If It's Grand Rounds You Seek, You Must Take A Peek

This is one of the wierdest ads for underwear I've ever seen!

'Nuff said.

But I wanted you all to "take a peek" over Dr. Barbados' blog at Barbados Butterfly ,where you can check out Grand Rounds for this week.

Not only was Emergiblog honored with a spot on this week's list of topics, but I have been asked by our esteemed co-ordinator, Nick of
Blogborygmi fame, to host sometime next month.

I will be ready with laptop and Diet Pepsi in hand.

Now, if I can just convince my husband that this duty requires a new Macintosh 12" G5 Powerbook with dual processors.

I will then consider my preparations complete.

When I Die and They Lay Me to Rest, I'm Gonna Go to the Place That's the Best

UPDATE: One of my readers has pointed out to me that it is a common misconception that juvenile onset diabetes is caused by an excessive intake of sugar, and is concerned that this misconception may have received a boost by this post. Those of us who read medical blogs who have a medical background understand this. Readers who do not may not understand that I am being sarcastic, that sugar intake has nothing to do with causing diabetes. I thought this was a legitimate issue and so I've added this update to the post. I appreciate the feedback.

hhhhhhhhhhhhh

Wow, I had no idea that eating Shredded Wheat was a nursing prerequisite! I would have put it on my applications!
How ironic that I used to eat it!

Under protest, of course.

It tasted like horse fodder.

Unless..... you smooshed it all up until it looked like a bowl of twigs, added enough sugar to ensure juvenile onset diabetes and then smothered it in milk, which you wouldn't drink afterward because little brown shredded wheat things were floating in it.

Ah, memories.

Now you can become a nurse by eating your Shredded Wheat composed of bite sized, frosted "mini-wheats" in a variety of flavors.

Sigh......

Another nursing tradition gone to the resting place of "Cap and Cape Heaven."

hhhhhhhhhhhhh

My initial experiences as a new RN (back when MTV was just a gleam in a cable company's eye) were in a Coronary Care Unit.

A CCU is a very different place than any other unit I've ever experienced.

Patients would talk to me. They often told me they were going to die. On that exact day.

And they did.

The one thing that the patients found hard to discuss were their "out of body" experiences during codes. This was not a topic that was widely discussed at the time. They were afraid the staff would think they were crazy.

Three patients opened up to me regarding their experiences during the years I worked in the CCU. Here are their stories:

• Patient One was a young middle-aged female, in her early 40s. This was unusual in itself because young women were not a common sight in the CCUs of the late 1970s.
  

• She had had an MI and had "coded" requiring defibrillation three days before. As I did her morning care, she happened to mention that she had felt she had left her body during that time, had followed a light at the end of which was her deceased uncle. Her uncle informed her that, "....it is not your time. Jeremy will meet you here." At which point she remembers being back in her room.
  

• The odd thing? Jeremy was her husband. And he was still alive.

• Patient Two was, again, younger man in his 40s who had had an inferior MI. As I began my evening care, he asked me how many people had died in the hospital last night.
  

• Now that is not a question I get everyday and I asked him why he wanted to know. "Oh, just curious," he replied.
  

• Later he opened up to me and said that last night two of the patient's "spirits" had come to get him, asking him to come with them. He said they were in the corner of the room. He told them he couldn't go, his son was a teenager and needed him. They asked three times and then they were gone.

• Patient Two had been defibrillated three times the night before.

• Patient Three haunts me to this day.
  

• She was not very old, maybe mid 60s and she kept going into unresponsive ventricular tachycardia. She required defibrillation multiple times. I remember standing at the bedside, paddles in hand, while my colleagues worked on her medications and IVs.

• Eventually things settled down and her rhythm stabilized. She called me over the bedside.

• "Do you believe in an afterlife?" she asked. "Interesting question, " I answered. "Why do you ask?" For the record, I happen to be a Christian with a very strong belief in the afterlife, but I sensed this was not the time to discuss it, so I kept the focus on the patient and her situation.

• What she said next was horrifying. She had been underground, cold, dark and surrounded by dirt, looking out of a coffin. All she could see was her sister's coffin next to hers. No warmth, no peace. Just coldness.
  

• Her sister had already passed away.

• I asked her if she felt the need to speak to the hospital chaplain. She said yes.
  

After I left CCU for the challenges of the ICU, I never heard any more stories of my patients' experiences with death. Unfortunately in the ER, I will never hear them, as most patients are intubated when coded.

I once described a code as having a tug-of-war with God. Every now and then he lets us win.

I like to think my patients are watching the struggle and appreciate the effort we make on their behalf.

Even if we lose.

Walkin' In The Rain

Is it just me or is the recent crop of babies exceptionally cute?

It's a very dangerous time for me.

My baby is almost 16 years old.

I have no grandchildren on the horizon for years.

I'm at that dangerous age between still being able to have a baby (just barely, I'm pretty sure my ova are using walkers to get to the Fallopian tube and I'd probably have to deliver in a convalescent home) and not having any grandkids to spoil.

The point being that all of a sudden I am in love with babies. Specifically, any and all pediatric patients under the age of one.

I got to hold an 8 month old for about 15 minutes the other day and he decided to carry on a full "conversation" with me. It was hilarious; I'd ask him triage questions like, "Are you allergic to any medication?" and he'd "talk" for 30 seconds.

