The Back of the Book Segment

Shame on you!

That's the first thing that came to mind when I saw this ad. I didn't even know they made Tampax back when the world was black and white.

Frankly, I wouldn't discuss any aspect of reproductive health with this angel of mercy. She gives me the willies.

Besides "Tampax" sounds like the latest SSRI antidepressant.

(Insert own Prince of Wales joke here. No pun intended.)

hhhhhhhhhhhhhhh

It wasn't reproductive health that I had to deal with these last few days. Apparently the post-Thanksgiving epidemic is not the avian flu, but all-too-human constipation.

Yes, the rectums of the world are clamoring for attention.

Again.

I had a 94-year-old in one bed and an 8-month-old in the next bed. Both were having evacuation problems that made Hurricane Katrina look like a precision drum corps. Both had eaten yams at their last meal.

I suggest that all yams be sold with a complimentary Dulcolax suppository attached. It's a lot cheaper than paying for an ER visit to have someone shove tap water up where the sun don't shine.

But wait! It's our friend, Beulah France, RN! Of New York! She of the toilet paper and Wheaties ads! She's baaaaaack. And she's discussing bowel habits again.

I guess two out of three people are "FOS" at one time or another in their lives.

Which means that some people are "FOS" all the time.

Like we needed an expert to tell us that....

The 2005 Medical Blog Awards

Wow.

Medgadget is hosting the 2005 Medical Weblog Awards

Thanks to Rita over at MSSP Nexus, Emergiblog has been nominated in the "Best New Medical Weblog (established 2005)" category!

Medgadget is still accepting nominations for the different categories, so if you have a favorite medical weblog or just want to see how the field is taking shape, pay a visit. Remember:

If the blog is great, you must nominate!

I'll be over at Medgadget, doing exactly that....

Take A Bite Outta Grand Rounds!

Grab a cookie and go check out Grand Rounds 2.10! This week, Graham is hosting at Over!My!Med!Body!
There is some major linkage action going on over there and I intend to savor every bit of it!

Graham is a medical student here in the San Francisco Bay Area - and I just now found his blog this week because of Grand Rounds. A virtual neighbor in more ways than one.

I just hope all the cookies aren't gone by the time you get there. That little teal surgeon cookie on the left has my name on it......

Charting the Course

Made it to the Notre Dame/Stanford game this weekend. I walked into the Stanford stadium thinking the Irish would grind the Cardinals into the turf, but by the time I left I would have accepted a hefty dose of IV Valium. I like my football nice and calm. A 30 point lead in the first quarter, a nice half-time show by the marching band and fluffy pom-poms to wave at the appropriate moments.

Last night was gut-wrenchingly close. Stanford played their heart out, but the Irish pulled it out in the last two minutes. It was the last game Stanford would ever play in their stadium. Right after the game, literally, they began to tear down the old stadium in preparation for what looks to be a fantastic replacement.

I could write an entire blog entry on the differences between the Stanford and Notre Dame cultures, both campus and football. Having experienced both this month, it was like visiting two different worlds.

If Stanford had been playing any other team, I would have rooted for them. But they were playing Notre Dame. 'Nuff said.

hhhhhhhhhhhhhhhhhh

I love charting! A well-written chart is a piece of art; every entry a chapter in the book that becomes The Medical Record.

Nurse's notes are my passion. I must chart in blue and I must have a medium-point, gel-ink pen that does not scratch the page as it flows. I accept no substitutions. I carry a small, six-inch ruler so that my lines are straight.

I do not chit-chat while charting; I eschew the tantalizing temptation of socialization with my colleagues until my nursing narrative is completed to my exacting specifications. I have claimed a small corner desk as my "office", to the distress of my fellow nurses, for that is the desk they use to surf upon the internet. I daresay that my attempts to construct a medical work of art supersedes their need to (1) check their cell phone bill or (2) make bets on the NFL.

I'm not kidding!

I really do enjoy charting as part of my nursing responsibilities. A well-written nurse's note acts as a timeline of the emergency visit. I make sure mine are:

• Legible
  

• Doctors may be notorious for illegible handwriting, but I know a lot of nurses who make doctors' writing look like calligraphy.

• If that note gets blown up poster-size to sit in front of a jury, I want my writing to reflect that I am a professional nurse, not a literary slob.
  

• Complete.
  

• You might be Nurse of the Year but as the old saying goes, "If you didn't chart it, you didn't do it.

• Check every box, chart every response, write N/A where applicable to show that a topic was at least considered
  

And, in addition to charting my actual nursing care, I make sure to chart:

• Times
  

• Time that patient was roomed.
• Time that the doctor evaluated the patient.
• Times of each test (lab, radiology)
• Times that the patient was out of the department.
• Time of discharge

• Consultations/Communication

• If I hear the doctor on the phone in consultation with another physician concerning my patient, I'll verify who they were speaking with and document it on my notes with the time of the call.

• When the EDMD goes back to the bedside to discuss the case with the patient or family, I will note that it occurred. I don't go into detail, perhaps I'll just write, "EDMD at beside, case discussed with patient and family".

• When I update the EDMD with patient information (medication response, a change in vital signs, etc.), I document what I said and when I said it.
  

• Patient comments and behavior.

• Verbal abuse - I will chart what the patient said, verbatim, including the foul language, in quotes.

• A threat to sue - if a patient makes a threat to sue while in the emergency department, I will quote it, again verbatim, in the record.

