Burnout Meme

Monkeygirl created a new meme and I've nominated myself to play.

Six things that are causing me to burnout:

1. JCAHO
I've explored this subject to death but their self-procreating idiocy and it's attendant reams of paperwork to prove that you are doing excellent patient care without taking into account that nurses now spend all their time charting instead of actual patient care. To meet all their requirements most hospitals have a nurse to administrator ratio of 1:1 - complete twaddle. Take the clipboards away and take care of the patients for crying out loud.

2. Not having the equipment to do my job.
Today I had a shocky patient and needed to do a manual BP but there was not one working cuff in the department. Last week the hospital was out of pediatric IV catheters - what in the hell do you want me to use? a 16 guage on that neonate?

3. Lazy ass co-workers
Stock your fucking rooms. I'm busy too but I get it done. If you take the last blanket out of the blanket warmer fill it. If you take the last form, make some copies. Don't leave your trash on the nurses station desk/med room counter/break room table etc. Make your patients comfortable - if they are wet change them, if they are cold give them a blanket. Give them a pillow, turn down the lights. I work with one nurse that will have two floats doing her orders and she'll be on the phone with her boyfriend. Enough already.

4. 20 year olds that are on disability for back pain.

5. Lazy ass housekeepers.
This is a hospital, it shouldn't be visibly filthy for the love of God. Why does no one but me see this as a problem?

6. Drug seekers and the entitlement crowd.

Music to my ears

We had a float from the telemetry floor today that had never been in the ER so she got buddied up with me.

That being said, we had the worst day I think I have ever had in the ER - and I've had a lot of them.

At 5 pm there were 14 hallway patients, 42 people waiting to be seen in fast track and the main ER and 4 ambulances waiting to unload patients. The ER nurses had been working like dogs all day but not making any headway against the never ending tide of sick and injured. No one had a break, a lunch or even a pee.

I could go on and on about how awful it was but you can use your imagination. It was about that time that the float nurse said "I get it now." Having seen it with her own eyes she finally understood why we were so pushy about getting the patients to the floor.

Music to my ears.

Triage

Let me start by saying I hate triage.

But everyone has to have their turn and today it was mine. So with only a little grumbling I headed up to "the box."

The first card I pick up says "lump." I call the patient in and it is a twentish male who states he has had a lump on his neck for 3 years. Yes he has a doctor. No he has not gone to his doctor about this problem. No nothing has changed recently. I want to say, but I don't-"so let me get this straight. you've had this lump for three long years. In all those three long years you never thought to go see your doctor about it. Nothing is new or different today but you have suddenly decided, after three long years, that it is an emergency and has to be looked at right away." Like I said, I want to, but I don't. Out to the waiting room he goes.

The next patient has dental pain. I see from the visit history in our hand electronic medical record that she has had 42 visits in the past two years for dental pain, migraines and back pain. One of the residents gave her 20 Vicodin 3 days ago. I wanted to say, but I didn't "So, did you ever consider going to a dentist instead of just coming here for pain medicine." Out to the lobby she goes.

The next patient has shortness of breath, ohhhh! Potentially a real sick person. The patient is nineteen and REEKS of cigarette smoke along with the smell of BO and rancid body oil that has soaked through their clothes from not bathing or changing. Their respiratory rate is under twenty and their oxygen saturation is 99% which is normal. During the triage he mentions that he has chest pain. Since we became a 'chest pain center' we have seen an influx of patients with 'chest pain' which they figure will get them whisked right back to a room.

The next patient is 999years old, well- really only 93 but they look that old. The complaint is dizziness so I take her back to a room. Dizziness could be anything from stroke, slow heart rate, dehydration along with several other worrisome things.

The next patient is an infant with diarrhea which he demonstrates by pooping all over the exam table and the wall. He got to go straight back to a room for some IV fluids and ultimately an admission.

Then there was a party of three, mom with back pain and two of her children with colds. During the endless triage process she decided to get the third child checked out "while we're here."

