What's In YOUR Pocket?

Ladies, do you love your undies? Is your bra healthy for your budget?
Are you glad you can stop ironing your unmentionables? I have no doubt that this ad would engender massive amounts of protest if attempted today. Of course, the bra would be an underwire push-up, the bottom would be a thong and the model would be Shakira in a nurse's cap with a navy blue cape. Of course, they can't be sexist so there would be a companion ad with Justin Timberlake extolling the virtues of STAT-n'-Strap, the jock strap made for the guy who's MAN enough to wear the title, NURSE!

Ahem....Aside from underwear, there is more to dressing for work than just putting on the uniform. What about all the adjuncts you need to be at your peak efficiency? The tools of the trade? The building blocks of patient care? Let us discuss these various items.

• Your ID - you know, the plastic badge with your name on it in big, bold letters. Taping a photo of Catherine Zeta Jones over your photo is not allowed. I tried. It is common knowledge that ID cameras add fifty pounds. They do so!

• Your stethoscope - You will occasionally be seen to grope at your chest, wondering where it is. You get so used to wearing this that one day you forget to take it off at work and will wear it into the grocery store. You listen to your coughing child's breath sounds and go to basketball/soccer/volleyball/football practice with it dangling from your neck. You will do this. At least twice.

• In your right pocket:

• Scissors. Not those dainty little silver "bandage scissors" that fit so neatly into the little pocket organizer you will never use and couldn't cut the tip of a Barbie glove. Puh-lease! I'm talkin' big ol' trauma shears that will cut through leather. These go in your right pocket with...

• A tiny calculator. For when the doctor orders 1/748th of the dose you have on hand.

• Tape. Also in your right pocket. With a tiny fold made on the end so you don't have to pick at it, especially since they said you can't wear acrylic nails anymore and you are a chronic nail biter and can't get the tape to unroll naturally and it's such a pain and...but I digress.

• Notepad. Also known as a paper towel, upon which you have written the last set of vitals for the patient in 8A, the results of the urine dip in room 10 and the repeat pain measurement of the patient in 8B who was discharged 30 minutes ago but you haven't had time to chart it yet.

• Three quarters, a dime and two pennies that you got as change for your coffee on your way in to work.

• Two Hershey's kisses from the candy dish at the nurses' station, still wrapped but smooshy.

• In your left pocket:

• Your precious pens!

• Your wonderfully smooth writing, gel-based, royal blue Uniball writing utensils, so associated with you that, if found, they are put in your box.

• A red pen to mark orders you have completed on the doctor's order sheet.

• A black Sharpie. Because no nurse should ever be caught without a Sharpie. Their uses are too numerous to list here. Let's just say that the one time you don't have it, you will need it.
  

• Little plastic thingys that have your hospital's code system, fire system and Mission Statement written on them for easy reference. They are supposed to be on your nametag but they always fall off.

• One Hershey's Kiss. Wrapped and smooshy.

• Your Palm Pilot. Until it drops out the second time and you go put it back in your purse.
  

• On your shoes - shoe covers! Goodness only knows what you're walking around on in an Emergency department. Blech!

That just about completes the outfitting of the typical ER nurse. I didn't mention breast pockets because they are useless; bend over and everything falls out. Of the pocket. You could spread out the items by wearing cargo pants but who wants to wear those? Some of us don't need any additional bulk at the thigh area. Same for those little pouches that you wear around your waist. They're great!

If you have a body like Shakira.......

Incoming!

What a sourpuss! How'd you like your Anacin delivered by this angel of mercy! She looks like she's ready to administer that entire box per rectum. How DARE you have a headache. How DARE you make her call the doctor
after hours. You. Will. Pay.

Her textbook for Essentials of Nursing 101 must have been "The Patient as Enemy: The Nasty Nurse Model".

There are times in the Emergency department when even the most dedicated nurse can begin to feel that way. The department is full. You are holding three med/surg and two ICU patients until you can get orders/beds/nurses to move them up. You're down a nurse because of a sick call and just try to get coverage on a Saturday evening. You have 8 people on the triage list and 14 sitting in the waiting room. Every other hospital in your county is on ambulance diversion, which means you must take the ambulance traffic. Dr. Surgeon wants everything STAT for the appy and Dr. Cardio is taking someone to the cath lab. Now. Ms. Scratchy Throat wants to know how much longer it will be and Mr. Groin Itch wants to leave without being seen. Thank god you are working with Dr. Efficient in the ER, but he's yelling for the charts you haven't had time to finish. You have been running for six hours, you haven't eaten for ten and more than likely you'll be overtime because someone just called in for the night shift.

In walks Mrs. Mom with her three children, all under the age of four, all of them with fever, all of them to be seen.

You want to scream. You want to pull out your hair. You want to laugh hysterically. You want to burst into tears. You want to yell at the top of your lungs, "NO FREAKIN' WAY!"
That's when you start to think of the patient as the enemy.......

Instead, you smile, ask "How can I help you?" while you do quick visual check of all three kids, take down their names and point them to the waiting room to await triage.

Why?

• Because the patient is NOT the enemy.
• Because the worst thing you can do to a patient is make them feel stupid, awkward or wrong for showing up.
  
• Because it is not their fault that they happened to show up on your weekly "Day of Hell".
  
• Because they may not have the education/background/experience to know what they are dealing with.
  
• Because your hospital has spent beaucoup bucks advertising and promoting your facility so that people WILL come in.
• Because sighing and rolling your eyes is not professional behavior.

There are many opportunities during the patients' stay in the ER to discuss the fact that they may have had other options. A call to their doctor. An Urgent Care clinic close to where they live. An appointment the next day. I mention this when I discuss the discharge instructions.
I tell patients that, while we are always available, there are ways of accessing health care that are cheaper, easier and often more timely than waiting in an ER.

The key to coming across in a caring way in the middle of "hell-shift" is to smile and focus. Smile at the patient. Focus on them when they are talking. Don't have one foot out the door while you answer their questions. Be pleasant. Acknowledge that it is busy but that you are there for them.

It isn't easy when you are tired and frazzled. But I find that just acting this way helps me to feel that way. It makes it a lot easier to get through the shift and your patients really appreciate it.

Because no patient wants to feel like they are the enemy.