Of course,the goal is to document, as objectively as possible, what is happening during the patient's time in the department. The nursing record is really the only part of the medical record that gives "real time" information. It pulls together and reinforces all the other documentation, including the EDMD dictation.

I've worked with doctors who do medical-legal chart reviews. They have story upon story about how a single entry in a nurse's note stopped a lawsuit in its tracks.

Pretty impressive.

It doesn't take any more time to document thoroughly, clearly and legibly than it does to scribble what looks like incoherent mumbling on a page. It does take organization, focus and good management of your time. It isn't rocket science.

I do it every shift.

With a medium-point, blue gel-ink pen and a six-inch ruler.

I'm So Vain, I Probably Think This Blog Is About Me

I wonder if anyone has informed the American College of Cardiology that Bayer Aspirin does not affect the heart! Boy, what a relief that must have been in 1928. And don't forget to demand it!

hhhhhhhhhh

I finished a twelve-hour shift in the wee hours of this morning. Everybody who has ever worked in an ER knows that the day after Thanksgiving is unadulterated hell. Friday was no exception. It reminded me of a story about Joe Montana who, near the end of his football career, took a particularly hard hit. As he lay on the turf he looked up and told the guy who sacked him, "I'm too old for this s***!"

I believe I shall take that as my personal motto.

I'll chalk up a few post-shift aches and pains to age. I'm mean, I'm not in my twenties anymore, my thirties are but a memory and while I'm still on the sunny side of fifty I thought I was holding up pretty good. Anyway, I come home, grab the computer and lay on the floor catching up on some blog reading. After about an hour or so, I decided I had better get to bed before dawn.

I couldn't get off the floor.

Every bone in my body ached , my spinal cord was my personal torture rack, my biceps devolved into a gelatinous mass and while I know I came home with my quadriceps, they seemed to have disappeared. Thank god I was able to use a table for support or I'd still be lying there.

When did I turn into such a wimp?

hhhhhhhhhhhhhhhhhh

Nothing will humble you faster or make your stomach sink lower than a med error.

I made one last night. I hadn't made one for many years but you never forget that sickly, nauseated feeling in the pit of your gut when you realize you screwed up. I didn't even realize I had made an error until I saw the written order.

Beware the verbal order! What I heard is not what the doc said (I heard a different dosage) and he didn't hear my repeat as I rushed to the med room.

The patient is fine and the doctor was totally cool (as ER docs usually are).

I'll probably be a bit queasy for awhile.....

hhhhhhhhhhhhhhhhhh

While thinking of blog topics the other day, I was considering writing about my worst experiences with doctors. I'm talking about in-your-face-screaming fits. I'm talking sarcastic, arrogant jerks. And then I realized that:

1. All these episodes happened over twenty years ago.
2. All the doctors were men. Old men.
   
3. All of the doctors were men who had gone to medical school in the 1940s and I'm sure, to them, female nurses were one step above bottom feeders.
   

And none of them happened in the ER.

I was stunned at how I could recall, today, my anger and frustration at not being able to stand up for myself; the humiliation and injustice of getting screamed at in front of other doctors and of holding myself together until I could make it to the break room to cry. It was as if had just happened yesterday instead of twenty years in the past. As if I was 22-years-old again.

It's funny. My body may be falling apart but there is a lot to be said for the self-esteem and maturity that come with age. Boy, would I love to give those jerk doctors a piece of my mind.

Nah. I think it's time to let it go.

For good.

Thanksgiving: An American Tradition

Abraham Lincoln said :

"[It is] announced in the Holy Sciptures
and proven by all history,
that those nations are blessed whose God is the Lord...
It has seemed to me fit and proper that... [God's blessings]
should be solemnly, reverently, and gratefully acknowledged,
as with one heart and one voice,
by the whole American people."

So as I head to work on this holiday of Thanksgiving, I'll be solemnly, reverently and gratefully acknowledging my thanks to God for my country and my freedoms.

I will also be thankful for our men and women serving in the armed forces and for the millions of people are newly able to embrace the freedoms that I take for granted every day.

I'll also thank God for my family, our health, and for my wonderful profession and for the continuing ability to make a small difference in the world.

Happy Thanksgiving!

Cracking Good Blogging at Geena's Place!

I love Grand Rounds.

It's like sitting down with a wonderful anthology every week.

This week Geena is hosting over at Code Blog, where she has put together a compendium of the latest in the medical blogosphere.

Grab your laptop, get your coffee, put your feet up and enjoy Grand Rounds 2.09!

If You're Going To San Francisco.....

I've known a few of these nurses.

To be honest, after twelve hours of running during a shift-from-hell, I've been this nurse. More than once. I hearby apologize to all the patients stuck with me as
their triage nurse on those days.

How can it be that I leave the house in one condition: hair blown dry and meticulously styled, make-up done so well that Mary Kay herself would have applauded, scrubs crisp but comfortable, the very slightest hint of citrus wafting in the breeze as I bounce to the car in anticipation of my workday....

.....and by the time I get home I smell like the Oakland Raiders' locker room after a game, my scrubs are sticky, my hair is drooping, my eyeliner is somewhere south of my chin and I feel like a beat-up hockey puck?

Did I ever really believe that nursing was glamourous? What the hell was I thinking?

hhhhhhhhhhhhhhhhhh

And now, an Emergiblog Public Service Announcement:

Driving at night can be hazardous to your memory.

