Olfactory Omniscience

Oh my god! It's the Disembodied Head Nurse!

She can wither you with one glance.

She is the bane of every staff nurse, intern and doctor who has the audacity to cross the threshold of her ward.

Years of knowledge will flee your brain with the raise of her eyebrow.

She's what you dream about when you've worked three double shifts and lived on coffee for two days.

It seems Pontiac thought she would be an appropriate commercial mascot.

What on earth does a big nurse head have to do with cars?

hhhhhhhhhhhhh

There is nothing quite like the ambiance of a dirty utility room.

Small. Claustrophobic. Windowless.

And now, thanks to JACHO, the door must be closed and you need a code to get in.

Enter at your own risk.

A nauseating bouquet of a myriad of body fluids in various stages of decomposition arises from the biohazard box in the corner whose lid lay slightly off-center. Three commodes line the opposite wall; one of them emits the subtle essence of the GI bleed who was its last customer. A sharp hint of ammonia breaks through the olfactory cacaphony; urine soaked test strips are lined up on paper towels in military formation to the left of the sink. Deflated foley bags and used suction canisters rest in the garbage. The linen bag adds the contributions of various excretorily challenged patients to the odiforous symphony.

And through it all is the pungent smell of dirty instruments soaking in Cidex.

I have an irrational fear of being in the dirty utility room when the big earthquake hits and not being able to get out.

I need a Xanax just to get through the two minute wait for the urine dipstick results.

hhhhhhhhhhhhh

Have you ever experiencedf GIBOHS?

That's GI Bleed Olfactory Hallucination Syndrome?

You come home from a long shift. You empty your pockets and deposit your scrubs in the laundry room downstairs, along with your nursing shoes. You take the time to luxuriate in a hot bubble bath as the tension of the day lifts off your shoulders. You put on your thick, flannel pajamas, grab a hot cup of herbal tea and curl up on the couch with a good novel.

And then it hits.

The fleeting but unmistakable smell of a GI Bleed.

You haven't been near a GI bleed since you admitted your patient at 1630.

The precise mechanism for GIBOHS is unknown. Sufferers have been known to say "Blech!" out loud in the middle of the night and compulsively bleach all their scrubs until the fabric frays. They believe that GI "odor" molecules have been fused with their hairshafts at the genetic-molecular level.

Should a fellow colleague experience GIBOHS, be supportive. Tell him you believe that he believes he smells what he smells. And then get as far away as possible.

It may be contagious.

Gather 'Round For Grand Rounds!

My goodness, such sour faces in this class!

They must be waiting for their grades...

Either that or they're depressed about those ugly uniforms.

They should be paying a visit to this week's Grand Rounds over at The Health Care Blog. Matthew has an unbelievable round-up of the medical blogosphere of 2005.

Go check out Grand Rounds - I guarantee you'll be happier than these students!

Holiday Wishes

Cherry Ames takes time during her busy holiday shift to wheel her patient to see the hospital tree...the other nurse looks like she is going to throw a pitch right to his head!

From all of us here at Emergiblog
(actually, it's just me, but I liked the sound of that)have a very Merry Christmas and a joyful, blog-filled New Year!

'Tis The Season For Miracles

I knew there was a reason I didn't want to be a home health nurse.

I flunked Bathtub Fundamentals.

I was unable to differentiate between soap scum and an acute exacerbation of mold.

The primordial ooze probably started in my bathroom.

I find it amazing that scrubbing bathrooms was considered a nursing function.

I don't even like scrubbing patients!

hhhhhhhhhhhh

The Christmas season is full of miraculous stories.

The Emergency Department is full of miraculous stories, too. I've been witness to a few of them.

I have witnessed the birth of a child from a woman who was not pregnant and had never been sexually active.

I have seen the miraculous appearance of track marks on the arms of a person who has never even thought of using drugs and has no idea how she got that awful abcess/cellulitis.