What the heck is going on? Is this like some cosmic joke of one last surge of maternal hormones before they all get taken away? (Sorry, guys, girl talk here).

I guess, for now, I shall live my maternal instincts through the babies at work.

Just another advantage of being a nurse!

hhhhhhhhhhhhhhhh

It was only 4:00 pm, but the sky was full of dark clouds and it seemed much later. This particular year, we weren't too worried about draught here in California as the rain never stopped. The clouds were just taking a breath before beginning the next deluge.

She walked into the ER with her baby in an infant seat. Not the cheap old-fashioned plastic versions, but the big car seat type that were now on the market. She completed triage and waited to be seen.

She was all of 17; maybe she weighed 105 lbs. A single mother who lived in the big city adjacent to the small community where my hospital was located. Her baby had a fever and she was concerned.

Not only was she carrying a huge car seat and baby, she had the usual accoutrements that go with transporting a baby. A huge diaper bag. A large purse.

The baby had a virus, nothing serious and we gave Tylenol (there was no ibuprofen back then).

As I gave her the discharge instructions, I noted that there was now a torrential downpour in progress and offered to help her carry some of her gear to her car.

She said, "No thanks!" and pulled out a huge umbrella. "I don't have a car. We came by bus."

Not only had that petite little mother carried that baby and equipment on a bus to get to our ER, she had to make two transfers to get to the bus stop outside the hospital. And now she was going home the same way. In the rain.

I asked her if there was anyone who could come and get her and the baby. Usually, she noted, but there was no one else home that day, so she just came in herself.

She never asked for a taxi voucher, never assumed that anyone but herself would be responsible for transportation home. She gathered up her equipment, picked up the baby.

There was no way in hell I was going to let that girl and her baby go home in that downpour by a two-transfer bus route.

I told her I would call a taxi. She said, "Oh no, thank you anyway but I don't have money to pay a taxi."

I gave her a taxi voucher.

I caught hell for it later. My boss at the time did not look kindly on giving out taxi vouchers.

Tough.

The look on her face when I told her she could go home by car was absolutely priceless.

If we didn't have vouchers, I'd have paid for it myself.

The baby may have been the patient, but that day I was able to take care of them both.

A Plethora of Paperwork

I am an addict.

It is true.

My drug has been available to the general public for five years now. I discovered it a year ago.

Most people can take it without becoming emotionally affected. I, however, am drawn to it as a moth to a flame.

I suffer emotional withdrawal symptoms when it is taken from me, as it invariably is.

I swore I would not become involved again, but my family is co-dependent and encourage my participation. I am often forced against my will to relapse.

At work, I have to sneak into the back room to get my fix. Some of my co-workers know. Others have never discovered my secret.

I'm so ashamed.

It's cruel. It's encouraging. Sometimes, it puts people in the "dawg pound".

I am addicted.....to American Idol.

Please help me.

hhhhhhhhhhhhhh

Life used to be so simple in the ER.

If a patient needed to stay in the hospital, you obtained a room number from Admitting.

You then would take a final set of vital signs to verify that the patient was indeed stable for transport, bring your nursing notes up to date and double check the lab work to make sure that no one missed the potassium level of 9 or the hemoglobin of 1.

A call to the receiving nurse was then placed to give "report", a verbal narrative of the history of the present illness and emergency department course, adding significant historical medical information as necessary: allergies, previous surgeries, etc.

After receiving a litany of 15 reasons why the receiving nurse can't take the patient right then, a negotiation ensues. A time for transport is agreed upon and the patient goes up with his chart.

Oh, how I long for the good old days.

Approximately one year ago, some agency (JACHO?) decides that things must change for the good of the patient! Here is what now must be done before the patient goes up:

• Report must be faxed.
  

• This entails writing the entire report. So, everything that you have just spent hours writing on the nursing notes must be summarized and rewritten on the fax report form. Even I, with my passion for charting, think this is asinine. It is also mandatory.
  

• It takes longer to fill out the fax report than it does to verbally report.

• The only advantage is the nurse can't give you 15 reasons for not taking the patient any longer.

• In my facility, the policy is the patient comes up 30 minutes after the fax. Oh, and we call to confirm that the fax is on the way. In the beginning they mysteriously weren't received.

• Okay, in the interest of fairness, sometimes faxes are sent to the wrong floor or a bed number is changed after report has been faxed.

• And the floor/unit nurses get a 30 minute "heads-up" after the fax and before the patient arrives so they can prioritize prior to getting the patient. Which I know I would greatly appreciate if I worked up on the floors.
  

• We tried faxing the nursing notes instead for a brief period, thinking that would cover all the bases, but how shall I put this, not all nurses are thorough "charters" and/or it was difficult to read through to get the pertinent information.

• We need to practice "medication reconciliation".

• This means that, when a patient is going to be admitted, an exact list of what medications the patient is taking, including vitamins and herbal supplements must be listed, along with the dosage, frequency and the last time the patient took the medicine. Allergies and adverse reactions are also noted for a second time (first on the nursing notes).
  

• The goal is a noble one: to make sure the patient is discharged with the medications "matching" the ones they came in taking, with or without changes.
  

• This is all done on a new form that acts as a physician's order sheet for meds (ie they can check to order the drug as written or to not order it.

• Guess who gets to get all this information ready for admission - yep, the ER nurse. They say the family can fill out the form and sometimes the patients come in with beautiful computerized lists that bring tears of joy to my eyes. But usually the family is anxious about doing that so it falls to the nurse to complete.