My last shift was a doozy. Non-stop running. It seemed as though the proverbial bus was letting patients out in one continual stream. I was exhausted by the end of my twelve hours and more than relieved to slide into the driver's seat to head for home.

It was the middle of the night and traffic was minimal as I headed north on Highway 101. The radio was putting out some good tunes. Matchbox 20. Gwen Stefani. Eagles. I harmonized along (Don Henley, eat your heart out!). I was tired, but not sleepy. The night was cool and I cracked the window open for some fresh air.

I drove smoothly along and soon I came up on the San Francisco International Airport.

Hmmm....the airport.

What the.......?????

I don't live near the San Francisco airport. In fact, my exit was twenty miles behind me.

Twenty miles!!!!

I was so shocked it took me a few seconds to get my bearings. I had no memory of the trip past my exit or how I had gotten that far down the freeway without realizing it. Scared the hell out of me. It's a good thing I snapped out of whatever reverie I was in or I would have ended up in Marin County.

I'm just thankful I didn't fall asleep at the wheel.

So all you nurses working long hours and driving at night, don't contribute to the nursing shortage by becoming trauma patients yourselves.

Stay awake. Stay alert.

Be careful out there.

Blogorrhea

Am I wrong to admit that my favorite Peanuts character is Pig Pen? Is it possible that deep in my soul I'm a rugged individualist, a rule breaker, a limit-pusher, a risk taker with an overarching disregard for societal norms regarding human appearance, completely apathetic to the opinions of those who would criticize?

Nah.

I just hate housework.

I did, however, do a bit of "housework" on the blog. I have organized my Blog Roll Call, for starters. I removed a ton of linkage from my button list. As a new blogger, I signed up for every blog service and counter I saw, thinking that, well, that was what bloggers did! Ha! Now I am a veteran of the blogosphere and realize that a cluttered template is a bad template! I can rest easier, my obsessive-compulsive need for organization quieted by the knowledge that my blog is free of extraneous propaganda.

I appear to be suffering from blogorrhea - the need to blog when one has nothing of import to say. The cure is sleep. I shall prescribe myself eight hours and return to see if this still looks as witty when I wake up as it does at 0330.

UPDATE: It looked better at 0330. But I love the Pig Pen cartoon so I'll post it anyway!

Medicinal Compassion

So this is what Stefanie Powers did before she became "The Girl From U.N.C.L.E"! (A TV show from the '60s, you young whippersnappers...). The intern with the cigarette breath and the full pack in his breast pocket is actor James MacArthur. God, I love trivia.

Smoking didn't used to make one a social pariah. I didn't smoke but my nursing colleagues in CCU did. They would all puff away while we would get report, sitting in the room in the middle of the unit! The odd thing was, it never bothered me. It never occurred to me that I should be bothered. Between my routine Hershey bar, coffee and their nicotine I was a very hyper, happy camper. If that happened today, I'd be choking and my eyes would burn. Somehow I developed politically correct physiological responses. The human body never ceases to amaze.

hhhhhhhhhhhhhhhhhh

It was a dark, stormy, late winter night. For weeks the Bay Area had been the recipient of a torrential deluge; a hard-driving, chill-to-the-bone downpour. I was working night shift in a quiet, "stand-by" emergency department.

We had cleared out patients left from the PM shift and finished our routine duties. About 0100 we were settling in for our usual night of nothing when a middle-aged man walked in and asked to see a doctor. He was a mess, his skin, hair and clothing thoroughly soaked. Water trickled to the floor as he sloshed to the triage chair.

He said he had chest pain. I started to run through the usual triage questions and assessments but soon realized something wasn't right. His speech was clear, his answers vague. A vague smell of alcohol and stale urine permeated the area. He wouldn't look me when he answered. I put my pen down. I had to know.

"Are you really having chest pain, or do you just need a place to sleep?", I asked. For the first time, he looked me in eye and said, quietly, "I need a place to sleep." He told me his story. He was homeless and an alcoholic. He had tried to take shelter under a bush in a park a few blocks away from the ER and intoxicated, had passed out. He estimated that he had been there in the rain for about four hours. His last drink had been just prior to walking to the park. He denied having any chest pain as he sat shivering in triage.

I put the patient in a room and gave him a gown and some pants along with a cocoon of warm blankets. I told the patient's story to the doctor on duty. There was no eye rolling, no sighing, no anger, no sarcasm, no disgust. He asked me to see if there was any food in the back for the patient, said there was no way he was sending anyone back out into the storm and then went in to perform his examination.

We hydrated the patient. We gave him medication for tremors. We fed him (I found some soup and crackers) and gave him a safe place to sleep (which he did, soundly). It took a few phone calls during the middle of the night, but we were able to find a shelter he could go to in the morning.

I'll never know what happened to the patient after that night, but I can tell you that I will never forget that doctor. Before laying eyes on the patient, he wanted to make sure a meal was available and decided the patient had a bed out of the storm. This doctor was a seasoned veteran of the ER with decades of experience behind him, yet he wasn't cynical or hardened. He couldn't cure alcoholism but he could treat this patient with dignity for the time he was under his care. He was no angel; he could be a bugger to the nurses when he was in a mood, let me tell you. For almost ten years I saw the respectful care he gave the less fortunate.

Compassionate medicine. He wrote the book on it.