I'll never forget the teenager whose family found him slumped over a toilet seat one holiday afternoon. They would have thought is was the flu except that he "just wasn't himself". He never drank. His ETOH level was .23. Truly a miracle.

A patients experiences a miraculous loss of all friends, relatives, and acquaintances when it comes time to leave the ER. A taxi voucher is their only way home and they can't call the person who brought them to the ER because they work!

And let us not forget the miraculous methamphetamine presence in the urine tox of those who never use meth.

I've had patients have a miraculous onset of destitution when it comes to filling a prescription. Or maybe it's a miraculous windfall that allowed them to purchase the alcohol and cigarettes in their paper bag.

It's not that I'm cynical this holiday season, I'm really the least cynical person I know.

But....will someone please tell me if I have "stupid" stamped on my forehead?

We're Talkin' Grand Rounds Here

Well don't just talk about Grand Rounds!

Go read them!

This week's "cocktail party" is over at Medpundit where the company is great and the topics are numerous.

And in celebration of this Christmas season, I will be replacing my usual cup of coffee with some holiday eggnog!

Care to join me? Grab a glass and meet me over at Medpundit's place!

A Nursing Study: Chocolate Selection in the Emergency Department

It's that time of year!

The breakroom table groans under the myriad of edible gifts sent in to the ER by the local doctors, the majority of them chocolate!

Whitman's is the best box of chocolates because it has a map on the lid of what is in each section. No guessing. Nothing worse than biting into a "carmel" only to find out it's a "creme". Blech.



Of course, I'd still eat the chocolate around the creme.

Nurses have ingenious ways of figuring out what is inside a piece of candy. One nurse I worked with took the surgical route; I once discovered a full box of See's candy with every piece perfectly sawed in half. Another colleague approached the problem laparoscopically; she took a 14 gauge needle and poked a hole in the bottom of each piece.

As a professional nurse, I believe in using the nursing process when choosing my selection:

• Assessment
  
• Shape - round, square, rectangular
• Firmness
  
• feel through the paper cup to maintain sterility
• soft, hard, slight give
• Texture - bumpy or smooth top
• Swirly on top - big or small
• Color - dark or milk chocolate

• Plan
• Eat now or later
• Solitary or multiple bites
• Place selections in mailbox so no one else gets them
• Consider milk as adjunct

• Intervention
• Eat a small bite as a test dose
• Take a second bite to confirm diagnosis

• Evaluation
• Satisfactory: consume entire specimen
• Unsatisfactory: commence ejection into garbage and begin process with another specimen

I have pretty good success with this system.

I will say that, professionally speaking, nothing good ever comes out of a round, smooth, soft dark chocolate piece of candy that doesn't have a swirly on the top. However.... I have been known to consume them when faced with a shortage of cocoa-based candy.

I don't believe I'll be facing that situation for a few more weeks, at least.

For Your Information

Thanks to The Medical Network Blog, I linked to Dr. Lei at Genetics and Public Health. She encourages medical/health bloggers to answer the following questions recommended by The National Center for Complementary and Alternative Medicine, part of the U.S. National Institutes of Health. The purpose of the questions is to give readers of medical/health related blogs the ability to evaluate what they are reading.

The responses for Emergiblog are as follows:

1. Who runs this site?

Emergiblog is run by Kim, a registered nurse with an ADN degree and (currently) 27 years experience who has spent the last 14 years working in emergency departments.

2. Who pays for the site?

The site is provided for free by blogger.com. It costs me nothing to maintain. I choose not to place advertising on the site for this reason.

3. What is the purpose of the site?

The purpose of Emergiblog is to give me a forum to discuss my experiences as a nurse in the emergency department and other topics related to nursing.

4. Where does the information come from?

It comes from my 27 years of nursing experience, the majority of my posting is anecdotal. All patients, staff and hospitals are either composites or have identifying information concealed or altered to allow for patient confidentiality. When applicable, links to information sources are given.

5. What is the basis of the information?

Please refer to question number four.

