Thursday, May 27, 2010
Ambulance triage was stocked with a monitor, computer, ID bands, first-aid supplies, and was next to the trauma/resus room in case the patient was really sick. There was plenty of room to move around the patient and if the patient was vomiting, or bleeding, or aggressive, there was room to get out of the way. There was privacy: the patient could tell the nurse about their private medical problems without the person in the next curtain hearing them.
Now, the patient is rolled in, registered, and the charge nurse sends the patient to the bed to be triaged there, either by the nurse in the area or by the "roving ambulance triage" nurse. EMS personnel is dismissed the minute the patient's butt hits the stretcher.
Does anyone see the problems here?
Formerly, the ambulance triage nurse had everything in one place. Now she has to run around the ED dragging her equipment and supplies with her, hoping to find a free computer with which to enter the information. While she's at the bedside, other ambulances are coming in and being sent to beds; the ambulance triage nurse can't stop what she's doing to ask what's up with the other patients in case one of them is sicker than the one she's triaging at the moment.
When EMS is dismissed immediately upon placing the patient in a stretcher, the triage nurse loses a valuable source of information about the patient in the event that the person is nonverbal, or speaks another language, or has some kind of altered mental status. The nurse is forced to rely on the nursing home paperwork, or the EMS written report, which can be sadly deficient.
Here's an example of what happened the other night when I was zooming around like an idiot doing this bedside triage that illustrates the two above statements:
I was at the bedside of a non-English-speaking patient. His family was there, but they didn't speak much English either. The complaint EMS gave the registrar was "vomiting for one hour." The patient was retching uncontrollably in the stretcher and looked much more sick than I expected. No one could give me any information about him, and as I approached him, he belched and I smelled a strange smell: pine-scented cleaner. The front of his shirt was soaked with it. I asked the family, "Why does he smell like this?" "Because he drank some floor cleaner," was the response I got.
Meanwhile, another patient had been put in another bed and I headed over there, dragging all of my equipment. The complaint was "cough, previous history of pneumonia." While I was spending time figuring out what was wrong with the man who had drank the floor cleaner, this woman was in a bed--with florid pulmonary edema, complete with pink frothy sputum, an 02 sat of 67% on a nonrebreather mask, and a pulse of 144. If I had seen her, I would have yelled for help and sent her to the resus room to be intubated. Instead, EMS put her into a bed, pulled the curtain, and left. Her companion was clueless about what was going on, and was calmly sitting by the bedside reading a magazine. The nurse in the area was completely overwhelmed with his 8 other patients and hadn't gotten a chance to even stick his head into the curtain to see what was up--he was waiting for the triage nurse (me) to tell him what was up.
Asking the nurse in the area to triage her own patients is asking for trouble. We have 52 beds in the adult ED, and we have SIX nurses assigned for patient care. Actually, about half the time we only have five nurses assigned for patient care, now that I think about it. Also, most of those areas can be doubled up when it gets crazy. I've been in a high-acuity area with TWELVE patients--ICU, telemetry, you name it. When would the RN in the area be able to leave her patients to triage another one? In addition, the new protocol calls for the nurse in the area to do her own EKGs. We have an EKG tech--why do we have to do them ourselves?
Management loves bedside triage. It makes our statistics look great: people get into beds immediately, EMS turnaround times are super fast. The director of the ED said, when a nurse pointed out that it was going to be tough for her to do her own EKGs, "So you used to have three things to do. Now you have four. Work faster. So what."
According to one of the managers, the powers-that-be based our new bedside triage protocol on two studies that showed it improved patient outcomes. One of the studies was done in California, where no nurse has more than four patients BY LAW, and the other? Done in a 30-bed ED where there were 15 nurses on staff at all times. Give me two patients and not only will I triage them, do their EKGs, scrub their butts, and care for them, I'll freaking teach them to speak French and give them a mani/pedi to boot.
In our ED, this new bedside triage is unsafe and unfair to the nurses. And it will go on and on, until someone gets overlooked and dies. And then a nurse will lose her job and maybe her license, and THEN we'll go back to regular ambulance triage.
Thursday, May 20, 2010
You know why? Because you clipboard motherfuckers CANNOT DENY that I know how to help save someone's life. You pencil-pushing, white-coat-wearing, sad-ass management types FAILED UP to your lame-ass jobs because you COULD NOT CUT IT at the bedside.
Please. Get away from that stretcher, because the last time you went near a critically ill patient was six zillion years ago. Take a hike and shove your clipboard and policy up your stupid fucking ass and then bend over and kiss mine.
Just back away now, and let me get this dude with a huge brain bleed to the OR. Because I KNOW how to set up and monitor an A-line, and I know how to titrate a cardene drip, and I know how to help intubate the fattest, no-neck patient and keep him sedated until we get upstairs to surgery. Step the fuck back and let me do my job.
No, Clipboard Nurse. You do not get to "jump in" and lend a hand. Me and my fellow bedside RN's got this one. Go push a pencil and SUCK IT!