Roses are Red, California is Blue

Well, I don't know if I'd want to use this all in my own home! Actually, it is referring to an antiseptic solution. But what an odd photo...

First of all, it isn't an operating room, no one is scrubbed.

Apparently the doctor requires three registered nurses to get the job done (no comment....).

No one is wearing gloves.

The patient doesn't appear to need sedation, but is unable to bend her arm at the elbow to facilitate bandaging. Notice that the nurse is holding both the elbow and the wrist, but the doctor seems to have tucked the patient's hand against his ribs. Must be one hell of a heavy arm!

A sterile field is set up along side the bed, but Nurse-on- the -left is holding the instrument in her fingers.

I have no clue what Nurse #3 is trying to get out of that cupboard, but it is awfully high. OSHA would have a fit!

Is that male head above the nurse on the right, the reflection of the photographer in a mirror?

We won't mention the light directly on the patient's face.

Thank goodness I don't get worked up about this stuff!

hhhhhhhhhhhhhhhhhh

I live in the great state of California, in the totally crazy San Francisco Bay Area. Been here all my life. I'm a red-state soul awash in a sea of blue-state liberalism. Everyone feeds on their hatred of "Ahnold". People actually believe Karl Rove tells President Bush to cause hurricanes- on purpose! We re-elect representatives and senators that have contests over who can sound the most idiotic. We'll take the protection of the Armed Services but you had better not try to recruit in the City. Peace and Love, dude! We can't give your daughter a Tylenol without your permission, but we can give her an abortion without you knowing. Our borders are so porous anyone and everyone can come on down illegally. Ooops, my bad.....I believe when you come into this country against the law you are now called an "undocumented worker". But hey, no worries, you don't have to be "documented" to get food stamps, health care, schooling, maybe a driver's license and they are talking about free college educations! Best of all you don't have to learn English! There are neighborhoods where you can't find a single billboard in English! Even the Kellogg's cereal boxes in my local Safeway are bilingual. The San Francisco Bay Area isn't a melting pot, it's a box of See's Candy, all nougats and nuts....

But when I walk through the door of my emergency department, none of the above matters.

I leave my politics at home.

I couldn't care less tell if a person is legal, illegal, documented, undocumented, insured, or uninsured. If you are sick you can walk into any ER in this country and obtain care. If you can't speak English, we'll find a translator to help you communicate. We'll do our best to refer you to a physician fluent in your language. If you can't pay we will give you a referral to our financial counselor for help in payment arrangements and give you referrals to low cost clinics for your follow up. If possible, we will give you discharge instructions in your native language.

Nursing is blind to ethnic, political or economic considerations. We deliver nursing care centered on our patient, respectful of their culture and with respect given to them as a human being. Every patient.

Oh, and that box of See's Candy? I'm the section with the four, thin crunchy strips that are usually in the upper left hand side. Yes....it's true....I'm a nougat.

Triage Tirades

I'm always happy to give advice on "heat- energy units"! Especially when I am standing in what appears to be a restaurant. In full uniform. Including cap and cape.

Aren't "heat-energy units" now called "calories"?
So, according to Cherry Ames, Restaurant Advice Nurse, the more you feed your kid in the winter the warmer he stays. If that were true for adults I could run around in a thong in a snow drift....

Oh, but look! This Wheaties breakfast is sponsored by none other than Beulah France, RN! Of New York! You remember her! She went from inspecting toilet paper to sponsoring breakfast cereal! I hope she washed her hands...



Since when did nurses get endorsement deals?


Unfortunately I don't think this is the last we will see of Nurse Beulah.

hhhhhhhhhhhhhhhhhh

A few years ago, it became a JACHO requirement to document how ERs were addressing cultural diversity. In the ER I was working at the time, the question, asked during triage, went something like this: Are there any cultural or religious beliefs that would affect your care today?

The usual response: a blank stare. Followed by, "What?" or "Huh?" or "I... don't... think... so". Apparently the general public did not find the concept of cultural diversity in health care as important as JACHO did. I've been asking that question for about three years now and in all that time I've had only three requests:

1. A Jehovah's Witness (no blood products)
   
2. A Muslim (who was observing Ramadan and while able to take medications if needed, would prefer a medicine that could be taken once a day)
3. A woman from Iran who would prefer a female doctor if possible.

Three positives out of literally thousands of triages, all of which would have been addressed during the course of the visit. No, instead we add it to the increasing number of questions/assessments required at triage. Oh, and don't forget to chart "negative" on this one. If you leave the section blank, they think you have not addressed it.

Oh, and don't even get me started: the gospel according to JACHO says that we have to measure the circumference of the head of anyone under the age of one. And then chart whether it is normal or not. What are we going to do about it in the ER? Acute head expansion in Bed 8A? Never mind that pediatric triages take forever! Oh, just work it into the triage, they say. Uh..... after we've worked to develop a rapport with the child, the trust of the parents, a full set of vitals including rectal temp done while listening to screaming that makes Dolby Surround Sound seem like an old RCA grammaphone, and obtain an entire medical and immunization history while the patient proves that a pissed-off infant has the vocal strength of thousands. Now we're going to wield the tape measure. I worked in an ER where this was an actually watched in Quality Assurance. You could write up a triage worthy of Kipling himself and they would still find that damn little empty box-with-no-number. The hospital I work in now got around it in a rather interesting fashion. The nurses refused to do it! And somehow we still passed JACHO. Amazing.