6. How is the information selected?

The postings are based on what I want to write about and what I feel will be interesting to read.

7. How current is the information?

It could be as current as my last shift or as long ago as my time in nursing school.

8. How does the site choose links to other sites?

My links are based solely on sites I have read and found interesting.

9. What information about you does the site collect, and why?

The site collects no information about anyone other than what is recorded on the site meters.
That information is used just for my own personal interest in seeing where my readers come from .

10. How does the site manage interactions with visitors?

Hopefully they comment and I comment back! I use word verification to stop spammers. All opinions are welcome and only posts containing profanity would be removed.

UPDATE: After approximately 5 bazillion people read this post, I decided it would be prudent to not have my last name on the blog, so I have removed it. Now I'll be anonymous to the next 5 bazillion!

It's A Grand Tradition at Grand Rounds

Boy, that guy in the middle looks really enthused, eh?

But you will be enthused when you go to visit Grand Rounds, this week hosted by Dr. Derek Lowe over at In the Pipeline

Dr. Derek makes organic chemistry interesting and is the go-to man if you are interested in the science behind drug manufacturing.

Keep the tradition alive and check out Grand Rounds!

'Till Her Daddy Takes The Beamer Away

This chick looks like a gangster's moll.

Fresh? As opposed to what...stale?

No innuendos here folks, move along.....

What a stupid question. "No, I prefer to dig for my cigarettes in the back of the catch-all drawer on the end table where we keep the latest TV Guide, why do you ask?"


Does tobacco go stale? How can you tell?

I'm no smoker, but it seems to me that if you have to worry about your cigarettes getting stale, you don't have much of a problem.

hhhhhhhhhhhhhhhhhh

In all my years as a nurse, I have never seen an auto accident happen or come across one where there wasn't anyone on scene already. Until last night.

It's after 0100. Work was slow; got out early. I'm sitting at a stoplight, singing along with Kelly Clarkson and minding my own business. A jeep is in the lane next to me, waiting for the red to change. Then...

BAM! The jeep goes flying 20 feet into the intersection. Twenty feet! Hey! We still have a red! But wait....there's a car next to me....it's a cherry red BMW and the driver is sitting behind an inflated airbag.

I was dialing 911 within 10 seconds of the initial sound. Thank god there was virtually no traffic. I circled around in a parking lot and brought my car up behind the BMW and turned on my flashers, still on the phone with 911 as I went to check on the occupants.

Scene is safe. No traffic, no gasoline smell, no smoke, only steam from what was the front of the BMW. Two drivers, no occupants. Jeep driver is out of car, stunned, ambulatory and frantically looking for her cell phone. BMW driver is sitting in the driver's seat with her hands on the steering wheel staring straight ahead until I open her door and ask if she is okay. Her first comment was "what happened"? Moves all extremities and denies pain. 911 operator says PD is on the way and we hang up.

It seemed like it took forever for PD to show up, but I know it had to have only been a few minutes. I lent my cell phone to the jeep driver and walked back and forth between the vehicles to make sure they were still okay.

The BMW driver seemed in shock, with a virtually flat affect the entire time. She didn't want to use the cellphone. Said her father was going to kill her. It was his car. Brand new.

For a reason that was not apparent to anyone on scene, this woman drives at full speed into the back of a car stopped at a red light. Dead-on straight hit. There were two empty lanes to her left, she could have swerved if she needed to. No brakes, no squealing tires....just the sick sound of the impact. Had there been any cross traffic, the jeep would have either broadsided a car or been broadsided by one.

If I had wanted that kind of excitement I could have stayed at work. As it was, I gave the PD my information as I was essentially an eyewitness. Don't think I'll be needed, it was pretty cut-and-dried as to what happened.

The odd thing? When I got home I had both neck and lower back pain, as though I had gotten rear-ended.

Now that's taking empathy a little too far....

And The Hits Just Keep On Comin'!

Sometime today Site Counter for Emergiblog will click over to 10,000!

