Things I *LOVE* in the Emergency Waiting Room

(please note that "love" is inside the "asterisks of sarcasm.")

I LOVE it when I'm insanely busy in triage with 20 people yet to be even triaged and my phone rings and it's an irate woman screaming at me about how her granddaughter has been in the waiting room for FIFTY-ONE MINUTES and was SENT IN BY HER PEDIATRICIAN because she is VERY SICK and WHY IS SHE WAITING SHE NEEDS TO SEE A DOCTOR RIGHT NOW! (Note: the kid has a cold. She's not feeling well. No one is, including me, lady.) Where is this woman calling from? The waiting room? No. FLORIDA.

I LOVE it when, in the evening, all the relatively healthy twenty- and thirtysomethings come out. They plunk down in my triage chair, and say, "MAN I am really SICK!" Did you take anything for your fever? No. Go home, take some NyQuil or TheraFlu, get a blanket and some soup, and watch some TV for a couple of days. If you are not sicker than the triage nurse, then you are not sick.

I LOVE it when an attending doctor from upstairs brings her kid in with a small chin laceration after a fall and demands to be hustled straight back into the pediatric ER for stitches sooner than the truly sick kids: the asthmatics, the dehydrated vomiters/diarrhea kids, the febrile infants. Thank goodness the pediatric attending in charge rolls her eyes when seeing the triage and says, "She can wait."

I LOVE IT when medical administration calls me up and tells me a "VIP" is coming in for a fever, and that it would be nice if said VIP "had a good experience" at our fine hospital, and that she wants me to use the one sort of private room in the ER for him when he comes. And could we expedite his labs and tests please. That's the one room we have left, and we tend to leave it open for true emergencies or people who come in on ventilators or who need resuscitation. Yeah. Well, I'd like the septic patients and the stroke notification and the STEMI codes to have expedited labs and have a "good experience" at our fine hospital, ie, I'd like them to continue being alive.

Rama Lama FA FA FA!

Not a lot of fun or interesting things have been going on at work. Lots of sick people. A zillion not-so-sick people. No funny things happening. Lots of work, lots of hassles, lots of understaffing. The other nursing blogs I read have been lamenting this as well. Eh, it's the time of year.

So, to make myself feel better, I'm going to offer a musical post. One of the bands DR plays with recently celebrated its 10th anniversary. To mark the occasion, they had a two-set show complete with guest artists who have appeared with or who are friends of the band over the years-- including yours truly. I did one song with them, on guitar. DR was on bass, and I got to play with their very cool guitar player, who I admire very much.

So here, for your enjoyment, is our version of the MC5's "Rocket Reducer #62," better known to fans as "Rama Lama." You can hear me wailing away on double lead with Daniel. (And yes, that's me yelling "I'm a MAN for ya, BABY!" behind the lead singer on the choruses. Blame the beer.)

Brain Scan

That doesn't look very good, does it! What are all those weird little guys in the periphery? Are they extra personalities? Are they hiding from the guy in the middle? And what's that guy for anyway? He looks like he's afraid that all the other guys are going to leap out and grab him.

thanks for the link, Medblog Addict and Scalpel!

Two Perspectives

WhiteCoat Rants has a great post up called The Difference Between Life and Living, which addresses the futility of keeping some patients alive using artificial means. Check it out--and read the comments. Some were very thought provoking, and inspired me to write this post.

As a student, I had a patient who was covered in bedsores, vented, and who would code once a day. Like clockwork. After about 15 minutes of chest compressions (crunch crunch crunch), defib, and drugs, we'd get her weak, tiny heart to start beating again. Until the next time. Then she got a pneumothorax. Chest tubes were inserted. This went on for the week that I was at her bedside.

I asked the doctors and nurses taking care of this patient if she had any relatives, or if we were coding her every day because we had no advance directives at all.

She had a son who refused to address any DNR issues regarding his mother. He snuck in and out for a few minutes each day during shift change so as to decrease his chances of being collared to discuss her. He was a doctor.

Eventually her case was brought up to the ethics committee and the son was forced to acknowledge that his mom was not coming back in any significant way. The next time she coded, she was let go.

Another case was one we had recently in the ER. A middle-aged woman with three young-adult sons was brought in for heart failure. It was clear that she was at the end of this disease and would not live very long. She was awake and struggling to breathe, and requested that she be vented so that all of her sons could be at her bedside. (Two were there and one was coming from a few hours away.)

For the next few hours, she was vented and on pressors, but was fully awake for most of the time with two of her sons holding her hands. I offered her sedation once an hour, but she would shake her head and refuse. Finally, her third son got there, and we got a bed upstairs for her (I'd been fighting to find a spot for her because I didn't want this family to have to experience this death in the ER with all of its lack of privacy). I asked again if she wanted to rest for a while, until we got her settled upstairs, and that it was relatively short-acting sedation, that she could be awake again in an hour or so. She nodded. Three hours later, she died quietly with her family at her bedside.

