ER Junkie Gets Her Fix

Christmas Day was pretty boring except for the last three hours, which involved lots of blood flying out of a patient's various orifices. This patient got six units of PRBCs, four units of FFPs, three liters of warmed fluids, two units of platelets. And a partridge in a pear tree.

When DR picked me up at midnight, I got in the car and he said, "Uh, ew. You smell like meat." My shoes and scrub pants were covered in blood. It was pretty gross. But also fun.

It was especially nice because when I called the ICU the next day, the patient was still alive and stable. Very satisfying.

Ethical considerations?

Shadowfax and Scalpel have interesting posts up about the ethics of medicating psychiatric patients without their consent.

Once, as a student nurse extern working on a medical floor, I had an interesting case.

A woman in her thirties was admitted for brittle diabetes; she had a tendency to alternatively pass out from low blood sugar (once on a heat grate in her house, resulting in bad burns to her legs) or be hot, dry, and miserable and in DKA. She lived at home with her family, but her parents were away in Europe for weeks, and her brother, who also had diabetes, was looking in on her, found her unconscious, and brought her to the hospital.

She was, as my mom would say, "half a bubble off plumb." (Frankly, I wasn't surprised--I would be too if my blood glucose was regularly around 17.) She was a little slow in her speech, she was emotionally labile, had a strange, flat affect, and had a few other issues, but was very sweet once you got to know her. She looked a little like Courtney Love coming off a bender. My kind of gal. She also had a little hint of a goatee, probably from metabolic problems related to her diabetes.

The decision was made to admit her to psych after she was medically stable. The psychiatrist wanted us to administer a B-52 (benadryl, ativan, and haldol), telling her it was insulin, then wait ten minutes to make sure it was working, and then he would tell her that instead of going home, she was going to be put on the psych ward. And then she would pass out from the meds and wake up on the psych unit.

I felt very conflicted about this. First off, there was no way she was going to believe that the injection I was giving her was insulin--it was a huge amount of meds (around 3 ccs as opposed to the relatively small amounts of insulin we had been giving her), it was an IM, not a SC, injection, and, those meds STING like a bitch, whereas insulin usually doesn't. Also, she was calm and alert and oriented; I felt bad about flat-out lying to her. I also was a starry-eyed nursing student, ready to use my therapeutic communication skills.

My preceptor also did not feel comfortable with it. She basically called the psychiatrist a chicken and stated that she refused to do his dirty work for him, and that if he wanted to lie about the shot, that he should do it himself.

We ended up compromising. We took a couple of male nursing assistants into the room with us, and I sat next to the bed (apparently I was the only one on the floor whom the patient trusted...ugh, guilt) and explained to her that I wanted to give her a shot to help her stay calm and cool while we all talked a little about her stay at the hospital. Her anxiety level immediately shot up and she said, "But I'm going home, today, right?" I told her that was what we would discuss. She started moaning, "no no no no no no no..." so I used my student nursey skills and said, "You seem very upset. Would you like this shot to calm down a little so we can talk?" After a few minutes, she agreed, so I stabbed her in the butt with the needle.

A few minutes after that, the psychiatrist came in and started to explain that we wanted her to stay a little longer, that we needed to do some tests to see what was causing her "hairy face," and that he wanted to transfer her to a floor where her "state of mind" could be evaluated "for a couple of days."

She LEAPED up off the bed and grabbed the shrink around the neck, screaming "NOOOO I WANT TO GO HOME I'LL KILL YOU I HATE YOU I HATE YOUUUUUUU!"

So much for the B-52. We wrestled her down to the bed, and held her there until the meds started to work. As she was drifting off, she said to me, "You hate me, don't you."

I replied, "No, I don't. I like you a lot."

She said, as her eyes shut, "You even like...my hairy...face?"

I assured her that I did. After she was asleep, she was transferred to the psych ward. I felt kind of bad about the whole thing for quite a while. But what else could we have done?

Merry Christmas!

And happy holidays etc etc!

I'm working Christmas Eve and Christmas Day, since DR and I don't really celebrate. He grew up culturally Jewish, and most of my family lives out of town. So is DR's daughter, visiting her mom's family in the Midwest. So I prefer to get paid time and a half for a relatively easy day. Besides, I get out of work at midnight anyway, so I usually meet him out at a party or something, and then we go home. It's nice!

