lay in his stretcher quietly until the resident was able to see him, evaluate him, and speak to the pain team to get IV medication orders. I left for the night before his disposition was decided upon, so I don't know if he was admitted or not.

Was this guy having a sickle cell crisis? Probably. Or had he just figured out how to manipulate us so he'll eventually get what he wants (admission with a PCA pump)? Maybe. But I'll tell you--a quiet and polite drug seeker is a heck of a lot easier to deal with than a loud, belligerent one. And I may get some crap from the nursing blogosphere for saying this, but there are times when I'm tired of being the drug police and am willing to administer these people some narcotics so I can take care of my sick patients without the drama of the screaming and crying and all the looky-loos staring at me and thinking I'm a big meanie for ignoring this "poor sick person."

Start Posting!

Well, I clicked on that button and did it. Who am I kidding? There are so many good bloggers out there, do we really need one more? When will I have time for this? I'm going back to school, trying to work four hours of overtime a week so I can save up money to buy my new toy, a scooter (WOOHOO!), in the spring, and play music at the same time: playing in the sporadic band I'm in now and starting my own musical invention: a SURF BAND with go-go dancers primarily made up of nurses and residents from the ED.

And I'm thinking I have time to blog? Heee heee freakin' hee.