My name is GuitarGirl RN, and I am an ambulance abuser.

One afternoon, a nice 95-year-old man came in, referred by his physician, for new-onset A-fib. With him were two people: a neighbor and a coworker. Yes, this man was still working. At 95, he was working as a law consultant. He was very sweet and funny.

Through the course of the afternoon and evening it became apparent that he would be admitted to telemetry. Finally, at about ten pm, the two people at his bedside decided that they had to go home. I happened to be in the room at the time (thank goodness). The next-door neighbor said, "Don't worry, I'll look in on Vera for you."

"Who is Vera?" I asked. "Your cat?"

No. Vera was his slightly demented, frail, 97-year-old wife. She was okay to be left alone for a few hours during the day, but she tended to sundown at night.

I told the patient and his visitors that I didn't feel comfortable with leaving Vera alone all night by herself, even though the neighbor said that he would look in on her every hour during the night. I felt that Vera might even be alarmed if she saw a strange man in her apartment, or woke to find her husband not there, and that she might try to leave to look for him, or fall and break something, or otherwise injure herself. The couple had no children and no one who could come and stay with her.

I called the nursing supervisor and talked to the ER attending, and they agreed with me that we needed a social admit for Vera. She could even stay in her husband's room with him. I told the neighbor and coworker the plan, and that they needed to bring Vera back to the hospital.

About an hour and a half later, I got a frantic phone call from the coworker. She said that she had called EMS and that they were refusing to transport Vera; that one of the EMTs there said that they had no obligation to take Vera to our hospital, and that if he DID transport her it would be to Scary Ghetto Hospital a mile away. I told her to put him on the phone.

He SCREAMED at me about this being ambulance abuse. HOW DARE I tell this lady to call EMS for MERE TRANSPORT (which I didn't--I assumed she would call a car service or something). He DEMANDED the name of my supervisor and my name, which I cheerfully gave him, and said, "Are you refusing to transport? Will you transport her later when she falls and breaks her hip? I know for a fact that if you had been called to transport her husband [he was a walk-in] that you would have brought her along for the ride because she can't be left alone."

He hemmed and hawed and mumbled something about telling his supervisor, and then hung up.

I relayed the situation to the nursing supervisor and to our ER attending, who happens to be the director of our EMS training program. His eyes bugged out a little and he said, quietly, "Send him to me when they get here."

Minutes later, the ambulance showed up. They were walking in this little, tottering old lady. Even 17-year-old "I vomited once yesterday" cases get wheelchairs. Our attending leaped up, got a chair for the lady, and redirected the EMS guy while his partner wheeled her up to be triaged. He rolled his eyes and apologized for his partner.

The reunion of the couple was very sweet. "Vera!" said the elderly man. "I missed you! Now we can talk before we go to bed, just like every night!" She tottered over to his bedside and gave him a kiss. "I'm so happy to see you," she said.

So, did I do the right thing? Or am I a vicious EMS abuser?

Fed Up

Today I had to “write up” one of our nurse techs. And he will probably be fired.

Basically, he refused to do something I asked him to do--something within his scope of practice, something that should have been easy. He should have jumped his butt up out of his chair and said, “Okay, I’ll get right on that.” Instead, he said, “No, I won’t.” Not, “I can’t right now, I’m helping so-and-so” or “I was just called to do an EKG,” or “Can I do it in ten minutes.” Not even some lame-o excuse that I knew was a lie, but that would have prevented me from saying the magic, union-required words that usually provoke the laziest tech to jump the hell up: “Are you refusing to do this?”

He looked at me and said, “I am not going to do it.”

Them’s firin’ words, folks.

Please note that this was not the first confrontation I’ve had with this person. Since I started in the ED, at very best he’s been cold to me; at the worst, he’s disappeared rather that do work when assigned to me, undermined me in front of patients and other techs, and apparently does this to other of my coworkers as well. He also had the nerve to tell me, as his excuse when I confronted him about this later, “I had to stay with my STEMI patient. What, you wanted me to leave the bedside?” First of all, he was NOT at the bedside (not even NEAR it) when I asked him to do what he refused to do. Second, there were two nurses and a doctor at this patient’s bedside; the EKG had been done, the bloods had been drawn. He wasn’t needed there. I told him to give me a break.