• Oh, and by the way, those beautiful computerized lists? We can't copy them. They must be re-copied, by hand, on the form.

• Signature recognition

• On a separate form, in addition to signing your name twice on the nursing notes, you must print your name, sign your name, and designate your work station.

• Apparently illegible handwriting is making signature reading a lost art.

• To my blessed delight, my facility no longer requires this form. But for many months this was also mandatory.

So, in one year, three new pieces of paperwork were added to the already hectic activity that accompanies a patient admission. Two of which require the nurse to sit, undisturbed, for a minimum of 20 minutes to complete in addition to all the regular paperwork. We have no recourse but to do as we are told.

I wish someone would tell these agencies off.

Where is Simon Cowell when you need him?

I'd Like To Place A Call To Grand Rounds!

It seems Miss Ames, RN has gotten a phone call!

Why, she's been invited over to Grand Rounds !

Kevin,MD is hosting this week and the best of the medical blogosphere is overflowing with stories, information and once again, new blogs to get to know (at least for me).

Kevin has quite a wonderful blog. I can't believe it has taken me this long to find it! I won't be a stranger.

Speaking of stranger, it looks like Cherry's co-worker is not happy about the call at all.

Could it be that Cherry takes too many personal phone calls at work?

Nah, Cherry Ames is the perfect nurse!

The other nurse is just upset that she wasn't invited to Grand Rounds.

But you are invited!

Do come!

hhhhhhhhhhhh

I also forgot to mention that Emergiblog has a post in the latest "Carnival of the Mundane", this time hosted by Kaply over at her blog. It's my post on using the nursing process to assess your boxes of candy. Truly a skill that all should possess.

Is Your Spleen Squeaky Clean?

Okay. I thought by now I had seen it all, but this.....this is really bad.

Be a nurse and make good money....why gosh it never occurred to me to be a nurse until I picked up these matches!

Granted, this is for "practical nursing", as opposed to what? Impractical nursing? Maybe they mean LPN. It's still insulting. And the nurse is wearing the coveted cap.

Learn from home in your spare time? What is this, an old Sally Struthers TV commercial? Who are your clinical patients supposed to be? Family? Neighbors? Your animals? Where do you get your equipment? How do you know if you're doing things right or not?

The course is endorsed by physicians. Well then, it must be A-OK! Not! But I betcha they don't hire the "graduates".

But wait! High school is not required! Whew! I bet that was a load off some folk's minds. 'Specially since you can be anywhere from 18 to 60!

Send for the free booklet! No salesman will call! Nobody will oversee your education! What more could you want?

One minute you have nurses beseeching you to join their ranks for the good of the country and the next thing you know they're soliciting from matchbooks.

I just hope they close their cover before striking......

hhhhhhhhhhhhh

I hate spleens. I really do. I mean, I'm glad I still have mine, and I fully intend to keep it. But spleens aren't very forgiving and sometimes they are downright sneaky.

Young girl, early teens, unrestrained front seat passenger of a car driven approximately 25 mph head first into a wall. Old car, long ago, no airbags to deploy.

Patient is ambulatory on scene without c/o neck, back or head pain. Slight pain to lower left ribs but nothing more. Mother arrives on scene and signs patient out AMA, stating she will transport patient to the ER. And she does.

My ER. My non-trauma center ER. As triage nurse for the day, I began taking the history. Slight pain on palpation when left lower ribs are softly touched. Pain increasing slightly with inspiration. Lungs clear. Denies SOB. I'm thinking pulmonary contusion, maybe rib fracture. The mechanism of injury was not great, but the patient was walking and looking good on scene and when he got to the triage station. Then, suddenly the patient begins to look rather, uh, sick. Icky. Pale. Nauseated. Shocky. Bad.

This is not good.

Mom gets sent out to registration and patient comes with me, in a wheelchair for obvious reasons but now she can't stand up straight anyway. I grab the ER doc on the way in. He examines the patient only to discover within about one-half second that it is not the ribs, it's left upper abdominal pain and we are goin' to the OR. Mom returns within minutes and gets the scoop. Two large bore IVs with a bolus (BP falling)while the OR gets ready and off we go.

Ruptured spleen.

I hate it when they do that.

hhhhhhhhhhhhh

It had been a helacious shift.

Everyone was very sick in some fashion or another, almost all requiring IVs and medications for pain or nausea (or both). Lots of respiratory distress and a couple of in-house codes to top it all off. (We lose the ER doc and an ER nurse for what is hopefully a short period of time when someone in the hospital has a cardiac arrest).

We had people sitting in the waiting room that I desperately wanted in rooms; they were miserable.

Finally we get one bed open. I'm about to call in the next patient. This guy walks up being supported by friends. "Hey, like, he has the flu, man. Been vomiting all night. He even passed out twice at home!" Sounds like he's dehydrated from gastroenteritis just like the rest of the county. But passing out twice kind of gives you priority for a bed. We don't take kindly to syncope (fainting).

I asked the patient to gown and lay down on the bed. He said it hurt to lay down. Well geeze, dude, if you don't lay down and you're dehydrated you're gonna pass out again! I said it a wee bit more professionally than that. Nope, he wasn't gonna lay down. Okay.