I swear to GOD if something doesn't change around here I'm leaving this unsafe shithole hospital and I'll go work in endoscopy or something, holding people's hands as they wake up from their propofol naps and giving them apple juice.
I don't need this fucking shit.
Monday, May 17, 2010
EMS stated that they had a hard time rousing him, but by the time he got to us, he was in full "let me outta here" mode, waving his hands around expansively, breathing his stench-laden alcohol breath on me, and explaining, "I'm OK now, please let me go, I need to see my girlfriend, I'm a bartender, it's ok, I don't need to stay here."
He failed my usual "walk a straight line" test miserably, as he almost toppled through a glass door, so I sent him back to his stretcher to sleep a little. I even offered him some food, which he declined, and told him he wasn't going anywhere for a while because he couldn't walk and had been found unconscious on the sidewalk.
He sat on the edge of the stretcher and tried to talk without slurring his speech. "No, listen, I need to go home. I have to work tomorrow."
"Yeah," I said, "Me too."
"No," he replied. "But you don't understand. I have a real job."
Monday, May 10, 2010
In addition to being excited, I'm very nervous; I've only been out of the country (well, off the continent) once; I'm going to be thrown in the deep end of a crazy ER where improvising with equipment is the norm (for example, often the power goes off and people take shifts using ambu bags when the ventilators fail); I don't speak the language (I speak decent Spanish and pretty good French but for some reason Haitian Creole is really confusing to me); and I often get homesick when away from my own bed and my hubby.
I'm a huge fan of doing things that are significantly outside my comfort zone; I'm looking forward to practicing nursing that will actually make a difference to people that really REALLY need my help; I'll be working with a few people I know and trust; and I'll have a great chance to use that thing between my ears--you know, my brain. I love critical thinking and relish the chance to figure things out quickly and efficiently.
I know I'll have a hard time for at least the first few days as I adjust to everything. I'm sure there willl be some crying into my pillow at night. I know there will be a few tearful emails to my husband: "Why did I do this? I miss you and the dogs! Why why why?" But I know by the end of the first week I'll be really in to the swing of things and ready to rock it out for the second week.
So, faithful readers: I'm asking you for advice. WHAT should I bring? WHAT should I pack it in? Have any of you done anything like this? Can you give me advice? Here's some of the advice I've gotten already:
- It's going to be 90 degrees, so wear scrub pants and t-shirts. And a headband.
- And clogs, but be prepared to throw them out when you leave. You'll be wading in rivers of blood and poop.
- Bring a BIG "fanny pack" to fit all your equipment in. (I've been looking at this one).
- Bring a headlamp, mosquito netting and spray, forceps, sphygmomanometer, shears, water purification tablets (I have some of this stuff, but not all of it, and though I will be staying in a hotel, mosquito netting is necessary because they may not have air-conditioning).
- 99-cent-store party favor toys for the kids.
Wednesday, May 5, 2010
Tuesday, May 4, 2010
incompetent EMT students today. They have been with me in ambulance
triage for TEN hours and their skills have not improved one iota. I've
repeatedly shown Dumb and Dumber how to use the Dynamap, and they
can't manage to get the blood pressure cuff on right, let alone take a
simple oral temperature.
We were swamped, and I exhorted Dumber to work faster. He looked at me
and said, "I don't do well under pressure." I asked him why he was
planning to be an EMT then, and he replied, "Money." The EMS crew we
were working with cracked up.
The other one told me that he was taking this EMT class to "save
lives," but doesn't want to work as an EMT; he plans to start a
business as a "trip monitor." He wanted to be able to "talk people
down and keep them alive" when they overdose on Special K (ketamine)
because according to him, calling 911 is the "worst thing you can do"
in a situation like that.
They spent most of their time "trying the oxygen," horsing around, and
generally getting in my way or being completely useless on one of the
busiest days this month. They were both like, "wow, this is some crazy
shit here! Is it like this every day?!"
I couldn't take it anymore and sent them home two hours early because
they were driving me bonkers.
They headed into the back to get changed and I waited for them to
present me with their paperwork to sign. When I saw them walking out
the side door, I realized they must have known I'd give them a bad
review and decided to split. I found out later that they'd approached
the busy and harried charge nurse, who signed their already-filled-out
forms, and they left.
My only consolation is that these two bozos will probably never become
EMTs and I'll never have to see them again.
Saturday, May 1, 2010
It was exciting, but what struck me most this morning was that while I was there, the patient wasn't the mound of flesh and humanity on the table. My patient was the thin green line on the cardiac difibrillator
monitor. I would watch the rhythm on the monitor change from a sinus(ish) tachycardia to a v-tach or v-fib, feel for a pulse and then announce, "docs, it's v-fib, charging, ready to shock, all clear?" and
then deliver the shock. I think I shocked her at least 15 times The other nurse was administering meds: code meds and the meds they use in the cath lab. I hung a few drips she was unfamiliar with, but the docs
made it clear that my job was supervising the two students doing compressions and that thin green line.