Tuesday, April 18, 2006

I've Moved!

Ladies and Gentlemen, Emergiblog has moved!

Emergiblog is now at its new domain site, so those of you who are kind enough to link to this site, please change your links to emergiblog.com

And then come on over and check out my brand spankin' new look and join me in a "blog warming" celebration.

That Great Day Has Come.

Blogger, we've had some good times together but it is time for this blog move along.....

Monday, April 17, 2006

No One Can Find the Rewind Button Now, So Cradle Your Head in Your Hands...

What a freakin' wimpy bedbath!

Gee, we don't want to overexpose our patient, now do we?

She looks like she's giving him a manicure!

And I guess we don't need privacy because nothing is showing! What's she going to do when she gets past (shock!) the elbow?

Were axilla off limits back then?

Well, at least according to the ad, the patient will experience a "delightful cleanliness"....of his distal phalanges.

I believe in truth in advertising so I've never understood how Ivory gets away with saying it is 99 and 44/100% pure.

What's in the other 56/100%



It was just supposed to be a quick four-hour shift.

I have a co-worker who has trouble with twelve hours shifts, as I do. She was scheduled for one tonight and I offered to do the first four in her place.

The unit was down to two patients, the break table full of Easter goodies and a kick-back attitude was to be had by all.

All the prerequisites for a Code 3 ringdown.

It came.

Cardiopulmonary arrest. Elderly. Found by spouse. Resuscitated en route. Still unresponsive but with a blood pressure, a pulse and (God bless all medics, every one) intubated with an IV. Technically was a DNR but papers were with the patient's doctor and not at home.

Lots and lots of activity. Many tubes placed where tubes usually go (foley, ng) and then a few new holes placed for those tubes that don't have a regular hole to fit it (central line). Many cooks in the broth. Much help to be had.

It did not look good.

The family decided that the ventilator would be removed and oxygen supplied through the ET tube.

Slowly but surely, the other nurses went back to their assignments and somehow I was the one who would be staying with the family until the patient expired, explaining what was happening.

I could insert a joke here, about the Energizer Bunny or the patient being like a Timex that takes a lickin' and keeps on tickin'.

But they really don't fit in this narrative.

My patient did not expire for over one hour.

During that hour I heard stories of what it was like to be married to, and now losing, a spouse of 70 years. We laughed over reminiscences the family shared. How one of the grandkids was the spitting image of the patient as a young person.

How one of the last things shared at Easter dinner just a few hours before was the patient saying what a good life they had had with their spouse. How happy they were.

How they had gotten the okay to travel abroad in four weeks. In their nineties.

I sat on one side of the patient holding their hand and the family sat on the other, stroking and holding the other arm. I offered them my place, but it seemed they found strength in leaning on each other.

And then, slowly, the resuscitation medications began to wear off and heart began to slow. Gradually, gradually until I documented asystole and turned off the monitor and oxygen.

Pretty technical.

Except that tonight there is a person who will be facing life on their own for the first time in seventy years.

Except that tonight there are adult children who are dealing with the loss of their parent. Grandchildren who will wish they had more time to know their grandparent.

Except for the fact that every time we lose a person who has lived as long as ninety years, we lose a treasure, a link to the past; a wealth of memories and experiences that will soon be relegated to textbooks.

Except for the fact that in ER, patients die quickly before you usually have a chance to get to know them or their families.

I haven't sat vigil with a patient and their family like that for many years. The opportunity to do so does not present itself often in the ER environment.


The family left.

I went into the bathroom and cried for two minutes....

... and then came out and made the requisite calls to the coroner and the donor network, finished my charting, posted my strips, circled my charges and swiped out for the night.


Another death.

Another holiday.

Something tells me I will have another "yearly visitor" around Easter next year.

And that gives me comfort.

In the meantime, I'll take the advice in the song written by Anna Nalick from which I took the title of this post and cradle my head in my hands.

And breathe.

Just breathe.

Saturday, April 15, 2006

This Season Is the Reason For Hope

To my Christian brethren, may you have a wonderful Easter Sunday as we celebrate the rising of our Lord and our reconciliation to God. For while Christ died for our sins, it is the Resurrection that gives us our hope. What can I say, eternal life rocks!