"Look," I told the friends. "Sit next to him on the side of the bed. If he feels dizzy lay him down."

He needed an IV, like yesterday. But..... three more patients walked in and I ran out to have them sign in for triage and make sure none of them was having a heart attack, stroke, etc. And someone had to take report from the medics who had brought in a possible stroke victim.

Did I mention that at this particular facility there were only 2 nurses after 2300? It was after 2300.

I heard loud cries for help from the friends of our vomiting, fainting guy. I rush in to find him, essentially unconscious, sitting between them. They hadn't laid him down. So I did. He woke up.

Blood pressure of 70 systolic when flat. And in pain.

I still thought he was a severe case of dehydration but a little voice inside my head made me act like a trauma nurse and put in two large bore IVs. One of them was a 14 Gauge. A freakin' hose. Had the ER doc at the bedside by that time and he did his exam. The patient's abdomen was rock-hard. It was so tender that even touching the hairs on his upper abdomen was excruciating.

No fever. Sudden onset. Denied trauma. Normal BMs. Weird.

The IVs kept flowing so that I could get his blood pressure up and try to address the pain issue. And the pain kept getting worse and the blood pressure would not respond. It seemed like it took forever to get my patient to the CT.

Ruptured spleen.

Massive hemoperitoneum.

Say what?

We didn't believe it. We had one "ruptured spleen" in surgery already. We thought they had faxed us the earlier report.

Then the truth came out. Three weeks earlier, a large tool had fallen onto the patients left side. It was sore, nothing major. He did notice he could no longer jog without pain, which he thought was weird, but nothing to see a doctor about. He had a hematoma on his spleen. It started bleeding that night, giving him the "flu" symptoms he presented with.

He made it. So did the first patient. I, however needed a weeks worth of Ativan after that shift.

So don't be surprised if you are ever in an ER for a sprained ankle and the nurse asks how your spleen is feeling.

It will be me.

I hate spleens.

Life Begins At 90!

I found this little nurse doll online and fell in love with her, although her cap is sort of out of proportion...

Boy, that last post on migraines sure inspired a lot of comments. It also introduced me to some excellent discussion boards and weblogs - I've now added a "Patients of the Blogosphere" link to the sidebar. Check them out for a look at us from the perspective of a patient. I'll add more as I come across them. I'll also be adding more in the paramedic section, too.

Usually I have a ton of time to blog, but no ideas. Now I have little time to blog and a TON of ideas! So tomorrow, it's just me and my blog.....

After I attend my grandfather's 90th birthday party tomorrow!

One day I'll tell the story of how he set off the LifeAlert system while climbing onto his roof to fix a tile. In his eighties. Couldn't figure out why all those sirens were coming closer and closer until they stopped in front of his house. Caught red-handed, he was!

He stopped a 4-pack-a-day cigarette habit cold turkey in 1963. I asked him if he still wanted a cigarette. He said sure, but wantin' didn't mean he had to have it. They just don't make 'em like that anymore...

Ambivalent Compassion - The Migraine Sufferer

I wish the dialogue was visible on this ad for Colgate toothpaste.

Wifey in gorgeous robe is upset because her husband pays no attention to her and not even her "illness" has changed his attitude.

Nurse Subtle informs Wifey that she has seen "bad breath" break up so many marriages.

Apparently Wifey's breath makes a cat-box smell like springtime in Paris.

Why, let's get a dental consult. Right here in the hospital.

Dr. Dental tells Wifey that her bad breath is caused by putrid, decaying animal flesh stuck between her teeth and saliva that's a-liva with bacteria. He prescribes Colgate.

Wife is shocked that she, of all people, should have to brush her teeth.

She tries the Colgate "dental cream". "Illness" cured.

And her marriage to her shallow, non-communicative husband who didn't have the cohones to mention her breath issue and won't even visit her when she is sick in the hospital is saved.

Much of the above dialogue was paraphrased by yours truly. But you get the idea.

Today's ads are Pulitzer-prize material compared to this stuff.....

hhhhhhhhhhhhh

Having been a nurse for as long as I have, I am definitely not naive. I don't consider myself cynical, either. I like to think I have reached a fine balance between the two that allows me to treat my patients with compassion and detect (and deflect) the bull that some patients will occasionally throw my way.

Nowhere is this balance of compassion and cynicism more obvious than with caring for patients with chronic pain issues. For this post I will focus on the migraine patient.

I'm no stranger to headaches. Twice in my life I have known what it is like to feel like your head is going to explode. So, the first thing I do after assessing my migraine patient's color in the triage room is I turn out the light before I get the history, as most of the patients will suffer from photophobia.

I make sure they have a private room with the lights out whenever possible. Sometimes they have to wait a bit longer for the advantage, but I let them know why they are waiting.

For new patients I ask them what has worked in the past. Some don't know, others can recite specific dosages. I ask because if they know, it saves a lot of time and the need for re-dosing. If a patient states that it usually takes 100mg of Demerol, IM, to take the pain to a tolerable level it seems silly to give it in 25 mg increments. Oh, the doctors can order it that way, but (1) trust me, it will NOT work until the usual dose is reached and (2) the patient stays longer in the ER because of the need to re-evaluated after every administration of the med.

Hopefully the doctor has given them prescriptions for pain at home. I make sure the patient has a ride home. I have bad feelings about putting a female patient under the influence of a narcotic into a taxi, although they will often insist it is their only way home.