The 19 year old with shortness of breath has a girlfriend with him, she is probably in her twenties and already has no teeth. Every time I go out she accosts me to ask how much longer he is going to have to wait. The patient himself has been on the cell phone continuously. How can one afford a cell phone when they apparently cannot afford soap.

By noon I have triaged 43 people and only 8 of them were sick. Short of breath boy left an hour ago, girlfriend in tow, screaming obscenities at all and sundry. Helpful hint, if you are screaming you are not short of breath.

The rest of the day is more of the same. The end of the shift is a welcome respite. And it'll be about a month before my number comes up again. Thank God.

Hot

It was 103 degrees today in Sunny Califonia! HOT, HOT, HOT!

There are a lot of wonderful things about living in California, summer isn't one of them. We have 9 wonderful months where you can do all kinds of wonderful outdoor activities and then comes summer. From mid-June through September it just sizzles and we scurry from air conditioned place to air conditioned car to air conditioned place.

It's a little early in the year for such heat. I sure hope it goes away.

Who's in charge here anyway?

I was discharging a 3 year old with strep throat and giving the discharge instructions to the parents. I was going over the prescription for Amoxicillin when the mom says "Oh, I can't get him to take medicine."

WTF? He's three. Who is the parent in this relationship. If you don't have some control over your three year old your life is going to be HELL when they get older.

When did parents stop being parents and turn into a bunch of namby-pamby pussies? Children don't know what is good for them and what is dangerous. It is up to you, their parents to make rules to keep them safe and healthy and ensure they grow up to be responsible, productive adults and you are FAILING MISERABLY!

Yet another reason why people should have to take a test before they are allowed to reproduce.

Tachycardia

It always amazes me how the people with a cold will call an ambulance but the really sick people will make their own way to the ER and sit patiently in the lobby until they are called for triage. They often give a vague, non-specific complaint when they sign in so the greeter doesn't catch that they need immediate attention.

We were short staffed one morning so we didn't have a triage nurse, we were all busy with patients in the back so when they called from up front for a lady with "weakness for a week" it took a minute for one of us to break away and get out front.

It happened to be me. The lobby was already full, when I called her name no one got up. I was about to give up when someone mentioned casually that they thought she was sitting next to them. I went over to check it out and found a woman slumped over minimally conscious, pale and diaphoretic with no palpable pulse. (Gives you an idea of the usual ER clientele that no one out there was worried about how she looked.)

We quickly got a gurney and rushed her to the back where she was found to be in V-tach, with a blood pressure of 48 by doppler. We quickly applied some electrical therapy in the form of cardioversion which converted her to sinus rhythm. Anti-arrhythmics, vasopressors, fluid boluses and eventually a trip to the cath lab which led to a 4 vessel CABG. She made a full recovery and made it home two weeks later.

Her story eventually filtered back to us. She had probably had an MI earlier in the week which was why she had been feeling bad, ischemia and necrosis made the heart irritable. She was feeling worse and worse but didn't want to be a bother to anyone. She called her doctor but couldn't get an appointment so she stayed at home until she couldn't take it any more and decided to drive herself to the ER. (In V-tach with no blood pressure!)

We had gotten three ambulances prior to her arrival, a 44 year old with nausea and vomiting for an hour, a chronic back pain and a sprained ankle. Ironic, isn't it.


picture credit

A Good Day

I had the best day today.

All of my patients we nice and thanked me for all I did for them.

We weren't balls to the wall so I had time to talk to them and explain what was going on and even do some teaching.

My kidney stone patient go 30mg of Toradol IV and went from pale, sweaty, writhing and vomiting to pink, dry and smiling. I believe if he could have a statue erected of me he would have done it, he was that thankful.

I got a bouquet of flowers from my son in the Air Force, a belated mom's day present.

I triaged a delightful 99 year old man with no medical problems AND on no medications that still lived alone independently and volunteered at the homeless shelter once a week. And he asked me out on a date.

I took care of a pale, lethargic, sick looking baby that perked up and looked like new after a couple fluid boluses. I was able to spend enough time with the mom to put her mind a little bit at ease.