How Do They Manage to Manage?

This is a great shot from an old Wyeth ad. Looks like an early rendition of a triage nurse. She is talking to the woman who rode off with Toto in the Wizard of Oz. She could use a whopping dose of Advil because you just know she is going to have a migraine at the end of the day. I love doing triage. Some people hate it. Some of my most exhausting shifts have been in that triage chair; I would sometimes have 45-50 people cross my desk in 8 hours. Some were easy, clinical issues. The babies always took the most time as they needed weights, rectal temps and, for some crazy administrative reason, measurements of their head circumference. And that's after you have taken all seven layers off them. Then their socks. Under their booties. In the summer. With a fever. I could write an entire dissertation on the phobia of fever. But I would deal with 100 babies with fever before I would consider doing what I consider the most thankless job in nursing: being the manager of a nursing unit.

Nurse manager. Clinical Coordinator. Head Nurse. Whatever the title, it's a rough job. They must balance the needs of the nurses and the unit with the orders that come down from Administration. They take the brunt of patient complaints and angry doctors. They are expected to encourage, counsel, dicipline, teach, assess and evaluate their nurses who are taking care of the patients for whom they have the ultimate responsibility. They are expected at meetings, they are expected to hold meetings. They pass along the edicts from Administration and deal with the objections of staff, even if they agree that the change/rule/requirement is needless. They need to be open to staff and allow them to ventilate. They try to balance the personal needs of their staff to the staffing needs of the department, often having to say "no" and then absorb the fallout.

And they are often paid less than the nurses they manage.

I've had many managers over the years. Some new, some experienced. Some calm, some hotheads. Some were born to be leaders and some just went through the motions. I actually took a job because I met a manager (and a Critical Care Educator) more enthusiastic about nursing than anyone I had ever met. I had a manager who was as close to super-woman as you could get with three departments at two facilities under her control and they ran like clockwork. There have been managers in small units that would bend over backwards to accomdate every request and managers at teaching hospitals who had so many nurses you were just one of the bunch and whose attitude was "sorry, no-can-do". I had managers who I could call if the night shift got nuts and managers I only saw every other month.

To most managers I was trouble-free staff and to a few I was their worst nightmare. (Let's just say God help the manager who has to deal with a nurse going through severe, depressive burnout.) Looking back at my relationships with various managers and now from the vantage point of maturity (I think), I realize what a staff nurse needs to do to help their manager be a good manager:

• Do your work to the best of your ability. That's a given. If you are assigned a special project to help with department flow, do it without being reminded. Keep your certifications up-to-date and make sure all appropriate copies are in your file. Keep your timecard correct. Make yours one less thing she has to deal with.
  

• Keep in contact with your manager. Sometimes it's not easy if you work the off-shifts, but check in now and then to say hi. Ask how you're doing. (This is not the same as your evaluation. Your evaluation should not be the time you find out there is a problem, but often that is the only time you actually sit down with your manager). Have they noticed any areas you could improve? Don't just assume that because nothing has been said that everything is okay. Oh, and don't try to do this on the run unless your manager has an open-door policy and is always available. Make an appointment.
  

• Managers deal with problems and complaints. Constantly. From all quarters. Don't have every encounter with your manager be a complaint-a-thon. The one thing you don't want your manager thinking when they see you is "oh no.....".
  

• Of course there are appropriate times for voicing a dissenting opinion or making a complaint or asking for help with a problem. When meeting with your manager,
• Have a couple of possible solutions in mind before you go in. You will come across as a problem solver (which you are) and will not come across as, heaven forbid, whining.
• If you are reporting a problems with a doctor or staff member
• Try to handle the issue with the person involved before involving your manager. This is not always an easy thing to do, especially if you feel intimidated.
• Document the problem as best you can. It's hard for managers to get a handle on issues when they have no data.

• Finally, let your manager know that they are appreciated from time-to-time. Just a note to thank them for handling your time-card issue or for taking up Dr. Smartmouth's temper-tantrum with the appropriate department. You get the idea. Yes, it's their job, but everyone likes positive reminders that their everyday tasks are appreciated.
  

Boy, there is no way on God's Green Earth that I would take on a Head Nurse position (I like the term "Head Nurse". I'm just old fashioned, I guess). I learned early on I don't have the temperment or the ability to handle that load. But this Indian appreciates a good Chief.

So here's a tip of my nurse's cap to the women and men of nursing management who run interference so that my job is easier. Thanks.

When Chicken Soup Just Doesn't Cut It

Here's a picture from an old Curad bandage ad. Looks like the poor guy was cornered by his sister's "Nurse Club". No boys allowed unless they're patients! Reminds me of my old skills lab in school. This must be what it feels like when you first come into the ER. Moments of activity punctuated by hours of sheer boredom.

Everyone winds up in an ER one way or another, either as a patient or a visitor. I know what patients can do that makes it easier on the staff, but what can patients do to make their visit easier on themselves? Having experienced the ER from the "other side" of the siderail, I've come up with a few ideas.

Right now:

• Make a list of all your medications. How much you take and when, including vitamins, herbal preparations and over-the-counter medications. Include your allergies.
  

• Make a list of past medical problems and surgeries. Be thorough.
  

• Put this information in your wallet, so that you can hand it to the triage nurse should you need to visit the ER. It's hard to remember everything when you are ill. (Women, keep track of your last period. It's important and will be asked). Keep your list on a computer so that it is easily revised as needed.

Before you leave:

• Decide if you really need to visit the ER. Most of the time it will be obvious, other times not so clear cut. Fever? Vomiting? Diarrhea? Congestion? Migraine recurrance? Call your doctor or utilize the advice line of your clinic if available. They can give you advice over the phone that can save you the time and expense of an ER trip. Doctors, if they know you, can call in any needed prescriptions. There is always a doctor on call. Yep, even at 3:00 am. If you are concerned enough to be considering an ER visit in the middle of the night, it's worth a call. This is especially good to do for kids, who never seem to get sick during office hours! Unfortunately, ERs are not allowed to give advice over the phone. It's a legal thing. They will tell you they will be happy to care for you if you come in, but they cannot help you make that decision.