To my Jewish friends and readers, I hope your celebration of Passover was everything you wanted it to be.

For those who do not celebrate the holidays of the past week, I wish you peace and value your friendship through blogging.

He has risen, indeed!

The Impact of Mental Illness: A Story

A woman wearing her mother's nightgown and carrying a pot of coffee enters the room and finds a man slumped over on a desk.

She does a quick check of the "NBC"s of initial assessment: neck, back and collar.

Neck: present, discoloration to right lateral aspect, r/o hickey vs. birthmark

Back: present, shirt intact, alteration in fashion sense secondary to style and color noted.

Collar: alteration in cleanliness secondary to poor detergent selection resulting in "ring-around" syndrome.

What is your diagnosis?

a. Scapular arrest

b. Hysterical syncope secondary to the viewing of gram positive cocci and the inability to distinguish it from the couscous he had for dinner.

c. Pseudo-syncope secondary to not wanting to engage in marital relations due to wife wearing her mother's nightgown

d. Acute onset of somnolence following completion of compiling Grand Rounds submissions


This story violates no HIPPA violations.

I won't use real names.

The person involved was not my patient.

She was our next-door neighbor and gave me my first experience with mental illness.

I was twelve years old.


The summers are hot in the Stockton/Sacramento area and that year was no exception.

I spent most of my time outside, sitting on the grass with my transistor and listening to AM radio, having not yet discovered that "weird" stuff on FM. I would memorize the American Top 40 every week.

My life consisted of eagerly waiting for my Tiger Beat and 16 Magazines in the mail and running to the local JC Penneys to buy my 45s whenever I had babysitting money.

Bobby Sherman lined my walls. Three Dog Night was the coolest band ever.

I wrote to every single diploma nursing program in the United States that summer and received a bazillion catalogs back. I'd pore over every one and decide who had the best cap.

One must make informed decisions, even at the age of 12.

Other than people who "went" crazy due to drugs, mental illness was never on my radar.


We lived next door to a young couple, Amy and Dave, relative newlyweds. My parents became friends with them. Our cookie-cutter tract houses had opposite floorplans, so our front yards were sandwiched between the garages. We saw a lot of them as we came and went through our daily routines.

Everyone was very excited when Amy became pregnant. She had a baby boy.

And then it started.

She invited me over to see the baby. But she was talking in an odd way and the baby, just a week old, was laying in the bassinet without a diaper and urinating everywhere. I may have been a kid, but I sensed something wasn't right. I got out of the house as soon as I could.

And I told my mother what I had seen.

My parents were already suspicious as Amy had shown up at our door without the baby a couple of times that week. They had tried to talking to Dave, but being at work all day, he did not believe that there was anything to be concerned about. My parents could not believe his attitude, but didn't want to interfere in their business.

And, then as if my observations weren't enough to clinch it, the next day I was out in the front practicing cartwheels and gymnastics on the grass when Amy comes running across the street from another house and begins doing cartwheels next to me. I ran for my mom.

That was it. We got involved.

We went over and got the baby, brought Amy into the house, called my father (a police officer) to come home from work and called Dave home from the office. I guess there was no CPS back then.

We cared for the baby until that night, when Dave called Amy's family and his family and they all came over. My parents discussed their concern over Amy's odd change in affect and behavior. My dad, being a police officer had seen mental illness and was pretty sure that Amy had had what was then known as a "breakdown". This was hard for the families to accept as the idea of mental illness was even more "hush-hush" in their particular culture than it was in the general population back then.

All I remember was seeing these ten adults (including Amy) sitting in my family room discussing the situation in somber tones. Being twelve, I was told to go to my room. I went.

Amy was diagnosed with schizophrenia and hospitalized. Her family took over care of the baby until she was able to do so.


This story has a happy ending.

Amy and my mom have kept in touch since we moved away a couple of years later. Amy has had good periods and not-so-good periods over the last 35 years and my mom can tell by her letters how she is feeling.

She and Dave are still married and the baby we took care of that night was eventually joined by two siblings, now all successful adults. My mom gets pictures every year and Amy never fails to ask how we "kids" are doing.