My boss got a thank you letter from a previous patient of mine with praise.

The doctors bought us pizza for lunch.

We got the STEMI patient to the cath lab in 19 minutes! Go us!

All four of my favorite ER MD's were on today.

Why can't all our days be like this?

You Know It's Gonna Be a Bad Day

I went in to see my first patient at the beginning of the shift only to find he had been incontinent of urine - the entire bed was soaked. I rounded up all the linen and bathing supplies and got one of the other nurse to help me. She rolled him over and I washed his back and bottom and pushed the dripping wet linen underneath him, usually I would start the dry linen but his old stuff was so wet we elected to roll him completely off of it to avoid getting the clean stuff wet. I reached across him and grabbed his shoulder and hip and rolled him to face me. He was kind of a big guy and ER gurneys are notoriously narrow so I had to roll him up against me to give the other nurse enough room to get the linen under him. Suddenly I felt a warm flood going down my leg and into my shoe. He was peeing and it was running off the mattress and all over me.

The sad thing was the rest of the day was so bad being peed on was the high point.

Happy Nurses Week

It's nurses week and the blogosphere is full of tales of gifts received from employers, pens, coffee cups, fleece jackets and so on.

So what did my fine institution do for their nurses this year?


Not a damn thing!

"We Need Some Help Out Here!"

We got the panicked call from the ER greeter - "There's a mom here with her baby and it's having trouble breathing - I think you better get right out here."

Our greeters are a very seasoned bunch and tend to not overstate things so we went right out there. Mom was about 20 and crying holding a limp, gray, grunting infant. I just grabbed the baby right out of her arms and headed to the 'crash' room without even looking to see if she was following. As I ran by the nurses station I yelled for help.

Not only was she not breathing well she was having some sort of seizure activity. Like a well oiled machine the team swung into action. One nurse started assisting respiration's with an ambu bag while another searched for an IV site, a third put on the monitor leads which showed a HR of 210 and a pulse ox of 79%. Cap refill was delayed and the abdomen was hard as a rock.

"What happened?" the doctor asked the mom, who was hovering in the doorway.

She came home from work and found the baby like this, dad had been home with the child. She was a normal healthy child but had been suffering from colic and was fussy.

Hearing this story a sick suspicion entered all of our minds. This baby had probably been beaten. We quickly intubated and started some fluid resuscitation then rushed off to CT scan. As we scanned the pictures coming up on the screen told the devastating story, traumatic sub-arachnoid hemorrhage and ruptured spleen spoke of violent shaking and violent blunt trauma to the abdomen - probably from being punched.

The baby was whisked off to surgery to remove the spleen. She survived the surgery but the neurologic damage was too great and the family elected to remove life support three days later. She was 3 months old.

How to tell if you have a problem

So we have this doctor in town, there is one in every town, we call him doctor feelgood. All of his patients are on some cocktail of Oxycontin, Vicodin, Soma, Klonopin and so on. But.....to give him some credit, he expects his patients to adhere to the rules, he only gives out a months supply at a time and if he finds out you are going to other doctors or ER's - you're fired from his practice.

Recently we had one of his patients that gave a history of being on high dose narcotics for back pain come in with vomiting. His story was nausea, vomiting and chills for 24 hours. On exam it was fairly obvious he was in narcotic withdrawal. When the doctor confronted him the patient admitted he had been out of his med's for two days.

Brother, you've got a problem. You've used up a month's worth of med's in 17 days AND when your doctor finds out you've been here he'll probably give you the boot.

When the ER doctor explained all this to the patient and told him that he would not give him a narcotic prescription but would give him med's to treat the symptoms the patient went BALLISTIC. It ended up with the police being called and the patient going off to jail for attempted assault on a health care worker.

Another fun moment in the ER.

Too Much Sun

I. Am. Sunburned.

Too much yard work even with #50 sunblock but I made a lot of progress, got my drip irrigation set up and working so it will all be automatic now. But I'm absolutely glowing right now and sleeping tonight will be hell.