The good news is that blogging is so much fun; thanks to all who have visited and commented!

The bad news is I will probably suffer an acute case of writer's block just thinking about 10,000 hits!

EneMan Update

I am now the proud owner of an official EneMan beanie baby, soon to sit in my ER as official mascot.

I am happy to report that Fleet Pharmaceuticals sent me an EneMan calendar for 2006. It's a hoot!


I have bid on an EneMan clock on ebay.

I'm hooked on this character.

Somebody help me.....

Respectfully Submitted

Someone tell this poor child she doesn't have to go into nursing!

She probably got the medical kit as a gift and she has to play with it while the relatives are there so they don't think she is ungrateful.

The minute they left the house that Christmas night, she went back to her Tinker Toys and Lincoln Logs.

And eventually became an architect.

hhhhhhhhhhhhhhhhhh

Dear Doctor,

As an RN, I have a deep respect for what you have to go through to be a part of the medical profession and the responsibilities you shoulder once you get there.

As an RN in the emergency department, I must deal with your misunderstanding of how the department and staff are to be utilized, and how this impacts patient care.

I respectfully submit these requests:

• Please don't write STAT unless you mean it.
  

• We take that literally in the ER. Don't be like the surgeon who had me running for an hour doing STAT medications, labs and paperwork for a patient whose surgery.......was the next day.
  

• Having an ER nurse running STAT for things that can be done on the med/surg floor is a blatant misuse of the ER staff.

• Please do your work-ups on the floor.

• We know things get done faster in the emergency department. The fact that you appreciate that is a testament to our efficiency. We are fast because facilitating patient-flow is an integral ER function. By holding a patient there for your convenience, you are interfering with that function.
  

• Once the ER doctor has seen the patient and made a diagnosis, they can admit the patient with holding orders and the patient can be seen upstairs.To keep a patient tying up an emergency department bed solely because it is easier for the physician is actually
  

• Unfair to the patient whose admission is delayed

• A delay of emergency resources to another patient.

• Please don't call and give me a list of orders for an incoming patient and then tell me the ER doctor is to evaluate the patient.

• I am no doctor, but this seems like a breach of professional courtesy. I have never worked with an ER doctor who appreciated this.
  

• If you wish to manage the care of the patient, please consider

• Seeing the patient yourself

• Talking to the ER doctor directly.
  

• Please admit your patients directly to the hospital.
  

• With all due respect, the ER is not an office adjunct.
  

• There is no need to utilize the ER when the diagnosis has already been made.
  

• It is a misuse of the ER and unfair to the patient, both financially and personally, to have to endure a needless emergency department stay.

• Please know that when you tell a patient to meet you in the emergency department, a room may not be readily available.
  

• We will do the best we can to open a room for you as soon as we can.
  

• Standing in the nurse's station acting frustrated and impatient does not help the situation, nor clear a room any faster.

• Calling ahead to alert the ER that you will be seeing an incoming patient can help the staff plan for your needs and most likely have an exam area open and waiting.
  

I know the ER staff enjoys caring for your patients and working with you to make sure they get the best care possible. It is easier to do both when the ER is utilized appropriately.

Thanks for reading.

Kim, RN

Thursday, December 08, 2005

Requiem For An Icon

John was my favorite.

February, '64. First grade. Ed Sullivan.

Paul was cute, but John was smart.

I followed his antics, his music and his opinions. Some ridiculous, some classic. Usually the polar opposite of how I was being raised.

He fascinated me.

So did Yoko. I may have been the only one who saw what John saw in her back then. You couldn't have one without the other. I wanted to climb up that white ladder and see "Yes" on the ceiling.

It was easy to be idealistic, then.

Today I won't imagine that there is no heaven and I can't imagine there is no hell. I have something to kill and die for, the protection of my country - I won't imagine the alternative.

I grew up.

On December 8, 2000 I walked the floor with my five-month-old daughter and cried.