Then there was the ER that required, for any patient coming in with a complaint of shortness of breath or cough for any reason, including infants, a ten-item questionaire to test for TB. Questions like:

1. Have you had a fever in the last 48 hours?
2. Were you born in this country?
3. Have you been in a homeless, in a shelter or incarcerated in the past year?
4. Have you had a cough?
5. Have you had night sweats?
6. Is your cough productive?
7. Do you smoke?
   

You get the picture. Imagine having to ask these of a two-week-old. Obvious MI? If the words "short-of-breath" came out of the patient's mouth, you had to do the screen. Croup so loud you could hear it three floors up? You had to do the screen. Status asthmaticus? Yep, the screen. Six week old with RSV? Screen 'em. Now there was nothing wrong with the screen itself except that it was a pain in the derriere when added to the triage. Most of the time, a waste of time.

And the icing on the cake? There was a separate sheet with SARS questions on it.

I bet Beulah France, RN from New York had something to do with it.

Here It Comes, Walking Down Your Street....It's Grand Rounds!

I suppose I should approach the subject of Grand Rounds with maturity and thoughtfulness. With professionalism and respect. With due diligence and wisdom.


Nah!

So I bet you're wondering what the Monkees have to do with Grand Rounds.

Well.......


(1) The Monkees were on Mondays at 7:30 on your local NBC station and this issue of Grand Rounds was released on a Monday.
and (2) I used to watch the Monkees and today I read Grand Rounds.

Doc Shazam is hosting this week and I read most of the selections already. Get ready for some productive clicking-of-the-mouse action. Great topics await.


Actually, this may have more to do with my associating the Monkees with Grand Rounds than anything else. I've been suffering from a lightheadedness for a week now. Thank god it isn't classic vertigo. Nothing serious, Doc thinks it's a viral thing, but no work and definitely no driving. Ativan and I have become acquainted this week as apparently it is the drug of choice for this. Too bad I can't work; I'd be a doll to work with as the motto for this drug is "...don' worry, be happy..." (sung in best Bobby McFerrin voice). Whew! I bet there were hippies in the 60s that never felt this mellow.

So, that explains my zany self today. I shall return to the serious, studious, diligent, professional blogging for which I shall be known as soon as I get my equilibrium back (not that I ever really had any to begin with....).

The Yearly Visitor

I often find myself with writer's block, especially when I stop to think that people are actually reading what I write. I have to remind myself that blogging is not a performance art, it is a (hopefully) creative outlet for emotions, opinions and commentary.

I often find myself blocked from adressing a specific topic because I'm only minimally anonymous on this blog, if at all. I worry about HIPPA regulations and patient confidentiality.
Sometimes it's easy to change the sex, age and chief complaint of a patient and not affect the story or its outcome. But what happens when you can't do that; when the details ARE the story? How can I describe what was the most tragic, gut-wrenching shift of my career with a patient I can't forget..... because she returns every Fall?

I have decided to tell this story in the form of a letter to my patient, covering up the details to the best of my ability. Who knows, I may just delete the whole thing when I'm done, but it is Fall again, and she does come around.

"Dear Melissa,

It's been many, many years since our meeting in the emergency department late that holiday night. The evening you told your mom that you would join the family over at Grandpa's as soon as your headache improved. You didn't show, and your mom came home later to find you unresponsive on the den couch. She called 911. We met around midnight.

The paramedics gave you some medication en route and you responded to one of those medicatons. By the time you arrived, to have called you agitated would have been an understatement. This was a different kind of agitation. Your eyes were open but they did not see. You thrashed and writhed but not because of any particular stimuli. You screamed a scream we could not understand but could not seem to hear when we tried to speak. You looked right through us. I'd never seen that stare before. I will never forget it.

We noticed that you were oozing blood from a nasal airway attempt en route. And you were dripping from both IV attempts the medics made. The entire department and half the hosptial met the ambulance that brought you to us and many things were occuring simulaneously. The nurses inserted a foley that returned red urine. Every place you hit while thrashing turned ecchymotic. You leaked around the IV insertion sites we put in. Somehow the ED doc managed to do an ENT evaluation. Blood behind both tympanic membranes.

Disseminated Intravascular Coagulation (DIC). All I knew at the time was that it was 60% fatal. The lab confirmed it. The question was why? The specialists started arriving. Internal Medicine. Hematology. Respiratory. An ABG was done; pressure was held. You didn't stop bleeding. Blood cultures done. More bleeding. You continued to thrash against the barriers we had put up. We tried sedating you but nothing worked; your respirations remained sixty and deep for hours.

Your mother stayed in the room with you after the majority of the procedures had been done.
I stayed calm and conversant even though I knew you were critically sick. I told her to try and talk to you because you could probably hear her. I told her you were the same age as my daughter. I learned you were taking college classes and happy with a part-time-job. I learned you had a recent break-up but seemed to be getting over it. I learned you had sisters. Your mom wondered if she should have your father called and get your sisters to the hospital.

I said yes.

The rest of the hours are a blur after so many years. No time to chart so I kept grabbing paper towels and putting my notes on them. By now, the other two nurses had to go back to taking care of the other patients in the totally full ER. You were nowhere near stable enough to transfer to ICU, although we had had the room for awhile now. I ran with IVs and medications and clotting factors and FFP and blood and reinforcing dressings and a million other things that needed to be done.