Please don’t get me wrong. Some (and note I didn’t say most) of the techs are very good and will bust their asses to help you--even when they’re not assigned to you. These techs get used up and wrung out and eventually leave for easier assignments because they can’t take it anymore (or if they’re smart, they go to nursing school or become EMTs and paramedics). Other techs are decent, and will help out if they’re assigned to you, but may balk if you ask them to do too much. Some are nice, but are completely useless. And others are surly, rude, mean to patients, disrespectful to any authority, foul-mouthed, loud, and generally unpleasant to be around. And it’s really hard to get rid of them, because they are unionized: they have to get “written up” several times to build a case against them. Then there’s the long, drawn-out process of dealing with the union. The only time they can be fired outright is if they refuse to do something. Like this tech did.

Our techs are “specially trained” by the hospital, and can do vital signs (temp, pulse, bp, resps, O2 sat), draw bloods, use the glucometer, and do EKGs. They’re also expected to do patient care, hand out food trays, feed patients who need it, and generally do whatever the RNs tell them to do (go get blood from the blood bank; run to the pharmacy; help a patient to the bathroom; etc etc). They are not allowed to insert IV lines or Foley catheters (although they used to be trained to do that). This “special training” given to them by the hospital allows the hospital to justify our outrageous nurse-patient ratios to the nurses’ union. The rationale is since we have these techs to share with the nursing tasks, we should be able to take on more patients. Which of course, as anyone knows, is crap. Especially when we have six nurses and two techs. We’re supposed to have four on the floor AT LEAST, plus one in the pediatric ER. Most of the time we have four total, and sometimes we have three--and when we do have what we need, the nursing office pulls one or more away to work on other floors. I understand what it’s like to work short, and I try to handle as much as I can. But there just are some things that will have to be delegated to the techs, and I expect them to be done, and done without the bitching and complaining. (If you want to bitch and complain, get a blog.)

What the administration needs to do is get rid of them (which they already have in critical care, where the patient-nurse ratio is 2:1), hire more nurses, and then live up to the 4:1 ratio we’re supposed to have in the ED. Just hire a person to do EKGs and I’ll be happy. I’ll scrub butts allll daaaay loooooong. Hell, I do it now, but with eight patients. Give me four to six and I will nurse the HECK out of them. I might even have time to do proper assessments and even CHART on my patients! Whoa, getting ahead of myself there...

Things I hear from the techs every day:

Me: “I just put patient X on the bedpan. Can you get her off in a few minutes, please?”
Tech: (sucks teeth) “I’m on my 15 minute break.”

Me: (at 10 pm) “I really need a favor; can you get me vitals on bed 16?”
Tech: “I just DID the vitals.” (Last vitals were entered at 4 pm)

Me: “Can you please help me change the (big fat diarrhea-soaked) man in 12?”
Tech: “I have to go do an EKG; I’m covering so-and-so’s dinner break.” (Meanwhile, you haven’t heard a page for an EKG in the last half-hour.)

Me: “I still haven’t gotten my four pm vitals yet; could you please do them?”
Tech: (to another tech) “This white girl thinks she can order me around because I’m black.”

Once, back when I worked nights on the floor, I actually had a tech raise her head off the desk where she was sleeping and “remind” me there were only two techs on (and both of them were sleeping at the nurses’ station) when I asked her to please answer a call for a bedpan as I sat there furiously charting away on my 12 patients at four AM.

Also, since techs are unlicensed personnel, I’m ultimately responsible for their doing their work correctly, something that makes me crazy, especially since I don’t review their job performance. So the only way I can make sure that management knows what’s going on is to complain when something is bad (which feels like tattling). And I try to make the good techs feel appreciated and like they’re part of a team. But I’m at a point now where the crappy ones can kiss my ass.

C'est Fini!

My first paper as a BSN student. Ok, so it was only five pages long, gimme a break, I haven't written a paper in like...fifteen years or something.

I sent it in through turnitin.com., a site that checks papers for plagiarism. It checks against dictionaries and encyclopedias and term papers available online. Very interesting. When I was a kid, we never had that sort of thing. Then again, we didn't have entire libraries available online, either. It made writing my paper a lot better!

And now I must get to work on my teaching plan, complete with a process recording. Ugh. I hated these in nursing school. Oh well.

Off to the mines!

Ooof.

Two of the worst days I've ever worked.

I feel like I've been hit by a truck. No, make that two trucks. Each carrying a circus-worth of elephants. And then the evil clowns leaped out and tap-danced on my spine.

I work a very busy shift: from 11:30 AM to midnight. The day shift has a few hours from 7:30 to about 11 when ambulance arrivals slow down, and the night shift is usually a little less hectic after about 2 am to 7:30 when they leave. But mid-shift is (almost) always busy. That's fine with me, because working this shift, I never have to wake up at 6 am, and I always get to go to sleep when it's still dark out.

