Overheard in Triage

Man: Do you have a CAT scan machine here?

Me: (stares at man)

Man: Seriously. Do you have a CAT scan machine?

Me: Yes, sir, this is a modern urban hospital. We have a CT scanner here.

Man: OK. How do I get one?

Me: A doctor has to order the test.

Man: Oh. So I can't just sign up for one?

Me: No.

Man: Are they expensive?

Me: They're not cheap. Do you have any medical problems that you'd like to discuss?

Man: No. I just wanted to see what my brain looks like. Thanks anyway! (gets up and leaves)

Thanks, Nurse Jackie

There's been a lot of...well, not "furor," mostly just talk... about Showtime's series Nurse Jackie. Blah blah blah, not a good example of a nurse, blah blah blah detrimental to the public image of nursing...blah blah blah.

I've only seen the first episode (I don't have Showtime, and am waiting to Netflix the whole season to watch all at once), but I can't say anything bad about it.

However, I've become a huge fan of the show because of its effects on patients and their families in the ED.

Yesterday, a very difficult patient was about to go upstairs to her room. For her whole stay, she had been complaining and needy and angry. Just before she was to be transported, she started demanding her Valium. The admitting doc hadn't put in any orders yet. I told her so, adding, "I can't get the pills out of the machine without an order from the doctor."

She smiled. "Oh, I understand. You guys have a Pyxis! Don't worry about it," she said knowingly, "I watch Nurse Jackie!"

Finally, an apology!

(Unfortunately, it was completely unnecessary, but whatever, I'll take it...)

We had a middle-aged guy come in with severe scrotal swelling and pain--it was so bad that he couldn't walk or even close his legs. If anyone even came near him, he would start crying and screaming "please don't touch me! Please!" He was a diabetic and on dialysis. And unfortunately, there was a really specific smell coming from his area--probably Fournier's gangrene.

I gave him a ton of pain meds but nothing was even touching his pain, and we needed to do a CT of his pelvis to see how bad it was--and to examine him. So the docs decided to do a sort of conscious sedation with ketamine. I've used ketamine on kids with no problem, but sometimes adults have an "emergence reaction" when it's wearing off--they can hallucinate and get a little nutso, so they have to be watched very closely.

I got him to the CT scanner on a portable monitor, gave him the meds, and we got the scan. Everything went well (except for the fact that the CT and manual exam pretty much confirmed gangrene).

When he started to wake up, he was relatively calm; a little moaning, a little thrashing, but mostly ok. When he was a little more awake, he kept looking at me and saying, "Miss? I'm so sorry, I'm so sorry!" I would ask him what for and he would say, "I didn't do anything nasty to you did I? I'm so sorry! Tell me if I did! Tell me the truth! I'm sorry, I didn't mean it..." I kept reassuring him that all was well.

Hours later when he was pretty back to normal, I went in to see him and asked how he was feeling. He told me he didn't really like the drugs we gave him. "They gave me weird dreams," he said. "Really?" I said.

"Yes," he replied, blushing and averting his eyes. I wonder what he dreamed?

Conversation of the Night

Man: My grandmother is very sick! She needs antibiotics!

Me: Yes, the doctor just ordered them, and I'm going to go get them right now.

Man: But she's having cardiac arrest over there! (gesturing to his little grandma who is sitting up in the bed, smiling and eating a tuna sandwich)

Me: Do you know what that means?

Man: Uh, no. It just sounded important.

You're kidding, right?

I was explaining my shift to one of the new attendings the other day. I work 11:30 AM to midnight. When I get on, I take other nurses' areas so they can go eat lunch. Then I go eat my lunch. Then I come back, and either give other nurses their 30-minute afternoon breaks, or I take an area from a nurse who is scheduled to leave at 4 pm. We've been very short-staffed lately, so often I'm in charge, doing ambulance triage, and, occasionally, manning the trauma room. Sometimes we have to close an area until 4 pm, because I can't staff it until I've given people their breaks. This attending said, "They should just open the area, and the nurses should go without their breaks. Us attendings don't get breaks when it's busy like this."

Them's fightin' words.

Nurses need breaks. Our attendings sit at a desk all shift long, occasionally getting up to see a patient (depending on what their shift is that day, teaching or nonteaching). Nurses are at the bedside. We clean butts, we move 300-pound patients with little or no help, we run around giving meds and assessing and even getting pillows and blankets in our CITY BLOCK LONG ED. We assist docs with procedures. We're the first line of defense when a patient's angry relative wants to know why they're waiting so long for care. Yes, sometimes patients and their relatives will ask at the doctors' desk when they're going to be seen--but that's a FRACTION of the complaints nurses field. A doc sees a patient for ten minutes and then writes orders that will take the nurse hours to complete: blood draws, blood cultures, IV access, Foley catheters, multiple meds, tests, monitors...and on a busy day when we're understaffed multiply that by EIGHT TO TWELVE patients. In addition to this, you need to factor in the admitted patients who need care: the doc's job is over with them, but they're still my responsibility to care for until they get upstairs, and I have to look them over and document and PHOTOGRAPH every dimple and freckle they might have, because god forbid it's a decubitus ulcer. They get to go pee once in a while. We don't. They get to eat and drink at their desk. We don't. They get to sit. We don't.

That's why we get breaks.

You know you're understaffed when

Management calls and leaves a message BEGGING you to come in "for any part of tonight at all...any part...a few hours, that's all...please...I'll make any deal you want: All your weekends off next month? Anything! Call me please..."

I'd consider it, but I just worked five out of the last 6 days--all 12-hour shifts. I'm beat, and I'm already ensconced on the couch with a beer, Star Wars Robot Chicken on DVD, and my knitting. I'm not getting up.

Ambulance Triage

These days it seems as if ambulance triage and walk-in triage is all I
do. Usually I would complain, but lately I'm so disgruntled with
management and the constant understaffing (8 nurses when we're
supposed to have 15), that I don't even care. And sometimes it's nice
to not have to make a commitment to a patient. "What's wrong with you?
Ok, bed 12. See ya!"