On the 26th, we're having some friends over for dinner, which should be fun. Italian food has been requested, so I'm making linguine with clam sauce, pork braciole, polenta, and a nice arugula, radicchio, endive, and orange salad. And maybe pastries from my favorite Italian bakery for dessert. Cannoli anyone?

Here are two holiday themed posts by two of my favorite bloggers: "Twas the Blog Before Christmas" by Dr. WhiteCoat, and "A Nurse's Twelve Days of Christmas" by GirlVet.

Enjoy and Merry Xmas, everyone!

Yes, I AM one of *those* nurses!

Below, I posted with a link to Emergency Emilly's wonderful list of cysts being drained. ER Nursey responded with "Oh no, you are one of *those* nurses LOL. I work with a girl that gets almost orgasmic during a good I & D ;)"

Yes, that's me.

Once, I had a young male patient with an abscess on his neck, close to his jaw, probably from an infection in a cut he got while shaving. He was a rather handsome and nice man, and his good looks were marred by the huge swelling below his jaw. He was really uncomfortable, too, as it was quite tender.

As often happens, surgery was called in for a consult. The surgeon who came to do the I&D was also an attractive young resident. She asked me to assist, and I eagerly agreed, as I wasn't too busy and MAN I love this shit.

We got him all positioned on the table, a basin and absorbent pads and towels under his neck, lidocaine at the ready, all of our supplies accounted for. I was on one side of him, holding his head still and preparing to hand instruments and things to the doctor. She was on the other side of him, injecting lidocaine and swabbing the area with betadine. She made the first incision, and a gout of pus poured out. At the same time both of us made noises more reserved for the bedroom than for the ED--and our eyes met across the patient. Both of us smiled.

Now that we both knew we were enjoying this, she threw herself into evacuating the wound with gusto. I helped by irrigating when asked, and handing over supplies as requested. The oohs and ahhhhs and "oh yeah, look at that..." and "oh, WHOA!" noises we were making were unmistakable.

Finally the wound was clean, packed, and bandaged. The patient sat up, and I asked how he felt. "That was intense," he said. "You guys were really...into it." And he blushed.

Ever since then, whenever I see that surgeon around the hospital, we always smile and wink at each other. Hopefully someday we'll get to meet again over a nice juicy abscess...until then, we'll always have Room 42 in the ED.

My name is GuitarGirl, RN...

And I am an ER junkie.

I didn't think it would happen to me, but then again, no one ever does. Sure, I love working in the ER. I like helping people. I like making people feel better. I never thought I would actually say the following words:

"You know, it only takes one good code to totally make your day."

But I did.

It was a decent day, some non-sick people hanging out, some actually sick people getting taken care of. Not boring, but not exciting either. Then, in comes two EMTs pushing a stretcher with a woman on it who looked like a very large blueberry. (Think: an aging Violet Beauregarde.) Our ambulance triage nurse was a little new, and actually started to get vitals while the patient was on the stretcher. I jumped up, because I happened to have a resus room open, yelled for the docs and headed over with the intubation box, motioning for the EMTs to roll the woman's stretcher into the room.

Fifteen minutes later, the woman was successfully intubated. (Kudos to emergency medicine intern Dr. S--the patient had a short, fat neck, was very obese, and Dr. S got the tube in on the first shot. When I congratulated him, he said he used echolocation to guide the tube in. From now on, I'm going to call him Dr. Bat.) She had a Foley in (also no easy feat!), two peripheral lines and a central line, cultures drawn and sent, and meds hanging. Her sats were great, she was comfortably sedated, her other vital signs were stable.

Aahhhhh. There's nothing like a good code to make the rest of your day just fall into place.

Oh...yeeeeaaaaaaahhhh....oh yesssssss.....

Emergency Em knows what I like. This.

I need a cigarette.

Bravery

Firefighters, soldiers, and police officers are brave.

But the people who are bravest of all are those who uphold their loved ones' wishes and make them DNR/DNI. Even when they know it means the imminent death of someone they might not be ready to let go of yet.

One of the things included in this job is talking with people and helping them explore end-of-life options. Will this person you love be the same if they are lying in a hospital on a ventilator for the rest of their lives? Who is the resuscitation effort for? The patient, who may never regain consciousness? Or the family, who is struggling with emotional issues like loss and even guilt over the DNR?