The photo in the Life magazine above is from what John called his "fat-Elvis" period around the time that "Help!" was shot. Not a happy time in his life, apparently, but I love that picture.

I wonder what John would have had to say about all that is going on today.

We gave peace a chance. The other side didn't get the memo.

Tuesday, December 06, 2005

Grand Rounds Are In Session!

Shhhh!!!

Some of us are trying to read this week's Grand Rounds
over in The Examining Room of Dr. Charles!

I believe this is the second time that Dr. Charles has hosted the medical blogosphere at his site and he has pulled together a great set of topics; be sure to check out the x-ray that should never have been taken. I can't read an xray to save my life, but that one gave me a bit of tachycardia.

Believe me, if I can spot your problem on xray, you have a major problem!

Monday, December 05, 2005

Do You Hear What I Hear?

What is the $64 Question?

Who is the poor woman that gave birth to twins who were obviously born 6-months-old?

Who is that psychotic-looking guy? If he's the father of the twins, someone better call child protective services. If he's not, someone better call security.

Is that why the nurse is giving that "get-me-out-of-here" look to her co-workers across the room?

I don't want to know the two perfect answers.

I do want to know what this has got to do with pens!

hhhhhhhhhhhhhhhhhh

Little pitchers have big ears.

So do family members.

If the ear size of the average family member of an ER patient were proportionate to their ability to hear every little iota of conversation in the department, they would have appendages the size of Dumbo.

Trouble is, they don't always hear what is actually said. For example:

Doctor says: this patient suffered a head injury secondary to a mechanical fall. He is drunk.
Family hears: He's a drunk.

We can't help if a family misinterprets what they hear, but we can try to make sure they don't hear what they can misinterpret.

Sometimes it's pretty obvious that they have overheard exactly what was said.

I have occasionally cringed over the years as I have received report at the nurse's station. Obese patients described as 'big, fat mama". Overly dramatic presentations described as "up for an Academy Award". Elderly females as "little old lady". Patients with migraines noted to be "full of bulls***". Adjectives like manipulative, stupid, obnoxious, ridiculous....all at the nurse's station, sometimes only a few feet away from the patient. At normal conversation levels.

Sure, we may use sick humor or sarcastic comments when talking amongst ourselves, but we sometimes forget we don't speak in a vacuum.

Remember "Get Smart"? We talk about patients as if we think a Plexiglas "Cone of Silence" drops over the station as we speak.

If only it did.

It isn't just derogatory remarks about the patients that the family hears. They listen to how we treat each other.

I recently took care of a patient in a room so close to the nurse's station that I could have carried on a full conversation with the patient, from the station, in a whisper. This patient was rather difficult and had a family who was, well, of the high maintainence variety. The doctor's desk is about 10 feet outside the door of that room and I knew the family was listening to every word I said because they would go totally silent when they heard me. I approached the doc to pass along a patient request. As is my custom, when in the presence (or hearing) of patients I refer to the ER doctor by the title "Doctor", as in "Dr. Smith".

Call me old-fashioned.

In this case, the name could easily have been Dr. Thomas Twit, because the first thing he did was snap at me for not using his first name. And I do mean snap. Loudly. The family heard every word (and will probably forever refer to this man as "Tommie").

I eventually informed this scion of professionalism that snapping at a nurse, especially one old enough to be his....well, much older sister demonstrated a lack of professional respect, especially within the hearing of a patient and family.

We need to help each other. If I'm talking too loud or begin to speak inappropriately I expect my co-workers to let me know. If my colleagues are doing the same, I will let them know it.

Being sick in an ER is bad enough without hearing yourself or a loved one spoken of in a derogatory fashion.

Oh, and if any of you are too young to remember "Get Smart".....please don't tell me, I'll just get depressed.

Thank you.

Friday, December 02, 2005

Smells Like Team Spirit

The 1963 Corvette Stingray!

I guess getting ogled by a bunch of student nurses was a selling point back then. Hard to tell if they are checking out the car or the grey-haired stud driving it.