I tell this story because I believe it has a lot to do with my ability to see the humanity behind "psych patients" and others who suffer with a mental illness.

A sense that mental illness was not something to be ignored or ashamed of, but something that could (and should) be dealt with.

This attitude followed me throughout my nursing education, throughout my life.

Not only because I saw the suffering, but because I witnessed compassion in how my parents responded.

Although I didn't appreciate it at the time, I was a lucky kid.

Friday, April 14, 2006

I Am A Scrubbing Bubble in the Toilet Bowl of Life

Oh man, is it a full moon or something?

I only did eight hours tonight but I'm beginning to think I work at Hell Community Hospital.

My patients were all wonderful. It's not them. They all had a sense of humor and were a pleasure to care for.

And I work in THE best ER in the San Francisco area, so it isn't the job.

It is the intensity of the illnesses, the number of patients who are seriously sick - every single patient I had tonight was admitted.

Honestly, I should have had a warning when

  • The unit was full when I walked in
  • I passed an ambulance on my way in the door and
  • My colleague-who-is-working-on-her-PhD nearly flew out the door. She had graciously offered to work the first four hours of what should have been a twelve hour shift for me and those four hours nearly did her in.
The next eight were no better. For the second time in a week I had no breaks. Not one.

Okay,I lied.

30 minutes before my shift ended I shoved two cold pieces of pizza into my mouth.

No break? What was I thinking.

We pulled it off without going on ambulance diversion and that is quite a source of pride for our ED docs. To tell you the truth, it makes me feel good, too.

Ambulance diversion has its place, but 99% of the patients we get are walk-in patients, even the sickest ones, and when an ambulance is en route with a Code 3 patient (life threatening, red lights and siren) we have to take them anyway.

So while it is psychologically a relief, it really doesn't help anything in the long run.

We are one of the hosptials with the least amount of ambulance diversion.

We're good.

Ya know, sometimes ya just gotta give props to yourselves.


I loved the title of this post. Made me laugh.

Too bad I couldn't think of a topic to go with it.

Sometimes I crack myself up....


Note to self: you can't read the syringe if you are wearing crappy, non-progressive contact lenses.

Since Etomidate is a general anesthetic used in rapid sequence intubations, this is "bad".

In these situations it is best to hand the medication to your colleague who is not visually impaired.

I redeemed myself by reading the Succinylcholine vial all by myself.


Okay, so I walk into Lenscrafters to get my spontaneously combusted frames replaced.

No I must tell you that up until my haircut three weeks ago I had a "John Denver" thing going.

I wore wire-rimmed glasses and my hair had grown so much that it framed my face with my bangs hitting the top of the glasses.

Now when a woman looks in the mirror and sees John Denver, it is time for a make-over.

So... I go get a major freakin' cool haircut, so very 2006. But I still have the wire glasses. That's okay, they're only six months old.

Then they break. So I walk into Lenscrafters and, to my delight, discover I had purchased replacement insurance that would give me a new pair at 50% off.

Screw these wire frames, I thought. I'm goin' designer frames....so I went for the frames they had to unlock. That's how cool these frames were.

But unfortunately it has been so difficult to cut my prescription into the lenses, they had to send them to THE BIG LAB.

So, instead of "about an hour", it's more like "about two days"

You see I have.....the big A.

Yes, it's true. I'm not ashamed. I have....astigmatism.

The bane of my life.

The reason so many beautiful vision options were closed to me over the years.

But I will not give in!

Astigmatism be damned, you will not keep me from my Versace frames!

I will have those frames if they have to get Donatella Versace herself to cut the lenses.

So, if you are ever in the San Francisco Bay Area and you see a nurse with a totally cool haircut and Versace frames, that would be me!

Oh, do stop and say hello, I won't look down on you from my Versace frames!

By the way, did I mention my new frames were Versace?

Thursday, April 13, 2006



Ladies and gentleman, this is a screenshot of what Comedy Central refused to air last night so as not to offend Muslim sensibilities. Mohammed hands the helmet to Family Guy, mutters "jihad...jihad.." and walks off.