With my pale Scandinavian skin I try to be very careful, I never go out unless slathered in sunblock, wearing a hat etc. Thankfully I don't burn all that easily, which you'd never believe if you saw me - fish belly white comes to mind. Not to mention that I am getting to the age when you don't want to actively seek out anything that will contribute to your wrinkles - they are doing fine on their own. But my care with the sun comes from another reason, one patient I just can't forget.

I had a patient a few years ago that came in for vomiting. He was in his mid-forties and had metastatic melanoma. He hadn't noticed the unusual mole on his back - it was discovered after a visit to the doctor for some shortness of breath that just wouldn't go away. A chest X-ray showed multiple lesions in his lungs. Multiple rounds of treatment with remissions and relapses later he was now in our ER with a bowel obstruction from the multiple metastatic lesions in his abdomen. The lesions were also now in his brain, liver and bones.

His pain was agonizing despite massive doses of narcotics. He weighed 97 pounds. A mere skeleton covered with a frail, tissue paper coating of yellowed skin. His hair, once lush and wavy, was now just a few brittle strands. He had bedsores on his bottom. If you have ever questioned whether hell exists, it does - and this poor man was in it.

We admitted him for pain management and I heard he died later that day. I've always remembered that man. I am religious about checking my skin and go to the dermatologist regularly also. Dying from melanoma is a horrible way to go. A now I've got this sunburn...........

I'm going to buy this.

Imagine the endless entertainment I will have. Talking on the cell phone and driving 57 MPH in the passing lane? Jammed.

Endless phone call with your friend talking about the fight you had with your boyfriend last night while sitting behind me in the theater? Jammed.

Your cell phone ringing incessantly while I am trying to eat? Jammed.

Carrying on a cell phone conversation while sitting on a toilet in the ladies room? Jammed.

Talking on your cell phone in triage? Jammed.

Cell phone glued to your ear while you are at the amusement park with your kids? Jammed. Dumb ass.

I can hardly wait. I hope they have overnight delivery!

Things you hope never happen

A long time ago in a hospital far, far away.

It was January, the temperature was approaching zero and it was snowing like hell. The ER I worked in was in a resort town that was all but deserted in the winter. There was a PA and myself and we had seen a grand total of seven patients so far that day.

It was after lunch. We had two patients in the department, a lady with vomiting getting IV fluids and waiting for lab results to rule out an appy and a little old man with chest pain that was waiting for an ambulance to transfer him to bigger hospital down the road to repair his broken hip. Both were sleeping and the PA and I were finishing up charting and charges.

A car pulled up to the ambulance dock and a man helped his heavily pregnant wife out of the car. I went out with a wheelchair to help them.

"My water broke and there is something hanging out of me, I think it might be the cord."

Oh my God. My heart almost stopped. We were a half an hour away from the closest hospital that did any kind of obstetrics and this was an obstetrical emergency. A half an hour in good weather and this was anything but.

We zipped into the ER and quickly got her up on the cart, stripping off her bottoms we saw that indeed there was cord protruding from her vagina. I helped her to get onto all fours with her bottom pointing into the air and the PA quickly slipped a sterile glove on and reached inside to push the babies head up off the cord to relieve the pressure and allow blood to flow to the baby. I grabbed the doppler and auscultated fetal heart tones which were 147, in the normal range. I placed an oxygen mask on the mom.

I stepped away to quickly call the supervisor to come and help. The PA couldn't move, if he took his hand away the fetal head would compress the cord cutting off the flow of blood and oxygen. She needed a c-section right away and our hospital couldn't do one. The general surgeon arrived and discussed the options with the parents, The elected to try for a transfer to the other hospital as long as things looked OK. The fetal heart rate remained reassuring.

Thank goodness the transfer went without a hitch, the PA had to go and the surgeon also went in case he was needed, the nursing supervisor had OB experience so she rode up front in case the baby delivered.. The other hospital was alerted and was on full standby, the patient was in the OR within 5 minutes of her arrival where they delivered a healthy baby boy via c-section without incident.

I don't think I've been that scared since.