And this brings me to the cynical side of my migraine ambivalence.

I've been burned.

• I had a patient appearing very ill (headache, vomiting, photophobia) and placed directly into a room. It was discovered that just an hour before, said patient was at our "sister" ER and both departments worked off the same computer system. All it took was one phone call to ascertain that the patient had received enough narcotics to allow him to have floated to our facility. Well, he just floated back home without anything from us!

• Sometimes a nurse will work in more than one facility. One of my patients was identified as having been at another facility already twice that week for the same complaint: migraine. I believe I already told the story in another post that related a nurse traveler who recognized a drug seeker from the east coast while working here in CA.

• There are the patients who take the taxi, drive around the block and then get in their car and drive off. I know this happens because the taxi drivers come back and tell us the patient only went to the corner and then got out of the taxi and walked back up to the parking lot.

• If "New Miracle Drug" comes out on Wednesday and the patient states he is "allergic" to it on Friday, it usually means that somewhere, somehow the patient received the medication and it didn't work. Saying there is an "allergy" to a medication is one way an illegitimate drug seeker will keep from getting that drug.
  

This is what ruins it for patients with legitimate pain issues that occasionally need to be addressed by the ER.

If you are a patient with a chronic/recurrent migraine issue:

• Carry with you a letter from your neurologist outlining your treatment plan, discussing what to do in a case of breakthrough pain and gives medication/dosage recommendations. Make sure it is updated often, in other words, don't bring a letter dated 2000.

• Bring a list of your medications and allergies/reactions with you. The apex of a migraine is no time to be trying to think of your medications. Keep it in your purse/wallet.

• Bring your ride home with you. Don't take the chance you'll be medicated and have no way to get home. Don't drive yourself to the ER when you are in that much pain, it isn't safe.
  

• If you are certain that your pain is unmanageable at home with what you have available, it may be worth placing a call to your doctor. Often, they will call ahead to the ER so that we are expecting you. They may even talk with the ER doctor to discuss your case and treatment options.
  

So you can see when you run into staff who seem suspicious or less than compassion filled, maybe you now have some insight as to why some ER staff tends to be on the "cynical" side when it comes to pain issues.

There is a line in the movie "Ghostbusters" that shows the guys in a TV commercial saying, "We are ready to believe you!"

We are ready to believe you here in the ER, too.

But trust me, we can spot a phony a mile away.

Don't Just Stand Around! It's Grand Rounds And Time For The 2005 Medblog Awards!

Who says there's a nursing shortage? Why I found these with no trouble at all!

Looks like they are standing around for Grand Rounds hosted this week by Allen over at Grunt Doc.

Tuesdays in this house are beginning to be known as "Dusty Days" because nothing gets done around here as I'm too busy reading Grand Rounds!

It's not like I ignore my familial responsibilities.

Really, I don't.....

Hey, how come there are only two brunettes in this entire batch of nursing dolls?

Of course, in reality, with the aging of the nursing force, half of them would have to have grey hair and the other half grey roots!

hhhhhhhhhhhhh

Well look at this! Seems Miss Cherry Ames, RN had an endorsement deal with Coke!

Well I think we should join her in a well deserved toast to the winners of the 2005 Medical Weblog Awards that will be announced today over at Medgadget .

You know how they say after the Academy Awards that just to be nominated was an honor?

It really is!

Thanks to all who gave Emergiblog their vote.

Have a Coke in honor of the winners!

As for me, I'll go open the champagne the ER doctors gave the nurses as a Christmas gift this year!

I Hear A Symphony!

Why, yes! It's Ozzie, Harriet, David and Ricky singing...no, gargling with Listerine!

Actually, I can't dis this ad because I love the Nelsons and in my family that would be considered sacrilege.

But, it did remind me that Emergiblog has a post in the "Best of Me Symphony" this week over at Gary's "The Owner's Manual". It's like a carnival, except that the post submitted must be at least two months old. Very eclectic!

By the way, I would rather have a cold than gargle with Listerine.....

Fashionable Psychiatry

This is why I rarely go to staff parties. It's not that I'm antisocial - far from it! Say that this Elmer guy is actually "Dr. Elmer", neurosurgeon.
It would be very hard not to burst out laughing with this image in my head the next time I had to work with him. It would probably go something like this:

Dr. Elmer: "Nurse Kim, this patient needs a brain operation, STAT!"

Me: "Bwhahahahahaha!"

Not very professional.

And let's not even think of how seriously my co-workers would take me after observing the effects of just a wee bit o' ETOH. It would be the talk of the hospital. They'd post photos in the cafeteria. They'd run it as a news crawl on CNN.

And worst of all, I might have to take Pepto Bismol.

Blech!

hhhhhhhhhhhh

I was once a psych nurse. I was burnt to the proverbial crisp after 10 years of critical care when a position opened in a local community inpatient psychiatric unit. I was hired.

And I was excited. Not only was I going to be working in a different field but I was going to be able to wear regular clothes!

No more uniforms!

I adjusted my wardrobe accordingly and my closet was full of new, professional wear. I began my psychiatric career looking like I belonged on "LA Law". Dresses. Suits. Heels!

My unit was an "open" unit that was directly adjacent to the "locked" unit - the entire floor was designated for mental health.