Score another round for the terrorists.

I feel like buying a T-shirt with Mohammed on it saying: No free speech for YOU!

And yes, I have been offended by some South Park episodes and I exercise my right to put my finger on the remote and turn it off.

Thank you for indulging me on this post. If anyone is offended I am truly sorry on a personal level, but in this country, especially at this time, this censorship is unacceptable.

Free Speech. What an amazing concept!

(I now return you to your regular Emergiblog.)

Tuesday, April 11, 2006

It Was the Best of Times, It Was the Worst of Times

Greatest hygienic handicap?

At least as your daughter's doctor views it?.

Hey, at least the doctor is a woman here, which was probably unusual for the times.

The poor, poor patient who is experiencing her...uh...monthy "visitor". She looks just beside herself with period-ness.

I wish I had the luxury of flopping in a chair. The more likely scenario is that I'd be in your face because you moved my chart 5 millimeters to the right.

I guess before the advent of Kotex, women had to use "makeshift, unsanitary" items for their hygenic issues.

Come to think of it, what DID they use?

You know, I don't think I want to know the answer to that after all.

All I can say is that the day Stayfree invented the adhesive strip should be a national holiday.

And don't even get me started on the efficacy of "wings". I might have to pop open a bottle of champagne.

(Oh, and the author of this "article" is Ellen J. Bruckland, Registered Nurse. Remember the name. We will be meeting her a few more times....)


Last night was a bitch.

I've had root canals that were less painful.

It started out bad.

The department was full to the brim, people were in the waiting room, our tech went home sick at 2200 and two hospitals in the county were on ambulance diversion. Okay, business as usual.....

.... but then my glasses broke. Not the nice break that can be fixed with a tiny screw at the earpiece. The frame itself actually broke in the middle of nowhere. It was like my glasses had osteoporosis and spotaneously fractured, with the lens falling out. Now realize, I am as blind as you can be without needing a cane. So here were my options:
  • Function for eight hours with my glasses held together with plastic tape that covered
    50% of my left visual field, making me look like an extra in "Revenge of the Nerds", needing only a pocket protector to complete the look.
  • Wear my prescription sunglasses all night, bathing the ER in a brown tint and making me look like an extra from "Miami Vice" or someone with a chronic migraine, which, by 0800, would have been an appropriate diagnosis.
  • Call my loving husband of 26 years and ask him to run my contacts down to me, allowing me to at least hear report and allow the PM shift to leave on time.
  • Run home and back going 80 mph down the freeway to retrieve my contacts myself, with only 3/4 vision, in the dark, having one co-worker go overtime one hour and ten minutes while I made the trip (I have the timing down to the second). Oh, and by the way, the contacts are not progressives so while I can read the monitor a mile away, I will be charting in an absolute blur, not to mention starting IVs by sticking the angiocath into the depths of the bluish haze running up a forearm.
I chose option number four because hubby would not participate in option number three.

(I am pretty sure that is grounds for divorce in California, but I've invested too much time in the marriage and anyway, I kicked his ass when I got home. It will be a cold day in hell before I get him ibuprofen or Sudafed the next time he's sick. Sorry honey, this nurse is off duty! But I digress.....)

So I run breathlessly back into the unit with my contacts in, my vision worse but my looks enhanced by the absence of frames and high-five my colleagues who are breathlessly running out the door they are so happy to escape.

And for the next eight hours I am running. No breaks. No lunch. No food. No coffee.

Just Diet Pepsi (my addiction always gets fed) and I barely got in a third of that.

For six of those hours, I took care of a patient who had chronic pain exacerbated by a fall earlier in the day.

We are talking agony here, folks. Serious pain. 50/10 on the pain scale. Just the slightest movement set off additional spasms.

Because of various other problems discovered in addition to the pain issue, this patient was a 1:1 for almost my entire shift. The emanations of pain that came from her room were heartwrenching. A family member was present, knowledgable regarding their relative's health issues and an absolute saint in the bargain.

I developed an even deeper respect for my sole co-worker that night, an RN who remembers when she would have 14 patients and would cover the LVN's 14 patients on the floors.

She makes me look like a baby nurse.