Then it got very quiet. I looked over to find that you had laid back down on the pillow. You became unresponsive except to painful stimuli. It happened that fast. I told the ER doctor that your breathing had suddenly dropped to 20 per minute and that you were no longer thrashing.
He intubated you without any response except a ET tube full of blood. An NG tube also was passed. No response. More blood.

The family came back in, this time it was your dad and your sisters. I explained what each tube was for, what we were waiting for. Your dad asked if this was bad.

I said yes. It was very serious.

More hours flew as I worked with you with your family at the bedside. By now we knew that your tox screen showed the presence of some pain medications and that your acetaminophen level was normal. Mom remembered some complaints of an upset stomach during the week.
I wish I could remember all the details and technicalities that went into my non-stop 7 hours of caring for you, but my memory is fading where the technical stuff is concerned. It has never faded where you are concerned.

At 0700, you were stable enough to go for a CT scan of your head. It looked like a pristine scan. No bleed. No swelling. Your mom joked about telling you she saw your brain. After the scan we went up to ICU where the new nurses took over and settled you into their unit. I heard them say to start Dopamine. I said good-bye to your parents and to you and returned to the ER.

I had seven-and-one-half hours of nursing care to account for when I sat down with a cup of coffee to do your chart. And I'm obsessive with my charting so it was a little after 0930 when I went back up to the ICU to give them the missing nurse's notes. I walked in just in time to see your agonal rhythm on the monitor. My heart sank. I was told they had decided to take you off the ventilator.

You were no longer breathing. I saw your heart stop beating. Your father fell into my arms, sobbing. Your mother cried and hugged me and thanked me. I touched your hand and said good-bye and held myself together as best I could.

Until I got to the ER, where I made it into the bathroom, shut the door. The sobs came. Hard. I leaned up against the cold tile wall in a fetal position sobbing so hard I ached. Half-an-hour I did that. I pulled myself together enough to get in the car where it started again. All I could say was "Oh God, Melissa, I'm so sorry" over and over. I couldn't come back to work the next night. Or the next night.

They said you died of an overdose of acetaminophen. Only you know the whole story.

I'm so sorry Melissa. I'm so sorry we couldn't save you. I will always wonder if there was something more I could have done. Something I missed. Something that would have stopped that cascade of death that overpowered us all that night. Sometimes, as we tug-of-war with God over a patient he lets us win. He won that night and Heaven is richer for it. We are the poorer.

I think of you often, but mostly this time of year. I wonder how your family is doing, I think of how old you would be now. And every time my family bows their head to say grace over Thanksgiving dinner, I say a prayer for you and your family. Put in a good word for us, too, okay?

Thanks for visiting me again this year, Melissa.
See you next November.

Your Nurse,
Kim

Happy Birthday!

As the wife of a Marine who served in the early 1970's, I'd like to take this time to wish the United States Marine Corps a happy 230th birthday. Semper Fi!

I'd Like To Thank the Academy.....

I'm happier than Linus when his blanket comes out of the dryer! Seriously! Emergiblog is now the "October Nurse Blog of the Month" over at Mediblogopathy! My heartfelt thanks to everyone who voted. I hope you stayed and checked out the site if that was your first visit. Hypnokitten has linkage to about a bazillion nurse blogs, with about 20 more or so set to be added. I have just scratched the surface. I intend to check out every one of them!



I am now the proud owner of the entire "Cherry Ames" nurse series AND a pristine "Cherry Ames" nursing game! And no, I did not decide to mortgage the house and attack eBay!

These were a gift from a colleague, the one who is going for her PhD in nursing! She is always afraid that she sounds like a boring academic, but she has the most amazing storehouse of nursing knowledge; history, nursing models, nursing theories. And she makes it interesting. She's the only (near)PhD in nursing I've ever met/seen who is young, dynamic and almost makes me want to go get my BSN. She would make an amazing nursing instructor.


If this photo does not depict how it feels after running for an entire night shift, then nothing does. Obviously, Tweety is a night nurse. I'd call the photo, "0800: Good Night Nurse" .
It was too cute to pass up.





My Lego Gal has received a makeover! Hey, if Emergiblog can win October Nurse Blog of the Month, I can get a Lego makeover!
A girl's gotta splurge now and then...

To Boldly Blog Where No Man Has Blogged Before....Grand Rounds

This week in Grand Rounds, we are boldly posting where no man has posted before. Join Rita over at MSSP Nexus Blog as she surrepticiously gives Star Trek's Dr. McCoy a Grand Rounds tour of the medical blogosphere. I am happy to note that Emergiblog was beamed in this week!

Rita was interviewed by Kent Bottles over at soundpractice.net. last week. I found it informative as I had very little knowledge of physician credentialing. She also discusses the medical blogosphere, blogging in general and even mentions Emergiblog! Thanks Rita!! Wow!

So, beam yourself into your favorite computer spot and settle in for a great week of Grand Rounds submissions.

Live Long and Prosper!

Weekend Hazards

I had a brief blogging holiday this weekend.

Just got back from 48 hours in South Bend, Indiana where I had the opportunity to see the Fighting Irish beat the Tennessee Volunteers in the Notre Dame stadium.

Apparently this little cutie doll is available through the Danbury Mint. I'll have to email subtle Christmas hints to all my family....

The fall colors are gorgeous in the Midwest. I need to go to the ocean this week to remind myself why I am here and not there.

