The Key To A Smooth Running ER? Nurses!

There is a person in this photograph who suffers from a rare, dare I say extinct affliction.

Yes.

It's an actual photo of "Flat Cap Syndrome".

Flat Cap Syndrome developed when the brim of one's nursing cap was larger than the fold behind it.

Some say that the victims were responsible for choosing to go to a School of Nursing identified by those caps.

Don't blame the victim.

Maybe it was the only School that she was accepted to.

Maybe.....maybe she didn't know....

By the time I graduated, designs in nursing caps had pretty much made Flat Cap Syndrome a thing of the past.

My cap was never flat, and to this day it stands proudly in its case in the den closet in pristine condition.

(Disclosure: it's in pristine condition because I just bought it off of eBay.

I have to get the green and gold ribbons on it and then I have to get the courage to wear it to work because my co-workers will have a field day with me.

If all of a sudden there is no more Emergiblog, it's because they killed me with ridicule.

Call the authorities.)

hhhhhhhhhhhhhhhhhh

Some of the advantages of working in different facilities are the exposure to different styles of nursing, different opportunities, different patient populations and differing protocols regarding what nurses are able to do on their own.

I'm not talking about using nurses instead of doctors, a la the problems that Dr. Crippen at NHS Blog Doctor describes, I'm talking about protocols that allow nurses, using certain criteria established by the ER physicians, to initiate care prior to the doctor seeing the patient.

Sounds like a great way to facilitate patient flow and satisfaction, right?

It is!

The best ERs that I have worked in are the ones that, per protocol, allow the RNs to do what they do best.

Conversely, the worst ERs I've worked in allowed the nurses to do nothing without an order.

• When I worked at "World Renown Medical Center With Hard To Get Into Medical School", this was the case. The nurses could not make a move without an order.
  

• Why?
  

• It was a teaching facility. How could the interns/residents learn to order appropriately if the nurse did it first? And forget verbal orders, if some resident gave an order you grabbed the nearest order sheet and made them write it. So often you'd have five or six different order sheets going.

• Why?
  

• Because if there was a descrepancy between what was said and what was done, guess whose derriere would be on the line? Right, the nurse's. Remember the old saying about how excrement flows downhill? It's true.

• And the wait to get into a room? Hours. We're talking 5-7 hours at times. You could be vomiting, have a 5-day migraine with photophobia, writhing on the floor with right flank pain secondary to a kidney stone and you would STILL be sitting in the ER with all the feverish, coughing bronchitis patients. And don't think asthma would get you a front row seat, either. If your O2 sat was normal, have a seat like everyone else.

• Why?

• Because the beds never turned over. Because one nurse would be responsible for six monitored patients plus the psych isolation room across the hall. Because....

• ... first the "Pulmonary Team" had to see the patient, then they would decide this was a cardiac problem and you'd wait a few hours for the "Cardiac Team" who would discover that the patient wasn't on that service after all and a different "Team" would come in an hour later, only to discover that said patient couldn't be admitted there anyway, but then the patient would vomit blood which meant that they were too sick to transfer and you had to wait for the "GI Team" to come down and finally admit the patient.

• Not to mention every single pediatric patient in the clinic area getting conscious sedation for their boo-boos.
  

Get the picture?

Then we have example number two.

• Small community hospital, one that I will call "Mini County Hospital". Sat right in the middle of a very ethnically diverse, lower-income area of a suburb that could be called the Meth Capital of the SF Bay Area. Many patients. Many clinical, non-emergent patients. Some very emergent patients.
  

• The nurses were not allowed to do anything. Nada. Kaput.

• Why?

• Because the department had a wide mix of nursing experience, from new grads to newly designated dinosaurs like me, and there were no protocols because they could not depend on all the nurses to have the same level of competency.

• So one day, Nurse Experience (me), brings in a patient with chest pain, starts a line while the tech does the EKG and within five minutes hands the doctor the EKG and the orders for CBC, Chemistry Panel, Cardiac Enzymes and portable chest to the unit clerk. No problem, right? Wrong.
  

• I was curtly asked, "Who the hell told you to order those labs?".
  

• I looked at Dr. Who Was In Training Pants When I Graduated From Nursing School and said that they were the standard labs ordered for a chest pain patient suspected of having a cardiac problem.

• "You are not covered to order these labs!

• I said , "Are you telling me that after (then) 24 years experience in nursing, that I cannot at least get a cardiac workup started?

• That was exactly what he was telling me. I had three times the experience and was old enough to be his.....older sister, but it didn't matter. The nursing expectations went to the lowest common denominator, that of a new grad.

• Which meant the patients in the waiting room waited, sometimes 8 hours for the same reasons stated above. The nurses could not facilitate patient movement. Because we worked with relatively new doctors, every child who vomited even once got an IV and a bolus. Most got septic workups.
  

Now let's contrast this with an ER that runs quite smoothly, which happens to be where I am now and plan to retire from when I'm so old I can't stand up straight.

• This ER has nursing protocols. Detailed, well written protocols. Here's what happens when you come into this ER:

• For example, you come in and your chief complaint is nausea, vomiting, diarrhea for three days with fever and you are extremely dizzy when upright. I'm your nurse.

• Before the doc shows up I will have orthostatic vital signs, an IV in, bloods drawn, a bolus of Normal Saline initiated (unless you are elderly or have heart trouble) ,at least a CBC and Chem 14 ordered (with additional blood in case more tests are added) and you can expect me to ask for and collect a UA and an stool specimen, which may or may not be needed, but they will be collected just in case.

• Or you are an elderly male who looks 8 months pregnant and hasn't urinated for 2 days except for a little bit here and there. You can barely walk, you are in so much pain. If I'm your nurse you will have a catheter in before you can say "ouch", assuming your prostate co-operates.

• Your wait on a bad day in our waiting room may be three hours max.

• Why?
  

Because the Registered Nurses in my department are covered by extensive ER protocols and we work with doctors who respect our judgement and know we would not order outside of our protocols.

My attitude is that by the time that doctor walks in to see the patient, everything he/she needs has been at least considered. I am able to do much more than described above, but it often isn't necessary because the doctors see the patients so quickly, they are usually right behind me.

(Yeah, I have a great job, which I appreciate all the more because I've had some bad ones.)

So the Emergency Departments that give nurses the most autonomy via protocols wind up being the ones that really need it the least. And they wind up being the ones with the highest patient satisfaction ratings.

A little ironic...

Doncha think?

ddd

Addendum: Dr. Who Was In Training Pants When I Graduated From Nursing School turned out to be one of the neatest persons I have ever met and he is a fantastic doctor. He was the one I missed most acutely when I left for my current job. Go figure.

The Sign of the Four

Ummmmm......

Oooookaaaaay......

Midol made Betty gay?

They key to same-sex attraction has been in an over-the-counter pill all this time?

How does that explain the guys?

Did they get into their sister's stash of Midol and there was no turning back?

Well, hey, at least Betty is happy. She probably called Steve, broke up and asked Shirley to the soda fountain hop.

Who knew?

hhhhhhhhhhhhhhhhhh

I have been "tagged".

Normally I do not participate in "tagging" because this is a professional blog where only professional matters are discussed. It is not about me.

Like hell!

It's TOTALLY about me!

So, thanks to Kimberly at R_N For Your Life, you shall now learn more than you ever wanted to know about....

Me.

• 4 Jobs I Have Had In My Life:
  

• Registered Nurse

• Nurse's Aide

• Telephone Sales for Montgomery Wards, in their Appliance Extended Warranty Department. Freakin' hell on earth.