My very first shift was the usual awkward time of learning the layout of the unit, shadowing the staff and learning the routine. It was around lunch time and I was alone at the nurses' station reading policies when I heard over the loud speaker:

"CODE BLUE: FOURTH FLOOR ROOM 5689"

Oh my god....that's over in the locked unit!

I may not be able to cure schizophrenia, but by god, I can work a code! So, in my new forrest green, belted dress with flared skirt and my Manolo Blahnik heels (okay, they were really Mervyns brand. On sale.) I ran through the door to the locked unit that was now open to allow staff in for the code blue.

I was the first person in the unit as the door was only about 50 feet from where I was standing.

Where the hell was everybody? Way down at the end of the hall was one staff person standing by a code cart that was out in the hall. Huh?

I ran, oh so professionally, down the hall and came to a crashing halt at the door to the patient's room. There was no way in hell I was entering that room. The only person in the room was the patient.

Spurting blood. From both wrists. And holding a knife.

The code team had been right behind me. The ER doc told the patient to drop the knife, and by this time the patient was woozy enough to comply. The code team then took over, suturing the wounds and stabilizing the patient.

The room looked like a war zone. Blood covered every surface, including the ceiling. The knife was a typical butter knife, the kind served with meals, the kind that you wouldn't think would be provided in a locked unit.

I wobbled unsteadily back to my assigned unit on my cheap Mervyn's pumps.

From then on I wore nothing but pants, polo shirts, sweaters and running shoes.

What the hell was I thinking?

Sometimes you just have to learn the hard way.

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I spent almost 2 1/2 years working in psychiatric nursing. Loved it. Great patients. Great staff. Then boredom set in, ER beckoned and I've worked there pretty much since.

Maybe someday I'll tell the story of the night my patient ran out onto the roof!

And no, I wasn't wearing heels that shift.......

Satirical Setting

Why yes, you can train to be a nurse and learn how to place your face inside a big white hammock!

Or...

You can go visit the Carnival of Satire over at "The Skwib" and check out all the, well, satire! Parody counts, too and Emergiblog's "Hitchhiker's Guide to the Emergency Department" made it into this week's list of postings.


I'm heading over to read the other postings now, why not do the same?

Hey Buddy, Can You Spare Some Robitussin?

Oh yeah? Well I got one too, chickie baby and it's gonna take more than a 50-year-old package of Vicks to get me moving.

It started with a simple little case of what I call "Lauren Bacall-itis". A little laryngitis that gave me a deep, sexy voice for a day. All I needed was Humphrey Bogart and I would have been a happy woman. Didn't even feel sick.

Then the aching. That was yesterday. No sweat. I little ibuprofen and I had a good six hours of relief. I coughed a few times, but hey, who doesn't?

This am I woke up with a tight chest, a wee bit of stridor cleared by a now painful, non-productive cough and a voice that sounds like a longshoreman.

Pardon my language, but WTF? I had the flu shot. And I have too much to do to be down-for-the-count.

I bit the bullet. I called in sick. I don't think that was a cause for joy amongst my co-workers who now have the dubious privledge of trying to cover my 12-hour shift.

That's another thing about being a nurse.

You can't ever get sick without feeling guilty about it.

Personal Space and the Race to Replace

This is not exactly a nurse I'd like to run into in a dark hallway.

But she's right! It didn't hurt a bit!

One of the Emergiblog posts was accepted into the Carnival of the Vanities, hosted this week by The Hip and Zen Pen blog.

The topics are varied, and you can submit what you consider your best post for the week. I submitted my "Who Let The Dogs Out".

I felt a little strange submitting to a non-medical carnival, but I am in good company - "Doctor" (formerly of the Medical Madhouse - see sidebar link) is also represented! So if you are looking for a very eclectic group of bloggers, check it out!

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I have never minded having to commute to work.

It gives me a chance to gear up , to change from wife/mom, maid/counselor, chauffeur and accountant/chef to my much easier job of working as registered nurse in an emergency department.

As I drive, I exercise my vocal repertoire of songs. I practice my harmonization techniques (I swear I could have been in the Eagles) and quite often give Steve Perry (formerly of Journey)
a run for his money in the high-note department.

Unfortunately, no one appreciates my talent.

I've had absolute strangers tell me to shut up as they drive by.

And this is with my windows closed.

But I digress....

I stop and pick up my 44 gazillion ounce Diet Pepsi that will last me all shift and assess the parking lot as I drive in and park in an area that, well, isn't exactly dedicated to the staff.

Now before I go on, let me tell you that when it is the end of my shift, which is usually sometime during the night or early morning, I give the oncoming nurse time to acclimate. Get a cup of coffee. Survey the department. Take a breath. I'm in no major hurry to leave, I know my relief is there and I don't want the oncoming nurse stressed the moment she walks into the unit.

I wish I had someone like that waiting for me when I got to work.

But no, I get Whirling Dervish, RN.

She meets me at the sliding doors and proceeds to follow me.

To the breakroom where I place my purse.

To the bathroom where I get my various accoutrements (pen, stethoscope, scissors, tape) out of my locker. Talking continuously the entire time, reporting on patients before I even know which assignment I have. I'm sure she would join me in the actual toilet but there is only room for one in the cubicle so she talks outside the door.

It wouldn't surprise me in the least if a chart was pushed under the door for my perusal while peeing. Which tends to be copious after all the Diet Pepsi.

After awhile she sounds like Charlie Brown's teacher: "wah, wah, wah-wah wah!"