She took every other patient that came in that night after our 0330 nurse left. Believe me, they didn't stop coming just because one nurse was busy.

And they were sick, no clinic stuff last night.

Just as we were ready to transfer my patient, the family member expressed concern over a possible need for some respiratory medications and the ER doc added an additional medication for pain, which I gave at that time, so the patient remained with me for another half an hour.

And then it happened.

We were able to stabilize my patient and by the time the patient left the unit, they were smiling and comfortable. They were telling jokes!

We had found the medication combo that stopped the overwhelming aspects of the pain.

The metabolic issue would be addressed after admission, but for now the pain was minimal. I told the patient that it was worth the additional half hour in the ER just to see her looking so good after so much suffering.

I needed to see that.

Maybe it is a selfish thing, but I felt like all the ministrations, medications, repositionings, revitalizing and compassion had made a difference.

I was overtime, finishing the shift with a zombie-like numbness. I checked the glucometer. I ordered the drugs - all night shift duties - while my colleague finished her charting and as I left, the day shift began dealing with the five patients that arrived between 0800 and 0810.

I drove home, took the ibuprofen and valium that I take for the back spasms and body aches that I never seem to feel while I'm working and fell into a sleep so deep my husband woke me up at 1800.

I never even heard the phone when my daughter called for me to pick her up after track practice, so I guess I gotta give the hubby a few props for picking her up when it was my turn to do so....


Tonight, during "American Idol", the contestants were singing songs written by Queen (and I hope you all voted for Taylor!)

I thought Freddie Mercury was a doll and I cried when he died in 1991, but I was never really "into" Queen as a group.

Until tonight.

Maybe it's my frame of mind, but I heard lyrics that reached out and grabbed me by the soul.

I don't want to sound like a drama queen here (no pun intended), but one song hit me in particular, especially considering the day I had just finished. The song is called "The Show Must Go On", written by Queen and sung, of course, by Freddie Mercury:

"Inside my heart is breaking
My make-up may be flaking
But my smile still stays on.......
The show must go on
The show must go on
I’ll face it with a grin
I’m never giving in
On - with the show -
I’ll top the bill, I’ll overkill
I have to find the will to carry on
On with the -
On with the show -
The show must go on..."

Or these lyrics from "Somebody to Love", again written by Queen, that describe so vividly what it felt like to be going through burn out a few years ago:

"Got no feel, I got no rhythm
I just keep losing my beat
I’m ok, I’m alright
Ain’t gonna face no defeat
I just gotta get out of this prison cell
Someday I’m gonna be free, lord!"

I'll stop here. I don't want to get too self-indulgent. I just can't figure out how this closet rock-and-roll groupie didn't "discover" this band long ago. I just downloaded "Queen's Greatest Hits I and II" from iTunes.

After all, who couldn't love a group who paid tribute to "Fat Bottomed Girls" loooong before Sir Mix-a-Lot came along with his "I like big butts and I cannot lie!" rap.

Now if you will excuse me, I have about 20 years of rock-and-roll catching up to do.....

The Beauty That Is....Grand Rounds

If heaven denied you beauty, you can at least get the latest in the medical blogosphere, this week hosted by Jon at Anxiety, Addiction and Depression Treatments!

If you get over to Grand Rounds, that is!

I can't guarantee that you'll become beautiful or start growing an animal on your head.

I can guarantee a wonderful list of topics from bloggers you have known and loved and those who are new to the Grand Rounds audience.

What have you got to lose?

Friday, April 07, 2006

Chart Wars

Got a nagging cough?

Have you tried.....Heroin?

Did you know that aspirin was the substitute for salicylates?

Piperazine: the antiarthritic? It's a worm medicine!

Hemicranin? Sounds like a neurosurgical procedure.

Somatose? It's the name of an Australian rock band (I'm serious, check out Google!)

You could send for samples! Yes, I'd like a sample of heroin, please. Would it be possible to have two? Actually, I 'll need a case if you can possibly oblige. Nasty cough, this is!


I have a reputation.

I am a chart hoarder.

I hoard charts.

99.9% of the time, if a doctor needs a chart, I have it.