• Waitress at Bumbleberry's Restaurant (now defunct - similar to Marie Calendar's); spent all my tips on albums

• 4 Movies I Could Watch Over and Over:
  

• A.I. (Artificial Intelligence) - hands down, the best freakin' movie ever made. So creepy, so sad, so totally futuristically cool! Such a beautiful mix of Speilberg AND Stanley Kubrick in one, beautiful homage to the eternal story of Pinochio and the moral question of our responsibility to artificially created intelligent beings. I own it, I watch it regularly. You HAD to see this on the big screen. I saw it four times in the theater. I was the only person bawling into my tissue! If you do watch it now, make sure it is on a large screen TV, preferably with all the lights out and when it is raining! DAMN good movie!
  

• I, Robot - Will Smith in the shower, OK? I'm just sayin'. A great rendering of Isaac Asimov's classic novel - his whole robot series is mesmerizing. SO sci-fi! When I came home (saw it twice in the theater), I looked into what it would cost to rent one of those robots that Mazda makes ("Asimo").....it was something like $300,000 per day. Guess I'll have to get me a robot vacuum instead.....

• Hitchhiker's Guide To The Galaxy - Martin Freeman as a yarn man vomiting up yarn in a bin. I'm just sayin'! Actually, I was also partial to Zaphod Beeblebrox. Hilarious movie if you are hip to British humor and if you are just hip in general. I saw it late on opening night (three times total) and there were only six of us in the theater and we were ALL hip to the Douglas Adams vibe. I laughed so hard I cried. Who you calling a nerd?
  

• Sgt. Pepper's Lonely Hearts Club Band - Barry Gibb in Technicolor, OK? I'm just sayin'! I saw this four times in the theater in one day! Of course, this was prior to my becoming an RN and having responsibilities. I saw it alone, then took my little sister, then took my friend and then took my fiance! And he married me anyway! I love the Bee Gees and they do fantastic versions of the Beatles' hits. Of course Peter Frampton looks like a powder puff but I saw him in concert a couple of years ago and he looks mighty fine with no hair!
  

• 4 Websites I Visit Regularly:

• James Lileks - at lileks.com , writer extrodinaire, hilarious blog called "The Bleat" - trust me, all he writes about is his day and you'll be rolling in the aisles! And he is one of my "blog parents"! If you check him out, you have to read his archives - he's been "blogging" since 1997!
  

• Praying For Karis - at www.aup.org/Karis. She is a friend of my son's at Notre Dame who has just gone through the second transplant of her entire digestive tract. This is a website the family put up a few years ago to keep friends and family in the loop.

• Stuff On My Cat - at stuffonmycat.com. This site is exactly what it says. Pictures of cat whose owners have put stuff on them. You have to see it. It's hard to describe.

• Emergiblog - at, well, here! (1) because it's my blog and (2) this is where I link to everybody else so I can read your blogs!
  

• 4 of my Favorite Foods

• Avocados

• Guacamole

• Diet Pepsi - fountain

• Quarter Pounder With Cheese - I have no shame!

• 4 Places I Would Rather Be Right Now

• Mendocino, California - I was meant to live on an ocean bluff

• Hollywood, California - as an American Idol finalist (or sitting on Simon's lap, I'm not picky).

• England and Scotland - because I definitely feel the roots of my ancestors calling to me from across the Atlantic, and because they have totally cool television and that is where Martin Freeman lives. And they have Judi Dench and Patricia Rutledge. Oh, I'm sorry, don't know who they are? Well, I suggest you spend more time with the BBC, thank you.

• Australia - I want to volunteer to work at Roo Gully, it is a sanctuary for kangaroos (and other animals) with the goal of getting them back into the wild. I am a foster mom to a 'roo and this would definitely be a working vacation. For a few months. For some reason my hubby says no. Maybe because there are no ugly men in Australia.

• 4 Most Wonderful Places I Have Been

• Mendocino, California - stunning

• St John's - the one place in the Carribean I remember with fondness
  

• Puerto Rico - shaking hands with Steve Perry

• Mexico - at the market in Mazatlan feeling guilty that I was supposed to bargain with the already low prices for these totally cool things.

• 4 Books I Could Read Over and Over

• Shelby Foote's 3000 page, 3 volume Civil War Trilogy. Truly amazing...

• The Complete Hitchhiker's Guide To The Galaxy (all the books)

• The entire Mitford Series by Jan Karon

• The entire Isaac Asimov catalouge

• 4 Songs I Could Listen To Everyday

• "My Immortal" - Evanescence

• Anything by Journey

• The entire "Mad Season" album by Matchbox 20

• Anything by Robin Gibb (or the Bee Gees)

• 4 Reasons I Blog

• I enjoy writing (and being read)

• I learn so much more - it's like free CEUs

• I love reading what everyone else writes and feeling like a part of the community

• It has brought home how similar we all are, no matter where we are from, that never ceases to give me goosebumps!

• 4 People To Tag

• I am too embarrasssed/shy to tag someone

• Any volunteers willing to take this on?

Now that you all have officially "Too Much Information" on me, I shall sink, red faced into the oblivion of the internet.....or more specifically a bubblebath!

UPDATE: DR. FLEA HAS VOLUNTEERED TO BE TAGGED!
UPDATE NUMBER TWO: BIG MAMA DOC IS UP FOR TAGGING!
UDATE NUMBER THREE: MARY AT "A MOTE IN THE LIGHT" HAS JUST BEEN TAGGED!

You Got To Know When To Hold 'Em.....

Holy cow!

I never saw this in Microbiology!

Just a bunch of stressed out student nurses trying to cram in it into one summer session going five days a week for five hours a day.

Mr. Graham Positive here was nowhere in sight.

Then again, I took Micro so long ago that if he was in my class he'd be wearing Angel Flight pants, a silk shirt open to the lower sternum showing (hopefully) chest hair and gold chains, as he walked to his desk in platform shoes and feathered hair a la Barry Gibb.

I think I need a cold shower.

hhhhhhhhhhhhhhhhhh

Ah, it isn't often that I feel a "rant" coming on but there is something that I feel very strongly about.

Maybe it makes me a heartless nurse.

Perhaps it makes me a bad mother.

The issue?

I cannot stand it when conscious sedation is ordered for children who have a laceration.

I am old-school. I believe in wrapping them like a mummy, placing them in a papoose and holding them during the suturing. It's faster, the pain stops after the lidocaine injections and the child is then up and ready to go immediately.

For the uninitiated, "conscious sedation" is a term used when a patient needs an especially painful procedure done. An IV is placed and they are given medications that (1) reduce the pain (2) sedate the patient and (3) cause amnesia so the patient doesn't remember what the procedure was like when they wake up.

During the procedure the patient is placed on a cardiac monitor, oxygen, a respiratory therapist is present in case there are airway problems, reversal agents are kept at the bedside in case of emergency, and the patient has the IV as previously mentioned.

It is a wonderful way to get patients of any age through procedures like reducing shoulder dislocations or fractures or hip prosthesis dislocations.

It also ties up one nurse with one patient for however long it takes that patient to recover. The patient is never left alone. The drugs are short acting, but recovery can take as long as one hour for some patients, depending on how much medication they were given and how fast they metabolize it. Vital signs are taken every five minutes during the procedure and then every 10-15 minutes after until the patient is awake, able to tolerate clear fluids, have vital signs near pre-procedure levels and can ambulate.

Is this really necessary for a child with a one-half inch laceration on his forehead?

Ah, I hear the chorus now....

From the parents: "But it is so traumatic on my poor child to hold them down!"

They'll get over it. I not only remember getting stitched at the age of three I still have the scar!

It does not "scar"you psychologically for life. Getting stitches is a part of life. Are we raising a generation of wimps for whom a boo-boo is a life altering trauma?

From the ER docs: "It's hard to hit a moving target!"

Then your nurse doesn't know how to hold. I developed the (not-patented) chest hold many, many years ago where the child couldn't move his head if he tried. Let's just say that it involved removal of my scrub jacket and namebadge, leaning over the gurney, placing my chest on one side of the head and using my arm to surround the top of the child's head and holding it against my chest.