• Find someone to go with you if possible. If you are given pain medication, you won't be able to drive home. Bring one person. Try not to bring the whole family, it gets very hectic in the ER and most have strict visitation policies that would keep them sitting in the waiting room anyway.

• Wear something easy to get in and out of. The first thing you will do is get undressed, so leave the complicated stuff at home. Leave your jewelry there, too.

While you are there:

• Bring a book, magazines, your iPod, something to keep you occupied. You will be waiting, and then you will wait which will be followed by waiting. It is the nature of the department and inevitable. ERs are notorious for out-of-date reading material and the waiting room TV may be stuck on C-SPAN. Save yourself an attack of acute boredom.

• Bring a small blanket or afghan. ERs are freezing. You will be practically naked. Most ERs have blanket warmers, but those blankets don't stay warm for long and they don't hand them out in the waiting room.

• You won't be able to eat or drink until it is decided you do not have a surgical problem. You will, however, have a dry mouth. It's like your saliva evaporates on arrival, or it's a side effect of medications you will receive. You may want to bring a bottle of water to sip, but don't open it until you get the green light from the nurse.

• Make sure you have your call bell on the gurney. Don't be afraid to request what you need to make you comfortable. You aren't "bugging" the nurses, they are there to help you.

After you leave:

• Follow the discharge directions. If medications are ordered, take them as directed.
  

• Make an appointment with your doctor to follow up.
  

An ER visit is never fun, but by thinking ahead and using the suggestions above, it can be easier.

The Write Stuff

I am so past tired I can't even move, which is why this ad for K-Y jelly has me giggling. Look at the concentration with which our professional nurse applies the sterile, water soluble substance to the ice-cold metal speculum. Acknowledge the physician, who doesn't trust her to apply it without direct observation. Pity the patient, for no particular reason. Pity me, who is so far gone, this ad is the epitome of hilarity.

Why is it that when I am not working I have a thousand topics for this blog fighting for prominence in my brain, but when I am working I get writer's block? Maybe because I just finished actually writing for twelve hours.

Many, many years ago I took a class on the legal aspects of nursing. The attorney was discussing the importance of good nursing notes and mentioned that nursing notes, in a malpractice trial, would be blown up into the size of a poster for all to see. It must have struck a nerve because ever since then I chart as though it is going to be billboard size. I am a meticulous charter. To the point of being obsessive. To the point where my nurses' notes are my masterpiece and it bugs me to have anyone else write on it. I have been known to re-write a triage because even one error drives me up the wall. I'd rather pile up my charts so that I can sit and chart without interruption rather than chart "on the fly". I must have just right pen. A gel pen, with a smooth, even, medium-point flow. No scratchy feel. The perfect weight in my hand. And blue ink. I must write in blue. I will not work for a place that requires black. With the perfect pen I can put to paper the drama that is the life of each patient, recording for posterity their encounter with the unexpected that is the emergency room visit. I AM SHAKESPEARE.


Somebody help me.....


Actually, I reallly do enjoy charting. I must be a frustrated novelist. Either that or I get a strange rush from filling in boxes and blank lines on paper.

Speaking of watches (and I was going to any minute), the Cherry Ames watch that I displayed a few posts back is wonderful in person. It arrived yesterday and I wore it to work today. The picture did not do it justice. I get a kick just looking at it.

One more 12-hour shift and I'm a free woman for a week. If I wasn't so numb from exhaustion I'd get excited about that.


(oh, and I really do hate to write in black..........)

Singin' The Time Clock Blues...

Oh, this is weird. I tried to load this as large as possible so the caption is legible. This is an ad for an amphetamine, of all things. Look at the caption on the top...."and there's a BRIGHT SIDE for your patients, too!" Does this mean the ad was targeted for nurses? Sluggish at work? Just thinking about the surgical ward make you tired? Pop a Dexamyl and have energy to spare! Look at the nurse on the right, she looks like she is belting out an aria from "The Barber of Seville". The poor patient looks like he's still under anesthesia. I thought it was for post-op patients. Then I read the header. Hyped-up nurses. Pardon me while I remove my jaw from the keyboard.......Hell of a way to pull a double shift.

My hospital is starting a time clock system. Punch in and out. I like paper time cards. There is something about punching in and out on a clock that makes me, as a professional, feel rather insulted.
Like Fred Flintstone, I'll slide down the back of a dinosaur at the end of the shift yelling "Yabba dabba dooooooo!" That's what punching in has always reminded me of. The beginning of the Flintstones. I bring this up because it means that I have to go in early tomorrow when I am already doing a twelve hour shift. We have to be trained to use the machine. Now, any time clock that takes an entire hour to learn how to use is already bad news. I can swipe my badge as well as anyone, what in heaven's name takes a full hour to learn? I guess I'll find out tomorrow. The bright side is I got a new ID badge with a new picture. In the last one I had a fat face and lopsided short hair. This one shows me with a fat face and symmetrical, longer hair. Two out of three ain't bad.

Why on earth I decided to do three twelve-hour-shifts in a row is beyond me. I always want to "help out" and it never sounds bad six weeks in advance. I work 3p - 3a, which means all I will be doing starting at 1230 tomorrow is work-sleep-work-sleep-work-sleep. I should be 110 pounds. But somehow I always manage to fit food into the schedule.

I guess I have the most flexible schedule because I don't have small kids, or maybe I don't have a life and I don't realize it, but it always seems I am helping someone out by doing extra on short notice, but when I want to get a day off at short notice, there aren't too many takers. There are some nurses who absolutely will not vary from their posted schedule or ever pick up a night shift. And there is something about being asked to work 3p-3a that makes some nurses get the freakin' vapors just thinking about it!

Ah, I'm just whinin'. I actually get everything I ask for if I ask for it in advance. Of course, there are some things that are NOT negotiable. The night of a Journey concert, for instance.
I am SO there and I don't care if you have to dig up Florence to cover for me. You know, little things like that.....

Speaking of concerts, allow me to divert from the ER for a moment. I am taking my 15-year-old daughter to a rock concert with me. We are going to see Rob Thomas in November. This was a GREAT sacrifice on my part because everything I do embarrasses her and I'm sure this concert will be no exception. I don't go crazy at concerts or anything but I did have to lay down some ground rules. She cannot tell me to: sit, stop singing, stop dancing or stop drooling. I'm joking about drooling. She has agreed. We shall see.