The other 0.1% of the time, my elbow is on it, a chart of mine is sitting on it, my eyes are gazing upon it or I have just moved it to the side to make room for my charts.

It doesn't matter. Doesn't even have to be my patient.

The docs always know I have the chart.


My philosophy of ER nursing is: Patient Flow = do now, chart later.

So, if the unit is crazy, I will chart medications given and IV start times when it is done. I will then write notes on scrap paper, pieces of tissue boxes or paper towels (hey, at least I'm honest) that I attach to the chart via paper clip.

These charts go into "my office". Then, when things settle down, I will take the various notes and create a consise, coherent narrative of the patient's ER visit.

This drives some of the doctors I work with nuts. Really nuts.


I don't mean to do it. Really I don't.

It's just that our doctors are dictaters.

(No, I did not say "dictator" as in Fidel Castro. I wonder how many search engines will send people here looking for his hairdo.)

Our doctors dictate all their charts. The amount of nuttiness I produce in any particular physician depends on their style of dictating.

There are four styles of dictation:
  • Those who dictate before they write the discharge instructions. It slows patient flow a little, but when they are done the chart is all mine.
  • Those who dictate as soon as the patient is discharged. This causes only a short period of distress as they usually find the chart in "my office" within five minutes and when they are done, the chart is all mine.
  • Those who dictate after they have a moderate amount of charts piled up and then realize they have seen more patients than their pile would suggest. This causes a moderate amount of mental distress for the doctor, which is easily resolved when they pull rank, come over and raid "my office" even as I am trying to complete my precise charting ministrations.
  • Those who dictate when the mood hits and don't care when the chart hits their pile. Very mellow, these guys. Take your time, just let them know where "my office" is and if they want the chart they'll go get it. This is usually a night shift style. God Bless the night shift.
And then there is the situation that makes even the most jaded, experienced nurse tremble with trepidation:


Hell hath no fury like that of an ER doctor, who after breathing a deep sigh of relief that their day is done, is handed five more charts......from "my office".

Yes, ladies and gentlemen, I lived to tell the tale.

It's a mistake that you make only once.

Trust me.


The War for the Charts reaches its apex when a patient is being admitted, for it is at this time that both the nurse and the physician need the entire chart at the same time.

The doc has to dictate and write holding orders and I need to write report and fill out a bazillion other pieces of paper, using the chart for reference.

Since the patient can't go upstairs until the doctor is finished and holding orders are written, they get the chart first.

The goal of both the doc and the nurse mesh at this time because we need to get the patient out before the admitting doctor, consultant or hospitalist arrives on the unit.


If we cannot get the patient up before the next physician reaches the ER, all bets are off.

They get the chart. The entire chart. For the entire time they are there.

And while I am always happy to give up a chair to a doctor who needs to write (I have a million other things to do as it is), they will s-p-r-e-a-d out the entire chart over the entire desk and take up all the space available, which usually encompasses "my office".

I can't even access my nurse's notes.

Geeze. I sound like a toddler who can't get to their crayons.


No matter who "wins" the War of the Charts, being the flexible,competent professional I am, I have learned to adjust my charting style to whichever physician is on at the time.

But it never fails.

Ten times a shift, I will still hear that eternal question:

"Kim, how many of my charts are you hoarding?"


And now for something completely different.

I have succumbed to the urge to make a South Park character of myself.

The halo is because I am an angel of mercy, doncha know.

In my right hand is a bottle of Magnesium Citrate for all the constipated patients I have to see every shift.

The iPod is there because it's cool.

In my other hand is holding a cup of oral contrast for an abdominal CT that will form a head like a glass of beer if you don't add the water at an angle.

See what you learn on the job?

South Park Characters

Thursday, April 06, 2006

Grand Rounds Streamin' Over at Urostream

Well, women may not be especially susceptible to forgetting to link to Grand Rounds, but this female sure is!

Switch my work schedule by one freakin' day and I forget only the major link of the week.

So, if you haven't already partaken of the treats over at Urostream and this week's Grand Rounds ,I suggest you do so STAT.

Only don't say that Kim sent you because then Keagirl will know that I am late and that would be, like, embarrassing!

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