Works every time.

ddd

Just a couple of my personal beliefs.

• Every person getting conscious sedation, including kids, gets an IV whether or not the doc believes it is warranted. Emergency situations are rare, but that patient is my responsibility, too, and my derriere is on the line if we aren't prepared for them.

• If conscious sedation is ordered, I feel it is the doctor's responsibility to explain to the parents exactly what that entails, including oxygen, monitoring, IV medications, etc. Just telling the parents that the patient will sleep through the procedure is not enough. They shouldn't have to hear that from the nurse who is having them sign that they have received informed consent.

End of rant.

Now, to end on a positive note:

Emergency room physicians are second only to plastic surgeons when it comes to stitching lacerations on patients of any age. I've seen some beautiful repair work by ER doctors in my time.

I'm No Fool, No Siree! This Week It's Grand Rounds For Me!

Well what on earth is Jiminy Cricket doing as my Grand Rounds mascot today?

Well first of all, our favorite NHS Blog Doctor, Dr. John Crippen is our Grand Rounds host this week.

Dr. Crippen likes the game of Cricket. Only yours truly thought Cricket was really Croquet.

Hence, the Jiminy Cricket mascot.

Dr. Crippen quite kindly posted an Emergiblog archived post this week, as this blogger was too exhausted to even hit the keyboard over the weekend.

It's one of my favorite posts from last October.

Perhaps I shall read this particular volume of Grand Rounds with a nice spot of Earl Grey tea to get myself into that wonderful British frame of mind.

Enjoy! I know I will!

Tangential Thoughts on a Thursday

Another Great Moment In Medicine:

All the nurses go to their rooms and every resident in the world gets a good night's sleep!

Sorry, nursing colleagues.

I couldn't resist.

It was my first thought when I saw the photo!

This is actually a Parke Davis ad, one of a series.

It's a medieval hospital.

Doesn't it seem like a lot of wasted space in the center there? How did they heat the thing?

The nurse up front looks like someone just told her she had to do mandatory overtime.

hhhhhhhhhhhhhhhhhh

There are some new links in town! Check out an new blog by ER physician Charity Doc , or soon-to-be Student Nurse Jack and Misadventurous Melissa who is a nurse colleague in southern CA. I've also discovered Krista at Picklecakes , also a nurse and not afraid to tell it like it is. I've also added to my patient blog roll call recently with Patricia at The Multiple Sclerosis Companion.

hhhhhhhhhhhhhhhhhh

I sure would love to hear the whole story about why Rich at Geek Nurse had to shut down his blog.

I was sorry to see that.

I have not worked in an ICU since 1989 and I was learning a lot from him, especially since I've never worked a Pedi ICU.

ddd

I love the job I have now and I wonder what I would do if given the ultimatum to shut down Emergiblog.

I know!

I'd quit and put up an online tip jar!

I could get free care in the ER!

I'd have to find a place for the homeless with wireless internet connection, a place to charge up my iPod, my cell phone, my coffee pot and have access to American Idol, BBC America and the Cartoon Network, but hey! All in the name of free speech!

In all seriousness, we miss you, Rich. Let us know "where" you are. You can't keep a good nurse down. Especially in the blogosphere.

hhhhhhhhhhhhhhhhhh

Now that life has settled back into it's normal routine after family health issues and lots of extra shifts, it sure is nice to catch up on all the posts I missed. I'm only a third of the way through my list of blogs (see sidebar). At least with my "live bookmark" feature on Firefox I can see who has new posts and who doesn't.

hhhhhhhhhhhhhhhhhh

I've decided to give Blogger one more chance.

I've checked out Typepad and I actually "own" the "www.emergiblog.com" domain name over at enom.com, I just haven't had the time to actually sit down and work with it.

I'm kind of attached to this format and changing designs is like getting a plastic surgery make-over. It would still be me but it wouldn't "look" like me.

But one more major breakdown that affects this blog and I will become so good at html my new site will look like the Taj Mahal.

Blogger may be free, but so is half the care I give in the ER. I still have to do my best.

hhhhhhhhhhhhhhhhhh

For one shining moment, I was a Large Mammal over at the ttlb ecosystem. Now I am a Maurauding Marsupial again. Sigh. How can that be when my Techorati score is up?

Yes, I pay attention to little things like ttlb and Site Meter.

Oh well. At least having a marsupial pouch is handy for my trauma scissors....

What I Think It Takes To Be An ER Nurse

"Mary Louise Shines"?

Yeah, and I'm Catherine Zeta Jones.

This is no real nurse. I haven't seen her in a single recruitment ad in all the hours I've spent searching the internet.

Interestingly enough, she comes from New York, just like Beulah France, RN, our favorite nurse consultant when it comes to harsh toilet tissue.

So we can avert the nursing shortage and gain valuable staffing by just using Pepsodent?

"You'll wonder where the yellow went, when you brush your teeth with Pepsodent!" I did not make that up. It's the old ad jingle. Never mind what year.

But wait!

Now she is recruiting for...clear skin?

She would never have recruited me.

She looks like a Stepford Nurse.


She speaks in thought bubbles.

And her cap is really yukky.

Hey, I have priorities, ya know.

hhhhhhhhhhhhhhhhhh

Ever thought about being an ER nurse?

Ever wonder if you "have what it takes"?

I didn't think I did until one slow day in ICU I floated down to a tiny, three-bed ER and absolutely fell in love with a whole new world.

So here is my own, personal subjective take on what makes an ER nurse an ER nurse:

• A Strong Personality

• Timid, fragile....no place for that in the ER. Things will get tense and tempers will fly.
  

• Do you cry if someone says "Boo!" in the wrong way? If you are a "Sensitive Sam", you will have a hard time. I know. I was a "Sensitive Sam" for a few years, myself. Then I got older. Now I can say "Boo"! right back and then some.

• Alternatively, if you are the type to hold a grudge, the ER is not for you.
  

• That doesn't mean you have to be a loud, boisterous person. Two of the best nurses I ever worked with were extremely quiet. They didn't say much, but they were the epitome of efficiency and their patients were in superb hands.

• An Assertive Personality

• All nurses are patient advocates, but in the ER you do not often have the luxury of time.
  

• Occasionally you will find that decisions are being reached (as in admit vs. return home) that you, as the nurse, can influence.
  

• If you feel a decision is being reached that is not in your patient's best interest (weak while ambulating and lives alone, for example), you must speak up. Can you do that?
  

• In ER, probably the easiest doctors you will ever deal with will be the ER docs. There is a sense of teamwork and communication between the docs and nurses that is really unique to the ER.
  

• But you will be dealing with specialists from every department: surgeons, eye specialists, hospitalists, cardiologists, neuro docs, etc.
  

• They don't always know the policies of the ER.
  

• sometimes they will make it quite clear that they could not care less about the policies or business of the department.
  

• It will, occasionally, be up to you to assert that you cannot carry out a specific order because of said policies or ask them if an order can be done after admission to free up an ER bed. Are you willing to do that?

• Energetic

• If your idea of aerobic exercise is to click the remote twice in a row, you need not apply to the ER.
  

• You will move. There will be shifts when you never stop moving. You need to be willing to walk in that door with roller skates on and well oiled to boot.

• You have to be willing to put in the energy that the job requires. Can you do that?

• Stamina
  

• Energy is a willingness to work. Stamina is the ability to work.

• You will never know what you will be dealing with on any given shift
  

• You have to be able to go the distance - finish the shift giving 100%.
  

• Often without breaks, sometimes without dinner.
  

• Maybe even after your scheduled shift is over. Can you handle it physically? (You'll learn your limitations. For instance, I do not have the stamina for 12-hour shifts. So I work 8 instead.)