There are many fascinating topics surrounding the world of emergency nursing and in the next post I might actually talk about them. For some reason, it is after 0300 and I am finding myself quite articulate and witty. Not a good sign. Time for bed......thank god I don't have to punch in for that!

Would You Like Fries With Your IV?

One of the most difficult skills I had to perfect in nursing school was Pepsi Pouring 101. As new students, we began with non-carbonated beverages, namely Kool-Aid. As our skills developed past the novice level, we moved onto Ovaltine (cold). Those students showing a particular aptitude were allowed to serve their Ovaltine hot. This was before microwaves, so it was quite labor intensive. I'll never forget the pride I felt the first time I was able to pour Pepsi for the waiting patients. A nurse's cap and an ice, cold Pepsi...doesn't get any better than that!

What happens when that kid on the couch who was just triaged for abdominal pain has to go for his appendectomy with a gut full of Pepsi? I guess if he aspirates it, the carbonation will keep his lungs inflated.....

I've discovered many stereotypes of nursing during my travels through the internet. I've discovered nurses as waitresses, nurses as whores (good heavens, be careful what you put in the search engine!),
and nurses as angels. My favorite is the "nurse as waitress" genre. I get teased about this at work. We have boxed lunches available for our hypoglycemia patients and the turkey sandwiches come with lettuce, tomato and condiments separate. I usually cover the table with a white towel and put the lunch together for the patient. This gets me untold good-humored grief from those who see me do this. Hey, the patients appreciate it; who wants to fumble with a bunch of packets when they're sick? No one's left me a tip, though.

I believe this image of nurses as waitresses are actually the result of old advertisements and the fact that in the old days, the nurses actually put the patient trays together. That was way before my time, but check out this Coke ad. These types of ads probably had a lot to do with it.

Of course, sometimes it can feel like you are a waitress as patients request that you address various needs. Every patient will ask for:

• A warm blanket. Even the ones in for ankle sprains. ERs are cold! Give everyone a blanket, even the ones who aren't cold. They will be.

• The bathroom. Show the ambulatory ones where it is. Give a urinal to the men. Get a bedpan ready for the women - every woman will have to pee within 5 minutes of getting settled in the gurney.
  

• Water. If they can have it, give them a cup. If they don't want it, they will.
  

• The call bell. They won't ask for it, but make sure they have it and tell them to use it if they need anything. Just having it available tends to make them more secure and less "needy". They also won't be wandering the halls looking for you.

I make sure everyone is set up in the room at the time I room them. It makes the patients more comfortable from the beginning and saves a lot of running around for me.

Oh, and by the way I was a waitress at one time. There are two traits waitressing and nursing have in common. The ability to juggle many clients at once and the ability to prioritize. It was a fun job. But it just didn't have that cap.......

Mmmmm....I Love This ER!

Boy, the things you find on the internet! I found this watch by accident; having noticed a Nancy Drew watch in a Google search, I figured there had to be a Cherry Ames version and here it is! I needed a new watch anyway, so it should be here within a week. Everytime I check a pulse, I'll be reminded why I became a nurse! How often do you own a watch that makes you smile?

Have you ever heard the song, "I Love This Bar" by Toby Keith? Every time I hear it all I can think is that someone should write a version called "I Love This ER". Okay, I'll do it! The original lyrics were by Toby Keith and Scott Emrich and the song is off the "Shock'n Y'all" album. My apologies in advance to them both. Here is my version:

We got winners,
We got losers,
Chain smokers and boozers,
We got chest pain,
We got fractures ,
Some psychotic nerve wrackers.
And the people who just had to crash their cars.
Mmmm, I love this ER.

We got dyspnecs,
Some have scabies,
Folks afraid they have rabies,
We got vomit,
We got bleeding,
Folks who cut themselves weeding,
And men who are afraid that they'll have scars.
Mmmm, I love this ER.

Chorus
I love this ER.
It's a hoppin' place.
Don't bother to get dressed up
But wear good underwear just in case.....
Expect to be late
Because you will wait.
Mmmm, I love this ER.

We got old folks,
Kids with fever ,
Homeless and overachievers.
We got nurses, we got medics,
Drunks whose lives are pathetic
And they pee enough to fill a Mason jar.
Mmmm, I love this ER...Yes, I do.

Instrumental Interlude

I like my books.
I like my friends.
I'd like to read on my lunch break.
If I could have one now and then....

But, I love this ER.
It's a happenin' spot.
And the patients all come in, at seven pm on the dot.
Give your co-pay
Before you stay.
Mmmm, I love this ER.

Mmmm, I love this old ER.

You Can Be An Emergency Nurse, Too!

How would I look in this uniform? Wonderful, if I was seven feet tall with the proportions of Barbie. Bruck's Nurses Outfitting Company also made the old nurses' capes. I checked to see if they were still in business but found nothing. Check out the $5.95 price tag! LOL! What was the nursing salary back then? One hundred dollars a month? I wonder what the nurses of the 1940s would think if they could see us now in our SpongeBob Squarepants and Betty Boop scrubs. Not that I wear those. Okay, I do pull out my "SpongeBob ScaredyPants" scrub top for Halloween and my Peanuts Baseball print in the Spring. I also have a Nurse Tweety Bird top with Tweety in a nurses' cap. I always thought Tweety was a guy!

For those of you interested in changing your career or working in a new specialty, you can be an ER nurse, too! In this exciting specialty you can:

• Have a verbally abusive 80-year-old flip you off behind your back as you gently guide his companion to a room. You will know about it from the ten people at the nursing station who witnessed it. You will have no clue what you did that prompted the gesture.

• Confirm the physiological link between pulmonary edema and the need for a bowel movement. Oxygen can't wait. Neither will stool. You'll learn to slap on the non-rebreather on the face and get ready to put the bedpan under the other end.

• Get smacked on the arm by a confused 102-year-old who does not appreciate the necessity for a blood pressure. Then again, that may be appropriate behavior for a 102- year-old who is spunky enough to protest a BP.
  