They certainly could not afford this car on a '63 nurse's salary. Apparently they couldn't afford any car because they are standing at the bus stop.

Don't they look a little old for student nurses, circa 1963?

In '63 a nurse might want to catch a guy who drove a car like that. In '05, a nurse can buy the car for herself and not worry about a guy who drives a car like that. Then again....

The nurse might be the guy who drives a car like that!

Oh the times, they've been a-changin'.....

hhhhhhhhhhhhhhhhhh

ER staff is often referred to as a "team". I say you can tell a person's best sport by how they conduct their nursing practice at work. Here's a description of the various "teams" and how they play.

• Cross-country
  
• Each person "runs" toward the "finish line", or the end of the shift. The members of the team work independently. You rarely find them sitting and if you do, they are charting. Interaction between team members is minimal, often consisting of helping with a task or a quick high-five as they run. The ER doc (coach) gives mini-goals (new orders) along the route. This team is made up of self-starters. To them ER is an endurance sport.
  

• Football
• All the team members tackle every task. The charge nurse (center) hikes the ball to the quarterback (ER doc) who passes the orders to the receivers (staff nurses) who then try to run it through the opposition (slow labs, lost specimens, broken equipment, infiltrated IVs, etc) and make a touchdown (patient discharge). Because the entire offense is on the field at once, it is often difficult to follow who has the ball or the ultimate responsibility for any fumbles. The quarterback is often sacked by the sheer number of plays they must call in one shift.

• Baseball
• The team sits in the dugout(nursing station), where they sit until a ball is hit in their direction (a patient in their assigned room), at which point they leave the dugout and enter the field. Once they have run the bases (discharged their patient), they return to the dugout. Every now and then the ER doc (manager) enters the dugout to provide motivation or chew out the team, prn. The triage nurse is the pitcher and the charge nurse is at bat. Spitting is discouraged, as is crotch-adjusting in patient care areas.

• Bowling
• The team members sit around the scoring table (nurses station) drinking coffee and socializing. Some read the daily newspaper or keep abreast of what inquiring minds want to know while they wait for the ER doctor to set up the pins (write an order). At this point, one team member will rise from a chair, grab the ball (pick up the chart) and approach the line (read the order), and send the ball down the lane (carry out the order). If faced with a difficult split, they will ask a colleague to send the ball down the second time while they return to the chair area. Bowlers rarely break a sweat. The triage nurse provides a constant supply of pins for the ER doctor to set up. The charge nurse keeps score and wonders why she didn't join cross country.

• Tennis
• This sport is played in small ERs at night when there are only two nurses on duty. They hit the ball back and forth (split the patients) so that they have uninterrupted time to complete their crochet, letter-writing, book,d DVD or memory book construction. The ER doc (coach) makes an occasional appearance on the court, only to be shooed back to his office by the players. ER docs love this team.

I've also seen ERs that play "dodgeball" or "dogpile" and a few that made the WWF look like a Pillsbury bake-off.

Sometimes the ER docs accuse me of playing "Keep Away" with the charts. Okay, so I tend to hoard my booty in the corner. (That's "booty" as in "treasure", not "boo-tay" as in derriere).

I suppose there are as many styles of nursing as there are nurses.

As for me, give me a shift staffed with cross country types any day.

It's A Bird! It's A Plane! It's....

I have now seen everything.

This is EneMan and he is the mascot for Fleet enemas.

I stumbled across him while surfing over at Respectful Insolence, where Orac has put up the calendar pictures from 2005.

Yes, EneMan has his own calendar. Last year he traveled the world, this year he travels through time.

Given the propensity for enema orders in my ER, I find this extremely funny.

I haven't stopped giggling for half an hour.

Someone actually dresses up and walks around as "Eneman". And you thought you had job issues.

I wonder if someone has to dress up as a rectum...

UPDATE: I JUST ORDERED THIS GUY OFF OF EBAY. I WILL BE THE PROUD OWNER OF ENEMAN!