• The Ability to Prioritize

• You have four patients, two cardiacs, one going to the cath lab, one GI Bleeder (stated at triage) and a patient with an ingrown toenail. Who ya gonna call?
  

• Sorry, the Ghostbusters are busy - you make the decisions.

• What orders go first on which patients?
  

• You can always ask your co-workers for help, but you need to know what you want them to do! Can you make decisions on the fly?

• Can you handle more than one crises at a time? Are you willing to take the chance that you will have to? Does the idea exhilarate you or make you nauseated?

• The Ability to be Flexible

• When your co-workers get overloaded (see above), are you able to see beyond your assignment and help prioritize their care?

• When your rooms are empty, are you willing to discharge, start IVs, medicate your colleague's patients? Are you willing to ask them if they would like your help?

• Someone calls in sick. Are you willing to pitch in and help cover for them?

• Your co-worker is having a bad day....sorta bitchy. Are you willing to cut them some slack?
  

• The doc wants to add some tests to the patient, increasing your already heavy workload. Can you take it in stride?

• Attitude

• You must have a positive attitude.
  

• No one wants to be around a constant bitcher or fault-finder.
  

• That can drag down the morale in an ER faster than an unsuccessful code

• Can you put on a positive front even when you are not feeling it?
  

• Then, again, there is a time and a place for ventilating. The nurse's station or the patient's room is not it. Can you wait to complain until it's appropriate?
  

• Your patients already feel bad. They are sick, they are angry, they are tired, they are impatient. Can you smile and be upbeat when everyone around you is not?

• Can you see your patient as an individual and empathize, not just see them as the "abdominal pain in the back room"?

And now the controversial statement that will make everyone upset:

I do not believe that a nurse should begin her ER career as a new graduate. It is imperative that she/he gain the skills of prioritizing and assessment/evaluation on at least a monitored unit. The "feeling in your gut that something isn't right" comes from your experience outside the ER. You need to have enough experience to have developed that sixth sense.

You should be comfortable with drips and coding and defibrillating (basically, Critical Care) well before coming to the ER. The other stuff is just clinical and can be picked up quickly.

You have to be able to carry your own weight in the ER.

There are always exceptions, I have worked with nurses who are barely out of school who were made to work ER. But they are few and far between.

If you were meant for the ER you will love every minute. If you were not meant for it, you will know almost immediately.

I think it may be in our genes.......

Baby, It's 5 AM and It Must Be Grand Rounds

I cannot believe I did this.

I forgot to link to Grand Rounds at HealthyConcerns.com
yesterday!

I complimented Elisa on the website and then totally blanked out when I posted yesterday. A great job was done and I'm still reading!

So a big shot in the gluteus maximus for me and a thorough washing out of my synapses with Wisk.

(I knew I'd find some way to work this photo into the blog! The title of this post is supposed to be a humorous take on an old Matchbox 20 song, but it really IS 0500 and it sure seems witty at the moment. I'll have to see what it looks like after some sleep.)

Tuesday Afternoon

I'm speechless.

And this is the improved version.

Does it come with stirrups?

Absolutely everything that comes to mind is totally inappropriate.

Oh, gee, my uterus is hanging out, I better go get a Mellier's!

They're on sale!

hhhhhhhhhhhhhhhhhh

When will I ever learn to say "no"?

Today was supposed to be a day off but I am picking up four hours for a co-worker tonight.

No biggie, we help each other out at work all the time.

But I forgot....

Tonight is American Idol!

Dang!

And it's voting night, too and I can't vote because I'm working until 2300.

I'm like an addict missing their visit to the methadone clinic.

If you are reading this, do a fellow blogger a favor and vote for Taylor, the grey-haired guy.
He is quirky and reminds me of Joe Cocker and quirky guys rock!

Thank you.

hhhhhhhhhhhhhhhhhh

Speaking of people who rock, we have had nursing students in the ER for awhile now. They are a blast to have in the department.

Usually there are one or two which is perfect for our department size.

We have a great ER, so they get to see what a nice community department is like and not get freaked out at the "Super Famous Medical Center With Super Hard To Get Into Medical School Whose ER Was Last Remodeled In the 1950s".

I don't have a student with me, because teaching is not one of my strong points. I'm more of the "Run with me and observe, Grasshopper. When you can grab the Ativan from my hand, you will be ready" type.

I know what I'm doing (usually) and in ER it's a combo of experience and instinct.

But students like to ask questions.

And I don't think "Uh...duh....let me stop and think about that...." gives off a good professional impression.

It is, however, good for me to do that once in awhile.

It's the "stop" part of the equasion that trips me up.

hhhhhhhhhhhhhhhhhh

I decided I needed a make-over. So I cut my hair off.

We are talking Natalie Portman here, folks. Like if I was wearing a cap, I'd have a hell of a time finding hair to pin it to.

So short that parts of my face that had not seen the sun for a year were fluorescent white.

I had kind of an early John Denver thing going, with wire glasses and overgrown bangs that met them. Not attractive.

So I put on my contacts and actually wore a complete face full of make up. Eye shadow, the works.

Apparently I now look younger, which is great, but good lord, what DID I look like before!

hhhhhhhhhhhhhhhhhh

I don't often lose it at work. Usually I can wait, hit my mental "Save" button and open the "Emotion" program at a more appropriate time. But every once in awhile, there is a tragic case/outcome and I start to lose it.

They say you should take time to decompress after something like that, but there is no time in the ER to go in the back and sob for twenty minutes and then come back out. No matter what happens in one room, you have a department full of patients you still have to deal with, and you have to look professional.

Being female, here are some tips that work for me, personally. Take from them what you will.

• Don't dwell. Stop thinking about the ramifications of what just happened. If you aren't directly involved in the care and came into scribe or be a "runner" leave the area and get back to your assignment.
  

• Distract yourself - get into another patient's room, bet back into triage. Get busy. Put on a smile and focus on the next patient, even if it takes an Academy Award performance to do it.

• Don't make eye contact with your co-workers for a few minutes after a tragedy/bad outcome. The last time I was faced with this, I glanced at my supervisor who was tearing up and I lost it.

• Wear waterproof mascara. I'm not joking.
  

Well that was a rather disjointed post! From uterine supports to waterproof makeup.

Such is my life.

Once Upon A Time

What on earth does Journey have to do with Emergency nursing?

Nothing.

So why is this old 1979 ad for a rock band on my professional blog?

Because I've had the, um...pardon my language, "hots" for Steve Perry for 21 years. (For the uninitiated he is the one on the far left.)

And because every single doctor and nurse I have worked with has gotten to take care of someone famous.

Except me.

I always "just miss" someone.

My only claim to fame is that I got to hold a real Super Bowl ring back in the early 80s.

Sadly, the owner is no longer with us.

But will the rest of you famous people kindly come into the ER when I'm working?

Thank you.

hhhhhhhhhhhhhhhhhh

Let me tell you a story.

Once upon a time there was an elderly patient. Tiny, petite and frail. Ninety-something. Bedridden most of the time, her caregivers sent her to an ER when they happened to notice a change in her vital signs, along with a depressed level of consciousness.

She wasn't, as health care givers sometimes say, "out of it". In fact, she mumbled something to her nurse about a "mother picking someone up". "Your mother?", the nurse inquired. At which point the patient opened her eyes and said, rather clearly, "My dear, I am over ninety years old. My mother is dead. I'm talking about your mother!"

Oh. Well that's different.

The tiny, elderly patient was with it enough to cooperate with a foley catheter insertion.

And to thank her nurse.

When undisturbed, the elderly patient would snore. And some of her vital signs would change, necessitating a bit of oxygen by nasal cannula.

As the care of the patient progressed, it was noted by a health care giver that that patient had on many medicinal patches. Patches that could account for a decreased level of consciousness. Patches that are often used for chronic pain conditions.

These could certainly account for the decreased mentation. It needed to be ruled out.