• Play the "pain is what the patient says it is" game with repeat migraine patients as they lay totally relaxed, speech slurred after a trillion milligrams of Narcotic-of-Choice by IV, but their pain is still at a 9.9 out of 10 on a 0-10 scale. They know they are playing the system and you know they are playing the system and they know-that-you-know and you know-that-they-know-you-know.

• Interact with a man who will not acknowledge women. He will not look at them and lord knows he will not talk to them. You'll wonder if it is a cultural issue, but then you will realize it is an obnoxiousness issue.
  

• Watch as a parent sweeps their infant off the gurney to the other side of the room because there is NO WAY IN HELL that you are going to take a RECTAL TEMPERATURE on their child. You pervert.

• Deal with Dr. Snailspace by realizing that the harder you push to mobilize patients the slower the doctor will move. Deliberately. Run interference with said patients as they express their frustrations at you, the nurse. No one ever yells at "The Doctor".

• Answer phone calls from potential patients who want to know how busy your ER is at that moment. Realize that anyone who can shop-by-phone for the ER with the shortest waiting time doesn't really need to be in an ER at all.

• Learn that when a particular surgeon writes for everything to be done "STAT" on his appendectomy patient has no intention on taking that patient to surgery until the next morning. Learn this by letting the surgeon know the patient is "ready" after running for 90 minutes to get everything done "STAT" as ordered.

• Realize that enemas are more of an emergency department function than you would have thought. Learn to be assertive as you let your internet-surfing-laid-back colleague know that he is expected to do the next one.

The stories you have just read are true. Just about everything has been changed to protect the innocent. But you get the picture.

Give Me A Break! Please?

Now this is interesting. Apparently Coca-Cola had an entire advertising campaign that focused on nurses. The writing reinforces the "goodness" and "wholesomeness" of Coke! Back then a sugar jolt, an overdose of caffeine and artificial caramel coloring were good for you! Some things never change! (Looks like that nurse on the left is trying to blow a tune over the top of the bottle. A break, a bottle of Coke AND entertainment! What a gal!)

But what is wrong with this picture? These nurses are on what is called a "break". In fact, there are three nurses on a break at the same time, indicating they must have a census of zero on their unit. I realize that those of you who are nurses may not understand the term, "break". A "break" is when you can leave the floor, take 10 or 15 minutes to sit with a beverage, put your feet up and re-energize before returning to patient care. The purpose is to help "care for the caregiver" and allow you to "take care of yourself" so that you do not become exhausted by the intensity of your labors. Breaks are separate and distinct from your meal period by the fact that you do not have to "punch out" on the timeclock. You are actually paid for these rest periods. These are so important that here in California, workers have a legal right to these relaxation respites. What a novel concept!

If you work on a unit that works breaks into your shift, drop to your knees and thank your personal Higher Power. For 99.9% of the rest of us, we have a few options. We can:

• Go tell your Charge Nurse that you will be taking your legally scheduled break, give a brief, succinct report on the status of your patients and retire to the breakroom. Be sure to take a full 15 minutes to allow the jaw of the Charge Nurse to be lifted off the floor.

• Inbetween medications, blood draws, treatments, call bells and doctor's visits, run to the bathroom and lock yourself in a stall. Even if you don't have to go. Open the "People" magazine you hid under the trash can and read the latest story on Britney Spears. If you hear someone waiting for the bathroom, make noise so they know it is occupied. They will leave the area. It is possible to read one "People" magazine article before anyone will get suspicious and come looking for you. Avoid "Time" or "Newsweek" as these articles are more time intenstive.

• Develop a "sudden" severe episode of hypoglycemia. You need not be a diabetic to use this tactic. Your colleagues will encourage you to imbibe some orange juice and thus will not begrudge the 10 minutes it takes for your blood sugar to equalize as you are "recovering" in the kitchenette.

• Remember that you left your ID/stethoscope/favorite pen/lunch/People magazine in your car and you must go get it. When in the car, turn on a classic rock station. You can remain in your car for the length of time it takes to hear one Motown single before you need to return to avoid suspicion. Be sure to return with something in your hand.

This all reminds me of a quote from "Cherry Ames, Student Nurse" when an instructor tells Cherry that "nurses never stand when they can sit and never sit when they can lie down"!

Speaking of Coke, take a look at this cutie I found when googling the Coke ads. Where has she been all my life? I tried to see if Pepsi had a similar ad campaign using nurses but I found only a few ads using nurses' aides. This was quite disappointing considering that I would take Diet Pepsi IV if it was available in an intravenous form!

Did anyone notice the new "photo" in the profile section? This was from a "make yourself a Lego person" site. This looks so much like me it is almost insulting. I was able to add a cape which was totally cool. Lego-Me is holding a cup of coffee and a book. Coffee to keep me awake and a book to read up on infectious diseases. Yeah, right. It's actually the People magazine I hide under the trash can in the bathroom.....for other people to use, of course!

Now I'm off to find out how to get a doll like "Cokey, RN" here.....

Personalities On Parade

To blog or not to blog, that is the question. Whether it is nobler in the mind to suffer the slings and arrows of outrageous somnolence...
You guess it, I worked nights last night. Now that it's over, I can use "The Q Word" and say that it was relatively quiet. Enough so that I was able to write the rough draft of this post. Now we'll see if what seemed so funny at 0400 holds up in the harsh glare of daylight....

An emergency department is made up of many personalities, the majority of them strong personalities. The meek, the mild and the timid do not gravitate to the emergency medicine milieu. There are some traits that you will see over and over in any ER and I've put together a list of just a few I have encountered over the years.

Ladies and gentlemen, I introduce to you....

• Seniority Sadie - this nurse was hired the day they broke ground for the hospital back in 1892 and she has never worked a single day anywhere else. She never misses a chance to let you know that if she wanted to she could get (fill in request here) ahead of you because she has seniority!

• Languid Lucy - Lucy has discovered that the faster you move, the more work you are given. Ergo, drag out your nursing care and you'll get less patients. Lucy is so laid back she needs a recliner.
  

• Dumping Dora - Dora is responsible for rooming the patients and believes that you deserve them all, thereby denying the other two nurses (of which she is one) the pleasure of a patient located in the vicinity of their assignment.
  