I don't even think a Diprovan drip would settle her down. Must be why she works the day shift.

But that's a whole different topic........

It's No Mystery, It's Grand Rounds!

Look, up in the sky!

It's a link to Clinical Cases and Images Blog

It must be time for Grand Rounds!

There's no mystery science there, just real-life stories and information from the medical blogosphere.

Emergiblog is proud to have been chosen as one of the contributors this week.

So grab your 'bots, settle in and get yourself up-to-date on what's happening in the world of health care!

When Your Patient Gets A "Two-For-One" Deal

One thing?

I can think of a million things I would have like to have said to a few doctors over the years but I was too young and intimidated. Now that I am of a certain age and incapable of intimidation, I realize it just isn't worth the effort.

Doctors just don't seem to yell as much anymore.

One, the working relationship between doctors and nurses has changed into more of a collegial partnership.

And two, I was dancing to the Bee Gees when they were still in diapers. Perhaps they are respecting the elders.

Anyway, this nurse in the ad feels confident that she can tell her doctor about acoustic ceiling tiles without stepping on any toes.

Was noise pollution an issue back then?

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Many, many years ago I learned that things are not always what they seem to be. Especially in emergency medicine. Here's an old story of a case that taught me never to assume anything.

Patients will often come into the ER self-diagnosed. Often they are right. The asthma exacerbation. The recurrent migraine. They've been there, done that and gotten everything but the T-shirt.

So, when a patient anxiously enters the department and with muffled voice says they are having an allergic reaction and their throat is closing off, it gets your attention. This is the definition of "immediate bedding".

Family reports that two weeks before, this middle-aged patient had significant facial puffiness following ingestion of an OTC (over-the-counter) medication. Patient self-medicated with Benadryl and no medical attention was sought. (Patient had no other medical problems and denied tobacco or alcohol consumption. They didn't have a primary physician, having not needed one before).

Not believing that the reaction was caused by the OTC med, the patient took it again that day. Within minutes the throat sensation was noted. Again, Benadryl was taken (twice the recommended dosage on the bottle) but when it did not work, they presented to the ER for treatment.

To say the patient was anxious was an understatement. They lay upon the gurney as stiff as a board. I've seen rigor mortis that wasn't that tight. No stridor, no wheezing, no tripod position, no facial swelling, just a thick, muffled-sounding voice that seemed difficult to produce and a look that could almost be described as panic.

The patient did note that in spite of the fact they were still uncomfortable, the throat was somewhat better. Perhaps the Benadryl was working. The ER doctor was at the bedside and the patient was diagnosed as having an allergic response and was treated appropriately.

I explained the medications calmly, reassured the patient that they would be feeling better in just a few minutes, perhaps a bit shaky from the medication, but certainly improved. The family was at the bedside. I left the call bell within reach and because I was covering the cardiac beds that shift, I went to check on my other patients.

I was summoned to the bedside of my patient with the allergic response within five minutes.

"Should I be having chest pains?" my patient asked. "My throat feels better". The monitor showed mild sinus tachycardia. I asked the patient to describe what they were feeling. Sharp, intermittent and mid-sternal with radiation to the left shoulder. No nausea, no diaphoresis, no SOB. I went to the ER doc thinking that what this patient needed was some Vitamin "A" (aka Ativan, given for anxiety). An EKG was requested. Of course it would be - I was embarrassed that I didn't just do it myself, but I was fixated on "allergic reaction".

Occasionally there is a moment when an EKG shows up on the screen that produces an "uh-oh" response from the technician - something isn't right. Well, I happened to be the technician doing that EKG and my response as it printed off the machine was "Oh s***!" It was BAD.

Twenty minutes later the patient was having a cardiac cath and three stents put in his coronary arteries, one of which was 100% occluded.

Was the patient really having an allergic reaction? Was the closing throat a symptom of the MI? What about the angioedema two weeks previously, seemingly related to the same medication taken by the patient that day? Was it just a fortunate circumstance that this essentially healthy individual happened to have his MI right in the ER?

I never learned the answer to those questions. I do know the patient did wonderfully and was discharged without complications.

But I still get a twinge of anxiety just thinking about that EKG!

It's A Tough Job, But Somebody (Else) Has To Do It

The voting is still going on over at Medgadget for the Medical Blog Awards of 2005. If you haven't voted already, please consider visiting the site and giving "Emergiblog" your vote for Best New Medical Weblog and Best Clinical Weblog. I believe the voting is going on until January 15th. Thank you!

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This poor man is trying to get in to see his wife. But no, the doctor has said the patient is to have no visitors.

Not even her husband?

He's even brought his wife flowers, grown in her very own greenhouse.

Why, that's wonderful, opines Nurse Sentry! They just might make her feel less depressed!

Umm.....maybe if she could have visitors she might be less depressed?

And so ends another chapter in the history of the nurse-in-advertising. This ad is actually for portable greenhouses! Go figure!

Do you even see nurses in ads anymore?

And how do you know they are nurses if they are there?

I miss my cap.....

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My philosophy of emergency medicine is very simple.

If there is a patient in the waiting room and an empty gurney in the department, I believe that the patient's butt should be on that gurney. Period.

The minute the gurney is clean the next patient is getting tucked in.

Not all emergency nurses share this view and some will go out of their way to, shall we say, divert the patient care to their department colleagues.