So my vote for bravest person of the year goes to the woman who, through her tears, said when asked, "No. He would not want to be on a machine to breathe. He's told me many times. He does not want it." And stood by her father's bedside with the rest of her family until he was gone. Peacefully.

The Grass is NOT Always Greener

The other night was tough. No ICU beds, boarding ICU patients for like three days, a vented patient in every area...pretty bad. Arguments with the nursing supervisors. Arguments with the upstairs doctors. I was generally feeling bad about the hospital and left mumbling about people practicing Tinkertoy medicine.

Then I met a former co-worker for drinks. Turns out he's going to be a co-worker again soon, because he's leaving his new job in the ER of a fancy-pants hospital. He told me the story of his "last straw" moment--a code in which, instead of beginning with the classic "Airway, breathing, circulation" of emergency medicine, began with a resident running in with a speculum to check the patient's vagina because he thought she had toxic shock syndrome, and that was why she was hypoxic and gasping and flailing around and had no blood pressure.

Said my friend, "I kept looking around for the camera. I thought I was being Punk'd or something."

I'll keep my job, thank you. At least we know that in a code you start from the TOP, not from the BOTTOM of the alphabet.

A quick post before bed

Out in triage, patient relations person comes in: "Do we ever just check a blood pressure? There's a 63-year-old lady out here who is asking."

Eh, it wasn't crazy busy at the moment, so I said, "Ok, send her in."

Lady: I just need my pressure checked.

Me: If it's really high, I might want you to stay to see a doctor.

Lady: Screw that, just check it.

Me: Well okey doke then. (Pressure is 145/93, pulse 87) Your pressure is a little elevated. Do you take your medications at home?

Lady: Always. Well, no. Sometimes.

Me: Have you been taking them lately?

Lady: No.

Me: Why not?

Lady: Well, pregnancy.

Me: Whose pregnancy?

Lady: Mine! I'm pregnant with St Francis of Assisi's baby! A little mouse lives in my uterus. I'm not staying around here when you OBVIOUSLY don't know what you're doing. (Storms out.)

Me: Well, allrighty. Bye now.

Wonder what OTHER meds she's not taking.

Bad Nurse. No Cookie.

I've been working more in our Pediatrics ED lately. It's fun and interesting, because we get to do stuff to kids that we don't usually do to grownups (like suctioning their noses for virus specimens).

One very busy afternoon, I was racing around, trying to get the zillion things done that I had to do, and as usual, I was talking to myself as I ran around. (Come on, ED nurses. You ALL do it.)

The cool fun pediatrics attending came up to me when I had a minute and said, "Hey, you're doing great! We love it when you're here because things really get done fast. But there's one thing to keep in mind about pediatrics being different than adult medicine."

Of course, wanting to learn all about new things, I gazed up at him, wide-eyed, ready to hear a pearl of wisdom about pediatrics. He smiled kindly and said, "We try to watch what we say around the kids."

*blink blink*

Apparently what I had been saying to myself as I zoomed around the ER was "Fuckety fuckety fuckety fuck."

Runny Noses are NOT Emergencies

According to Wikipedia, the Emergency Room is a department that “provides initial treatment to patients with a broad spectrum of illnesses and injuries, some of which may be life-threatening and require immediate attention.” The important part of that sentence is the last six words.

Life-threatening and require immediate attention. This describes an acute condition: something extremely serious and critical but that is brief and severe. A chronic condition, on the other hand is one of long duration, typically described medically as one that has existed for six months or more.

Now, understand that chronic conditions can have acute exacerbations: asthma, sickle cell disease, COPD, CHF, among others. We treat these in the ED, and they’re considered emergencies.

What we don’t (or shouldn’t have to) treat in the ER: Colds. Bug bites. We won’t immunize your kids. No, that small laceration does not need stitches.

It’s perfectly ok to come to the ER if you have any doubts about your condition. But once you’re here, you need to trust our judgment. Of course there are cases when people who originally were not thought to be acutely sick became critically ill in a waiting room, as far as I’m aware they’re the exception rather than the rule.

When I tell you in triage that you (or your loved one) is currently in no danger of loss of life or limb at the present time, that while I understand you are feeling badly, but that there are people who are more ill than you and who will be seen before you, you need to accept it. Please know we’re keeping an eye on you as you wait to be called. We’re aware you’re here. Please don’t say, “But HOW DO YOU KNOW nothing’s wrong? I could be DYING right now!” (I’m SO tempted at these times to explain that we’re ALL dying, just very slowly. I’m also tempted to say, “Because it says RN after my name,” and point to my ID badge.)