Would she wake up if a very tiny amount of a medication was given to this tiny, elderly lady?

A medication that would block the effectiveness of these patches for a brief 20-30 minute period?

She went into withdrawl within sixty seconds.

Every osteoporotic-related pain receptor in the poor woman's body blasted wide open.

She cried . She writhed in agony. She shook, curled up in a fetal position as she held the hands of her nurse and recited continual "Hail Mary"s. This poor woman went from sleep to incomprehensible agony without ever understanding what happened.

The nurse calmly and repeatedly assured the patient that this was temporary, and her pain would soon be gone.

The nurse was not calm inside. Indeed, she was nauseated at the suffering she was witnessing. In fact, had caused. The nurse kept down the lump that was forming in her throat. She held the patient's hands and prayed with her.

Twenty-to-thirty minutes was all it would take and she would be painfree again.

It took an entire hour.

The patches that were so necessary for her comfort finally kicked back in and the patient once again appeared relaxed and with a depressed level of consciousness.

But not that depressed.

Upon hearing her nurse sneeze as she was being transfered to her hospital bed, she said "Honey, take care of that cold. You don't want to get sick!"

ddd

The preceding story may or may not be true.

The patient may or may not exist.

And the nurse may or may not have held in the tears when she got home that morning.

Top O' The Mornin' To Ya!

It is my understanding (hat tip to: Grunt Doc) that yesterday was "Match Day" for the fourth year medical students.

To all our medical school colleagues/bloggers who made it through yesterday with your sanity intact, I hope you were able to "match" with your desired facility/specialty/residency.

When I worked at the local World Class Medical Center with Super Hard To Get Into Medical School, I was told that there were no longer "interns" but that they were now called "first year residents". I called them fun to work with!

Either way, congrats to those who matched with their first or second choices.

And now that Blogger has graciously allowed me to view my own blog again (what is up with that?), I shall wish everyone a Happy St. Patrick's Day and may the wind always be at your back and may no one steal your Lucky Charms!

As for me, tonight is a twelve hour night shift, so it's back to bed for this EmergiNurse....

Hitting the Nail on the Head

Well, here it is!

The health coverage we've been waiting for!

$540 for hospital expenses for sickness or accident!

That just about covers your first hour.

$135 to your doctor!

This covers the first telephone consult with the hospitalist. Thank goodness! Your own doctor won't be caring for you so it has to go to somebody!

Loss of work is up to $300! Well, for a nurse in the San Francisco Bay Area, that is a whole six hours! Ah....peace of mind!

And your life is worth $1000. Wow - I thought mine was valued at around $689.99.

It is not available for those over 70. Because you have, like, ten seconds to live.

War coverage, however is available.

Nah, I get that free on TV.

hhhhhhhhhhhhhhhhhh

I am a compulsive nail biter.

When other babies were sucking their thumbs in the womb, I was bitting my nails off.

I'm not talkin' itty bitty nibbles now and then. I'm talking down to the very last morsel and then peeling the rest to the cuticle. And then making sure it's even, without any curves or stray pieces to distract me. And my nails grow so fast, there is always something for me to "groom".

I am sure this behavior is listed somewhere in the DSM-IV (or is it V now?) as an obsessive, compulsive, neurotic behavior with sociopathic overtones.

(Stay with me, this is going somewhere....)

And then I discovered the greatest invention of all time.

Acrylic nails.

I am the only person on the face of the earth who got acrylic nails just to have their nails reach the end of their fingers. There were times when my own nail remnant was so small they were glued onto the bed itself.

Finally, I had, dare I say it.....pretty hands! And they grew so fast I actually had to have them redone once a week! I was cured!

Then I blew it by opening my mouth to one Nurse Nasty.

She trained under Florence Nightengale. She was there in the Garden when Adam and Eve blew it and caught the first virus known to man. She probably treated Fred Flintstone for gout. Michael Crighton used her as a technical consultant when he wrote "Jurassic Park".

One early morning after a horrifically busy shift in a horrifically busy ER known as "County Hospital Wannabe", Nurse Nasty approached me with an ongoing issue. I had been Charge Nurse that night and my input was needed.

You see, we had been working with a registry nurse who had fingernails that were two inches long from the end of her fingers. Two long, curved inches. I'm sure she paid good money for them, but they looked obscene and how she managed to do patient care really was a concern.

So Nurse Nasty thought it would be best if Nurse Nails didn't return to the ER as long as she had what looked like ten lethal weapons on her hands. I agreed.

And then I made the fatal mistake.

I held out my hands with their tiny stubs of acrylics that just reached the ends of my fingers and said, "It will be a cold day in hell before I ever give up my nails."

You see, no one realized I had acrylics on my stubby fingers.

She wrote me up for making that comment. Just for making the comment.

She wanted my manager to know about my "insubordination" regarding "the new nail policy".

ddd

The "new nail policy" was that acrylic nails were no longer allowed in hospitals.

When researching the issue, I discovered that infection control officers in various hospitals around the country had traced groups of iatrogenic infections to nurses with acrylic nails. Specifically, a pseudomonas outbreak in a nursery and a fungal infection in post-op bypass incisions.

Serious stuff.

ddd

I was allowed two weeks to let my acrylics grow out so that I could remove them.

And I did.

I'm pretty sure I could put them on again without anyone knowing now that I no longer work in that ER.

But I won't. I don't want to be passing infections to my patients - the danger is bad enough without having ten bacterial incubation chambers on my hands.

But the very day that I retire, you'll find me in a nail salon, getting a full set of stubby little acrylic nails. Then again, I may even add an eighth of an inch, just for fun.

Fill Your Glass to the Brim With Grand Rounds!

Well, something tells me that this nurse will have an empty glass pretty quick here.

Which brings us to this week's Grand Rounds

This week the Rounds are hosted by our favorite PICU nurse at Geek Nurse.

This week's theme was "Glass Half Empty, Glass Half Full".

Emergiblog is represented and I am honored to be a part of the collection of stories submitted this week.

Although I have to admit that my cup of coffee will be empty by the time I'm done and I may have an empty glass of Diet Pepsi sitting by the computer, too!

Nothing like a Tuesday morning in a quiet house with a hot, fresh cup of coffee and Grand Rounds! One of life's not-so-little pleasures.

Bartender, Make Mine A Double

I wish I had Photoshop.

The line for this ad should be, "Are YOU A Registered Nurse?"

This is me after two twelve-hour shifts in a row and five within 6 days.

Actually, this was me after Grand Rounds...

Except I'm in sweats and, hopefully, not drooling.

I am, however, according to some family members, snoring.

The last movie I "dragged" myself through was "Hitchhikers Guide to the Galaxy." Managed to "drag" myself to that one three times. In one day.

My family has given up a lot more than one evening a week.

Because I live a Nurse Day Life.

ddd

"Hey Bartender, I'll take a double."

"Pretty strong stuff you're askin' for, little lady."

"Sure is. Been handling it for twenty eight years. Sometimes on the rocks, sometimes straight up, but I wake up to it every day."

ddd

You see, the nursing life doesn't come without sacrifices.

I've been the first on the scene of a code and saved a life with the push of a button.

• I've missed the chance for memories of many holiday dinners with family members who are no longer here, because I had to work.

I've had a patient tell me that I'm the first person who has actually listened to them.

• I returned to my job five weeks after my son was born by C-section, because I had used up all my "sick time" leading up to his birth because I was sick for two months prior to his arrival.
  

I've been thanked by the homeless for a warm blanket and a meal.

• I slept through my daughter's Confirmation because I had been up for 36 hours, working twelve-hour nights and unable to sleep the day before.

I've hugged the parents of a young woman who died unexpectedly after spending 8 hours working to save her.

• My daughter told me years later that the smell of one particular cologne made her sad to this day because it used to mean I was going to work.

I've helped first time parents gain confidence in working through their child's first illness.