Here are a few behaviors I have witnessed over the years:

• Selective Vision - there are five charts in the "orders to be done" rack, but they are not seen because the nurse is too busy reading about Brad and Angelina in an old People magazine.

• Selective Selection - the nurse approaches the rack, assessess the work to be done and leaves the NG tubes and enemas to the next nurse. They are, however happy to adminster the ibuprofen and put a band-aid on the skinned knee.
  

• Cleanliness Is Next To Godliness - the nurse develops an acute onset of obsessive-compulsive disorder as he/she is too busy to take another patient because the IV tray contents must line up perfectly. In every room. And if she doesn't do it, who will?
  

• The Waiting Game - everyone sees the chart for the patient in the waiting room, but no one makes a move, waiting to see if another nurse will grab it first.

• Ambulance-induced Abdominal Discomfort - it begins with the ring-down and reaches its apex when the rig pulls up to the door. Immediate residence in the staff restroom is required. Spontaneous relief occurs as the patient is settled into the gurney and report has been taken, as demonstrated by the sound of a flushing toilet.

• Tech Support - run your ER tech to the point of exhaustion, doing things you can actually do yourself, but why bother?
  

• Helpless Hattie - oh dear, she just can't seem to get that darned IV in, would you please help? At which point you immediately insert a line into a vein the size of a fire hose.
  

• The Charter - the nurse sits at the corner desk, hunched over a chart and furiously writing. As she is known for her compulsive charting, no one questions her motivation.

In reality, she is making a list of topics for her next blog entry.

Hey...I never said I was perfect!

The Polls are Open!!

The polls are open for the 2005 Medical Weblog Awards! I went to vote and was surprised to find that Emergiblog was nominated in two categories: Best New Medical Weblog of 2005 and Best Clinical Weblog! Holy cow! So hop on over to Medgadget , check out the nominees and select your favorites.

I would be honored to receive your vote for "Emergiblog"!

Hurry to Grand Rounds and Pass the Pepperoni!

Hey, even Darla had a nursing cape!

I know pizza isn't ususally a part of Grand Rounds, but in my unit, we eat!

There's no food over at Random Acts of Reality but you will find this week's compendium of collegiality, aka Grand Rounds.

Alas, Emergiblog is missing-in-action this week because yours truly was grandly rounding around the ER for a total of 32 hours this holiday weekend. Blogging isn't my life but life can sure interfere with my blogging!

I hate when that happens.

Who Let The Dogs Out?

Update: Welcome to all who have linked over from the Carnival of the Vanities! This is my first post to a non-medical carnival. Have a look around and let me know what you think!

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Well, this is what I expected to feel like this weekend, but with the exception of the first five hours of my New Year's Eve shift (3p-3a), it was actually very nice! I rang in the New Year in the waiting room with the ER doc and a spunky 70-year-old woman who was waiting for a taxi to take her home. I was very glad to see Dick Clark back on duty this year, he's obviously made remarkable progress since the stroke.

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The following story is absolutely true. I have not changed a single detail, HIPPA be damned. My patient will never see this story.

She can't read.

I was sitting at the desk when I noticed her. She wandered into the emergency department around 0230, and began looking around. At first I could not tell if I was dealing with a male or a female. I tried to make verbal contact, but she didn't acknowledge me. She turned and entered the empty cardiac room. I followed her, speaking as pleasantly as I could.

She walked right past me.

She looked old and walked as though her legs were arthritic. Her coat was dirty, wet and malodorous. Even through her fur coat I could see that she was very thin. (Homeless in a fur coat, go figure.)

The doctor and the two patients who could see the nurse's station from the rooms frankly stared as the patient walked past, proceeded to enter the station and walk back into the break room. Excuse me? I was so stunned by her behavior it took me a moment to react.

As I entered the break room, fully intending to escort this rather, uh, assertive female out of the department, I noticed that her face lit up at the sight (and smell) of our New Year's buffet on the break table. She just wandered around the table, looking and taking in the smell of meatballs, hummus, cheese....our usual selection of fattening foods. She never attempted to take any, but when I offered her a piece of chicken she nearly attacked me to get at it. Shocked, I dropped it and she bent over and devoured it. On the floor.

Through it all she never made a sound.

I noticed an open, festering wound on her lower left leg; this contributed dramatically to the odor emanating from her body. She would not leave the break room until I coaxed her out with more food. Again, I dropped it and again she ate it off the floor.

In 26 years of nursing I had never experienced this on the job.

Needless to say, I was a bit concerned. I managed to get her out of the department and into the ambulance bay and we barricaded the doors so she could not get back in. Our local police department was on the way, so I kept feeding her crackers so she would not get agitated.

Oddly, she began following commands so I knew she wasn't deaf. She sat on the floor in the ambulance area and then proceeded to lay down. I wasn't so afraid of her by now so I scratched her ears.

Oh, did I forget to mention that she was an approximately 80 pound, long-haired German Shepherd?

We called the phone number on her tag. The owner had left her in his car, fully intending to leave her there until later the next day. That poor dog was starving. Somehow she was able to break out and that is how she wound up in the ER. No one would be coming to pick up our patient during the night. Animal Control was called.

Once her tummy was full, she was a calm, loving dog.

She liked me.

It took Animal Control an hour to get to the ER, during which time this patient benefited from 1:1 nursing care.

No charge, of course.