If you’re an otherwise healthy 25-year-old man, and your initial complaint is of nasal congestion, fever, body aches, and cough for ONE DAY...you probably should not be in the ED. This is NOT life-threatening and does not require immediate attention. You should be at home, drinking NyQuil and hanging out on the couch. You’re sick. It sucks. Have some soup, have some orange juice, have some ibuprofen, take a nap, watch some TV. If you don’t feel better in a couple of days, call your doctor. Or go to a clinic. In the ED, we don’t have soup, we rarely have OJ, we don’t have comfortable beds, and we don’t have TV. (Though that’s about to change...ugh...)

If you’ve been to three dermatologists over the last six months to try to figure out what that gross rash is on your hands and arms, and they’ve given you steroids and creams and pills and they’re not working, and the rash doesn’t hurt and it’s not infected, and it’s not really bothering you except that it looks yucky and you really would like to know what it is...you probably should not be in the ED. Seriously, dude. You’ve seen SPECIALISTS. We’re just gonna give you a referral to a SPECIALIST.

If you’re a 65-year-old overweight man with a history of heart attack and coronary artery disease, and you come in and sit in my triage chair and are puffing like a locomotive, and your lips are a little blue, and your primary complaint is, “my feet and legs are all swollen up, and I can’t seem to catch my breath even when I’m taking it easy” and your heart rate is 120 and your blood pressure is not so great and your lungs sound like a famous breakfast cereal, then DING DING DING!! You WIN! You are having an emergency and you get to be taken back to a bed.

Nursing Home Fol-de-Rol: I'll Hop on That Bandwagon!

Since Nurse K and Monkeygirl are doing it...

A while back we got a little old lady from a nursing home. She was nonverbal, had a history of Alzheimer's and stroke, among other things. I actually don't remember what her primary complaint was. Anyhoo, at about ten-thirty at night I got a frantic call from a nurse at that nursing home.

Nursing Home Nurse: We have a small problem.
Me: Ok, shoot.
NHN: Well, um...it seems that we sent you the wrong patient.
Me: WHAT?!?
NHN: Well, not the wrong PATIENT, just the wrong paperwork for the patient that you have.
Me: WHAT?!?

Apparently the geniuses over at that nursing home decided that it was a good idea to put two little stroked-out ladies with almost exactly the same names IN THE SAME ROOM TOGETHER. Seriously. If the first lady's name was Marsha Jones, the roommate's name was Martha James. (The really interesting thing was that the ladies' actual names were very unusual, unlike the pseudonyms I've provided. But they were only two or three letters apart.)

Tools of the trade

ERNursey has a great post series about her top 10 list of ER equipment. Since I'm working on a couple of bigger posts that aren't ready yet, and since DR and I have had a slew of gigs and things that are keeping me busy, I decided to post about my favorite personal ER equipment. These are all things I keep on me every day that make my job easier:

Mini Sharpie I have two of these--one in red and one in purple. The black ones are very hard to come by! I keep them on a ring that's attached to the back of my ID badge. I use them to write on IV bags (sometimes we're out of IV labels, so I just write right on there). I also write the number of the bag on fluids when I hang them--like "1/2," "2/2," or just #1, #2 etc. so I can remember to keep up with the I&O. Also, they're really helpful when drawing up multiple syringes of meds--like in an intubation. I write the name of the drug and the dosage on the syringe. I know this sounds like a no-brainer, but it's great to have something on me that writes on everything. Oh--and in a code, I've been known to use this to write vitals, drugs give, times, etc on the bedsheets. I try to use ballpoint pen when I can for that, though.

Stethoscope uh, duhr. But you'd be astounded how few RNs actually carry their stethoscopes around. They leave them on the desk or on the med cart or whatever. I don't like to leave it slung around my shoulders because the weight of it causes my shoulders to tense up. Weird. So I have a geeky holster that I use. It clips to my belt.