It was two days of non-stop ambulances, and standing-room only in the waiting room. We were doubling them up in rooms, lining them up down the halls, borrowing stretchers from endoscopy to accommodate everyone. At one point, the "critical care area" had SIXTEEN patients in it. And one nurse.

And pretty much everyone was sick--including the staff. I took three residents back to the nurses' lounge to mainline Zofran into them so they could keep working. We sent one poor resident home, because she couldn't assess patients without leaving them to vomit every ten minutes.

I was precepting two orientees (thank jeebus one of them was a nurse with some ER experience), and then when the day shift left at 8 pm on the first day, I ended up being in charge for a while because the regular charge nurse had been in a fender-bender on the way to work. She was okay, just two hours late. I sent the preceptees to help out in areas that were being slammed and basically worked on getting patients upstairs--getting charts ready, badgering administration to get beds clean, and taking patients up and leaving them in the hallway. One floor had been saying that three areas that were slotted to receive patients from us had no actual beds in them. For the last five hours. Well, if they can sleep on a stretcher in the ER, they can sleep on a stretcher upstairs. I brought all those patients up.

The next day was even worse. A sample of the patients that we were dealing with?

In one area, we had three septic, intubated patients on pressors. Then we got a 57-year-old guy in stable v-tach. (yeah, that's an oxymoron if I every heard one.) The guy was sitting up, talking, no chest pain, no sob. The monitor was going crazy--loooong runs of v-tach interrupted by weird, slow, large-complex beats. We had him on amiodarone and esmolol drips, and it was not helping. He was a lovely, cooperative man. And I say "was," because about an hour after he got there, of course, he coded and died. He should have been up in the CCU, not down in the ER.

One of the 96-year-old, contracted, vented septic patients coded too. We got her back and stabilized.

We had a ruptured ectopic transferred from another hospital. Actually, it wasn't ruptured at the other hospital--it ruptured on the way over. Nice.

A ton of chest pains, a ton of renal failures. Some DKAs. A million things to do.

Then I was assigned on the second day to pediatric triage for my last four hours. Sometimes when we have enough nurses, we have a separate pediatric triage person to lighten the load, since pediatric patients often take a lot of time to triage.

Ugh. Three septic babies in a row. They went straight back. Then another three babies: all of whom had been born between seven and ten days ago and who were all "constipated." Then a parade of puking toddlers (I ended up going and getting a mop and bucket, because my little triage room was flooded with cheese-smelling puke.) A few asthmatics, who always go straight back. Pediatrics was swamped; kids in every bed. Then a motor vehicle crash showed up. Six patients: two adults and four kids, ranging in ages from 12 to three. And then an anxious 19-year-old who was away from home. He showed up with his coaches--he had been elbowed in the throat by accident while playing sports. His voice was gone, his throat was visibly swollen, and he kept saying, "it's getting harder to breathe." He went right back too.

I limped home an hour late. Sat on the couch watching TV until three am. Then went to bed and got up today around one pm. I have a paper to write and lots of things to do. But I'm beat, so here I sit, drinking coffee.

My feet hurt.

Cheerful Chicken Rings

So last weekend DR's 13-year-old daughter, SBR, moved from our big city to the country with her mom, stepdad, and little brother. She was very excited, because not only will she have her own room, she will have her very own horse in her very own backyard. (Her mom and stepdad have adopted two retired harness racers, and the family also boards a pony from S's summer camp for the winter.) We went up to visit yesterday, and the house and property are lovely--and they have two adorable new puppies romping around. We brought our dogs up and a good time was had by all.

However, not EVERYTHING has been rosy up in the wilderness. SBR went from her teeny tiny private school (with a total of about 300 kids from pre-K to 8th grade) to the Big County Public School. She has to take a school bus. The school is huge. There's a zillion kids in her class. The first two days were pretty rough, as the guidance counselor who was supposed to take her around and show her where her classes are was out sick, so poor S had to find her way around with a hand-drawn map someone made for her. She missed lunch. She misses her friends from her old school. The only upside is that she doesn't have to wear a uniform, and since she was in honors classes at her old school, she's ahead with her schoolwork, so we don't have to worry about her falling behind.

She's making friends, but a few days this week she felt so miserable, I decided to try to do something to cheer her up. There is a silly song I made up about some alternate menu items at White Castle--we go there sometimes after gigs when we don't feel like driving to the late-night Chinese noodle place. Whenever S hears me sing it (in a goofy voice, of course), she cracks up.

So of course, I had no choice but to record it and email it to her. It worked. And now, not only does she laugh whenever she hears it, her mom and stepdad are singing it constantly because they can't get it out of their heads. So beware! Click below to hear me humiliate myself for the happiness of a child.