• My husband and I have worked opposite hours for 26 years so that someone would be home with and available for the kids.

I've had the opportunity to listen to the stories of the elderly who weren't oriented to place but could describe their participation in World War II in vivid, fascinating detail.

• I've missed family vacations because I could not get the time off.

I've held the hand of an intubated, post-arrest patient and had them squeeze when I asked if they could hear me.

• I've missed seeing my daughter's basketball games and cross-country runs because they were scheduled on my weekend to work.

I was meant to be a nurse.

• I give so much energy to it that twice I've suffered from depressive burn-out without my patients ever knowing.

ddd

There have been times when I have been exhilarated with nursing and times when I would give anything to be doing something else.

But somehow, when God handed out the gifts, mine was the ability to care for the sick.

Not the ability to play guitar in a rock band or sing like Ann Wilson, or play the violin in a world-class orchestra.

Didn't even get a voice good enough to be slammed by Simon Cowell.

I think He was trying to tell me something.

Given the sacrifices, frustrations and impact that nursing has made on my life, would I choose to do it all again?

Yep.

Your ER Bill: A Bitter Pill (Or Why You Pay Through the Nose For Injuries to Toes)

Oh great.

This never even occured to me until I saw this ad.

All those times I ran into the back to grab a bite of the Super Garlic large pizza with extra garlic-flavored cheese on a garlic filled crust.....

Could I?

Do I?

Must I add Tic Tacs to my pocket arsenal of patient tools?

I suppose I could always say that it's an olfactory hallucination that always happens with chest pain or dyspnea or abdominal pain or stubbed toes.

You know, blame the patient.

Knowing me, I will now become fanatical about this and brush my teeth four times a shift and lose twenty pounds eating nothing but Certs for breakfast, Tic Tacs for lunch and Ice Breakers for dinner with a snack of Altoids in between.

But I will not give up my coffee or my diet Pepsi. A nurse has to take care of herself somehow!

hhhhhhhhhhhhhhhhhh

It's a holiday weekend. The doctor's office is closed

Besides, your doctor is on vacation anyway for two more weeks.

Your left big toe is three times its normal size secondary to an ingrown toenail you hoped would go away by itself but you dropped a desk on it and now you are in agony and really would like to walk without a scream escaping from your throat with each step.

You decide to go to the ER.

Welcome!

Have a seat in the triage room. If it isn't a crazy night, the nurse will take a look at your toe, commiserate with your suffering, grab you a wheelchair, elevate your foot, take some vitals, get a history and send you to registration.

Okay, your registration is complete and your nurse has your chart in hand and she calls your name. You are wheeled to your room, where you hop on the gurney.

Congratulations.

You have just spent a few hundred dollars.

The ER doc will see you, commiserate with your suffering but she knows what to do! After an x-ray to make sure you did not fracture your toe, your toe is numbed, your rather severely infected abcess is drained and the offending nail is cut out.

Your nurse places a gauze bandage on your toe. You may need a cast shoe for comfort for a few days.

It's sort of late by now and your doctor wants to save you the trouble of going to the pharmacy so she asks the nurse to give you your first dose of antibiotic before you leave.

Congratulations.

You just spent a considerably few hundred dollars more.

You are given your discharge instructions, prescription and told to follow up with the doctor on call for yours in two days to recheck the wound and make sure it's healing well.

Thanks for using our Most Excellent ER! Take care!

ddd

Six weeks later you get the bill from the Most Excellent ER and it is well over one-thousand dollars.

After you pick yourself up off the floor, you look at the bill to see where it says they gave you a heart transplant, because surely an ingrown toenail can't have cost that much!

But it does.

That charge includes:

• the triage, the registration, the "room charge" which is based on your initial complaint

• the medications used to numb you and the antibiotic used to treat you which were obtained from the drug dispenser maintained by pharmacy

• the disposable instrument tray used to cut you, the gauze used to bandage you and the cast shoe used to help you obtained from the equipment dispenser maintained by central supply

• the nurse who went over your discharge instructions (and was assigned to your care)

• the fact that you had a procedure (the incision and drainage of your infected foot).

But still, you say, over one-thousand dollars?

Yep.

Because you took advantage of a service that is available to everyone who needs it, twenty-four hours and a day, seven days a week. The ER. Your bill pays for the salaries of those four RNs and one tech who are there whether there is one patient in the department or twenty patients every hour or none at all during a night shift. Your bill covers the services of those who have no insurance but never pay their bill, those who are indigent, or homeless and post-cardiac arrest.

You are paying for the advantage of having, and using a 24/7 emergency health care operation.

Oh, and by the way, the ER doctor and the x-ray department radiologist (the specialist who will ultimately read your x-ray officially) bill separately. They are not employees of the hospital.

ddd

Now I gave an example of someone who really had no other choice. This infection could have turned serious very fast and they were in excruciating pain. I added the element of the x-ray to make a point.

It doesn't make economic sense to use an emergency department for a non-emergent problem. If you aren't sure what constitutes an emergency, or if your pain is umbearable, we are there for you. Don't take a chance.

But...if you are not in any danger of losing your life, limb or eyesight

• Call your doctor, even after hours. Speak to whomever is on call. See if they have some advice they can give you over the phone. They may say, go to the ER! If so, come on down!

• Wait until office hours the next day, if you can. That sore throat you've had for a week will not go away just because you visit an ER that night. Trust me. Even if we start treatment, you won't be immediately cured. You may have to go through a possibly lengthy ER wait/visit when your doc may have been able to fit you in.

• If you feel you are not having an emergency but must be seen, and if you have access to an Urgent Care Center (often called a "Doc-In-The-Box" as a joke), use it. It will be cheaper and hopefully faster than most ERs.

ddd

An Emergency Department is there to care for anyone and everyone who needs their services.

No one can be turned away.

It can be a lifesaver or it can be one very expensive band-aid.

If you need the ER, use it! If you have another option, you'll save time and money.

New Friends, Loose Ends

Ah, the cigarette anatomy class!

That double filtered Viceroy tip always messed me up on exams.

I could never get the number of filters right.

One nurse (on the left) had clinical experience with the double filter, so for her, this was just a review.

Wearing caps was a requirement for that class.

Just for the record, that is exactly how my cap looks except the stripe is forest green with a tiny gold stripe in the middle.

hhhhhhhhhhhhhhhhhh

I've added a couple of links to my sidebar.

Marcus at Fixin' Healthcare was his state's representative at the winter meeting of the National Governors Association.

The weekend was devoted to the 2006 Healthy America Forum. Marcus has devoted a series of posts to the topic(s) of the forum.

Many of us are exasperated by the state of healthcare, Marcus is actually in a position to help affect changes. Very exciting!

The first three posts should have been in Grand Rounds, but (ahem) they vanished into the ether and more have been posted. Check 'em out!

Treatment Online is a web site that describes itself as "... the internet destination for the very best in psychological support and evaluation."

Jon had submitted a great article from that site, on "ADHD and Amphetamines" that also pulled a vanishing act this week at GR.

It was a good article for me because I have little knowledge of ADHD, and yet saw a nephew's GPA rise from a 1.8 to a 3.8 after he was diagnosed at 14 and placed on medication. Another good read, sure to be controversial in some areas.

And I think that brings me up-to-date on missing linkage! LOL!

Oh, do yourself a favor and click on Doc Around the Clock on my sidebar to check out his parody of "American Idol" called "American Demerol". It's so good Randy would put him in the dawg pound!!! Get ready to split a gut laughing......

Report From the President of Horrendous Treatment of Most Links (HTML) Annonymous

Who needs Belladonna when you've got "Grand Rounds"?

Trust me, I had functional GI spasm.

And functional cerebral spasms, functional throat spasms, functional tear duct spasms, functional screaming spasms, non-functional (thank god) waves of nausea and acute diaphoresis that would have made a cardiologist blanch.