• Freaking Freda - Everything is a crisis for poor Freda. God have mercy on her if she gets orders on two patients at once. A deep sigh will emanate from the very depth of her soul with each patient she is assigned. Freda is constantly bordering on carpal spasms secondary to hyperventilation.

• Passive-aggressive Pete - Pete is the type that will listen all night to your excitement about the new shift you've applied for and never say a word....And then he'll go apply for the same position in the morning.

• Write-'em-up Wanda - Wanda is a quiet, observant soul. Wanda sees all. Wanda hears most. Wanda disapproves of some. Wanda says nothing. And then Wanda writes 'em all up and turns it into the manager.
  

• On The Dot Scott - Scott begins preparing for the shift change one hour ahead of time and meets the oncoming nurse at the door with his hat on and car keys in hand. He considers it overtime if he stays five minutes past the hour.

• Goody Glenda - Efficient, pleasant, happy, eager-to-help, always sees the good in everyone and every situation. You aren't sure what you want to do most, work with her or slap her silly.

• Betty Burnout - Betty is tired of nursing and has nothing left to give. She walks the department as if she had a 5000 pound weight attached to her right foot. She's so depressed she sucks the air out of the room. She can be seen desperately perusing the jobs section of the paper, looking for something that pays as well, but doesn't require caring.

• Dr. Sam Sarcasm - spouts off with a sarcastic, often hostile comment every time you want to tell him about a patient or discuss a case.
  

• Nasty Nan - brusque and short-tempered, Nan treats the patients like they are an interruption in her shift instead of the reason for it. Antagonizes on contact.

• Pulitzer Petula - is obsessed with charting. Has pathologically legible handwriting. Will redo an entire nurses' note instead of crossing out. Doesn't want anyone else writing on her literary masterpieces. Must have the precise pen at all times.

• Naomi Know-It-All - Naomi is a nurse with an advanced degree who thinks she is the last word on all topics nursing.
  

Oh yes, I'm in the list. Meet Pulitzer Petunia, yours truly. I could write an entire month's worth of posts on what was like to be Betty Burnout. There are times when I've been an On The Dot Scott and I've been teased about being a "Glenda" on occasion. I've never stayed anywhere long enough to be a Seniority Sadie. (Oh, and by the way I've never worked with a "Naomi Know-it-All", that contribution came from a colleague who is on her way to her PhD and was afraid that would describe her someday).

Now, bear in mind that these are composites and any resemblance to coworkers, past or present is purely coincidental.....really!

Empathy by Experience

In the spirit of full disclosure, I think this should be posted at the door to the Emergency Department. I'm sure it certainly feels like this to the patients.

I became a nurse at a relatively young age, when I didn't know my head from a hole in the ground. With age and life experience came an increasing ability to empathize with what my patients were going through.

I understand why parents are absolutely petrified by febrile seizures. Nothing like finding your 18-month-old blue on the side of the bed and beginning rescue breathing. I know the fear brought on by caring for a child with a fever of almost 105 degrees.

I understand what it is like to have a syncopal episode during your orthostatics after losing 6 pounds in two days from gastroenteritis. And trying to explain to an ER doctor, after eight hours, liters of saline, with a blood pressure of 80 systolic, fire-like pain in your entire GI tract and two children at home under age 5 that you want to be admitted.

I understand what it's like to have abdominal surgery for a ruptured, hemorrhaging ovarian cyst, 11 1/2 hours after I presented with severe abdominal pain. I know what it is like to have an NG tube shoved up both sides of your nose to the point that you feel it is perforating your eye sockets, because they let me DRINK two liters of water so I'd have a full bladder for the ultrasound. I know what it's like to wait for the specialty consult for six hours until office hours are completed. And finally, I know what it's like to have your insurance company count your "first post-op day" as the same day you went to surgery even though you didn't go to surgery until 2330.

I know what it is like to stand by the bedside of your 62-year-old father who has had a massive right sided cerebral hemorrhage, who was transferred to another hospital because they had a better neurology service and was met at the ambulance doors of the ER by a nurse saying, "Oh great, who is this? We weren't expecting this!" and putting my father in the hallway for his care, before admitting him to the oncology unit because there was no room on the neuro floor and then not getting a neurologist consult until over a day later.

I also know what it is like to be admitted for chest pain, have a great nurse and to hear the emergency room doctor fight for me to get a private room because "she's one of us and we take care of our own". And I didn't even work at that hospital!

So, when patients show up in the emergency department, I greet them with a smile and try to make the entire experience easier by explaining what will happen and why. I always give them their call bell so that I can come to them and they don't have to send a relative to search for me. I try to make the family feel as though they are welcome, even if it's just giving color books or stickers to siblings. I facilitate whatever I can. I'm not a perfect nurse, but I've discovered it doesn't take a lot of energy to treat people with a smile.

It's funny. Patients are always saying, "Sorry to bother you, but...." I tell them that it's never a bother, that it's what I'm there for.

It's what I do.

As a nurse.

The Tyranny of The Bed!

The most frustrating aspect of emergency nursing is trying to get patients up to their floor after they've been admitted. Back in the old days, when the ER called to say they were ready to bring a patient up, they came up right then, whether you were ready or not. But it seems that things have changed. Getting admitted patients to their rooms has become fraught with obstacles, delays and much gnashing of teeth. Over the years I have discovered that it is really no one's fault. Every problem in admitting can be related to.......THE BED!!!!!!!Here are the top ten reasons why:

1. THE BED is not in the room. No one knows where it might be or when it will be returned.
The hospital "orderly" will be sent to look for it.

2. THE BED still has a patient in it. No one knows when this patient will be discharged or
why it was reassigned while still occupied.

3. THE BED is not clean. Housekeeping was called "half-an-hour" ago, but no one knows
who called and no one knows why they haven't answered their page.

4. The nurse assigned to THE BED is at lunch.

5. There will be no nurse until 7:00 pm for THE BED. Please hold the patient in the ER for
the next three hours and no, there is no one to come in early.

6. The admitting doctor wants to see the patient in the ER, not in THE BED.

7. The nurse can't take report because she is at THE BED of another patient.

8. The floor can handle only one transfer to THE BED at a time. The other four patients
waiting for their version of THE BED will have to wait.