Oh, it wasn't all fun and games you know! I suffer for my team! There are many health hazards associated with being a Notre Dame fan. Such as:

• Acute lumbar pain secondary to prolonged exposure to a wooden bench, aka my stadium seat. Not that I sat in it for any length of time....oh, no, I also have:

• Acute bilateral quadriceps quivering secondary to repositioning to a standing position every time Notre Dame was, how shall I say it...on the field?

• Laryngitis secondary to prolonged use of vocal cords to express my true feelings of the referees.

• Acute hearing loss secondary to the woman behind me expressing her true feelings of the referees.

• Acute ocular strain secondary to the Tennessee shade of orange - it looked like orange sherbet.

• Anxiety, acute, secondary to potential for intimate relations with the guy on my left as we had to sit very close. Luckily hubby was on the right so I squished a millimeter in his direction.

• Hypercholesterolemia secondary to multiple ingestions of hot dogs and bratwursts.

• Increased cardiac workload secondary to doing more walking in two days than I have done in two years.
  

• Acute motion sickness secondary to flight turbulence. Let us say a prayer of supplication to the patron saint of Dramamine.

• Jet lag manifested by the sensation of being hit by a truck, somewhat offset by the Bloody Mary the nice Southwest flight attendant served enroute home.

Add to all this the near-syncopal episode when I discovered my son keeps his dorm room clean and the mania experienced when shopping in the Notre Dame bookstore, you can surely understand that cheering for Notre Dame football can have serious health consequences.

In keeping with the emergency department focus of this blog, let it be noted that there were two South Bend ambulances on standby at the stadium.

Go Irish!

Paramedics, Ya Gotta Love 'Em!

Well, the doctor might not be calling on houses these days, but a quick phone call can get health care right to your door in minutes.

Let's hear it for the paramedics.

Who else can stop an allergic reaction in its tracks, splint the leg that is pointing in three directions, put in the IV to start the Morphine - while in a moving vehicle, hydrate the vomiting, control the bleeding, sweeten the hypoglycemic, medicate the seizing, catch the newborn, reassure the worried, C-spine the neck, begin treatments for the asthmatic, intubate the apnec and defibrillate the defibrillating...

....all before they get to the hospital back door.

They deal with dangerous neighborhoods, hostile environments, and hysterical family members in uncontrolled working conditions. People comment on how stressful my job as an ER nurse must be. My job as an ER nurse is nothing compared to what the medics deal with out in the field.

I've worked in ERs where the medics were treated with respect and camaraderie as part of our team and I've worked in ERs where they can barely get out two sentences before undergoing an interrogation from the staff that would make Gitmo look like a cake walk.

It goes without saying that the ERs that treat the paramedics as team members are the better departments.

I've heard horror stories of (and seen in action) nurses treating medics badly, and I don't understand where the animosity comes from. By the time the medics deliver the patients to the ER, they have a history, first set of vitals, an IV, the initial medications - all of these things are not only beneficial to the patient but it makes the ER intake much easier. They're just doing their job; nothing there deserves a hostile response.

Sometimes I see patients who should have called 911 but decided against it. Patients with acute MIs, asthmatics, possible CVAs. They are usually worried about causing a fuss, or they are in denial about how severe their condition may be. Often the family will want to call but are afraid of making the patient angry. They are surprised when I mention that their pain or their shortness of breath could have been addressed much faster en route via ambulance.

Utilizing the EMS system is like having the emergency department make a house call - life saving treatment meets you at the front door....

....delivered by friendly, competent, caring professionals.

Here's a tip o' the hat, a raise of a glass and a big "thank you" to all the paramedics. You're the best!

Do Your Patriotic Duty and VOTE...for Emergiblog!

Oh wow! I actually made the list of nominees for Nurse Blogger of the Month over at Mediblogopathy!

I would love it if you checked out the contest and voted for Emergiblog!

The great thing is that in checking out the other blogs, I've found a few I didn't even know existed! I suspect that the links in the Blog Roll Call will be expanding in the next few days!

Thanks for checking out Emergiblog! What can I say, but NURSES ROCK!

Sister, Can You Spare Some Advice?

Oh yeah. We know 'em. Hopefully we know more than one!
But don't think you're gonna find out who it is by calling the emergency department!

We don't give advice over the phone.

The secretary has informed you that we don't have an advice nurse in the department. They have told you that we are not allowed to give advice over the phone. They may have even mentioned that the unit was very busy and no nurse was available.

But you insist on speaking to a nurse. And, after all, "Customer Service" is our middle name and so you are asked to wait and are placed on hold.

A person calls an emergency room for advice for many reasons:

• They are injured and are from out-of-town.

• Their doctors never returned their call.

• They aren't sure if they are sick enough to require a visit.

• Their relative is very ill and they are worried.

• They have a question about a medication.

They usually want help with one or more of three symptoms:

• Pain

• Fever

• Vomiting

I can't give advice on any of them.

But I don't mind taking the calls because even though I can't give advice, I can listen

I can also ask questions to get the gist of how severe an illness may be. I tell callers that while I can't actually give advice I'd be happy to listen and perhaps direct them to someone who can help.

• I can tell them:

• That their regular doctor has someone on call 24 hours a day and that they can call the doctor even though it is the middle of the night.
  

• I once had a caller who was adamant that they could not get through to the answering service after trying for hours. I knew we were getting through okay, so I called the answering service and had them call the patient.