I think I have some hair left.

I even invented some new four-letter-words!

Nothing like hosting Grand Rounds to bring out your inner creativity.

But I figured it this way: would a nurse walk out on a patient just because they were going bad? Of course not.

So I pulled a double shift!

I'd like to offer some advice for future hosts of Grand Rounds that I learned the hardest way possible.

• DO NOT TRUST BLOGGER or whoever you use to produce your web page/blog.
  

• Write the entire post using a web word processor and then post it to the blog.
  

• Our colleague at Clinical Cases and Images-Blog suggests using Writely - The Web Word Processor . For when it absolutely, positively has to be posted correctly.
  

• The following does not constitute backing up

• Saving your html to a folder on your "desktop". I thought I had backed up. All it did was "translate" the html into a wierd version of the Blogger posting page.

• Saving a copy of the actual submission in a folder on the desktop. Nice, but didn't do me a bit of good because once you save it, the web address is altered.

• Saving as a draft as you go along means nothing if Firefox crashes. Which it did, exactly five seconds after I had finished rebuilding the post the first time.
  

• Save all emails with the submissions in them. Thank god I did this. I would have been helpless without them.

• When I posted all links were functional. Once posted, I went to fix a bad link, and the repost showed that the bottom third of the links had ceased to be links. I then took the entire post offline thinking it would be easier to work on before more people saw the broken version. I think that was where the first mistake was made. But I'm not sure why. Once it is up, leave it up and work on it while it is posted.
  

• Do not bullet your links. I had a submission with multiple links and I put them in a bullet format. It wasn't until I put them in as links in the narrative that I was able to make links of the submissions below.

• Even though Grand Rounds is officially on Tuesday, have it ready and post it on Monday night so if it turns into a disaster you have time to fix it. Thank god I posted it at 1701, one minute after the deadline (I was excited to see it!). Had I discovered it any later than that, there would have been no time to have something on Tuesday morning.

I am as compulsive about my blog as I am with my charting, and the original Grand Rounds had every link in red, italicized and underlined. The colors you see on it now, I had nothing to do with any of them. All I wanted by that time was just a functional link.

How do you explain to your husband that there are approximately 60 professionals/patients from around the world who are depending on you to get their stories out and you can't let them down? He wonders why I have such a stressful hobby. Doesn't have a clue. Only a blogger would understand.

I was so excited to be hosting and I wanted everything to be perfect. I had planned the theme weeks in advance, so this has felt like a major failure. Ironically, I get my first Instalanche and it is bittersweet.

Thanks to everyone who sent their support. I owe a few of you some linkage, will put it in the next post. Won't be Grand Rounds, but I'll send folks your way.

Now, no more downer stuff!

I want to thank Rita over at the MSSPNexus Blog who made me laugh at loud with this photo she enclosed in an email.

I get all my stuff off the internet, people are always asking me where I find it, but this one definitely came from her.

Thanks, Rita, I definitely needed that!

Oh, and by the way, are you wondering if I would host Grand Rounds again?

If given the chance?

In a heartbeat.

Welcome To Grand Rounds (Redux)

Welcome to the Emergiblog edition of that wonderful weekly compilation of everything that is great about the medical blogosphere!

Yep, it's Grand Rounds!

Right on my own blog!

Excuse me for a moment whilst I don my professional demeanor. (I've been running around the room yelling "YES!" and pumping my fists in the air ever since Nick told me this was my week!
Until I posted the Rounds on Monday night, went to fix a few links and found that my html had become unrecognizable. Was it me or Blogger? I have no idea. What you will be reading and seeing is a resconstruction of one week of work in less than one night. Do I have your sympathy? Excellent! Now let's get to business!)

(Takes a breath)

There, that's better.

I've chosen our Dixie Cup nurse as the Grand Rounds mascot this week because this is exactly how I read Grand Rounds every Tuesday. With a cup of coffee (or three!) in my hand.

I do not, however, drink from a dixie cup.

hhhhhhhhhhhhhhhhhh

Our theme this week is "Grand Rounds in the Emergency Department"! And since no one is ever turned away from an ER, all submissions will be seen, but not necessarily in the order that they arrive! They must first be "triaged".

So please, have a seat in the triage room, your nurse will be with you in a moment.

TRIAGE!

Because we do what we do for the patients, I decided to put our patient bloggers here in the "Triage" section, right up front.

Amy at Diabetes Mine gives some straight talk on the "herbal remedies" and dietary supplements that supposedly "cure" diabetes. Check it out at Herbal Remedies If I was ever diagnosed as a diabetic, Amy's site would be the first place I'd go after seeing my doctor.

Jenni is the "editrix" of Chronicbabe and she submits a post written by Laurie Edwards entitled In the World of Doctors, First Dates Matter. Great, upbeat site for patients with all types of chronic illnesses. Laurie notes how her husband and the doctor who she works the best with share the same qualities. Interesting perspective.

Our friend, Nurse Practitioners Save Lives looks at her experience on the other side of the siderail over at The Nurse Practitioner's Place in the post NPs Save Lives Goes Under the Knife. When you are done reading the submitted post, go to the main website and read the post previous to this. A very powerful look at what our patients (and we) think pre-op. I believe the phrase "kiss my missing meniscus" shall be my professional motto.

My favorite Difficult Patient recounts a horrendous experience in The Emergency Department: ARMY Style . One can only hope that there have been improvements in the last twelve years. If you know a military family, let them know you are available for help if they need it.

At HealthyConcerns.com , Elisa says "People blog a lot about health care gone wrong, but my first experience with non-routine care at Kaiser went smoothly, and I figured it's only fair to share the good patient experience too!" Read about her experience at Healthy Story: You Know I Give Props When They Are Due

EMERGENT!

In the emergent category we find the "Top Ten" posts of the week as judged by, well, me, the woman who was made "more than romance".

#1 - First place in my "Top Ten" this week goes to Rita's submission from MSSP Nexus Blog and her post on patient safety: Triumph Built on Tragedy. She includes a link that I feel is important enough to include here: Josie King Foundation.

#2 - What do you do when your patient has run out of options? Keith over at Digital Doorway took my breath away with his post entitled How Do We Move On From Here?

#3 - TC at Donorcycle sees life through the eyes of a transplant coordinator. How do you approach a family and when? Check out There's No Good Time

#4- I didn't know whether to laugh or cry, either, so I did both. TSCD at Sunlight Follows Me tells of a "lost" patient at Lost and Found .

#5 - Mary at The Mote in the Light hits home with a post about children with multiple disabilities in the ER. It's called Anybody Know Anything About This Kid? There are some good links within the post. Check it out.

#6 - I'm a sucker for an English accent, even on the internet. Dr. Crippen, our well known colleague at NHS Blog Doctor initiates a discussion on What Do You Call the Patient?

#7 - Miracle Workers? Not Doctors. was submitted by Graham over at Over My Med Body I would like to make copies of this and hand it to every single patient who walks through the ED door.

#8 - Interested in the state of the nursing profession in the United States? I've never heard it said better than over at The Blog That Ate Manhattan. The post is entitled:
Bi-Continental Bitching, but there is no bitching. Just an insightful, consise look at the nursing profession from a physician with a patient's viewpoint. I wish I had written it.

#9 - Keagirl at UroStream offers some good reasons to assess your undergarments at Clean(ish) Underwear Wanted. Newly minted MDs beware, after this you may want to pass on that urology residency!

#10 - Occasionally things in the ED get hot and heavy. Our pediatric colleage, Flea
gives us our Grand Rounds "Code Three" of the week at When Kids Leave Home and the Dog Dies Don't let the title fool you and don't read it without checking out the comments section!

#11 - Being the closeted rock groupie that I am, what's a Grand Rounds without a Spinal Tap moment? So I'm emulating Sir Nigel Tufnel and taking it to "eleven" with a post of my own entitled They Called Him "Mac".