9. The hospital is full. Each room has someone in THE BED.

10. It's Change-Of-Shift and there is no one available to help put a new patient in THE BED
Never mind that report was recorded an hour before shift change and only requires the presence of the oncoming nurses.

As I've always said about ER, "The longer you stay, the longer your stay!" When you think about it, ER is the only department (with the obvious exception of Labor and Delivery) where you have no control over when your patients show up. In our world, THE BED is eternally ready.....

IN MEMORIAM......

September 11, 2001


WE WILL NEVER FORGET

Degree Digression

If caring were enough....anyone could wear a cape. On a lark, I looked on eBay and there was a navy blue wool nurses cape with red wool lining!
I kid you not. Did I bid on it, you ask? You're darn right I did! And if you're looking for a cap, they are on eBay, too. Not used ones, either. Real, new ones that look just like my school cap before the ribbons are on. Did I bid on one, you ask. Of course not. Not yet. Look, I'll do anything to dress up like a nurse from the 40s and I thought about wearing this outfit at work on Halloween. Everyone will think it's a costume, but it will be a thrill for me. Stupid, I'm sure but at the moment it is almost 0400 and I'm somewhere between
too-awake-to-sleep and too-tired-to-function. I have no doubt that I will read this later this morning and cringe. But for now, I get a kick out of the idea!

I've come to terms with something recently; I have absolutely NO urge to get my BSN. I used to think that I should, if I could and that I would. Eventually. Now the kids are virtually grown, I have the time, I could swing the funds and I don't want it. I'm a bedside nurse. Always have been, with the exception of a foray into psych nursing and telephone triage. It's what I love, when you get down to the core of why I'm a nurse. It's what I am good at. It's what my Associates degree prepared me for. The thought of writing papers and researching and comparing differing nursing models while dealing with the obnoxious topic of nursing diagnoses makes me comatose. (Good ol' Sister Callista Roy's Adaptation Model was good enough for me in school and it is good enough for me now. And if you had told me in 1977 that I'd be saying that in 2005, I'd have said you were nuts!)

Ironically, I love learning! I read the journals, I love attending classes, and working in the emergency department requires me to keep up-to-date on all the specialties. I want to increase my fluency in Spanish, take a class on Shakespeare, pick up a violin - maybe even learn to play it, speak Japanese and, well, you get the idea.

But....I've no interest in managing a department, I respect those who can. Teaching is not one of my gifts. I enjoy the hospital environment; I've never been interested in public health nursing. I've never needed a BSN to accomplish what I've wanted in my career.

I work with a wonderful woman who is just short of getting her Phd. in nursing. I work with nurses with their BSNs, nurses who are Diploma graduates and some have their MSN. There is room for all. Everyone brings a different talent, a different ambition, a different perspective. When all is said and done, we're all caring for the patients and my place is right at the bedside.

It's Everything I Wish I Didn't Know....

Because I am an emergency nurse, I know:

A full-sized, stainless steel eating utensil can be consumed by an alert, oriented adult patient. By accident.

Death by acetaminophen overdose begins insidiously and ends in tortuous suffering.

A female can be pregnant and not know it until you advise her that, while she indeed has bowel sounds, your stethoscope was just kicked by a tiny foot.

An adult can be perfectly healthy and dead from meningiococcemia in 48 hours.

The urge to void and the time to do so are never concurrent.

An x-ray will show which brand of deodorant, by shape, is residing in a rectum.

Dialysis on a patient who is over 100 years old will be considered.

A child will cling to her nanny while the mother is sitting on the other side of the exam room.

The busier the shift, the more food you should have on the break-room table.

"The flu" can turn out to be internal bleeding three weeks after the intital trauma.

Following the guidelines of regulatory agencies (cough...JACHO....cough) will add three additional pieces of paperwork to your admission packet.

A nurse can count five different species of insect on a homeless patient.

Doctors with the most illegible handwriting are the most appreciative of legible writing on nurses notes.

These are just a few of the things I've learned.

Because I'm a Nurse.

It's Raining Men!

Check out this ode to testosterone! Yeah, baby! In-your-face recruiting and I love it! Somehow I don't think many men out there came to nursing by reading Cherry Ames as a child. The integration of men into nursing had already begun by the mid '70s. The concept of male nurses was very natural to me; I never knew it any other way.

In my graduating class of 1978, there were four men, making up 13% of the students. It wasn't until I moved into critical care and emergency nursing that I actually worked with men on the job. Most of them came to nursing as a second career.

The ubiquitiousness of men in nursing was brought home to me at the nurses' station during a recent PM shift. There I sat, a lone molecule of estrogen in a sea of, well, guys. Three RNs, the doc, the ER tech, the unit clerk and a respiratory therapist. Men. Each and every one. The topic of conversation ranged from motorcycles to Nascar to who bench pressed how much in what gym. This was as far from the classic image of nursing as a female-based profession as you were ever going to get. With my usual air of prim professionalism and with the utmost reverence and respect, I listened to the banter... and proceded to imagine all of them in nurses' caps. I guess the guys with shaved heads would have to glue them on.

We need nurses badly and recruiting tools that focus on men are one way of combating the shortage. This recruitment poster cut right to the chase and I'm sure it was effective in getting men who wouldn't have otherwise considered nursing to give it a thought or two. It almost got it right. Intelligence. Courage. Skill. I'd add "caring" to that list. It's what nurses do best. Male or female.

A Grand Round Was Had By All!

It's that time again! Time for Grand Rounds, hosted this week by Corpus Callosum! A list of wonderful topics, in which a post of Emergiblog humbly resides. It looks like a movie extra surrounded by Acadamy Award winners and I am thrilled, to say the least. There is enough reading material at Grand Rounds to keep us all satiated for a week. Enjoy!

Welcome to those who have found Emergiblog through the Corpus Callosum link! Grab your coffee (no one is ever NPO at Emergiblog), look around, peruse a post or two, have a seat in the waiting room and your triage nurse will be with you in just a moment....

There's a Flag on the Play

Hyperventilation. Tachycardia. Flushing. Abdominal butterflies. Exhilaration interspersed with moments of head-banging. Inability to control inappropriate language when confronted with stupid authority figures. A compulsive need to wear green, particularly as face paint. Episodes last approximately four hours and occur at weekly intervals beginning at the end of summer. Miss a fix, severe depression ensues. Rarely fatal, it consumes the lives of its victims until the end of November. There is no cure. Be prepared for the acute onset of......

