Did we go on ambulance diversion? Naw. I was triaging the ambulances that were threading their way through the crowd of evacuated patients. We even were intubating one guy in the trauma room. Nice.
Thursday, September 25, 2008
Monday, September 22, 2008
Stiff as a board on the stretcher, with her arms curled up in a familiar posture, shaking (more like tremors than tonic-clonic action). Nonrebreather in place. Wearing light blue scrubs.
I looked at the paramedics. "What the heck is this?"
"Status dramaticus," one of them responds, rolling his eyes. "Freaking out at home, her young son called us. We found her on the floor like this. Gave thiamine, glucose, narcan with no response. She's been like this off and on nearly the entire time. Apparently her boyfriend broke up with her, and she went out for a few cocktails. Her ex-husband was there too."
The patient smelled like sake. Her pupils were responsive--when I could get her tightly clenched eyelids open--and then she would roll her eyes up in her head. Almost no response to sternal rubs, pinches, or anything else. Pseudo seizure? It didn't look real. Unfortunately, I couldn't get a good O2 sat on her, so into a monitored bed she went, as I called to the doctors for assistance.
On the monitor, she was tachycardic (at about 120); 02 sat was 97 on a room air. Blood glucose 169. Blood pressure 140/80. And the shaking and eye-rolling continued. We called her name: "Mary! Mary! We are trying to help you! Please open your eyes and look over here!" She would stop for two seconds, moan and flop around, and then start with the clenching again. One milligram of ativan later, the clenching stopped, and the moaning and rolling started. Having determined that she was in no immediate danger, the docs went back to seeing the zillion other sick patients in our packed ED.
Our charge nurse stayed at the bedside for a few more minutes while I went to finish entering the triage and get ready to leave for the night. I was chatting with the paramedics as they were finishing their paperwork when their eyes widened. I looked behind me: Mary was walking down the hall, weaving slightly, toward us and the exit. "You have gotta be kidding me, " I said.
"Mary. Where are you going? Mary. MARY! Stop right now." I put my hands on her as she passed by and she shoved me hard enough to make me stagger.
"I'm OUT OF HERE!" she shrieks, yanking out her 18 gauge IV. Blood spatters on the floor.
Everyone grabs gloves, and the paramedics (two large guys) make a wall in front of her and restrain her as I get a stretcher. She starts struggling mightily and we almost lose our grip--she nearly avoids slamming her head on the railing of the stretcher. The doctor and I make eye contact and nod, and I give her the other milligram of ativan and five milligrams of haldol in her thigh. She is screaming and struggling, "LET GO OF ME!!!!! LET GOOOOOOO!!!!! Tell these MEN TO LET GO!!!"
I tell her we will let go if she stops struggling, and if she starts fighting or screaming again, we will tie her down. I tell her she cannot leave, that I've given her some strong medicines, that she's intoxicated, and that she needs to stay here so that she will be safe. We start wheeling her into our psych seclusion room. As we're pausing to take the other stretcher out of the room, she tries again to get off the bed. "I'm leaving this mickey mouse hospital."
"No, Mary, you are not. Get your butt back on the bed. This is not an option for you." As she sees that we're rolling her into the seclusion room, her eyes widen.
"No WAY. I am NOT staying in here." I assure her that she is; that she was brought in "unresponsive" and that she has to stay for her safety.
"Yeah?" she says. "Obviously your staff has NO CLUE how to handle an emergency. YOU LEFT AN UNCONSCIOUS PATIENT just LYING on a stretcher!"
"Mary, you were NOT unconscious."
"YES I WAS!"
I realize the futility of this conversation. "I'm not even discussing this with you. You are staying in this room, and this young lady is going to make sure that happens." With the one-to-one in place, I left for the night. Almost forty-five minutes late.
Sunday, September 21, 2008
I also marvel at the fact that regular, educated yuppie-looking people will come back the day after being diagnosed with strep throat because they took their antibiotics and they still feel sick. This happens amazingly often.
I guess that these people are so healthy ordinarily that they have never needed antibiotics and have never felt sick for more than an hour or so at a time.
Saturday, September 13, 2008
Work has been a shitfest lately. No funny things, no really interesting things, just a shitfest. Tons of work, not enough staff (approaching dangerous staff levels at this point), management doesn't care, and people are leaving like rats fleeing a sinking ship.
And blah blah blah. I'm even boring MYSELF at this point. I mean, how much can you really bitch and moan without repeating yourself. Snore.
I swear, I'll think of something soon.
Thursday, September 4, 2008
I went out to relieve triage for an hour. Poor E was deep in the weeds--people were waiting over an hour for triage. I'm whipping through triages as fast as I can when the patient relations person knocks on my door to tell me there's a "chest pain" outside. I look at the birthdate: 1983. Hmm. Unlikely that this is cardiac. But since there's such a backlog of people to be triaged, all I need is for some young, undiagnosed heart problem to keel over outside while waiting an hour for triage. So I tell her to send him in next. When I say, "So, what's going on with you today," my standard greeting, he says, "I have pancreatitis." No chest pain. Abdominal pain. When I ask him about the chest pain, he says, "Oh, well, it really hurts and I needed to see you as soon as possible, so I put chest pain on there." Seriously.
Then back inside to do ambulance triage for the rest of the day. The nurse manager was completely useless as charge nurse--not keeping the tracking system up to date, which forced me to run around the ED with every new arrival, looking for an appropriate place to stick them in while the nurse manager, instead of delegating tasks and trying to find beds for the admitted patients and getting them upstairs, was getting blankets and starting IVs. I was lining patients up in the hallways where I could keep an eye on them until we found a spot for them...and then we get a stroke code. And a cardiac arrest. And patients from a car wreck. This continued on for ten hours. Interspersed among these patients were people who thought that, because they took an ambulance in, they would be rushed, "ER" style, into a bed as nurses and doctors swarm around them. One woman had back pain, and had been seen yesterday for it. She was given a prescription for something (she couldn't remember what), but it made her nauseous and didn't help her pain. So she took an ambulance back to the ED. When I triaged her and led her out to the waiting room to get registered and wait her turn, she looked at me and said, "I gotta wait here? Oh, fuck this shit, I'm leaving!" and walked out.
Finally, I got down to my last fifteen minutes. It was 11:45pm, and I was exhausted and tired of dealing with people. Two EMTs walk in with a middle-aged man, who sits on a stretcher holding an emesis bag. Complaint? Felt sweaty and dizzy and vomited twice, just after eating some potato salad left over from the holiday weekend. Vital signs all normal; pulse was 99, slightly high, but OK. BP fine--149/78. Sweaty. Blood glucose 145. No past medical history, not taking any meds. Absolutely no pain anywhere--no chest pain, no abdominal pain, no blood in his vomit, no shortness of breath. Just dizzy. One of the attendings sees me triaging him and pulls me aside. "He vomited twice and called an ambulance? Pfft. Put him outside to register." I concur. I start walking him out to the waiting room, and he seems unsteady on his feet. I start feeling uncertain--a little tickle in my brain that's telling me to wait a minute, there's something else here. I sit him down in a chair and take his pulse with my fingers. Irregular. ARGH. I call for an EKG. Sure enough: new-onset A-fib. Ding ding ding! he gets a bed with a cardiac monitor.
And that goes to show: even after twelve hours of grinding labor and dealing with idiots, I can STILL be a good nurse. No matter how tired you are, the assessment skills still stay sharp.