Apron Pocket Thing Speaking of geeky, this is the HEIGHT of geekiness. It straps around my hips. I refer to it as my Bat Utility Belt. But I wouldn't be without it. As a relief nurse, I don't have a set "area" for most of my day; I can't set up a supply cart to my liking. So I carry this instead. It has all sorts of pockets, and two little velcro/snap straps. I have one around my trauma shears and one holds my little tiny Mag-Lite. In the narrow, long pockets, I keep three angiocaths of different sizes; two small flushes, two large flushes, and a pencil. There's a tape loop too. Oh, it's awesome. In the large pocket (behind the one with the flap), I keep two large needles, a supply of alcohol wipes, and some large bandaids. In the little flap pocket, I keep small things I can never be without: a small bottle of 0.4 mg sub-lingual nitro tablets, a glass vial of epinephrine (1:1000, for athsma/respiratory emergencies), lip balm, a tiny pencil sharpener, extra erasers, a three-way stopcock (these are in super-short supply, so whenever I find one I pick it up), and a little plastic dingus that helps open those annoying glass vials (you know, the ones you have to break open without cutting your hands). All this stuff fits in there without any problems. I love this thing. And I don't care that I look like a complete doofus.

Also, I'm seriously picky about pens. Currently I use one of those 4-color ones. But any pen I use has to have black ink (at least), no rubber grip (I stick them in my hair to hold them, and the rubber grip really snags), and has to be a "clicky" type pen.

And that's my must-have equipment list.

People Are SO CREATIVE!

And again, I'm not being facetious.

I wish I could knit so I could make one of these for our friends who are having babies. It's Baby's First Teratoma! (Courtesy of the AntiCraft) Lookit that widdle eyeball sticking out! It's so keeeeuuuuute! According to the knitting instructions, "you cannot have a proper teratoma without at least one eyeball." I wholeheartedly agree. Reach inside! Pull out an eye, a tooth, a tiny hand and foot. Is it stuffed with crocheted hair?

Will someone PLEASE make me one? I want to cuddle up with it at night. It's only fair, since I never had a real teratoma of my own. I promise to hug it and kiss it and love it and call it George. Or Georgina. (Do teratomas have a gender?)

Note: a teratoma is a kind of tumor that contains different kinds of tissue types. (Teratoma means "monster tumor" in Greek--awesome!!) Sometimes those tissue types are identifiable-- like teeth and hair and hands (very rarely), or bits of brain and lung. Wikipedia has a decent article about them.

I have a soft spot (ha!) for teratomas, because when I was doing my OR rotation in nursing school, I got to see a surgery during which the doctors removed a tumor from the base of a young man's spine. It was full of hair and little bones and all sorts of weird fluids and stuff. It was a sacrococcygeal teratoma! It was fascinating! Ah, good times, good times...

WTF!!

Last night I was out in triage and had a walk-in patient with a badly dislocated arm. It was dangling down almost past his knee. He was obviously in pain, but sat quietly as I finished with the patient I was triaging when he came in.

Since it wasn't too busy, I checked his hand for capillary refill and then decided to take him straight back to a bed, since he was definitely going to need conscious sedation. On the way back, he commented on the changes that had happened to the hospital, and mentioned that he was a paramedic. I asked how he had dislocated his shoulder; he said he had lifted a heavy object and it had popped out, something that had begun happening with increasing frequency. He said yes--ever since he had been shot.

Wha?

Apparently a year or so ago he and his partner had been called to an abandoned building to help an unresponsive person. They administered Narcan--upon which the person came awake, and then shot his partner, killing him, and shot the paramedic in the chest and shoulder. The bullets nicked his aorta and destroyed his spleen. As I helped him into a gown, I saw the scars on his chest.

He said that ever since then his shoulder has had a tendency to come out of joint.

Now, please keep in mind that I don't know if this story is true or not. I don't even know if this guy is or was actually a paramedic; I'd never seen him before this point. I can't say with any certainty that the scars I saw were from what he said they were from. I just thought it was a horrific story.

Nurse K Is Back!

And attracting crayzees as usual!

Go over and check her out!

Welcome back, Nurse K!

All (you know) on the Western Front

Today was a pretty good day. Took care of some really sick people and some not-so-sick people. Made most of them laugh at least once. Made a lot of them feel better. Was busy enough that I'm tired now, but not so busy I couldn't do my job well, and I feel good about it. No one was lining up to yell at me. Patients' relatives were all appreciative and polite. Had a minor skirmish with a new CT tech, but we apologized to each other and now we're buddies.

Sorry that's not very interesting, but I'm really glad because it was my first day in three 12-hour days in a row and I don't think I could take three insane days.

And now I'm going to bed. As soon as I have a minute, I'll blog about our musical adventures lately--and maybe with pictures!!