URGENT!

Here in the urgent category we have submissions pertaining to patient care.

Whoa! Dr. Kevin at Kevin,MD gets a fiesty comments section going when he posts a blurb on Why This Mother Dumped Her Pediatrician ! Watch out for flying scalpels! And pacifiers!

I thought I had a warped sense of humor. Well Dr. Michael C. Hebert at the (appropriately) named Michael C. Hebert, MD - Journal has a post that will make you laugh. The Kool 100 . I can't even give a synopsis and do it justice. You'll have to read it!

I am personally familiar with incapacitating nursing burnout. Our Cheerful Oncologist takes a look at doctor burnout in The Hidden Lives Of Doctors, Part IV . The post is great, but as usual, there are wonderful comments attached.

Helen is a reader of the Nee Naw blog, run by London ambulance dispatcher Mark Myers. She could not believe this horrific story and neither can I. Check out Caring Goes Out the Window . And then pick your jaw up off the floor.

Our Wandering Visitor discusses informing patients of exactly what a "code" entails in the appropriately named post, Codes.

Shadowfax at Movin' Meat weighs in this week with Well That's Just Not Fair . I used to joke that if I could tell your scan was bad, you were in trouble because I'm not radiologically literate. That's not funny anymore.

Dr. iBear at Doc Around the Clock tells a humorous and poignant story of a patient almost cured in The Hunchback of Notre Dame.

Dr. Emer at Parallel Universes gives us three of his most memorable ED shifts at Notable ER Stories

It's our early successes that build the most confidence and paramedic student PDX EMT at Drug Induced Hallucinations describes one of his success stories at Tales From the ED (1)

The ED doesn't often get of view of what it's like "upstairs" when we send a patient, but this week GeekNurse gives us a peek into a PICU admit in Incoming! God forbid you should ever need a PICU, but if you did, you'd want this nurse at the bedside.

This post from Jodi, in her last months as a student nurse, at Coffee and Conversation In A Smoky Room had steam coming out of my ears. It's called Scut and it's about her ER experience. Why do nurses treat future colleagues like they have the plague?

It just wouldn't be Grand Rounds without a visit from Doc Shazam at Mr. Hassle's Long Underpants and a very poignant story about The Blind Man and the Butterfly

Dr. Aidan at The Examining Room of Dr. Charles takes a lighthearted look at Medicare Part D (is that an oxymoron?) in Bridging the Gap - One Doctor's Approach To Explaining Medicare. Wish him a quick recovery, won't you?

Whether you are a fan of Johnny Cash or not, you must check out this post submitted at
Clinical Cases and Images - Blog . A very unique post for Grand Rounds, it includes a video of Johnny's rendition of "Hurt". Powerful.

New to Grand Rounds, Barely, MD discusses the Avian Flu (H5N1) and Why We Care. and the relationship between research and journalism at Premature Birth and Journalism. Hits a double on his first "at bat"!

Welcome.Big Mama Doc looks at Formalities on this side of the Atlantic at Fat Doctor . What ever happened to respect?

Our favorite Internal Medicine Doctor reads between the lines in a medical/sports post at Doctor as he points out some informational discrepancies in Does Ian Thorpe Have HIV?
Let's hope this world-class athlete can shake whatever it is that is plaging him.

He's new to Grand Rounds, he teaches anatomy and he's starting medical school in September! Let's all give a Grand Rounds welcome to Brad Wright at Anatomy Notes who describes for us his experiences with Nasal Irrigation (his own). He uses only the finest ingredients, not the least of which is humor.

NON-URGENT!

Here in the non-urgent, but no less important, category are submissions that look at hospital life and patient care "behind the scenes" through an administrative capacity, or posts that delve into research and its applications.

Bob from the Health Care Law Blog reports on a new forum for health policy blogs. Get the details at New Carnival: Health Wonk Review


Grrlscientist from Living the Scientific Life (Scientist, Interrupted) submits a fascinating post on the Avian flu. In her words: "A new report (linked) shows that industrial poultry farming is smack-dab in the middle of this avian influenza crisis, NOT WILD BIRDS, as is so widely reported. So what shall we do about this?" See Avian Influenza: A Story About Industrial Fowl Play?

Eat dirt! No, that's not the latest put down, but the subject of Dr. Andy 's Grand Rounds submission this week: Eat Dirt, Prevent Asthma! Hmm....I'd love to see the dosage on that!

Kate at Healthy Policy looks at the pros and cons of employer-based healthcare in Do We Want to Keep it With Employers? Is it a system we keep, or should we forego it
altogether?

Truma teams are amazing. I'm lucky enough to live in an area with many Level I facilities. Dr. Bard Parker at A Chance to Cut is a Chance to Cure tells us why in his submission entitled Practice Makes Perfect V. He explains the difference between designation and verification in Trauma Center Confusion.

A second post at Clinical Cases and Images-Blog has to do with Residency Program Blogs These are blogs by residents for residents. Links to examples provided.

Tony at Hospital Impact submits a hilarious post by Nick Jacobs entitled Classic Email Thread At My Hospital . Sounds familiar, doesn't it? And do not miss the link at the end re: the email between two attorneys.

Ruth over at The Biotech Weblog looks at Detecting Exposure to Bioterrorism Agents Using Genetic Blood Test. Cutting edge research, with potential applications for other diseases.

Coturnix over at Circadiana submits a post on the Diurnal Rhythm of Alcohol Metabolism. If you are running out of booze, better drink in the morning!

Chemist Gloria submits her post at Straight From The Doc discussing studies showing that Xenon Gas Prevents Postoperative Brain Damage in Bypass Patients

In keeping with the cerebral function theme, Sumer at Sumer's Radiolgy Site references a study on Quantifying Stroke Related Brain Damage. Short. To the point. Impressive.

InsureBlog contributes with a post submitted by H.G. Stern with the great title of InsureBlog: Perry Mason vs. Dr. Kildare. Can medical malpractice reform actually lead to lower health insurance rates? Better service? Good links with additional information.

Tara at Aetiology gives her input on the "Superbug" Hit List Published by the Infectious Disease Society of America. Pardon me for a moment while I go wash my hands....

Adam Scavone submits an interesting post from The Agitator. Per Adam: "Radley Balko is following the appeal of Dr. Bernard Rottschaefer, who is being prosecuted by the D.E.A. in their war on pain doctors...They're accusing Rottschaefer of not being able to correctly identify a patient who was lying to him... the prosecution of pain doctors for not being omniscient needs to be known. The post is at: Rottschaefer's Appeal This Week: Comments.

Kumbaya? Dmitriy, the Publisher of The Medical Blog Network reports from the California Regional Health Information Organization, Summit III, making sense of how capable are RHIOs of truly serving the interests of consumers. What Is Rhetoric and What Is Reality? I'm hoping the ED linking is the "reality"!

David at Health Business Blog wonders Can Blogging Boost the Rate of Progress in Medicine? I'd love to find out the answer to his hypothetical research example! It would explain a lot!

Our friend over at Interested Participant jumps in with Macho Mammas Give Birth to Boys (!) and I think I'll let him give the synopsis: "Scientists have established that eggs taken from female mammals have varying levels of testosterone and that those with the highest levels are more likely to develop into male embryos." Intriguing findings, but all I can picture is women with beards!

(Epilouge: I've spent nine hours re-doing the work of an entire week. Twice. Blogger is bad and Firefox crashed. I apologize for how this is going to look online, but if I don't post, I'll lose it again. News in my next post. Next week's host: GeekNurse . Don't forget the Grand Rounds archive on Blogborygmi and Nick did a prerounds interview with me on Medscape - I'll get that link tomorrow. When I stop seeing links before my eyes. For now it's GOOD NIGHT NURSE!)