• Hey Docs! Call your patients. I often hear that a message has been left for you, but they never heard back.
  

• If it is a pediatric patient, there is a local pediatric advice line open 24 hours.

• Any questions on medicine I can refer to the local 24-hour pharmacy.

• I let them know that while I can't make the decision of whether or not to be seen, we are open 24/7 and are happy to see them should they decide to utilize the ER (which usually earns me a dirty look from the ER doc on duty...)
  

• I can tell them to hang up and dial 911 immediately.

Every now and then, the call is a definite life-threatening emergency. It's because of those rare times that I don't mind taking an "advice call". First of all, I've learned how to "give advice" without really "giving advice". All the patient really wants is someone who will hear and validate their concerns, which can all be done by listening and letting them know that we are there should they need to come in.

It's funny. All of the above can be done, and in my facility are usually done by our unit clerks whenever possible.

But sometimes, it's just got to be the nurse.

Back in the Old Days....

Grand Rounds 2.06 is up over at Kidney Notes
this week and I'm going to be spending a good part of tomorrow morning with a cup of coffee reading the posts. Looks like a fantastic group of topics again this week. Check out the crocheted GI tract (I'm serious!).

If you are old enough to remember the people in this photo, well.....you're old. Is there anyone who didn't watch "General Hospital" at one point or another? I'm not sure who this hapless student nurse in the ugly blue cap is, but the guy on the right is "Steve Hardy, MD", CEO of the hospital and on duty in the emergency department 24 hours a day, seven days a week. He also did surgery on a few occasions and was the first TV doc I knew who defibrillated a patient in asystole waaaaaay back when I first knew what that meant. The nurse on the right is "Jesse".
Never knew her last name. Head nurse of the ER and this photo is the only time she was ever caught smiling. I'm so old that I remember when old-lady-nurse "Lucille" was an ER nurse that constantly picked on "Student Nurse McGillis" who obviously never rotated to any other department in the hospital but the ER. Probably graduated in the hallway. I used to pray that I would never have to work with a nurse like Lucille and thought that all nursing instructors were there to make you feel like a piece of dirt. Luckily, my real-life experience was not like that; I felt like a piece of lint in nursing school.

That reminds me of the time during the last quarter of our last year of school (when "Grease" was the word and "Star Wars" was new...) a bunch of us decided to play "hooky" from clinicals on this particular Thursday and go down to Santa Cruz for the day.. Never mind that most of us were from the same clinical group, we all "caught a bug" at the same time and called in sick. Had a great day, but I got so badly sunburned I made a lobster look like an albino. The next morning I was in so much pain I couldn't even put a bra on (trust me, no one would have noticed) and I walked like Lucy Ricardo in the episode where she fell asleep in the sun and had to wear the scratchy designer suit in the fashion show. Anyway, there was no way I could miss another clinical so in I waddled. My instructor (Claudia, bless her heart), with a barely straight face, asked me if my "flu" was better. Of course, we hadn't fooled her for a minute. There were no repercussions; she probably figured I was suffering enough.

The next rotation nearly caused me to quit nursing all together. We were rotating through intensive care and all of a sudden I went into panic mode. I realized I had no clue what I was doing. I thought I was going to kill someone in my ignorance. The fear came out of nowhere and was as intense as anything I've ever felt in my life. These patients were sick and I was just a stupid, clueless 20-year-old who was going to be let loose on the public in six weeks.
At least that is what was going through my mind at the time. Then one morning I was assigned a patient on a ventilator. I walked into the room, took one look at this prostrate human being with tubes in every orifice and in orifices made just for the tubes and I snapped. I got numb and said to myself, "I'm quitting. Now. I don't want any part of this. Ever." I turned around, told the staff nurse and my instructor that I was ill, picked up my stuff and walked out of the hospital.

My plan was to drive by the college and turn in my resignation/drop my classes right then. Just thinking about dropping out took about five tons of pressure off my back. Instead, I felt so spent that I went home first, I told my mom what my plans were. By the way, it never occurred to me to tell my instructor how I was feeling.

Thank God for moms. She went ballistic. Told me I had only six weeks to go and was crazy to drop out now and if I wanted to be a secretary later that was fine but at least get the degree and how could I possibly even remotely think of wasting all that time and effort just now before it was time to graduate, etc, etc. And for pete's sake don't make any decisions until after the weekend when you've thought about it!

I went back to lecture that Monday, but only to do what my mom suggested: to finish the degree. Then a miracle happened. The next Thursday my instructor met me to give me my assignment, which was to observe the ICU nurse as she cared for her patient. I didn't have to do any procedures unless I wanted to. And she paired me up with an absolute angel of a staff nurse. By the end of the day I was measuring MAPs and suctioning an ET tube and understanding arterial lines and hanging IVs.

That instructors name was Pat and she knew exactly what was going on. I never told Pat that I was scared or anxious or ready to quit. I never told anyone but my mom. Pat had sensed what I needed and put me right where I needed to be with the exact person I needed to be with.

I graduated, obviously! And after a three month stint on a med-surg unit, guess where I ended up wanting to work. Yep, critical care! Go figure.....

(Blogging is a funny thing. I had no idea that I would end up with this post when I started.
Must be because I am reading lots of blogs of nursing students and they are bringing back memories I had long forgotten. Back to ER musings tomorrow....)