Notre Dame Football.

As I write, my fighting Irish have just won against Pittsburg. I'm wearing my Joe Montana #3 green and gold ND jersey. That's why they won. They always win when I wear it. Since this is the first time I've worn it, it's 100% effective!

The highlight of college football in this area is the Stanford vs. Cal Berkeley match up. This is known as "The Big Game". Many years ago I worked at Stanford's emergency department on a night when it was Stanford's turn to host "The Big Game". Big mistake. There are approximately one-trillion people on the Stanford campus for this game and they aren't tee-totalers, if you get my drift. Normal, rational, intelligent, law abiding, mature adults turn stark raving mad! Folks old enough to remember "American Bandstand". In black and white. Not the college kids. Their grandparents! Take the usual complement of diverse, interesting cases usually found at a teaching hospital and forget 'em. All resources are geared toward treating Adult Onset College Football Insanity Syndrome patients in epic numbers.

Not that there is anything wrong with that. You don't know the suffering until you contract the disease yourself. My daughter's college had no football team, so I was spared the onset of symptoms. Then my son was accepted into Notre Dame. Oh....it starts slowly at first. One week you watch a game. The next week you might have a bit o' green on your socks. Before you know it you're wearing game jerseys and setting up a shrine for former quarterbacks on your television set and lighting candles to the leprechan and wanting your son to get the autograph of that cute guy on defense and then before you know it you are swearing to God you'll never buy another thing on eBay without your husband knowing if he'll JUST LET THEM SCORE ONE......MORE.....TOUCHDOWN.........!!!!!!!!!!!!!!!!!!!!

Not that there's anything wrong with that. I'm mean, I've never painted my face green and I've never had a green beer because no one has ever offered me one. I'll be attending the Stanford vs. Notre Dame game in November and I have zero intention of needing the services of the Stanford Medical Center Emergency Department.

I will, however, also be attending a game on the Notre Dame campus this season. God help the Irish when they get a load o' me. I may go stark, raving nuts.

Not that there's anything wrong with that.

Backpack Your Way Through a Disaster

I don't live in a hurricane-prone area. I'm smarter than that. My house sits directly on top of a major earthquake fault. I take my natural disasters without a warning system. I prefer the earth rocking as opposed to Hurricane Calgon taking me away. Californians are used to living with the occasional movement of terra firma, but deep in our subconscious we are always waiting for THE BIG ONE. While listening to the coverage of the horrible devastation and the frightening lawlessness going on in the South, I felt a gnawing sense of dread creep over me.

I'm not ready. There isn't an earthquake preparation item in my entire house. Well, wait, there is the backpack I bought at Safeway two months ago. It has a first aid kit and water for one. 'Kay. Oh yeah, I have a great big spotlight thingy.....but no batteries. I have a wonderful C. Crane radio that gets perfect reception....if there's power. I'm an ER nurse. There is no excuse for this.

So how do you start getting prepared? You can go to the store and stock up, but it might take awhile to get everything you need. Instant gratification is appropriate, at least to get started. I wanted a pre-packed pack. A google search for "MRE" (meals-ready-to-eat) resulted in my discovering TheEpicenter.com, an online emergency supply service.

The best products I saw were backpacks pre-packed with everything, including complete MREs and water for three days. MREs are complete meals (entree, side dish, dessert) with a shelf life of, like, forever (translation: five years). Two of the two-person kits provide total sustenance and emergency supplies (light, blankets, first aid, toiletries) for a family of four in two easily carried backpacks. Need to evacuate quickly? Just grab the backpacks and run. Water servings were available in individual packets and reasonably priced. Ever wondered what you would do when the plumbing went out? Portable toilets for $17.00 and packs of sanitizer for decontamination.

The backpack idea is a good one. Have pets? Put a small bag of their food in a backpack with an extra leash for a dog, or one of those new disposable cat boxes for the family felines. Be sure you have a cat carrier. Don't forget water;put a few bottles in there. How about a clothing backpack? Perhaps a set of sweats, underwear, socks for each family member? A list of phone numbers and addresses? How about the little ones - perhaps a backpack with special toys or stuffed animals. Don't forget the deodorant and toothbrush if you're packing your own.

Do you take meds? Try to keep a two week supply in your emergency pack. Don't forget Tylenol, Advil, Benadryl, Sudafed...the usual medications. Pack small packages of these with your backpack.

Consider a smaller version of the above in your car trunk, especially if you drive long distances or live in areas of harsh weather.

(I'm not going to address whether a firearm should be included in these emergency preparations. Just ask yourself that great, eternal, philosophical question: what would Ted Nugent do?)

A disaster can hit anytime, anywhere. It can take days before emergency aid can reach the affected area in a disaster. You can't depend on the local authorities or resources. Make sure your family is covered with the necessities for at least three days, whether you can shelter in place or whether you have to evacuate.

I'm relieved to say that two of the two-person backpacks are enroute to my house at this very moment, along with extra water packets. I'll breathe easier when they get here and less anxious knowing I'm prepared. Now all I need to pick up are some batteries.....

Will You Help?

Today I am joining hundreds, possibly thousands of bloggers across the world in a single request. Will you contribute to the
relief efforts to help the Americans devastated by Hurricane Katrina?

America is no stranger to the devastation caused by hurricanes, flooding and earthquates. When the worst happens anywhere in the world, we are there to provide the necessities and to help pick up the pieces. Now the pieces are in our own backyard and those devastated are our fellow citizens.

America knows what to do. We know how to do it. It will take money to make it happen. You can help get it done. How? By giving. I strongly recommend both the American Red Cross and Samaritan's Purse. I have great respect for both these organizations and know that they are already on the job. Your donated funds can get the supplies to those who need them the most.

Be as generous as you can. Any amount will help those that are hurting so badly right now.
After 9/11, America stepped up to the plate to help. It's time to step up there again. I'm proud to say I did my part. Please join me. Let's hit a home run.

(Thanks to Hugh Hewitt, Glenn Reynolds at Instapundit, and NZ Bear for gearing up the blogosphere for this fund-raising effort.)